Incisional and Ventral Hernia Repair

Incisional or ventral hernia is a very common multifactorial disease that requires surgery to prevent complications, including pain, discomfort, bowel obstruction, incarceration, and strangulation. To perform herniorrhaphy, it is essential to understand the pathogenesis of hernia, the anatomy and physiology of the abdominal wall, and surgical techniques. Several repair methods are available, including open suture repair, open mesh repair, the component separation technique, and tissue expansion assisted closure. Currently, laparoscopic incisional or ventral hernia repair is commonly used with the major advantage being the lower recurrence and all defects can be addressed at the time of surgery as well as reduced postoperative pain and length of hospital stay. On the other hand, to do it properly, a full understanding and appropriate selection of mesh and management of probable complications, such as seroma, bowel injury, enteric fistula, and recurrence, is essential. Therefore, the surgeon and the techniques used are of paramount importance in the repair of incisional ventral hernias.

Current Status of Bariatric and Metabolic Surgery in Korea

Bariatric surgery is considered to be the most effective treatment modality in maintaining long-term weight reduction and improving obesity-related conditions in morbidly obese patients. In Korea, surgery for morbid obesity was laparoscopic sleeve gastrectomy first performed in 2003. Since 2003, the annual number of bariatric surgeries has markedly increased, including adjustable gastric banding (AGB), Roux-en-Y gastric bypass, sleeve gastrectomy, mini-gastric bypass, and others. In Korea, AGB is much more common than in others countries. A large proportion of doctors, the public, and government misunderstand the necessity and effectiveness of bariatric surgery, believing that bariatric surgery has an unacceptably high morbidity, and that it is not superior to non-surgical treatments to improve obesity and obesity-related diseases. The effectiveness, safety, and cost-effectiveness of bariatric surgery have been well demonstrated. The Korean Society of Metabolic and Bariatric Surgery recommend bariatric surgery confining to morbidly obese patients (body mass index ≥40 or >35 in the presence of significant comorbidities).

The Current Status of Bariatric Surgery in Korea / 임상당뇨병

Bariatric surgery is considered to be the most effective treatment modality in maintaining long-term weight reduction and improving obesity-related conditions in patients that are morbidly obese. Since 2003 when the first bariatric surgery was performed in Korea, the annual number of cases has markedly increased. The adjustable gastric banding procedure is known to be less invasive and less destructive than gastric bypass or sleeve gastrectomy, and it is unique that the proportion of this procedure is much higher in Korea than in other countries. This phenomenon arises from a misunderstanding that bariatric surgery has an unacceptably high morbidity rate and that it is not superior to nonsurgical treatment to improve obesity and related diseases. To overcome this misunderstanding, it is essential for doctors as well as patients to understand that obesity is a disease entity that requires an intensive treatment and to comprehend that bariatric surgery is a viable treatment for obesity.

Early experiences of minimally invasive surgery to treat gastroesophageal reflux disease / 대한외과학회지

PURPOSE: There are fewer patients with gastroesophageal reflux disease (GERD) in Korea compared with Western countries. The incidence of GERD has increased in recent years however, concerning many physicians. Here, we report our early experiences of using a recently introduced method of laparoscopic antireflux surgery for the treatment of GERD in Korean patients. METHODS: Fifteen patients with GERD were treated using antireflux surgery between May 2009 and February 2012 at the University of Ulsan College of Medicine and Asan Medical Center. Laparoscopic Nissen fundoplication with 360degrees wrapping was performed on all patients. RESULTS: Eleven male and four female patients were evaluated and treated with an average age of 58.1 +/- 14.1 years. The average surgical time was 118.9 +/- 45.1 minutes, and no complications presented during surgery. After surgery, the reflux symptoms of each patient were resolved; only two patients developed transient dysphagia, which resolved within one month. One patient developed a 6-cm hiatal hernia that had to be repaired and reinforced using mesh. CONCLUSION: The use of laparoscopic surgery for the treatment of GERD is safe and feasible. It is also an efficacious method for controlling the symptoms of GERD in Korean patients. However, the use of this surgery still needs to be standardized (e.g., type of surgery, bougienage size, wrap length) and the long-term outcomes need to be evaluated.

Improvement of Type 2 Diabetes after Bariatric Surgery in a Patient with Severe Obesity / 임상당뇨병

The prevalence of obesity is steadily increasing worldwide and is commonly associated with metabolic diseases including hypertension, hyperlipidemia, and type 2 diabetes as well as increased mortality. Bariatric surgery is an effective treatment modality for patients with severe obesity and type 2 diabetes that are refractory to conventional treatments. We performed bariatric surgery (biliopancreatic diversion with duodenal switch) in a 23-year-old man with severe obesity and uncontrolled type 2 diabetes. Before surgery, the patient experienced continuous weight gain and aggravated glycemic control despite dietary restrictions, exercise, and medications including high dose insulin. After surgery, his weight was reduced by 17 kg and he was able to stop insulin treatment. This case suggests that bariatric surgery is an effective therapeutic option when severe obesity and type 2 diabetes are refractory to usual treatments.

