Spigelian Hernia: A Rare Ventral Hernia.

Ventral hernias occur when abdominal contents or the peritoneum displace through a defect in the abdominal wall. Among these, spigelian hernias are an exceptionally rare subtype, representing 0.12% to 2% of all ventral hernias. This case study focuses on an 86-year-old female presenting with a ventral hernia, notably a spigelian hernia, lacking common predisposing factors. The study emphasizes the use of laparoscopic techniques for repair, aiming to offer insights into managing this infrequent hernia type and aiding clinical decision-making. Due to its low incidence and challenging diagnosis and identification, reports such as ours detailing both the clinical course and the operative steps can assist others in their clinical decision-making.

A Rare Case of Complete Inguinoscrotal Bladder Herniation With Ureteric Involvement: Assessing Diagnostic Challenges and Complex Surgical Management.

Inguinoscrotal hernias involving the urinary bladder are exceedingly rare, constituting a small subset of inguinal hernias. We present a case of a 47-year-old male with long-standing scrotal enlargement and obstructive uropathy due to complete herniation of the bladder with ureteric involvement. Diagnostic imaging confirmed the condition. Following an open laparotomy, the bladder was reduced, and a modified Bassini technique with orchiopexy was used for repair. Recurrence of the inguinoscrotal hernia with evidence of the bladder in the scrotal sac required additional surgery. This case underscores the rarity, diagnostic complexity, and potential complications of inguinoscrotal bladder hernias. Specialized surgical techniques and a multidisciplinary approach are crucial for successful management, especially in cases of complete bladder herniation. Future considerations should include innovative approaches to enhance primary repair outcomes for extensive hernias involving the bladder.

Image guided preoperative abdominal wall botox injection for large ventral hernia repair: A case series.

This case series aims to explore the application of preoperative CT guided Botox injections in three different cases of abdominal wall reconstructions. Each of the three cases highlights the role of chemical component separation in achieving myofascial release and contributing to a successful surgical repair. The use of Botox in the preoperative planning of abdominal wall repair aims at creating a tension-free environment for midline closure and promoting an overall positive postoperative course for the patient. This case series presents as a valuable contribution to the different surgical approaches in abdominal wall reconstruction and the collaboration between Interventional Radiology and Surgery in treating such patients.

"Slim-Mesh" Technique for Diastasis Recti Abdominis, Including Obesity-Related Cases.

Background and Objective: We operated on a series of mostly obese patients with diastasis recti abdominis using the "Slim-Mesh" technique to repair/reinforce the diastasis and linea alba/recti muscles without plicating and traumatizing them. Additional objectives were to decrease operation time and intra- and postoperative complications. Methods: We considered T1 cases diastasis after pregnancy and T2 cases obesity (BMI ≥ 30 mg/kg2); D1, D2, and D3 when the diastasis measured 2-3, 3-5, and ≥ 5 cm, respectively; H0 and H1 without and concomitant umbilical and/or epigastric hernia, respectively. At our Department, between May 2010 and November 2022, 47 patients with diastasis recti were operated on with the "Slim-Mesh" technique to reinforce/repair the traumatized linea alba/recti muscles, without plicating them. This was a prospective (83%)-retrospective study. Results: We studied 23 males and 24 females. Mean age and BMI was 58 years and 29 kg/m2, respectively. Groups D1, D2, and D3 comprised 6, 23 and 18 patients, respectively; groups T1, T2, H0 and H1 comprised 22, 25, 13 and 34 patients, respectively. Mean operation time for all cases was 100 minutes. Mean length of hospital stay was 2.3 days and follow-up time was 5 years. We had 6 late postoperative complications: 3 hernia recurrences and 3 trocar site hernias. Conclusion: Considering the lack of agreement on the best surgery for diastasis recti abdominis repair, in our experience the "Slim-Mesh" technique is a valid, safe and easy-to-reproduce way to save, repair and reinforce linea alba/recti muscles in diastasis recti patients, including the obese population (53%).

Bilateral Spigelian Hernias Robotic Repair: A Novel Approach to a Rare Surgical Entity.

