Minimally invasive approach to incarcerated or strangulated groin hernias: A 2018 EAST Master Class Video Presentation.

Groin hernia repair is one of the most common general surgical procedures performed worldwide. Although only a small percentage will become incarcerated or strangulated, this is an indication for repair. Minimally invasive surgery is becoming the standard of care for most procedures, and we believe this to be a safe and feasible approach for incarcerated or strangulated groin hernias. We present a description of our recommended approach with technical details and accompanying video clips to highlight these techniques.

Minimally invasive surgery techniques for the management of urgent or emergent small bowel pathology: A 2018 EAST Master Class Video Presentation.

Although minimally invasive surgery techniques have been rapidly and widely adopted among nearly all fields of elective surgery, their use by trauma and acute care surgeons for urgent or emergent pathology has somewhat lagged behind. Trauma surgeons are frequently called upon to manage traumatic or emergent surgical small bowel pathology, and many of these may be ideally suited for increased incorporation of minimally invasive surgery techniques. This surgical technique video and associated article provide a technical guide and "how-to" instructions for laparoscopic and other minimally invasive approaches that can be utilized in the management of traumatic small bowel injuries, small bowel obstructions, or other emergent small bowel pathology.

Acute Kidney Injury in the Critically Ill Patient: A Current Review of the Literature.

PURPOSE: A comprehensive review of the literature to provide a focused and thorough update on the issue of acute kidney injury (AKI) in the surgical patient. METHODS: A PubMed and Medline search was performed and keywords included AKI, renal failure, critically ill, and renal replacement therapy (RRT). PRINCIPAL FINDINGS: A common clinical problem encountered in critically ill patients is AKI. The recent consensus definitions for the diagnosis and classification of AKI (ie, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease/Acute Kidney Injury Network) have enabled us to standardize the severity of AKI and facilitate strategies for prevention. These strategies as well as treatment modalities of AKI are discussed. We provide a concise overview of the issue of renal failure. We describe strategies for prevention including types of fluids used for resuscitation, timing of initiation of RRT, and different treatment modalities currently available for clinical practice. CONCLUSIONS: Acute kidney injury is a common problem in the critically ill patient and is associated with worse clinical outcomes. A standardized definition and staging system has led to improved diagnosis and understanding of the pathophysiology of AKI. There are many trials leading to improved prevention and management of the disease.

Role of drains in laparoscopic appendectomy for complicated appendicitis at a busy county hospital.

Laparoscopic appendectomy (LA) has become the treatment of choice for acute appendicitis with equal or better outcomes than traditional open appendectomy (OA). LA in patients with a gangrenous or perforated appendicitis carries increased rate of pelvic abscess formation when compared with OA. We hypothesized routine placement of pelvic drains in gangrenous or perforated appendicitis decreases pelvic abscess formation after LA. Three hundred thirty-one patients undergoing LA between January 2007 and June 2011 were reviewed. Patients with perforated or gangrenous appendicitis were included. Group I had a Jackson-Pratt (JP) drain(s) placed and Group II had no JP drain. Data included patient demographics, emergency department laboratory values and vital signs, and computed axial tomography scan findings, intra-abdominal or pelvic abscess postoperatively, interventional radiology drainage, and length of stay. Clinic follow-up notes were reviewed. One hundred forty-eight patients were identified. Forty-three patients had placement of JP drains (Group I) and 105 patients had no JP drain (Group II). Three patients (three of 43 [6%]) in Group I developed pelvic abscess and 21 of 105 (20%) patients in Group II developed pelvic abscesses requiring subsequent drainage. This was statistically significant. Patient demographics, temperature, and mean white blood count before surgery were similar. Presurgery computed tomography (CT) with appendicolith and CT with abscess were more prevalent in Group I. The use of JP drainage in patients with perforated or gangrenous appendicitis during LA has decreased rates of pelvic abscess. This was demonstrated despite the drain group having appendicolith or abscess on preoperative CT.

A 3-year experience with necrotizing fasciitis: favorable outcomes despite operative delays in a busy acute care hospital.

Necrotizing fasciitis is a rare severe soft tissue infection that has historically been associated with high mortality. We sought to evaluate our experience with necrotizing fasciitis focusing on outcomes based on timing of operative intervention. Our study hypothesis was that delays in surgical management would negatively impact outcomes. Fifty-four patients were identified for a retrospective chart review from January 2008 to January 2011. Data analysis included demographics, admission laboratory values, imaging results, examination findings, timing and nature of operations, length of stay (LOS), and outcomes. Surgical intervention in 12 hours or more was considered a delay in care. Our study cohort was high risk based on a high prevalence of intravenous drug abuse, diabetes mellitus, hypertension, and end-stage liver disease. The average time to surgical intervention was 18±25 hours and the overall mortality rate was 16 per cent. A delay to surgery did not impact mortality or the number of débridements and LOS. Mortality was high, 45 per cent, in patients requiring amputation. We observed a high-risk population managed with aggressive surgical care for necrotizing fasciitis. Our mortality was low compared with historical data and surgical delays did not impact outcomes. Those patients requiring amputation had worse outcomes.

A case of a traumatic chyle leak following an acute thoracic spine injury: successful resolution with strict dietary manipulation.

BACKGROUND: Chylothorax is a rare form of pleural effusion that can be associated with both traumatic and non-traumatic causes. Thoracic duct ligation is often the treatment of choice in postsurgical patients; however the optimal treatment of this disease process after traumatic injury remains unclear 1. We present a rare case of a thoracic duct injury secondary to a blunt thoracic spine fracture and subluxation which was successfully treated non-operatively. CASE PRESENTATION: A 51 year old male presented as a tier one trauma code due to an automobile versus bicycle collision. His examination and radiographic work-up revealed fractures and a subluxation at the third and fourth thoracic spine levels resulting in paraplegia. He also sustained bilateral hemothoraces secondary to multiple rib fractures. Drainage of the left hemothorax led to the diagnosis of a traumatic chylothorax. The thoracic spine fractures were addressed with surgical stabilization and the chylothorax was successfully treated with drainage and dietary manipulation. CONCLUSIONS: This unusual and complex blunt thoracic duct injury required a multidisciplinary approach. Although the spine injury required surgical fixation, successful resolution of the chyle leak was achieved without surgical intervention.