Comparison of Laparoscopic Transperitoneal Versus Retroperitoneal Adrenalectomy / 대한내시경복강경외과학회지

PURPOSE: This study was designed to evaluate outcomes of transperitoneal and retroperitoneal approaches in laparoscopic adrenalectomy for resectable adrenal mass. METHODS: Laparoscopic adrenalectomy was performed on 134 patients with resectable adrenal mass between February 2004 and February 2009. We retrospectively reviewed the results of transperitoneal approach (TPA) and that of retroperitoneal approach (RPA) in terms of clinicopathologics and surgical outcomes. RESULTS: 80 patients (39 men and 41 women) underwent TPA, of them, 68 were located in left and 12 were located in right. 54 patients (25 men and 29 women) underwent RPA. In RPA group, 9 were located in left and 45 were located in right. There were no difference in clinicopathologics (including age, gender and BMI), in postoperative complication and in mortality. Operative time was shorter, blood loss was smaller and less pain killers was administered in RPA group (p<0.05). CONCLUSION: Our study shows that both approach (TPA and RPA) have a good peri-operative outcomes, but RPA is less painful and has a shorter operative time than TPA. It is needed to choose operative approach based on certain patient selection criteria for high patient and surgeon satisfaction.

The Comparison of Laparoscopic and Open Incisional and Ventral Hernia Repairs / 대한내시경복강경외과학회지

PURPOSE: We performed a prospective study for the purpose of analyzing and comparing outcomes after laparoscopic and open incisional hernia repairs. METHODS: Open incisional hernia repair with Rives-Stoppa method was performed on 35 patients between April 2003 and March 2008. Laparoscopic incisional hernia repair with intraperitoneal onlay mesh (IPOM) was performed on 35 patients during the same periods. Clinical features and surgical outcomes were compared in both groups. RESULTS: There were no significant differences in patients' clinical characteristics. There were no significant differences in defect size, location and surgical complication. While, the operation time and hospital stay were shorter, and postoperative pain was less in laparoscopic repair group (p<0.05). There was one recurrence in laparoscopic group and there were three recurrences in open group. CONCLUSION: Laparoscopic incisional hernia repair is safe and feasible procedure comparing to open method. We suggest that laparoscopic repair is initially recommended for incisional hernia if there is no contraindication or excessive adhesion.

A Tailored Approach for Recurrent Groin Hernias

PURPOSE: Recurrent groin hernias are a significant problem with high recurrence rates. There is a great deal of controversy regarding their management. This study examined the outcome of patients who had undergone a repair of recurrent groin hernias. METHODS: This study examined retrospectively the medical records of all patients who underwent repairs of recurrent groin hernias (a total 239 cases) between January 1998 and December 2006. The repair was tailored to the previous operation and the patients' medical condition. The types of previous operations, present operation, complications and re-recurrence rate were analyzed. RESULTS: Of the 2,542 groin hernias operated on, 239 cases (9.4%) were treated for recurrent groin hernias. The types of previous surgery were conventional open tissue repair in 199 cases (83.3%), Lichtenstein repair in 28 cases (11.7%), open mesh repair (PHS, Perfix plug) in 6 cases (2.5%) and laparoscopic repair in 6 cases (2.5%). The recurrent groin hernias were repaired using a laparoscopic method in 123 cases (51.4%), open mesh repair in 92 cases (38.4%), Lichtenstein repair in 18 cases (7.5%) and a conventional open tissue repair in 6 cases (2.5%). Postoperative complications occurred in 40 cases (16.7%), which included 10 seromas, 4 wound infections, 3 hematomas, 2 wound swellings, 8 scrotal swelling, 5 dysurias, 2 chronic neuralgias. There were 6 cases of re-recurrence in the 239 cases of recurrent groin hernias (2.5%). CONCLUSION: A tailored approach based on the previous repair and the medical condition of the patients with recurrent groin hernias is associated with a decrease in the incidence of major postoperative complications and a low recurrence rate (2.5%).