Spigelian hernias are an uncommon protrusion defect noted between the rectus abdominis and the transversus abdominis muscles, at the semilunar line, with a low incidence of approximately 0.12% to 2% of all ventral hernias. Furthermore, the incidence of bilateral cases is noted to be even lower in the general population. They are associated with bowel incarceration and strangulation; hence surgical repair is indicated. Therapeutic alternatives for Spigelian hernias include open repair, however laparoscopic repair stands as the standard of care in these cases. Feasible and successful robotic repair has been reported, with associated advantages in terms of visualization and surgical instrument dexterity. We present the first ever reported cases of bilateral Spigelian hernias repaired using robotic approach. Two female Puerto Rican patients referred to our institution complaining of abdominal pain, where imaging studies found bilateral Spigelian hernias. In both cases, a transabdominal preperitoneal repair was performed using the Da Vinci Surgical System. Both patients were discharged home tolerating oral intake with adequate wound healing. On follow up visits, patients denied abdominal discomfort and had adequate wound healing. Robotic surgery for Spigelian hernias poses an advantage over laparoscopic repair as improved visualization, mobility, and precision in movements allow for more gentle tissue manipulation. Furthermore, this is the first evidence of safe and effective repair in the uncommon entity of bilateral cases, providing a newer alternative in the setting of such presentation.

Descriptive Anatomy of the Porcine Ventral Abdominal Wall as a Basis for Training Ventral Hernia Repair Techniques.

Background: In recent times there has been a surge in innovative techniques concerning complex abdominal wall surgery. The availability of simulation models for comprehensive training and skill set development remains limited. Methods: Cadaveric dissections of the porcine abdominal wall were conducted to assess the suitability of anesthetized porcine models for training in both minimally invasive and open surgical procedures. Results: The panniculus carnosus, a typical muscular layer in mammals, is the outermost layer covering the anterolateral abdominal wall. Beneath it, there are four main pairs of abdominal wall muscles, mirroring the human anatomy. The rectus abdominis muscle runs straight along the linea alba and is surrounded by the rectus sheath, which is formed by the fusion of the lateral abdominal wall muscles and differs along the different regions of abdominal wall. The orientation of the muscle fibers in the lateral abdominal wall muscles, i.e., musculus obliquus externus, internus and transversus, is comparable to human anatomy. Although the transition lines between their muscular and aponeurotic part differ to some extent. Relevant for the adoption of surgical techniques, the transversus abdominis muscle is well-developed and resembles a bell curve shape as it transitions from its muscular to aponeurotic part. Conclusion: Despite minor differences in abdominal wall anatomy between pigs and humans, the porcine model provides a high level of fidelity in terms of both anatomical features and the development of skill sets relevant to hernia surgery.

[Treatment of recurrent incarcerated Bochdalek hernia in an adult]. / Recidív, kizáródott, felnottkori Bochdalek-sérv mutéti megoldása.

Az igen ritka felnottkori nem hiatális, azaz nem paraoesophagealis típusú transdiaphragmaticus sérveket - a veleszületett rekeszizom defektusok mintájára - általánosan Bochdalek, ill. Larey-Morgagni-sérveknek nevezik. Etiológia tekintetében a nem diagnosztizált és kezelt veleszületett eredet, a traumás kontúziós-szakadásos, az iatrogen, ill. a recidív típus említendo meg.Esetismertetésünkben egy felnottkori recidív, kizáródott Bochdalek-sérv sikeres mutéti ellátását ismertetjük. A 23 éves férfi beteg kórelozményében 11 éves korában bal oldali Bochdalek-sérv miatt végzett thoracoscopos rekeszizom sutura szerepel. Epigastrialis fájdalmak, hányinger, hányás, akut hasi megbetegedés klinikai tünetei miatt jelentkezett Intézetünkben. Az elvégzett sürgos mellkasi és hasi CT-vizsgálat a bal mellüregben elhelyezkedo, kizáródott, vékonybélkacsokat tartalmazó Bochdalek-sérvet igazolt. Sürgos laparotomia során az életképesnek bizonyult sérvtartalmat (a vékonybéltraktus 2/3 része, a colon flexura lienalisa és a pancreas farok) a hasüregbe reponáltuk, a sérvkaput direkt suturával zártuk, és szövetszeparáló sebészi hálóval fedtük, valamint a mellüreget draináltuk. A postoperatív szak eseménytelenül zajlott. Kontroll-CT-vizsgálat a reconstruált rekeszizom és pleuro-peritonealis rétegek folytonosságát mutatta. A 10. posztoperatív napon panaszmentesen bocsátottuk otthonába.Megbeszélés: Mint minden kizáródott sérv esetében, a diagnózis mihamarabbi felállítása és az idoben elvégzett mutét kulcsfontosságú. A mellkasi drenázs szükségességét minden esetnél körültekintoen mérlegelni kell. A mutét után a mell- és hasüregben kialakult új anatómiai viszonyok miatt cardialis és respiratoricus szövodmények alakulhatnak ki. Álláspontunk szerint a betegség ritkasága miatt centrumban kezelendo. Ezen ritka állapot sikeres gyógyítása többszakmás együttmuködésen alapul, melynek meghatározó eleme a helyesen megválasztott rekeszi felszínt helyreállító mutéti technika alkalmazása.

Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia.

BACKGROUND: Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement. METHODS: A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed. RESULTS: 54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%). CONCLUSION: In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.

The Role of Procalcitonin in Predicting Failure of Non-operative Management in Bowel Obstructions.

Procalcitonin has been investigated as a marker for bowel ischemia. This study examined the role of procalcitonin in predicting failure of non-operative management (NOM) in bowel obstructions. Patients with bowel obstructions at a single center from August 2022 to January 2023 were prospectively enrolled (n = 79). Lactic acid (LA) and procalcitonin were collected after surgical consultation. The primary outcome was success or failure of NOM. Univariate analysis, multivariable logistic regression, and performance measures of procalcitonin and LA in predicting bowel ischemia was performed. Of 79 patients included, 48 (61%) required operative intervention during index admission. There were no significant differences in demographics, comorbidities, procalcitonin, nor LA between groups. Time from last bowel movement was associated with failure of NOM (OR 1.03 [95% CI 1.01-1.06]; P = .008), though initial procalcitonin or LA was not. Procalcitonin >.3 ng/mL had acceptable sensitivity in screening for bowel ischemia.

Peritoneal flap technique for abdominal wall expansion in the management of complex ventral hernias: a multicentre study from India.

INTRODUCTION: Large abdominal wall hernias often require techniques for wall expansion to improve surgical outcomes. The peritoneal flap hernioplasty (PF) is one such technique that utilizes the hernia sac to reconstruct the abdominal wall, however, with limited published data. It is a modification of the Rives-Stoppa mesh repair where a part of the bisected hernia sac is utilized to reconstruct the anterior fascia and the other part for the posterior fascia. We present a collated retrospective analysis of the outcomes from three centers performing PF with or without transverse abdominis release (TAR) in patients with complex ventral hernias. METHODS: The PF was performed in patients with incisional hernias, both midline and lateral. The primary outcome measured was hernia recurrence. The secondary outcomes were to evaluate pain, surgical site infection, seroma, hematoma, wound dehiscence, pseudo-recurrence, Clavien-Dindo score for complications, and the patient's reported quality of life. The quality of life was assessed by oral questionnaires in the follow-up period. RESULTS: We analyzed 63 patients (38 female, 25 male) with a mean width of hernia defect of 11 cm SD 4. Based on the European Hernia Society (EHS) classification 42 patients were W3 and 21 were W2 hernias. Fifty patients had a midline hernia, while the rest of the patients included transverse, subcostal, and rooftop incision hernias. The classical peritoneal flap procedure was done in 29 (46%) patients, while the peritoneal flap with TAR was done in 34 (54%) patients. Four patients had symptomatic seroma (6%), seven superficial surgical site infection (SSI) (11%), one deep SSI (1.5%), one skin necrosis (1.5%), and one anterior peritoneal flap necrosis (1.5%). No patient required postoperative ventilatory support. The mean pain score on day one was 3/10. There was no recurrence in the mean follow-up of 17 months (range 5 to 49 months). Overall, 58 of 63 (92%) patients reported being satisfied with their surgery. CONCLUSION: In our multicentre study, we found the PF technique with or without TAR for midline and non-midline ventral hernia leads to satisfactory outcomes in terms of low recurrence, low rate of complications, and a good quality of life in the medium to long term. It appears to be a useful technique in the surgeon's armamentarium to repair W2 and W3 hernias needing expansion of abdominal domain.

Intra-abdominal hypertension and compartment syndrome after complex hernia repair.

