Feasibility and complications after transoral endoscopic thyroidectomy via vestibular approach (TOETVA) - a single-center first experience case series.

BACKGROUND: This paper reports on the first experience after implementation of a transoral endoscopic thyroidectomy via vestibular approach (TOETVA) as an alternative to (partial) thyroidectomy or isthmusectomy in a single center. Feasibility, implementation and specific complications are addressed. METHODS: All patients who underwent a TOETVA procedure in our center between November 2019 and March 2023 were included. The surgical technique was performed as described by Anuwong et al. All procedures were performed by two dedicated head- and neck surgeons. RESULTS: A total of 20 patients were included. All patients underwent TOETVA surgery as planned and no conversions were needed. Observed complications were post-operative wound infections (POWI) (2/20; 10%), clinically significant seroma (1/20, 5%) and unilateral hemiparesis of the larynx (3/20; 15%). Permanent mental nerve damage was seen in 3/20 patients (15%), and 4 other patients (20%) experienced transient neuropraxia. CONCLUSIONS: TOETVA is a feasible alternative to (partial) thyroidectomy or isthmusectomy in selected patients. Special care should be taken when placing the trocars in the oral vestibulum to prevent mental nerve damage. Experience and training are essential for implementing the TOETVA procedure. TRIAL REGISTRATION: This study was registered to ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: NCT05396703.

The first experience with the Dextile anatomical mesh in laparoscopic inguinal hernia repair.

BACKGROUND: The Dextile Anatomical mesh (Medtronic) is a polypropylene heavyweight mesh and has a 3D patented anatomical shape which adapts to the contours of the extra-peritoneal inguinal region without the need for fixation, potentially reducing the risk of hernia recurrence and chronic post-operative pain. This retrospective study will be the first study to assess the outcomes of the Dextile Anatomical mesh compared to another three-dimensional mesh, the 3DMax mesh (Bard). METHODS: Between 2019 and 2022, all patients who underwent an elective unilateral inguinal hernia repair were assessed. 416 patients in the Dextile Anatomical mesh group and 540 patients in the 3DMax mesh group were included. Outcomes were intra- and post-operative complications, inguinal hernia recurrence and chronic post-operative inguinal pain. RESULTS: No significant differences were found between the two groups regarding intra- and post-operative complications including wound infection, antibiotic use, hematoma, seroma, urinary retention and delayed wound healing. 1-year recurrence rate was comparable for the Dextile Anatomical mesh group and the 3DMax mesh group, respectively, 3.8% and 3.0%, P = 0.45. Chronic post-operative inguinal pain was similar for the Dextile Anatomical mesh (3.4%) and the 3DMax mesh (3.0%), P = 0.72. CONCLUSION: This retrospective study comparing the relatively new Dextile Anatomical mesh (Medtronic) with the 3D Max mesh (Bard) in unilateral inguinal hernia repair showed that both meshes are safe and effective to use. There were no significant differences in intra-operative outcomes, recurrence rates and chronic post-operative inguinal pain.

Hiatal hernia recurrences after laparoscopic surgery: exploring the optimal technique.

INTRODUCTION: The recurrence rate of hiatal hernia (HH) after laparoscopic surgery with crural repair and Nissen or Toupet fundoplication is high (< 25-42%). HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS) or mesh placement but the effect in the long-term (> 1 year) is still unclear. We determined the recurrence rate of HH after surgery and established whether the use of reinforcement techniques could reduce long-term recurrence rates. METHODS: In this retrospective cohort study patients were included if they underwent a laparoscopic fundoplication in this hospital between 2012 and 2019. HH was measured with computed tomography and baseline patient characteristics and surgical details were collected. Primary outcomes were recurrence of symptoms and re-intervention, secondary outcome was effect of surgical reinforcement techniques. Statistical analyses comprised chi-square tests, Mann-Whitney U tests and uni- and multivariable logistic regression analyses. RESULTS: In total, 307 patients were included, 206 women and 101 men. During primary surgery, 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients and mesh in 17 patients. After primary surgery, recurrence of HH was diagnostically confirmed in 64 patients (20.8%). Use of VMS during primary surgery was significantly associated with fewer recurrences (OR = 0.34, p = 0.048), corrected for confounding factors. Secondary surgery was performed in 54 patients (17.6%) and tertiary surgery in five patients (1.6%). Mesh and VMS were used more during secondary and tertiary surgery. CONCLUSION: The recurrence rate among HH patients in this cohort study was 20.8% with a mean follow-up time of 6 years. Secondary surgery was performed in 17.6% of the patients. In future, the use of VMS might lead to fewer recurrences after primary laparoscopic repair of HH.

