Mondor's disease mimicking a Spigelian hernia.

Superficial thrombophlebitis of the thoracoepigastric veins (also known as Mondor's disease) is an uncommon disorder that typically affects middle-aged women and classically involves the chest wall including the breasts. Only one previously published, non-operative case of the disease, describes how the condition can resemble a strangulated Spigelian hernia. Herein we describe another similar case in which the diagnosis was made intra-operatively. The extremely unusual and similar clinical findings we observed demonstrate that Mondor's disease can occur in the Spigelian hernia belt and cause diagnostic confusion.

Subxiphoid incisional hernias after median sternotomy.

BACKGROUND: Subxiphoid incisional hernias are notoriously difficult to repair and are prone to recurrence. The few reports on subxiphoid hernia published over the last two decades have not fully addressed the etiology, pathology, treatment, and outcome of this problem. This review was performed to analyze the published experience and increase the understanding of these difficult hernias. METHODS: We reviewed the extensive literature, including the Medline and Current Contents computerized database searches, and searched the available bibliographies. RESULTS: Seven retrospective studies of a total of 113 patients who had clinical subxiphoid hernias after median sternotomy were found. An additional surgical technique describing a modified median sternotomy preventing the hernia, and a single review article on selected technical considerations of subxiphoid ventral repair were also found. CONCLUSIONS: The incidence of subxiphoid hernia after median sternotomy can be possibly reduced by paraxiphoid extension of the sternotomy, reinforcement near the xiphoid end of the incision, or by optimizing closure of the distal sternotomy and the linea alba. Abdominal wall reinforcement by open-mesh closure or laparoscopic transperitoneal prosthetic repair can effectively deal with the defect. Long-term outcome analyses are not yet available.

Incarcerated Spigelian hernia in morbidly obese patients: the role of intraoperative ultrasonography for hernia localization.

BACKGROUND: Spigelian hernias are uncommon and their diagnosis can be difficult. Ultrasonography is, as a rule helpful in making the diagnosis, but extensive exploration is sometimes needed to locate the defect. METHODS: Two patients are described in whom the diagnosis was made preoperatively by ultrasonography, but intraoperative location of the hernias proved extremely difficult because of the patients' obesity. RESULTS: In the first patient, the hernia was located by means of intraoperatively performed ultrasonography. In the second patient, ultrasonography was combined with intraoperatively insufflated pneumoperitoneum and this proved successful in identifying the position of the sac. CONCLUSION: Intraoperative ultrasonography is a valid option for accurate localization of Spigelian hernias, especially in obese patients; extensive intraoperative dissection, distortion of tissue planes, and associated morbidity risks may be avoided.

Gastrointestinal 'crosses'. A new shade from an old palette.

BACKGROUND: We present our experience with an as yet undescribed type of intentionally ingested metallic foreign body that was specially designed to arrest in its passage and cause perforation of the gastrointestinal tract. The two halves of a standard paper clip are tied crosswise with a rubber band, forming an elastic "cross." With its branches squeezed to lie parallel, the cross is wrapped into a small strip of paper and ingested. After being released from its wrapper, the branches of the cross spring back to their original position and cause perforation of the bowel wall. DESIGN: Case series. SETTING: University hospital, Bulgaria. PATIENTS: Five male prisoners from the same jail undergoing laparotomy for foreign body removal during 1 week in January 1994. INTERVENTIONS: Laparotomy, removal of the foreign bodies through incisions of the bowel wall, immediate restoration of the gastrointestinal tract continuity, and peritoneal lavage and drainage. OUTCOME MEASURES: Morbidity and mortality. RESULTS: Two of the patients were initially observed but subsequently underwent surgery for perforations of the gastrointestinal tract. Three of the patients underwent immediate operative treatment. There were 20 total crosses ingested; all foreign objects impacted and perforated the stomach (50%), first duodenal portion (25%), and fourth duodenal portion (20%). There was no morbidity or mortality among the five patients treated. CONCLUSIONS: Because ingested crosses that have been released from their wrappers never move distally, the only definitive solution is to operate early.