PURPOSE: Abdominal compartment syndrome (ACS) is a well-known concept after trauma surgery or after major abdominal surgery in critically ill patients. However, ACS as a complication after complex hernia repair is considered rare and supporting literature is scarce. As complexity in abdominal wall repair increases, with the introduction of new tools and advanced techniques, ACS incidence might rise and should be carefully considered when dealing with complex abdominal wall hernias. In this narrative review, a summary of the current literature will highlight several key features in the diagnosis and management of ACS in complex abdominal wall repair and discuss several treatment options during the different steps of complex AWR. METHODS: We performed a literature search across PubMed using the search terms: "Abdominal Compartment syndrome," "Intra-abdominal pressure," "Complex abdominal hernia," and "Ventral hernia." Articles corresponding to these search terms were individually reviewed by primary author and selected on relevance. CONCLUSION: Intra-abdominal hypertension (IAH) and ACS require imperative attention and should be carefully considered when dealing with complex abdominal wall hernias, even without significant loss of domain. Development of a true abdominal compartment syndrome is relatively rare, but is a devastating complication and should be prevented at all cost. Current evidence on surgical treatment of ACS after hernia repair is scarce, but conservative management might be an option in the early phase and low grades of IAH. However, life-saving treatment by relaparotomy and open abdomen management should be initiated when ACS starts setting in.

Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release).

BACKGROUND: Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR. METHODS: This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36 months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score. RESULTS: The average follow-up was 38.3 ± 12.7 months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery. CONCLUSIONS: This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.

Clinical outcomes and costs of retromuscular and intraperitoneal onlay mesh techniques in robotic incisional hernia repair.

BACKGROUND: This study aims to compare clinical outcomes and financial cost of intraperitoneal onlay mesh (IPOM) versus retromuscular (RM) repairs in robotic incisional hernia repairs (rIHR). METHODS: Patients who underwent either IPOM or RM elective rIHR from 2012 to 2022 were included. Demographics, operative details, postoperative outcomes, and hospital costs were directly compared. RESULTS: Sixty-nine IPOM and 55 RM were included. Age and body mass index (BMI) did not differ between both groups (IPOM vs RM: 59.3 ± 11.2 years vs. 57.5 ± 14 years, p = 0.423; BMI 34.1 ± 6.3 vs. BMI 33.2 ± 6.9, p = 0.435, respectively). Comorbidities and hernia characteristics were comparable. Extensive lysis of adhesions (> 30 min) was required more often in IPOM (18 vs. 6 in RM, p = 0.034). Defect closure was achieved in 100% of RM vs. 81.2% in IPOM (p < 0.001). Median (interquartile range) postoperative pain score was higher in RM than in IPOM [5(3-7) vs. 4(3-5), respectively, p = 0.006]. Median length of stay (0 day) and same-day discharge rate did not differ between groups (p = 0.598, p = 0.669, respectively). Six (8.7%) patients in the IPOM group versus one (1.8%) patient in the RM group were readmitted to hospital within 30 days postoperatively (p = 0.099). Perioperative complications were higher in IPOM (p = 0.011; 34.8% vs. 14.5% in RM) with higher Comprehensive Complication Index® morbidity scores [0(0-12.2) vs 0(0-0) in RM, p = 0.008)], Clavien-Dindo grade-II complications (8 vs 0 in RM, p = 0.009), and surgical site events (17 vs. 5 in RM, p = 0.024). Within a follow-up period of 57(± 28) months, recurrence rates were similar between both groups. Hospital costs did not differ between groups [IPOM: $9978 (7031-12,926) vs. RM: $8961(6701-11,222), p = 0.300]. Although postoperative complication costs were higher in IPOM ($2436 vs RM: $161, p = 0.020), total costs were comparable [IPOM: $12,415(8700-16,130) vs. RM: $9123(6789-11,457), p = 0.080]. CONCLUSION: Despite retromuscular repairs having lower postoperative complications than intraperitoneal onlay mesh repairs, both techniques offered encouraging results in robotic incisional hernia repair at a comparable total cost.

The Utilization of Laparoscopic Ventral Hernia Repair (LVHR) in Incarcerated and Strangulated Cases: A National Trend in Outcomes.