Using an E-Health Application for Post-operative Monitoring After Inguinal Hernia Repair: A Feasibility Study.

BACKGROUND: E-Health care is already well established in some (non-) surgical specialties and is considered as a means of improving patient-centred care. Considering the demand of remote health care changes, especially in the COVID-19 pandemic, it is essential to investigate the feasibility of e-Health care within one of the most performed surgery procedures: inguinal hernia repair. METHODS: A total of 60 patients used the e-Health application in this study compliant. Primary objectives were to investigate the accuracy of the "deviating post-operative course" alerting by the e-Health application. Secondary objectives included patient perspective and e-Health costs analysis. RESULTS: Forty-four patients reported no deviation in the post-operative course using the e-Health application of which 93.2% (n = 41) was in concordance with the findings during standard follow-up. Within 16 patients reporting a deviating post-operative course, a true complication was found in 25% (n = 4). Based on in-hospital costs, a hypothetical e-Health follow-up scenario was more expensive (€59.5 per patient) than current standard follow-up care (€28.2 per patient). Usage of the e-Health application showed a high perceived overall patient satisfaction: 4.2 (on a Likert-scale of 1-5). CONCLUSION: An e-Health application is a promising tool for identifying patients who require in-person or phone follow-up assessment. Patients' perspectives surveys revealed high potential and willingness of using this application. A hypothetical e-Health follow-up scenario showed to be more expensive compared to current standard follow-up. If the identified (dis)advantages can be improved, e-Health follow-up care appears to be promising in terms of safety and feasibility. Future studies can leverage on this study and further investigate the use of e-Health within the field of general surgery.

Patient-reported outcomes after incisional hernia repair.

PURPOSE: Patient-reported outcomes (PROs) are pivotal to evaluate the efficacy of surgical management. Debate persists on the optimal surgical technique to repair incisional hernias. Assessment of PROs can guide the selection of the best management of patients with incisional hernias. The objective of this cohort study was to present the PROs after incisional hernia repair at long term follow-up. METHODS: Patients with a history of incisional hernia repair were seen at the out-patient clinic to collect PROs. Patients were asked about the preoperative indication for repair and postoperative symptoms, such as pain, feelings of discomfort, and bulging of the abdominal wall. Additionally, degree of satisfaction was asked and Carolina Comfort Scales were completed. RESULTS: Two hundred and ten patients after incisional hernia repair were included with a median follow-up of 3.2 years. The main indication for incisional hernia repair was the presence of a bulge (60%). Other main reasons for repair were pain (19%) or discomfort (5%). One hundred and thirty-two patients (63%) reported that the overall status of their abdominal wall had improved after the operation. Postoperative symptoms were reported by 133 patients (63%), such as feelings of discomfort, pain and bulging. Twenty percent of patients reported that the overall status of their abdominal wall was the same, and 17% reported a worse status, compared to before the operation. Ten percent of the patients would not opt for operation in hindsight. CONCLUSION: This study showed that a majority of the patients after incisional hernia repair still report pain or symptoms such as feelings of discomfort, pain, and bulging of the abdominal wall 3 years after surgery. Embedding patients' expectations and PROs in the preoperative counseling discussion is needed to improve decision-making in incisional hernia surgery.

Safety and efficacy in inguinal hernia repair: a retrospective study comparing TREPP, TEP and Lichtenstein (SETTLE).

