Robotic repair of a right-sided Bochdalek hernia: a case report and literature review.

BACKGROUND: Bochdalek hernias (BHs) are usually diagnosed in the neonatal period, occurring in 1/2200-1/12,500 live births. There are few reported cases of BHs in adults. Robotic repair has not been described in current literature as opposed to the laparoscopic approach. Here we present a case of an adult with clinical signs of bowel obstruction secondary to a BH which was repaired using a robotic approach. CASE REPORT: A 74-year-old gentleman with past medical history of benign prostatic hyperplasia presented to the emergency department with a 1-week history of nausea, vomiting, diarrhea, and decline in appetite. Computed tomography (CT) imaging of the chest and abdomen revealed elevation of the right hemidiaphragm and evidence of small bowel obstruction. The patient was managed conservatively with nasogastric tube placement and bowel rest. He underwent colonoscopy which could not be completed secondary to a transverse colon stricture which was confirmed by barium enema. Upon repeat CT imaging, the patient was found to have herniated colon through a right-sided diaphragmatic hernia which caused colonic narrowing. The patient's intestinal obstruction improved clinically with continued conservative management and he underwent robotic repair of a right posterior diaphragmatic hernia. The hernia defect was closed with interrupted figure of eight Ethibond sutures. A right-sided chest tube was placed. Intraoperatively, the herniated proximal transverse colon was noted to be ischemic and a right hemicolectomy was performed. He recovered well and was discharged home on postoperative day 5. CONCLUSION: Congenital diaphragmatic hernias usually present in the neonatal period and are rare in adults. Operative repair is recommended and laparoscopic repair has been described. Based on the existing literature regarding laparoscopic repair and the current case report, robotic repair also appears to be a viable and safe option.

Laparoscopic appendectomy is the preferred approach for appendicitis: a retrospective review of two practice patterns.

BACKGROUND: This study aimed to compare the results of laparoscopic appendectomy (LA) and open appendectomy (OA). METHODS: A retrospective analysis of 264 patients who underwent appendectomy (155 LA and 109 OA) over an 8-year period was performed. The variables analyzed included patient data (white blood cell count [WBC], duration of symptoms, American Society of Anesthesiology [ASA] score), operating data (length of the procedure and pathology), postoperative data (postoperative complications and length of hospital stay), and total costs. RESULTS: Patient demographic data (age and sex), preoperative WBC, duration of symptoms, and pathology all were similar in the two study groups. Six cases were converted to OA and included in the LA group data. There was no statistical difference in the average operative time between the LA (mean, 55.7 + or - 22.3 min; range, 20-128 min) and OA (mean, 58.9 + or - 23.7 min; range, 29-135 min) groups (95% confidence interval [CI] -8.8-2.43; p = 0.26). The overall incidence of minor and major complications was significantly less in the LA group (3.2%, five incidents) than in the OA group (17.4%, 19 incidents; p = 0.0043). The median length of hospital stay (LOS) was significantly shorter in the laparoscopic group (median, 2 days; range, 1-8 days) than in the open group (median, 3 days; range, 1-11 days; p < 0.001). The mean total cost was $5,663 in the laparoscopic group and $6,031 in the open group (non-significant difference of -$368; 95% CI, -$926-$190; p = 0.19). CONCLUSION: The findings show that LA is associated with fewer complications and similar total costs compared with OA. Therefore, LA can be recommended as a preferred approach to appendectomy.

Barriers to implementing a surgical beta-blocker protocol.

BACKGROUND: Experience with a quality improvement (QI) program undertaken to increase the use of beta-adrenergic blockade in at-risk patients at both a major academic medical center and a community hospital suggests barriers to implementation. METHODS: A retrospective and prospective cohort study was performed to establish the incidence and effectiveness of beta-blockade use pre- and postimplementation of a standardized screening tool and a major education program as part of a QI project. Data gathering involved a baseline phase pre-intervention; 6 weeks postintervention; and 3-6 months postintervention. RESULTS: During phase I (baseline) 56% of eligible received beta-blockers, but targeted measures (a pre-induction heart rate < 70 or a systolic blood pressure [BP] < 110 mmHg) were achieved in only 11% of patients. Phase II saw a significant overall increase in beta-blocker administration (79%) and efficacy (50%). However, during phase III (3-6 months postimplementation), the rate of beta-blocker administration fell to 61% overall, while overall efficacy remained stable at 52%. Significant differences between the academic and community hospitals were observed throughout the study. CONCLUSION: Implementation of a quality program for beta-blockade is significantly affected by the presence or absence of ongoing physician and staff education beyond the study period.