Surgical Approach to Bilateral Inguinal Hernia. A Case-Control Study.

Introduction: Bilateral inguinal hernia can be safely repaired simultaneously, open or minimally invasive, in an elective sce-nario. The choice of surgical approach depends on the patient's status, hernia characteristics, surgeons and patient preferences. Whether age criteria should be considered when selecting between the two approaches is still a matter of debate. Considering that there is no consensus regarding the best repair in bilateral inguinal herniorrhaphy, the aim of the study is to perform an analysis regarding elective surgical approach of patients with bilateral inguinal hernias. Material and Methods: To study the relationship between exposure to an open versus laparoscopic approach in patients with bilateral inguinal hernia, we conducted a case-control study. In our retrospective analysis, cases (23 patients) were the open-approach hernia repair, and controls (82 patients) were laparoscopic hernia repair. We analyzed two sets of variables: first, related to patient characteristics (age 65 years, BMI 30 kg/m2, smoking habit, HTA status, COPD status, DM status, use of anticoagulants, presence of neoplastic status) and second, variables related to hernia features (inguinoscrotal hernia, recurrent hernia and complicated hernia). Results: The mean age for cases was 73.26 (Ã+-12.99) years and that of controls, was 56.48 (Ã+-15.15) years. Univariate analysis demonstrated four variables with statistical significance: age 65 years, inguinoscrotal hernia, neo-plastic status, and anticoagulant use. When introduced into the multivariate analysis, we noted that only two variables, age 65 years (OR=4.183, 95% CI [1.289, 13.572], p=0.017) and use of anticoagulants (OR=38.876, 95% CI [1.305, 1158.011], p=0.035) reached statistical significance. Conclusion: This study demonstrates that when we refer to bilateral inguinal hernia repair, patients aged 65 years are at risk of having an open procedure at least fourfold more than patients aged 65 years. In addition, the use of anticoagulants increases the risk of open hernia repair 38 times more than that of minimally invasive repair for the same age group. Interestingly, in our study, hernia characteristics were not found to be associated with open hernia repair and age 65 years. In our study we found that age 65 years is associated with electing open hernia repair over minimally invasive repair, which can be linked to age-related risk factors. Further re-search is needed to investigate the impact of age and age-related risk factors on surgical outcomes of bilateral inguinal hernia repair.

Surgical Outcome in Bilateral Inguinal Hernia Repair: Laparoscopic Total Extraperitoneal Approach (TEP) as Best Approach?

Introduction: Bilateral inguinal hernia is a distinct entity in the inguinal hernia category. Open and minimally invasive techniques for the treatment of bilateral inguinal hernia have been previously described. If resources and surgeon expertise are available, guidelines recommend laparoscopic repair for this entity. Methods:We analyzed data from 83 patients who underwent laparoscopic inguinal hernia repair (total extraperitoneal repair - TEP) of 158 hernias (146 inguinal hernias and 12 other types). Patients had bilateral symptomatic hernias. Results:Male predominance, with a mean age of 56.7 years, was noted. Lateral hernias (according to EHS classification) were prevalent (71.08%). In the majority of cases (77.11%), meshes made up of a custom polypropylene monofilament mesh were used, followed by Bard 3D Max mesh and Ultralight mesh. Regarding postoperative complications, seroma was the most frequently encountered one in our series (7.23%), followed by urinary retention and 'feeling' of mesh (2.41%). Hydrocele, wound hematoma, cord hematoma and chronic pain were seen in 1.20% of patients. No wound infections were observed. The average operative time was 97.77 minutes (SD=17.08); when associated surgery was present, it prolonged the operative time, and we found statistical significance (p=0.002). Similarly, the presence of recurrent hernia extended the operative time, which was found to be statistically significant (p=0.003). The conversion rate in our data was 2.41%. Drainage, which was performed in 13 patients (15.66%), decreased the incidence of complications, especially seroma (p=0.026). The mean length of hospital stay was 2.93 days (SD=1.81), with most of the patients having been discharged on the second postoperative day (37.35%). Only one recurrence was identified (1.20%). Conclusion:The laparoscopic approach for bilateral inguinal hernia treatment is feasible and has been proven to be advantageous. Our study emphasizes that the TEP procedure has low rates of complications, conversion and recurrence; hence, we recommend bilateral hernia repair.

Necrotizing fasciitis of the chest wall: A clinical case report and literature review.

Necrotizing fasciitis of the chest wall is a very rare pathology, but with significant mortality, representing a therapeutic challenge. All international reports indicate the need for early diagnosis and an aggressive medical-surgical attitude in order to improve the prognosis. In addition to a review of literature, we present a case developed secondary to a thoracic pleural drainage for pyopneumothorax associated with significant bronchopleural fistula in a destroyed tuberculous left lung. Along with medical treatment, extensive surgical debridement was required. Despite drainage incisions and negative pressure wound therapy (NPWT), the evolution of the fasciitis was difficult, due to bronchopleurocutaneous fistula. Thus, the Azorin procedure (transcervical mediastinoscopic closure of the left main bronchus) was performed. Once this procedure was completed, the inflammatory phenomena were controlled which allowed for a second step consisting of left pneumonectomy, with the application of specific methods for the prevention of bronchial fistula. The clinical case was a therapeutic challenge requiring a complex, staged, multidisciplinary approach due to both the immunocompromised terrain and the severity of the lesions. In conclusion, early recognition and aggressive and combined application of medical and surgical treatment methods can ensure therapeutic success.

Retroperitoneal Functioning Paraganglioma--A Rare Case of Secondary Diabetes.

INTRODUCTION: Paragangliomas are rare neuroendocrine tumors that arise from the extra-adrenal autonomic paraganglia, which can derive from either parasympathetic or sympathetic paraganglia and are closely related to pheochromocytomas. CASE REPORT: We present the case of a young male patient of 37 years old, who was admitted for hypertensive crisis and palpitations. His medical history included medically controlled type 2 diabetes mellitus, (diagnosed 10 months ago), Hepatitis A. Hormonal evaluation revealed elevated urinary metanephrines and normetanephrines, with mainly increased normetanephrines (2330 ug/24 h). Plasmatic metanephrins were in normal range, but levels of plasmatic normetanephrins were elevated (952 pg/ml). The assessment of pituitary and aldosterone-renin axis values were within normal limits. Abdominal computed tomography showed left adrenal nodular lesion on the external arm, bilobulated, size 32/33 mm with maximum axial and cranio-caudal diameter of approx. 45 cm, suggestive of a benign lesion, keeping the cleavage plane to vecinatate structures. Left adrenalectomy was performed by laparoscopic approach. We mention that immediately after induction of anesthesia were recorded blood pressures of 298/143 mmHg. Histopathologic and immunohistochemical examination diagnose paraganglioma, without invasion of adjacent tissues. The patient evolution was favorable, with the remission of the symptoms and normalization of hormonal markers. It is imperative to note the remission of diabetes in the postoperative period. DISCUSSION: This is the case of a young patient with functional retroperitoneal paraganglioma, who presented with symptoms of pheochromocytoma. Compared to pheochromocytomas, paragangliomas are rarely symptomatic and functional. Association with diabetes is even more rare. Specialized investigations allowed the proper diagnosis and the therapeutic approach above was the result of a multidisciplinary cooperation.