Inguino-Femoral Hernia in Women

PURPOSE: Inguino-femoral hernias in women are less common than that in a man, and we have had limited experience for hernia repair in women. The purpose of this study was to evaluate the characteristics of inguino-femoral hernias in females and to establish the choice of specific treatment for inguino-femoral hernia in females. METHODS: This retrospective study was based on the medical records of 566 patients who underwent 657 cases of herniorrhaphies for treating inguino-femoral hernia in adult females from January 1998 to June 2006. We evaluated the incidence of hernia, the operative technique and the length of the operation, the complications and the postoperative recurrence rate. The operative findings and median time to reoperation for a recurrent hernia were also evaluated. RESULTS: During the 8.5-year period, we performed 2,931 herniorrhaphies in 2,274 patients. Of these, 657 herniorrhaphies were done in females (22.4%). The types of hernia in females were indirect inguinal hernia (67.3%), direct inguinal hernia (10.2%), the pantaloon type (10%) and femoral hernia (14.9%). Femoral hernia was more frequent in females (14.9%) compared to males (3.5%) (P<0.001). The overall rate of reoperation due to incarceration in the females was higher (2.5%) than that in the men (1.1%)(P<0.001). Femoral hernias in females was found at reoperation in 39.7% compared with 17.2% in the males (P<0.001). CONCLUSION: The incidence of inguino-femoral hernia in females was higher than the results of most published studies and the reoperation rate was higher in females. The increased frequency of femoral hernia at reoperation in females suggests avoiding injuries to the posterior wall of the inguinal canal and the need for exploration of the femoral canal at the time of the primary operation.

Delayed Perforation of the Gallbladder after Blunt Abdominal Trauma

Isolated injury of the gallbladder rarely occurs after blunt abdominal trauma and, if so, is usually associated with damage to other intra-abdominal organs clearly necessitating surgical intervention. Blunt abdominal trauma is often overlooked because there may be no visible signs on the abdominal wall. It is important to closely follow patients and look for early signs of organ damage, as isolated injury of the gallbladder often follows a vague and insidious clinical course. A combination of special investigations may be required to confirm the diagnosis of this relatively rare but serious injury. Our case was a 38-year-old female, admitted to the hospital with a history of blunt abdominal trauma secondary to a fall. Initial computed tomographic scan demonstrated an edematous gallbladder; a follow-up computed tomographic scan showed a 5-cm collection of fluid around the gallbladder, suspicious for gallbladder perforation. Diagnostic laparoscopy followed by laparoscopic cholecystectomy was performed without complications. The postoperative course was uneventful and the patient was discharged on postoperative day three.

Composite Neuroendocrine Carcinoma with Adenocarcinoma of the Stomach Mimicking Double Primary Cancer

A 67-year-old man presented with a 3-month history for intermittent epigastric pain and postprandial discomfort. Upper gastrointestinal endoscopy and contrast-enhanced axial computed tomographic scan demonstrated two separate tumors of the gastric antrum and the duodenal second portion, suggestive of the preoperative diagnosis of a double primary cancer. Pancreaticoduodenectomy with lymph node dissection was performed, and the microscopic features and immunohistochemical profiles of the resected specimen confirmed the diagnosis of the composite neuroendocrine carcinoma with adenocarcinoma of the stomach (mixed exocrine-endocrine carcinoma).

Spontaneous Rupture of a Primary Splenic Cyst Causing Hemoperitoneum

A 14-yr-old male presented with a hemoperitoneum caused by a spontaneous rupture of a primary splenic cyst. The laparotomy showed a ruptured spleen at the lower pole from one of the multiple cyst-like lesions, measuring approximately 2 cm in diameter. After the splenectomy, a microscopic examination confirmed the diagnosis of a primary splenic cyst lined with a mature, well-differentiated squamous epithelium. A hemoperitoneum caused by a spontaneous rupture of a primary splenic cyst is a rare but potentially lethal complication, because most patients with a splenic rupture present with some degree of hypovolemia.

Computed Tomographic Findings of Anomalies of Intestinal Rotation in Adult Patients

Anomalies of the intestinal rotation mainly produce clinical manifestations in infants and children, but are uncommon in adults. We report three adult patients who presented with a surgical abdomen and the characteristic computed tomographic findings associated with anomalies of the intestinal rotation. Two patients presented with acute appendicitis, and one presented with an intestinal obstruction caused by colon cancer. In all patients, the computed tomographic findings were suggestive and were helpful for making a preoperative diagnosis of the anomalies of intestinal rotation: (1) a left-sided colon and/or (2) mesenteric vascular inversion. A computed tomographic scan is useful not only for providing an accurate diagnosis of a suspected surgical abdomen but also for detecting associated rotational anomalies, which may require a separate surgical correction.

Posterior Tibial Artery Aneurysm: A Case Report

Aneurysms of the infrapopliteal arteries are rare and they are commonly associated with trauma. We report here on a rare case of a true aneurysm of the posterior tibial artery in a sixty-year-old female. There was no history of trauma, and the serologic tests for the possibility of vasculitis were all negative. The color Doppler ultrasound examination and the multi-detector computed tomographic scan confirmed the diagnosis of a posterior tibial artery aneurysm and these tests revealed no evidence of aneurysms or occlusive lesions in the other arteries. Aneurysmectomy and end-to-end microvascular anastomosis were performed successfully. Preoperative multi- detector computed tomographic scanning is a valuable, noninvasive diagnostic tool to delineate not only the state of the aneurysm, but also that of the distal arterial tree.