BACKGROUND: This pilot trial investigates whether the trans rectus sheath extra-peritoneal (TREPP) mesh repair is a safe and effective procedure compared to the currently most performed inguinal hernia repair techniques TEP and Lichtenstein. METHODS: Three hundred patients older than 18 years with unilateral inguinal hernia were included in this retrospective cohort study, of which 58 (19.3%) underwent TREPP, 190 (63.3%) TEP and 52 (17.3%) Lichtenstein. The primary outcome of this study was inguinal hernia recurrence rate within 1 year after surgery. Secondary objectives were chronic post-operative inguinal pain (CPIP) lasting more than 6 months, (major) complication rates and operating time. RESULTS: Recurrence rate within 1-year post-operative was low overall in the study population and did not differ significantly between TREPP, TEP and Lichtenstein, respectively 1.7, 2.1, 0.0% (P = 0.591). The rate of CPIP for which the patient contacted the hospital was similar in the study groups: TREPP: 1.7%; TEP: 1.6%; Lichtenstein: 1.9%; (P = 0.591). The mean operating time in minutes (SD) was significantly shorter in the TREPP group compared with the two other patient groups (TREPP: 22.2 (± 5.7); TEP: 38.7 (± 14.8); Lichtenstein: 49.3 (± 17.1), P < 0.001). No major complications occurred in any patient of the study groups. CONCLUSION: TREPP seems to be an effective and safe technique for unilateral primary inguinal hernia repair. It is found to be comparable to TEP and Lichtenstein in terms of recurrence rates, chronic post-operative inguinal pain, and clinically significant adverse events. This pilot study proves the need for future research into the TREPP technique.

Resection of hepatic and pulmonary metastasis from metastatic esophageal and gastric cancer: a nationwide study.

The standard of care for gastroesophageal cancer patients with hepatic or pulmonary metastases is best supportive care or palliative chemotherapy. Occasionally, patients can be selected for curative treatment instead. This study aimed to evaluate patients who underwent a resection of hepatic or pulmonary metastasis with curative intent. The Dutch national registry for histo- and cytopathology was used to identify these patients. Data were retrieved from the individual patient files. Kaplan-Meier survival analysis was performed. Between 1991 and 2016, 32,057 patients received a gastrectomy or esophagectomy for gastroesophageal cancer in the Netherlands. Of these patients, 34 selected patients received a resection of hepatic metastasis (n = 19) or pulmonary metastasis (n = 15) in 21 different hospitals. Only 4 patients received neoadjuvant therapy before metastasectomy. The majority of patients had solitary, metachronous metastases. After metastasectomy, grade 3 (Clavien-Dindo) complications occurred in 7 patients and mortality in 1 patient. After resection of hepatic metastases, the median potential follow-up time was 54 months. Median overall survival (OS) was 28 months and the 1-, 3-, and 5- year OS was 84%, 41%, and 31%, respectively. After pulmonary metastases resection, the median potential follow-up time was 80 months. The median OS was not reached and the 1-, 3-, and 5- year OS was 67%, 53%, and 53%, respectively. In selected patients with gastroesophageal cancer with hepatic or pulmonary metastases, metastasectomy was performed with limited morbidity and mortality and offered a 5-year OS of 31-53%. Further prospective studies are required.

Overall survival before and after centralization of gastric cancer surgery in the Netherlands.

BACKGROUND: Centralization of surgery has been shown to improve outcomes for oesophageal and pancreatic cancer, and has been implemented for gastric cancer since 2012 in the Netherlands. This study evaluated the impact of centralizing gastric cancer surgery on outcomes for all patients with gastric cancer. METHODS: Patients diagnosed with non-cardia gastric adenocarcinoma in the intervals 2009-2011 and 2013-2015 were selected from the Netherlands Cancer Registry. Clinicopathological data, treatment characteristics and mortality were assessed for the periods before (2009-2011) and after (2013-2015) centralization. Cox regression analyses were used to assess differences in overall survival between these intervals. RESULTS: A total of 7204 patients were included. Resection rates increased slightly from 37·6 per cent before to 39·6 per cent after centralization (P = 0·023). Before centralization, 50·1 per cent of surgically treated patients underwent gastrectomy in hospitals that performed fewer than ten procedures annually, compared with 9·2 per cent after centralization. Patients who had gastrectomy in the second interval were younger and more often underwent total gastrectomy (29·3 per cent before versus 41·2 per cent after centralization). Thirty-day postoperative mortality rates dropped from 6·5 to 4·1 per cent (P = 0·004), and 90-day mortality rates decreased from 10·6 to 7·2 per cent (P = 0·002). Two-year overall survival rates increased from 55·4 to 58·5 per cent among patients who had gastrectomy (P = 0·031) and from 27·1 to 29·6 per cent for all patients (P = 0·003). Improvements remained after adjustment for case mix; however, adjustment for hospital volume attenuated this association for surgically treated patients. CONCLUSION: Centralization of gastric cancer surgery was associated with reduced postoperative mortality and improved survival.

