Para-inguinal hernia; presentation, diagnosis and surgical treatment, a case report.

INTRODUCTION: Para-inguinal, or peri-inguinal, hernias are a rare type of hernia of the inguinal region that present in a similar fashion to but do not anatomically correspond to inguinal or femoral hernia pathologies. Surgeons should be aware of this rare pathology, diagnostic imaging and surgical treatment approaches including minimally invasive techniques. In this paper, we discuss the different groin region hernias and describe the first case reported of a successful TEP repair of a para-inguinal hernia. PRESENTATION OF THE CASE: 62-year-old-female who presented to the clinic with symptomatic large right groin bulge. Examination revealed a large incarcerated right inguinal hernia above the inguinal ligament without strangulation. Intraoperatively, it was found that she had a fat containing incarcerated right para-inguinal hernia with a defect just superior and lateral to the deep inguinal ring. She underwent a successful laparoscopic repair with mesh utilizing Total Extraperitoneal approach (TEP). DISCUSSION: This a case report discussing a rare groin hernia entity called Para (Peri) Inguinal hernia. This hernia presents in a very similar fashion as inguinal hernias but the defect is separate from the known inguinal or ventral hernia defects. Presentation, Diagnosis and Surgical treatment approach is discussed in this case report. CONCLUSION: Para-inguinal hernias are a rare hernia type of the groin. They might be challenging to differentiate from inguinal hernias clinically and might be diagnosed on imaging or intraoperatively. Repairing them utilizing minimally invasive inguinal hernia repair approaches can be completed successfully.

The utility of a second head CT scan after a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs).

BACKGROUND: New direct oral anticoagulants (DOACs) are commonly used in the management of atrial fibrillation and VTE. Currently, there is no strong evidence to support the current practice of routinely repeating computed tomography (CT) head in anticoagulated patients within 24 hours after their first negative CT scan to assess for new and delayed intracranial hemorrhage (ICH). Our hypothesis is that the vast majority will not have new CT scan findings of ICH and those who do would not require any further intervention. METHODS: This is retrospective cohort study. IRB approval was obtained. Subjects included adults age ≥ 18 taking DOACs who presented to our level III trauma center with confirmed or suspected blunt head trauma between August 2013 and October 2019 and received at least one head CT scans. RESULTS: 498 Patient encounters met inclusion criteria. Only 19 patients (3.8%) had positive traumatic ICH on the initial CT head. Those had a higher ISS. 420 out of 479 initial negative CT encounters received a second CT head. Only 2 (0.5%) had delayed positive second CT scan for ICH. 95%CI [0.06%, 1.7%] Patients who developed a new ICH on the second CT head after an initial negative CT scan had a lower Glasgow Coma Scale (GCS) on presentation and a higher ISS. None of those patients required neurosurgical intervention CONCLUSION: Our data suggests that the risk of developing a new or delayed traumatic ICH for patients on DOAC on a second CT head within 24 hours following an initial negative CT is very low and when present did not require neurosurgical intervention and thus does not support routinely obtaining a repeat CT head within 24 hours after a negative initial CT scan. Patients presenting with lower GCS and higher ISS had a higher chance of having a delayed ICH.

Does Size Matter? Correlation of Excised Gastric Specimen Size in Sleeve Gastrectomy to Postoperative Weight Loss and Comorbidities.

BACKGROUND: We present the correlation between excised specimen size in laparoscopic sleeve gastrectomy and patient demographics, comorbidities, and postoperative weight loss. OBJECTIVE: This study aims to address whether the size of gastric specimen excised during laparoscopic sleeve gastrectomy has any correlation with patient demographics, comorbidities, and postoperative percent of excess body weight lost. SETTING: Study was performed at a community teaching hospital in Michigan. METHODS: We examined data from 204 patients who underwent sleeve gastrectomy between August 2011 and January 2015. Data was collected retrospectively including demographics, comorbidities, body mass index (BMI), percent of excess body weight lost, and the size of the gastric specimen removed including specimen volume in cubic centimeters, length, width, and thickness in centimeters. RESULTS: We found that gastric specimen size does not correlate with initial BMI or change in BMI at 3, 6, or 12 months. Larger specimen sizes were found in males, increasing age, and patients with diabetes mellitus. CONCLUSIONS: There was no correlation between excised stomach size in laparoscopic sleeve gastrectomy and postoperative weight loss (percent of excess body weight lost) or change in BMI. Male gender, diabetes, and increasing patients' age correlated with larger excised stomach size. Initial BMI and having histological gastritis did not correlate with excised stomach size.

Isolated unilateral adrenal gland hemorrhage following motor vehicle collision: a case report and review of the literature.