Congenital posterolateral diaphragmatic hernia in an adult.

A Bochdalek hernia (BH) occurs when abdominal contents herniate through the posterolateral segment of the diaphragm. Most BHs present with life-threatening cardiorespiratory distress in the neonatal period. Rarely, hernias that remain clinically silent until adulthood present as life-threatening surgical emergencies. Our recent experience with a life-threatening emergency due to a BH in a 29-year-old male patient prompted us to reinforce that this entity does exist in adults and should be considered in the differential of acute abdominal pain.

Recurrent Spigelian hernia: a rare cause of colonic obstruction.

Spigelian hernia is considered a surgical rarity. Recent articles describe only six recurrent hernias and a scant number of patients with colonic obstruction resulting from incarceration. A patient with intestinal obstruction resulting from recurrent Spigelian hernia with strangulated colon is described. The patient underwent tension-free repair using a prosthetic mesh. Recent literature suggests that the deficiency of connective tissue in patients with hernias justifies the widespread use of permanent mesh for tissue reinforcement and avoidance of recurrences. The rare case presented should be regarded as an illustrative example for application of the tension-free repair principle in the definitive management of recurrent Spigelian hernia.

Entero-colocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: case report and review of the literature.

BACKGROUND: The underlying risk associated with visceral mesh erosion is the close opposition of adjacent intestines to the prosthetic graft. This highly morbid condition has been described with most types and techniques of abdominal wall mesh repair. PATIENT: We report the case of a 52-year-old man who presented with an entero-colocutaneous fistula 10 years after prosthetic mesh repair of an incisional hernia. The fistula was excised and the abdominal wall defect repaired with a tissue-impervious composite. CONCLUSIONS: The use of a tissue-impervious barrier avoids development of enteric fistula when a prosthesis is placed directly over the viscera.

Trocar-site hernia complicated by necrotizing fasciitis--case report and review of the literature.

Only a few reports have been published describing necrotizing soft tissue infection (NSTI) following laparoscopic surgery; none identify trocar-site hernia as an etiologic factor. We present a case report and review of the literature. A 43-year-old previously healthy man underwent uneventful laparoscopic cholecystectomy. An unrecognized strangulated lateral trocar-site hernia resulted in fatal NSTI. A Medline database search (1966-2002) identifies ten detailed reports of NSTIs following laparoscopic surgery. Multiple risk factors were identified in almost all patients. The mortality rate was 20%. Patient survival from NSTI requires early recognition, aggressive surgical intervention, and intensive medical care. NSTI can occur following minimally invasive surgery, and physicians should maintain a high index of suspicion when patients begin to develop postoperative symptoms. Trocar-site hernia arises as another etiologic factor for NSTI in the domain of minimally invasive surgery.

Parapubic hernia: case report and review of the literature.

Parapubic hernia is considered rare, with 18 hernias described in five articles published since 1971. The hernia results from iatrogenically or traumatically detached rectus abdominis muscles at the pubic bone and presents a therapeutic challenge because there is no strong aponeurotic anchoring structure in the defect's caudal aspect. We describe a patient with a large parapubic hernia repaired by a combined preperitoneal and onlay prosthetic method. This report adds another dimension to the prosthetic repair options in parapubic hernias and illustrates the effectiveness of the tension-free repair principle in their definitive management.

Handlebar hernia: ultrasonography-aided diagnosis.

Traumatic hernia resulting from blunt impalement of the abdominal wall, known as "handlebar hernia," is seldom addressed in the surgical literature, with only 28 previously reported cases. We describe our experience with this rare traumatic hernia diagnosed by physical examination and confirmed by ultrasonography. Published reports suggest handlebar hernia's potential for serious underlying injury and the diagnostic importance of computed tomographic scanning. The case presented here demonstrates the value of bedside ultrasonography in diagnosis confirmation and surgical planning for this condition.