Evaluation of PET and laparoscopy in STagIng advanced gastric cancer: a multicenter prospective study (PLASTIC-study).

BACKGROUND: Initial staging of gastric cancer consists of computed tomography (CT) and gastroscopy. In locally advanced (cT3-4) gastric cancer, fluorodeoxyglucose positron emission tomography with CT (FDG-PET/CT or PET) and staging laparoscopy (SL) may have a role in staging, but evidence is scarce. The aim of this study is to evaluate the impact and cost-effectiveness of PET and SL in addition to initial staging in patients with locally advanced gastric cancer. METHODS: This prospective observational cohort study will include all patients with a surgically resectable, advanced gastric adenocarcinoma (cT3-4b, N0-3, M0), that are scheduled for treatment with curative intent after initial staging with gastroscopy and CT. The modalities to be investigated in this study is the addition of PET and SL. The primary outcome of this study is the proportion of patients in whom the PET or SL lead to a change in treatment strategy. Secondary outcome parameters are: diagnostic performance, morbidity and mortality, quality of life, and cost-effectiveness of these additional diagnostic modalities. The study recently started in August 2017 with a duration of 36 months. At least 239 patients need to be included in this study to demonstrate that the diagnostic modalities are break-even. Based on the annual number of gastrectomies in the participating centers, it is estimated that approximately 543 patients are included in this study. DISCUSSION: In this study, it is hypothesized that performing PET and SL for locally advanced gastric adenocarcinomas results in a change of treatment strategy in 27% of patients and an annual cost-reduction in the Netherlands of €916.438 in this patient group by reducing futile treatment. The results of this study may be applicable to all countries with comparable treatment algorithms and health care systems. TRIAL REGISTRATION: NCT03208621 . This trial was registered prospectively on June 30, 2017.

Endoscopic ultrasound guided versus surgical transrectal drainage of pelvic abscesses.

BACKGROUND: Pelvic abscesses are common but only small case series reporting outcome of either endoscopic ultrasound (EUS) guided or surgical transrectal drainage have been reported. METHODS: We performed a retrospective consecutive cohort study, assessing effectivity and safety of EUS guided or surgical transrectal drainage of previously untreated pelvic abscesses from all causes, diagnosed using CT scan between 09/2010 and 06/2014 in a Dutch teaching hospital. RESULTS: Forty-six patients with comparable demographics, apart from stoma presence (p = .016), were included. The success rate after a single intervention was 83% in the EUS guided compared to 48% in the surgical transrectal drainage group (p = .013). However, the mean duration of drainage was threefold in the EUS group [42 versus 13 days (p = .001)]. The length of stay in hospital was similar for both EUS and surgical group [24 versus 20 days (p = .56)] as was abscess resolution during follow-up [78% versus 74%]. We recorded a total of 12 anastomotic leaks [3 versus 9]. In the occurrence of leakage, only one stoma was finally closed in each group. CONCLUSION: EUS guided and surgical transrectal drainage of pelvic abscesses from any cause are safe, nonetheless EUS guided drainage(if feasible) seems more effective after a single treatment, with high overall cure rates.

Functional Compromise Cohort Study (FCCS): Sarcopenia is a Strong Predictor of Mortality in the Intensive Care Unit.