INTRODUCTION: Early after its adoption, minimally invasive surgery had limited usefulness in emergent cases. However, with improvements in equipment, techniques, and skills, laparoscopy in complex and emergency operations expanded substantially. This study aimed to examine the trend of laparoscopy in incarcerated or strangulated ventral hernia repair (VHR) over time. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for laparoscopic repair of incarcerated and strangulated hernias (LIS-VHR) and compared over 2 time periods, 2014-2016 and 2017-2019. RESULTS: The utilization of laparoscopy in all incarcerated or strangulated VHR increased over time (2014-2016: 39.9% (n = 14 075) vs 2017-2019: 46.3% (n = 18 369), P < .001). Though likely not clinically significant, demographics and comorbidities statistically differed between groups (female: 51.7% vs 50.0%, P = .003; age 54.5 ± 13.7 vs 55.4 ± 13.8 years, P < .001; BMI 34.9 ± 8.0 vs 34.6 ± 7.8 kg/m2, P < .001). Patients from 2017 to 2019 were less comorbid (18.9% vs 16.8% smokers, P < .001; 18.2% vs 17.3% diabetic, P = .036; 4.6% vs 4.1% COPD, P = .021) but had higher ASA classification (III: 43.3% vs 45.7%; IV: 2.5% vs 2.7%, P < .001). Hernia types (primary, incisional, recurrent) were similar in each group. Operative time (89.7 ± 59.3 vs 97.4 ± 63.4 min, P < .001) became longer but length-of-stay (1.4 ± 3.3 vs 1.1 ± 2.6 days, P < .001) decreased. There was no statistical difference in surgical complications, medical complications, reoperation, or readmission rates between periods. CONCLUSION: Laparoscopic VHR has become a routine method for treating incarcerated and strangulated hernias, and its utilization continues to increase over time. Clinical outcomes have remained the same while hospital stays have decreased.

Assessment of the quality of online patient information resources for patients considering parastomal hernia treatment.

AIM: The aim was to examine the quality of online patient information resources for patients considering parastomal hernia treatment. METHODS: A Google search was conducted using lay search terms for patient facing sources on parastomal hernia. The quality of the content was assessed using the validated DISCERN instrument. Readability of written content was established using the Flesch-Kincaid score. Sources were also assessed against the essential content and process standards from the National Institute for Health and Care Excellence (NICE) framework for shared decision making support tools. Content analysis was also undertaken to explore what the sources covered and to identify any commonalities across the content. RESULTS: Fourteen sources were identified and assessed using the identified tools. The mean Flesch-Kincaid reading ease score was 43.61, suggesting that the information was difficult to read. The overall quality of the identified sources was low based on the pooled analysis of the DISCERN and Flesch-Kincaid scores, and when assessed against the criteria in the NICE standards framework for shared decision making tools. Content analysis identified eight categories encompassing 59 codes, which highlighted considerable variation between sources. CONCLUSIONS: The current information available to patients considering parastomal hernia treatment is of low quality and often does not contain enough information on treatment options for patients to be able to make an informed decision about the best treatment for them. There is a need for high-quality information, ideally co-produced with patients, to provide patients with the necessary information to allow them to make informed decisions about their treatment options when faced with a symptomatic parastomal hernia.

An 8-mm port site hernia after robotic-assisted ileocecal resection: a case report.

BACKGROUND: Robotic-assisted surgery is steadily becoming more prominent. The majority of reports regarding port site hernias (PSHs) have involved laparoscopic procedures. Currently, it is common to suture the fascia at port sites that are 10 mm or larger; however, the closure of 5-mm port sites is not considered mandatory. The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) utilizes a distinctive 8-mm port. We report a case of an early-onset PSH at an 8-mm port site after robotic-assisted ileocecal resection. CASE PRESENTATION: A 74-year-old male patient with a body mass index of 19.7 kg/m2 was diagnosed with cecal cancer and underwent robotic-assisted ileocecal resection. A 3-cm midline incision was made at the umbilicus for insufflation. Under laparoscopic visualization, three ports (12 mm, 8 mm, and 8 mm) were inserted in the lower abdomen. An 8-mm port was inserted in the left subcostal region, and a 5-mm port was inserted in the left lateral abdomen. The procedure was performed without significant intraoperative complications. The fascia was closed only at the umbilicus and 12-mm port site; the fascia at the 8-mm port sites was not closed. The patient was initially discharged without complications; however, on postoperative day 11, the patient was urgently hospitalized again because of PSH incarceration. After manual reduction, the fascia was sutured closed under local anesthesia. The hernial defect was small and barely allowed the insertion of a little finger. There was no evidence of compression or significant damage to the fascia. On postoperative day 27, the patient was discharged after experiencing good recovery. CONCLUSIONS: Robotic-assisted colectomy could contribute to the risk of PSHs because of its surgical characteristics. Although routine closure of the fascia at 8-mm port sites is not mandatory, it may be beneficial in certain cases.