Spigelian hernia in a child: case report and review of the literature.

Spigelian hernias (SHs) are rarely observed among children. The diagnosis is not difficult to make once it has been considered. The condition requires a high index of suspicion because of its high potential for life-threatening complications. A 12-year-old boy underwent open appendectomy for presumed acute appendicitis. A normal appendix found at laparotomy suggested another etiology for the acute abdomen. Incarceration of the greater omentum in a spigelian hernia was found, and the hernia repaired. The repair of pediatric SH is straightforward and utilizes endogenous tissues. Patients should be followed up for as long as possible to develop data on the durability of the repair technique selected.

Necrotizing soft tissue infection of the chest wall.

Necrotizing soft tissue infection (NSTI) of the chest wall is a relatively rare but highly lethal surgical infection which has received little attention in the medical and surgical literature. The data reported are based on a literature review, including a Medline database search, and search of existing bibliographies. Twenty well-documented cases of primary chest wall involvement by NSTI were found. Thirteen patients were male. Patients' ages ranged from 10 weeks to 78 years. Thirteen patients were postoperative (65%). The diagnosis was initially considered in only 3 of the postoperative cases, a cause of significant delays in surgical treatment. Among those who lived long enough for their wounds to close, 2 had secondary healing, 5 experienced delayed skin grafting over the granulating wound, and 1 had skin grafting combined with muscle transfer. Mortality was 60%. Chest wall NSTI is a rapidly spreading, highly lethal infection. A high index of suspicion, early diagnosis, and aggressive approach are essential to its successful treatment.

Noninvasive characterization of myocardium after transmyocardial laser revascularization.

AIM: The therapeutic mechanism of transmyocardial revascularization (TMR) is not yet fully understood, and continues to be a subject of controversy and active research. Immediate direct laser channel flow, gradual angiogenesis, denervation, and perioperative infarction of the ischemic area have been all discussed, without clear evidence indicating superiority of individual factors. METHODS: We utilized a prospective noninvasive physiologic dynamic method to assess laser-related myocardial injury. The study protocol included EKGs and echocardiograms, including intraoperative transesophageal echocardiograms (TEE) on consecutive TMR patients. CPK-MB was measured postoperatively, with 5 samples at 6-hour intervals. RESULTS: Fifty male patients averaging 62 years old were enrolled in the study. Two patients experienced postoperative myocardial infarctions, from which 1 died. The average CPK-MB values were 12.8+/-1.28 immediately after surgery, 19.2+/-2.4 at 6 h, 15.2+/-2.3 at 12 h, 12.2+/-6.3 at 18 h, and 11.7+/-1.3 at 24 h. In only 5 patients were the CPK-MB values over 30 units at their peak. The intraoperative wall motion remained unchanged in the patients studied, both using TEE and transthoracic echography. CONCLUSION: Significant myocardial injury after TMR appears unlikely, as indicated by CPK-MB and myocardial wall dynamics. Furthermore, TMR does not seem to aggravate baseline myocardial ischemia. We found no evidence to support a hypothesis that surgical myocardial injury constitutes the mechanism of therapeutic action in TMR.

Cystic lesions of the pericardium. Review of the literature and classification.

Pericardial cystic lesions (PCLs) occur infrequently but are significant for their varying clinical presentation and pathological multitude. A review of the literature (including Medline and Current Contents database searches, and search of existing bibliographies) finds confusion in nomenclature and an absence of appropriate classification. A new classification system is proposed based on exo- or endophytic growth, presence of adhesions, and compression of myocardium or great vessels. A multitude of pathological entities with diverse pathogenesis, disease courses, and prognoses may present as PCLs. Detailed knowledge of lesion types and alternatives among diagnostic and therapeutic options permits a selective approach to patient management. The usefulness of a unified classification system should be evaluated in a substantial patient population, with detailed statistical analysis.

Rectal "oven mitt": the importance of considering a serious underlying injury.