BACKGROUND: Functional compromise in elderly patients is considered to be a significant contributing factor in increased postoperative morbidity and mortality. It is described as a state of reduced physiologic reserves including, e.g., sarcopenia, cachexia, malnutrition and frailty with increased susceptibility to adverse health outcomes. Aim of this study was to investigate the association of sarcopenia with mortality in ICU patients. METHODS: A retrospective analysis of a total of 687 patients admitted to the ICU from January 2013 until December 2014 was performed. Indirect measurements of functional compromise in these patients were conducted. Sarcopenia was assessed using the L3 muscle index by using Osirix© on computed tomography scans. Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ) scores were extracted from the digital patient filing system and were used to assess frailty and nutritional status. These factors were analyzed using logistic regression analysis as predictor for in-hospital mortality and 6-month mortality, which was the primary endpoint along with other secondary outcome measures. RESULTS: Age was an independent predictor of in-hospital mortality, OR 1.043 (95% CI 1.030-1.057, p < 0.001). Analysis of sarcopenia showed OR 2.361 (95% CI 1.138-4.895, p = 0.021), for GFI OR 1.012 (95% CI 0.919-1.113, p = 0.811) and for SNAQ OR 1.262 (95% CI 1.091-1.460, p = 0.002). CONCLUSION: This study shows a promising role for the sarcopenia score as a predictor of mortality on the ICU, based upon CT imaging at L3 level and SNAQ score. Further research is necessary to test this in larger cohorts and to develop a possible instrument to predict mortality in the intensive care unit.

Value of geriatric frailty and nutritional status assessment in predicting postoperative mortality in gastric cancer surgery.

OBJECTIVES: This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery. METHODS: Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality. RESULTS: From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3%. Patients with a GFI ≥ 3 (n = 30, 24%) had a mortality rate of 23.3% versus 5.2% in the lower GFI group (OR 4.0, 95%CI 1.1-14.1, P = 0.03). For patients who underwent surgery with curative intent (n = 125), this was 27.3% for patients with GFI ≥ 3 (n = 22, 18%) versus 5.7% with GFI < 3 (OR 4.6, 95% CI 1.0-20.9, P = 0.05). SNAQ ≥ 1 (n = 98, 61%) was associated with a mortality rate of 13.3% versus 3.2% in patients with SNAQ =0 (OR 5.1, 95% CI 1.1-23.8, P = 0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification. CONCLUSIONS: This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.

The introduction of a laparoscopic liver surgery programme: a cost analysis of initial experience in a university hospital.

BACKGROUND AND AIMS: In the era of expanding costs of healthcare, this study was conducted to perform a cost analysis of introducing a laparoscopic liver surgery programme for left sided liver lesions. MATERIALS AND METHODS: Consecutive patients treated by laparoscopic liver resections of left lateral segments were included. Controls were a group of 14 patients undergoing open resection for similar pathology. Primary outcomes were costs. Secondary outcomes were complications, conversions, blood loss, length of operation, and length of hospital stay. RESULTS: The laparoscopic approach for hepatic left lateral resection (bisegmentectomy 2 and 3) was performed in fourteen patients (group I, median age 54 [range 26-82] years). In the open group, fourteen patients from a prospectively collected database with the same type of resection were selected (group II, median age 64 [range 29-76] years). Costs of theatre usage in the laparoscopic group were significantly lower (p=0.031). No significant differences in costs of disposable instruments, ward stay and total costs were observed between the two groups. There were three complications in the laparoscopic group compared with two complications in the open group. In the laparoscopic group there were 2 conversions (14%). Median blood loss was significantly lower in the laparoscopic group (50 mls [range 0-750], (p=0.001) versus the open group (500 mls [range 150-750]). Furthermore, operation time was also significantly lower in the laparoscopic group (116 [range 85-261] minutes) versus the open group (165 [range 96-217] minutes, p=0.016). Median length of stay was 6 [range 4-11] days in group I versus 6 [range 5-13] days in group II (p=0.508). CONCLUSION: Costs of laparoscopic liver resections proved to be equivalent to open surgery. Furthermore, implementation of a laparoscopic liver resection programme seems feasible and safe with reduced blood loss and operation time and comparable morbidity and length of stay.

More than 25 years of surgical treatment of hydatid cysts in a nonendemic area using the "frozen seal" method.