BACKGROUND: Adrenal gland trauma is a rare condition that typically stems from blunt force trauma, and is associated with multiple organ injuries. Alternatively, isolated adrenal gland trauma is extremely rare, accounting for only 1.5 to 4% of all adrenal trauma cases. While isolated adrenal trauma is a mostly self-limiting condition, it is potentially life-threatening, representing a significant cause of bleeding, and/or hypotension due to adrenal insufficiency and adrenal crisis. Due to its rare occurrence, there are no reported guidelines for monitoring and observing isolated adrenal trauma. CASE PRESENTATION: Here we report on an isolated adrenal hemorrhage from a blunt trauma without associated injuries. A 53-year-old white man presented with abdominal pain after a high-speed motor vehicle accident. An initial evaluation revealed minimal abdominal pain and negative focused assessment with sonography for trauma examination; computed tomography imaging revealed a significant fluid collection consistent with adrenal hemorrhage. He was observed in our intensive care unit for 24 hours, and had stable hemoglobin and vital signs, after which he was discharged. At 1-month follow-up, he reported persistent intermittent abdominal pain, which was completely resolved by the 4-month follow-up. CONCLUSIONS: This case report demonstrates isolated adrenal gland injury resulting from significant blunt trauma to the abdomen. There are no current guidelines for monitoring isolated adrenal hemorrhage. Recognizing possible adrenal injury in blunt trauma cases is important due to potentially severe adrenal hemorrhage; therefore, we recommend follow-up with serial abdominal computed tomography until the resolution of hemorrhage and symptoms.

Epidermoid cyst of the spleen, a case report.

INTRODUCTION: Splenic tumors are rare and are either primary or secondary, benign or malignant. Most have none to minimal symptomatology and are found incidentally. Splenic cysts can be infectious, congenital, or traumatic. Epidermoid cysts and parasitic cysts are examples of primary cysts and usually have a classic presentation on imaging. Despite advanced imaging modalities and patient's clinical presentation, it can be difficult to diagnose an epidermoid cyst without histological examination. The purpose of this paper is to discuss typical findings of primary splenic cysts on imaging, but how they may differ in appearance. PRESENTATION OF CASE: 51 year old female who presented with vague abdominal discomfort and was found to have a large splenic mass with cystic components on imaging which did not demonstrate a typical primary splenic cyst appearance. Patient underwent an uneventful hand-assisted laparoscopic total splenectomy and had an uneventful recovery with histopathology revealing an epidermoid splenic cyst. CONCLUSION: Primary splenic cysts are difficult to diagnose and differentiate with imaging alone. They have a variable presentation and can present like as a cystic mass. It is important to include them in the differential diagnosis of splenic masses since histopathology is the final determinant of the diagnosis.

Laparoscopic Sleeve Gastrectomy: Preoperative Weight Loss and Other Factors as Predictors of Postoperative Success.

BACKGROUND: Correlation between weight loss before bariatric surgery and postoperative success has been discussed and investigated. It also has been a requirement for some surgeons and insurance companies. OBJECTIVE: The aim of this study is to address whether weight loss before sleeve gastrectomy is a predictor of postoperative success in terms of excess body weight lost (EBWL). SETTING: Study was performed at a community teaching hospital in Michigan. METHODS: We examined data from 204 patients who underwent laparoscopic sleeve gastrectomy between August 2011 and January 2015. Data was collected retrospectively including demographics, comorbidities, body mass index (BMI), percentage of EBW lost prior to surgery, percentage of EBW lost, and change in BMI at 3 months (191, 93.6%), 6 months (164, 80.4%), and 12 months (134, 65.7%). RESULTS: When examining postoperative mean percentage of EBW lost and change in BMI, we found that the group who lost >5% of their EBW before surgery had a statistically significant more weight loss than those who lost <5%. CONCLUSIONS: There was a statistically significant differences in adjusted postoperative mean percentage EBWL and change in BMI between those who preoperatively lost >5% of their EBW and those who lost <5% favoring those who lost >5%, but both groups still achieved similar postoperative weight loss success at 1 year. Increasing preoperative BMI resulted in decreasing postoperative percentage EBWL.

Gastrointestinal symptomatic outcomes of laparoscopic and open gastrectomy.

AIM: To compare the laparoscopic and the open gastrectomy approaches for short term morbidity, length of hospital stay and also long term gastrointestinal symptoms. METHODS: Patients who have undergone gastrectomy had their medical records reviewed for demographic data, type of gastrectomy, short term morbidity, and length of hospital stay. Patients were contacted and asked to complete the Gastrointestinal Symptom Rating Scale (GSRS). The GSRS measures three domains of GI symptoms: Dyspepsia Syndrome (DS) for the foregut (best score 0, worse score 15), indigestion syndrome (IS) for the midgut (best score 0, worse score 12), and bowel dysfunction syndrome (BDS) for the hindgut (best score 0, worse score 16). Statistical analysis was done using the Mann-Whitney U-test. RESULTS: We had complete data on 32 patients: 7 laparoscopic and 25 open. Of these, 25 had a gastroenteric anastomosis and 6 did not. The table shows the results as medians with interquartile range. Laparoscopic gastrectomy had a better score than open gastrectomy in the DS domain (0 vs 1, P = 0.02), while gastrectomy without anastomosis had a better score than gastrectomy with anastomosis in the IS domain (0 vs 1, P = 0.05). CONCLUSION: Patients have little adverse gastrointestinal symptoms and preserve good gastrointestinal function after undergoing any type of gastrectomy. Laparoscopic approach had better dyspepsia and foregut symptoms. Performing an anastomosis led to mild adverse midgut and indigestion effects.

Management of preoperatively suspected choledocholithiasis: a decision analysis.

BACKGROUND: The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5-15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients. METHODS: A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality. RESULTS: One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality. CONCLUSION: LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.