A 20-year-old man presented with a rectal "oven mitt," which was removed transanally. Rigid proctosigmoidoscopy revealed no apparent perforation, but subsequent contrast enema using meglumine diatrizoate demonstrated an extraperitoneal rectal perforation, which was probably caused by a wooden stick used to forcefully introduce the glove through the patient's anus. Thus, rectal injuries may be caused not by the foreign object itself, but by another object used as an introducer.

Hydatid cysts of the liver: TN(R)C classification.

BACKGROUND: Liver hydatid disease remains a serious public health problem. Its incidence is increasing but still there is no standardised protocol for assessment of the severity of the disease or for classifying the lesion in each individual case. OBJECTIVE: To construct a new and maximally descriptive classification system that could help in better assessing the extent of the disease, both in primary and recurrent cysts. DESIGN: Description of a newly created classification system. SETTING: University hospital. METHOD: Review of the literature and own observations. RESULTS: Classification system describing T (topography of the cyst), N (natural history of the cyst), R (recurrent cyst) and C (complication of the cyst). CONCLUSION: Consideration is given to almost all aspects of classifying liver hydatid cysts. A new concept for classification is presented which can become the basis for further multi-institutional comparison of data.

Application of a new water jet apparatus in open hepatobiliary surgery: hepatic resection, cholecystectomy, common bile duct lavage.

The presently accepted technologies for hepatobiliary surgery have some limitations and disadvantages. Use of water jet dissection is rapidly spreading and its indications are continuously being widened. In 1988 we developed a new bimodular jet-cutter "Parenchimotom-01". After the experimental application on 110 dogs, the apparatus was introduced into clinical practice. Between 1992-1995 we have successfully performed 11 liver resections, 14 cholecystectomies, and 2 lavages of the common bile duct on 25 patients. Marked decrease in blood loss, operative time, rate of complications, and length of hospitalization were noted. We suggest the water jet dissection to be a sophisticated and maximally effective instrumental technology that offers numerous advantages over the other techniques so far commonly accepted in hepatobiliary surgery and which may improve the treatment and prognosis in patients with different hepatobiliary disease entities.

The Lichtenstein open tension-free inguinal hernia repair using a new prosthetic mesh-Bulgarian irresorbable ampoxen.

The routine use of mesh for repair of inguinal hernia has been popularized by Lichtenstein and coworkers. We adopted this technique and performed it widely using a mesh unknown in the Western world. Ampoxen [multifilamented polycaproamide, impregnated with 5-Nitro-8-Hydroxyquinolinum (Nitroxolinum, DCI), MEDICA, SA, Sandanski, Bulgaria] was discovered in 1975 and proved to be an excellent prosthetic material for replacement of attenuated or destroyed abdominal wall; furthermore, this mesh is very cheap and became widely applicable in our country. This report describes our experience with the first 846 adult inguinal hernia repairs under local anesthesia using Ampoxen. All 846 patients had excellent results, without recurrence. There were nine wound infections (1.1%), 16 testicular oedemas (1.9%), no seromata and no deaths. In no patient was the prosthetic mesh removed. There were no complications related to the use of Ampoxen; this mesh is permanent, has a great degree of fibrous tissue reaction, and wide spectrum antimicrobic activity. We advocate the Lichtenstein technique using irresorbable mesh (particularly Ampoxen) for all adult groin hernias except Types 1 and 2 (according to Nyhus' classification), and for all adult recurrent groin hernias.

Bouveret's syndrome: a rare consequence of malignant cholecystoduodenal fistula.

We report a case of duodenal gallstone obstruction, resulting from cholecystoduodenal fistula. Fistulization was associated with a repeat chronic inflammation and metastatic carcinomatous infiltration. The diagnosis was confirmed by ultrasonography, barium meal examination, and gastroscopy. An attempt at endoscopic extraction was unsuccessful and the patient was referred for operative therapy. We present a graphic algorithm for decision-making in Bouveret's syndrome.