BACKGROUND: Hydatid disease of the liver remains endemic in the world and is an imported disease in The Netherlands. The aim of this study was to evaluate the treatment and outcome of surgically treated patients for hydatid disease in a single center in The Netherlands. METHODS: This retrospective study included 112 consecutive patients surgically treated for hydatid disease between 1981 and 2007. The primary outcome was relapse of the disease. Secondary outcomes were infections, complications, reoperations, length of hospital stay, and mortality. RESULTS: In all cases, echinococcosis was diagnosed by computed tomography or ultrasonography (US). Serology (enzyme-linked immunosorbent assay, immunofluorescence) confirmed the diagnosis in 92.9%. Most of the cysts were seen only in the liver (73.5%). All cysts were operated on with the frozen seal technique. Relapse of disease was seen in 9 (8.0%) cases. Five (4.5%) required surgical treatment at a later stage. Twenty (17.9%) complications were recorded. Four (3.6%) needed radiological drainage and three (2.7%) a reoperation. Follow-up was performed with US and/or serology at a mean of 24 months (range 0.5-300 months). All but one complication were seen in the liver-operated group, this proved not to be of statistical significance (P = 0.477). Patients with complications stayed significantly longer in hospital than did the patients without complications (P < 0.001). No mortality was observed in this study. CONCLUSIONS: The present study suggests that the frozen seal method of surgery for hydatid disease is safe and effective. Future studies are needed to prove its position in the treatment of hydatid disease as new developments show promising results.

A man with chyloperitoneum: a case report.

Diagnostic image. A 60-year-old man with an adenocarcinoma of the stomach and kidney-cell carcinoma, developed chyloperitoneum after surgery.

[Diagnostic image (346). A child with prominent cranial fissures]. / Diagnose in beeld (346). Een kind met geprononceerde schedelnaden.

A 2-week-old boy was presented with prominent cranial fissures. He was diagnosed with malleability post partum.

Primary retroperitoneal mucinous cystadenoma with sarcoma-like mural nodule : a case report and review of the literature.

Primary retroperitoneal cystadenomas are extremely rare. This is the first report in literature to describe a primary retroperitoneal cystadenoma with a sarcoma-like mural nodule. A 45-year-old woman complained of a left-sided abdominal mass. A computed tomography scan revealed a cystic mass with a mural nodule, which seemed to originate from the tail of the pancreas. At laparotomy the cyst was not adhered to the pancreas but localized retroperitoneally. Histologic examination showed a mucinous cystadenoma with only foci of borderline malignancy with a mural "sarcoma-like" nodule. In view of the surgical and histopathological findings, the mucinous cystadenoma was regarded as primary retroperitoneal. This case demonstrates that in the era of radiological preoperative refinement, pathological diagnosis remains of utmost importance, especially for rare cases.

Life-saving therapy for haemorrhaging liver adenomas using selective arterial embolization.

BACKGROUND: Emergency treatment for patients with a ruptured hepatocellular adenoma is controversial. The aim of this study was to evaluate management with selective arterial embolization. METHODS: The study included 11 consecutive patients treated for ruptured hepatocellular adenomas between 2001 and 2006. After initial haemodynamic support, all patients received selective embolization of branches of the hepatic artery. The primary outcome was effectiveness in stopping the bleeding. Secondary outcomes were complications and changes in tumour size after embolization. RESULTS: A single embolization brought haemorrhaging under control in ten patients; one patient needed three embolizations. None of the patients required emergency surgery. In the follow-up of 19 (range 7-49) months, no general or hepatobiliary complications were observed. All 25 adenomas, including those without signs of haemorrhaging in the same liver lobe, were either smaller or not detectable on computed tomography or magnetic resonance imaging after embolization, with the median diameter decreasing from 7.0 to 2.5 cm (P < 0.001). CONCLUSION: Selective embolization of the hepatic artery is a safe and adequate first approach in the management of patients with haemorrhaging hepatocellular adenomas. Furthermore, arterial embolization reduces the size of adenomas in the liver.

Symptomatic abdominal aortic aneurysm with inferior vena cava malposition.

A 66-year old woman was admitted with an acute symptomatic abdominal aortic aneurysm. After preoperative assessment, she was directly operated on via transperitoneal approach. Intraoperatively, a left-sided inferior vena cava was diagnosed. The preoperative study of the abdominal computed tomography had not revealed this venous malformation. Retroperitoneal venous anomalies are a major source of unexpected haemorrhage during aortic reconstruction. Thus, for optimal preoperative preparation, a systematic close examination of the preoperative contrast enhanced CT scan of the abdomen is advised.