Prolonged Ileus Due to Underlying Shigella Infection After Bilateral Open Inguinal Hernia Repair.

We present a rare case of prolonged ileus caused by underlying Shigella infection after surgical hernia repair. Infectious disease is an uncommon cause of postoperative prolonged ileus in adults. Our 48-year-old male patient underwent bilateral open inguinal hernia repair and open umbilical hernia repair without complication at an academic institution, with same-day discharge. Eight days later, he presented to the emergency department with complaints of severe cramping abdominal pain, nausea, emesis, and watery diarrhea. Physical examination, computed tomography scan of the abdomen and pelvis, and abdominal X-ray were initially concerning for bowel obstruction. The patient was admitted to the general surgery service. Concern for ileus with underlying gastritis arose after a small bowel follow-through showed contrast eventually reaching the rectum. A subsequent gastrointestinal pathogens panel was positive for Shigella. The patient's symptoms resolved after appropriate antibiotic treatment. Shigellosis and other infectious diseases should be considered in the differential diagnosis of postoperative prolonged ileus.

Robot-assisted repair of delayed traumatic diaphragmatic hernia: a case report.

Traumatic diaphragmatic hernia is a sign of severe thoracoabdominal trauma that is often difficult to detect because of nonspecific presenting symptoms, delayed presentation, and distracting injuries. Diagnosis depends on imaging and a high degree of suspicion in patients who present with respiratory or gastrointestinal symptoms after trauma, and prompt surgical repair is required. This case reviews a patient who presented to the emergency department with burning epigastric pain radiating to the left chest and hematemesis ~1 month after sustaining a blunt abdominal injury. Imaging studies revealed a substantial portion of the gastric body in the left hemithorax. Robot-assisted reduction of the stomach was performed followed by repair with tension-free primary closure without mesh reinforcement and gastropexy. The patient was monitored for return of bowel function and discharged upon recovery. This case report highlights the diagnostic challenges of traumatic diaphragmatic hernia and the benefit of robot-assisted repair.

Sigmoid carcinoma contained within a scrotal hernia in an octogenarian: case report.

Scrotal hernias are common in the general population. Patients often present acutely reporting pain or sometimes with more severe symptoms if the hernia is strangulated or incarcerated. An 81-year-old man presented with left-sided iliac fossa pain with no other associated symptoms. On clinical exam, a left-sided non-reducible inguinoscrotal hernia was detected with no evidence to suggest strangulation. Imaging revealed a probable colorectal cancer with likely liver metastases. The patient went on to have open surgery to excise the tumour with clear oncological margins. Colorectal cancers contained within scrotal hernias are very rare occurrences. In this case, the surgeon had the advantage of preoperative images that identified the cancer. In some cases, this cohort of patients do not have such scans prior to surgery and the surgical team can be faced with a much more complex operation than anticipated.

Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic Review.

Introduction: Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTX) have been used together in the preoperative preparation of patients with loss of domain hernias. This study aims to evaluate the efficacy and safety of the combined use of PPP and BTX. Methods: A systematic electronic search was performed according to the PRISMA criteria. A literature search of scientific articles was conducted up to December 2023. Articles were chosen based on the reference to BTX and PPP in loss of domain ventral hernias with a defect width greater than 10 cm before surgery. The GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. Results: The research yielded seven articles, with 217 patients analysed in total. BTX was performed 29.5 ± 1.7 days before surgery and PPP was inflated 14.8 ± 5.8 days before surgery. PPP complications were reported in 25.6% of patients, The average reduction of the volume of hernia (VH)/volume of the abdominal cavity (VAC) ratio was 7.6% (range 0.9%-15%). Only 40 patients (18.4%) required a PCS or TAR to repair the loss of domain hernias. The SSI and SSO rates were 17.5% and 26.2%, respectively. No differences in SSI and SSO rates were found between the different repair techniques. The recurrence rate was 5.9% (13/217). Recurrence was significantly higher in patients who underwent IPOM repair than other techniques (p < 0.001). Conclusion: BTX and PPP may be useful tools for the management of loss of domain hernias presenting lower SSI and SSO. The combination of BTX and PPP reduces the use of more invasive repair techniques.