A rare presentation of appendicitis contained within an incisional hernia post loop ileostomy reversal - A case report.

INTRODUCTION AND IMPORTANCE: Appendicitis within an incisional hernia is rare, with current literature describing a small number of cases, occurring through a variety of surgical incisions. We describe a case of appendicitis contained within an incisional hernia following reversal of a loop ileostomy, on a background of previous sigmoid cancer resection. This is the second such case we were able to identify on literature review. CASE PRESENTATION: A 45 year old man presented with one day of migratory abdominal pain, predominantly focused at a tender, irreducible lump in his right lower quadrant, underlying the scar from previous reversal of loop ileostomy. CT on admission revealed an incisional hernia, containing an inflamed appendiceal tip. He underwent an uncomplicated laparoscopic appendicectomy and primary suture closure of the hernia defect, and was discharged the following day. Acute appendicitis was confirmed on histopathology. DISCUSSION: Placement of a defunctioning ileostomy is common in the management of colonic cancers, and incisional hernias are a common complication. It is however rare for an appendix to be contained within a hernia sac, and even rarer for appendicitis to develop in this setting. As a result, the presentation of this condition may mimic that of an incarcerated or strangulated incisional hernia, with pre-operative diagnosis typically relying on diagnostic imaging. CONCLUSION: Incisional hernia appendicitis is rare and presents a diagnostic challenge. Early recognition of this dual pathology is necessary to allow for prompt surgical management of both the appendicitis and hernia, as well as guiding the approach for hernia repair.

Negative Pressure Dressings (PICOTM) on Laparotomy Wounds Do Not Reduce Risk of Surgical Site Infection.

Background: Surgical site infection is a common cause of post-operative morbidity. Although a number of studies on negative pressure dressings including PICOTM (Smith & Nephew, St. Petersburg, PL) have shown reduced rates of surgical site infections (SSI), more evidence is required. This study sought to determine if PICO dressings reduce surgical site infections or other surgical site complications in primarily closed laparotomy incisions after clean-contaminated surgery in moderate-risk patients. Methods: Patients undergoing laparotomy and bowel resection were randomly assigned to PICO or conventional dressings. The incision was assessed one-week post-operatively for any infection. Patient notes including outpatient appointments were later examined for any delayed infection during the same or subsequent admissions or in the outpatient setting. Patient characteristics such as body mass index (BMI), incision depth, and comorbidities were noted to identify any group who may show more benefit from the negative pressure dressings. Results: From March 1, 2015 until September 30, 2017, 217 patients consented to participate in the trial. Twenty-nine were subsequently excluded, leaving 188 patients with 96 receiving PICO and 92 receiving a standard dressing. Twenty-seven (14%) patients developed a surgical site infection; 13 received a PICO dressing and 14 received standard dressing (p = 0.73), indicating no difference in surgical site infections between the two types of dressing (odds ratio [OR] 1.1). Thirty-one (16.5%) patients developed other surgical site complications. Eleven of these patients received a PICO dressing and 20 received the standard dressing (p = 0.06, OR 2.1). Conclusion: This study does not support the routine use of PICO dressings on uncomplicated laparotomy incisions in moderate-risk patients.

Post-operative telephone review is safe and effective: prospective study - Monash outpatient review by phone trial.

INTRODUCTION: Studies have shown that post-operative telephone follow-up is satisfactory and effective. As high quality evidence is scant, we conducted a randomized controlled trial to compare it against outpatient clinic review for emergency laparoscopic appendicectomy or cholecystectomy. METHOD: Patients who received emergency laparoscopic appendicectomy or cholecystectomy were eligible for this study. Once recruited, they were randomly allocated to either clinic review or telephone follow-up on discharge. Participants were reviewed at 2 weeks after operation and contacted again at 4 weeks after initial follow-up for satisfaction survey. RESULTS: One hundred and seventy-nine participants were recruited with one withdrawn consent and six excluded. Ninety-six underwent laparoscopic appendicectomy and 76 had laparoscopic cholecystectomy. Ninety-six attended clinic review and 76 had telephone follow-up. The two groups were similar in baseline variables. Non-attendance rate was higher for clinic review cohort (24% vs 6.6%, P = 0.002). Participants who received telephone review reported higher satisfaction level (9.31 vs 8.85, P = 0.002), and most patients prefer telephone follow-up (73.1%, P < 0.0001). No difference was detected for missed complications (P = 0.354). CONCLUSION: Telephone follow-up post laparoscopic appendicectomy or cholecystectomy is safe, satisfying and effective.

Incomplete excision of squamous cell carcinoma of the skin: a prospective observational study.

BACKGROUND: Squamous cell carcinoma is the second most common cancer of the skin. It behaves differently from basal cell carcinoma. Few large-scale studies have identified risk factors for incomplete excision of cutaneous squamous cell carcinoma. The authors report the largest prospective study to identify the risk factors for incomplete excision of these lesions. METHODS: A total of 517 histopathologically confirmed squamous cell carcinomas were excised from January of 2001 to December of 2002 at the Peter MacCallum Cancer Institute. Of these, 480 primary excisions were analyzed. Data pertaining to patient age, sex, lesion size, margin of excision, recurrence, previous excision, site, anesthetic choice, and repair method were collected prospectively. RESULTS: The overall incomplete excision rate was 6.3 percent. Lesions on the ear (p < 0.003), re-excisions (p < 0.001), and invasive lesions (p < 0.001) were associated with the highest incomplete resection rates. Age (p = 0.61), sex (p = 0.075), tumor size (p = 0.521), surgeon's experience (p = 0.092), and recurrent lesions (p = 0.408) were not statistically significant risk factors. CONCLUSIONS: Statistically significant risk factors were ear lesions, invasive lesions, and previously incompletely excised lesions referred for re-excision. The authors recommend more care with tumor markings, taking margins of at least 5 mm, using deeper margins, and referring patients to more experienced centers.