Celiac Artery Aneurysm Associated with Chronic Pancreatitis: Case Report

Celiac artery aneurysms are extremely rare. Among the numerous conditions that can lead to a celiac artery aneurysm, acute or chronic pancreatitis has been described as one of the less common causes. A 54-year-old alcoholic man with a 7-year history of recurrent pancreatitis and iron deficiency anemia presented with a 15-day history of gastrointestinal bleeding. The contrast-enhanced axial CT scan and abdominal arteriography demonstrated that a 3-cm sized aneurysm had developed on the celiac artery and there were multiple calcified densities in the pancreas; these findings were suggestive of a diagnosis of celiac artery aneurysm with gastrointestinal bleeding that was caused by chronic pancreatitis. Aneurysmectomy without revascularization was performed successfully. We report here on a rare case of celiac artery aneurysm that was caused by chronic pancreatitis.

Primary Splenic Tuberculosis Presenting as a Large Solitary Mass

Tuberculosis may be difficult to diagnose when it presents in an uncommon extrapulmonary site. Although there has been a resurgence of abdominal tuberculosis in immunocompromised patients, which is largely due to the extensive use of immunosuppressive drugs and the increasing incidence of a human immunodeficiency virus infection, splenic tuberculosis is rare, particularly in the immunocompetent patients. Almost all cases of splenic tuberculosis present as multiple hypoechoic foci on sonography or multiple focal hypodense lesions on contrast enhanced computed tomographic scan. To our knowledge, splenic tuberculosis is an extremely rare condition. An 80-year-old man was found to have a large solitary splenic mass mimicking a splenic neoplasm on sonography and contrast enhanced computed tomographic scan. A diagnostic splenectomy revealed a large solitary mass in the spleen, which was consistent with splenic tuberculosis microscopically. We report a rare case of splenic tuberculosis in an elderly man presenting as a large solitary splenic mass on sonography and contrast enhanced computed tomographic scan.

Repeat CT Scan for Non-operative Management of Blunt Splenic Trauma

PURPOSE: This study was performed to evaluate the value of repeated CT scans for the non-operative management of patients with clinically stable blunt splenic trauma. METHODS: 49 consecutive patients with blunt splenic trauma were prospectively studied. Of these, 29 (59.2%) were initially managed non-operatively according to their clinical status and initial CT findings. A repeat CT scan was obtained within 7 days of admission. RESULTS: Of the 29 non-operatively managed patients, 5 (17.2%) required delayed surgical intervention: 3 presented with a change in thier clinical status, whereas the other 2 did not. In all 5 patients, a repeat CT scan revealed a deteriorating appearance of the splenic injury: active bleeding or an increased hematoma in 3, with splenic artery pseudoaneurysms in the other 2. CONCLUSION: This initial experience suggests that a repeat CT scan can provide valuable clinical information in selected cases on the diagnosis and management of a splenic injury to document the healing or progression of the injury.

Endovascular Treatment in the Trauma Patients with Vascular Injury

PURPOSE: The role of vascular and interventional radiology in trauma patients is evolving. Endovascular treatments are helpful in treating vascular injuries in trauma patients. In some situations, endovascular treatments are as effective or more effective than surgery, but less invasive. We performed this study to evaluate the efficacy of endovascular treatments in the trauma patients with vascular injury. METHOD: Between September 2000 and September 2003, a total of 10 consecutive trauma patients with vascular injury who received endovascular treatments were included in this study. RESULT: Of the 10 patients, the most common injured arteries were the iliac arteries (5 patients), and the most common associated injuries were pelvic (8 patients) and long bone (6 patients) fractures. Transarterial embolization was performed in 9 patients, and stent-graft placement in 1. Clinical success was achieved in all 10 patients. After endovascular treatments, 3 patients with fluid collections were treated with ultrasound-guided, percutaneous drainage. Two of 10 patients died of complications other than hemorrhage. CONCLUSION: This initial experience suggests that endovascular treatment for trauma patients with vascular injury is safe and effective, and that it can also reduce the unnecessary laparotomies in these difficult cases.

Protein S Deficiency Presenting as Severe Peripheral Arterial Insufficiency

Among the numerous conditions that can lead to a hypercoagulable state, protein C and S deficiencies have been frequently described. Although protein C and S deficiencies have frequently been associated with venous thromboembolic events, instances of arterial thromboses have been reported, especially in young patients. The exact incidence of protein C and S deficiencies in patients with peripheral arterial insufficiency has not been established. Given the paucity of adequate studies to define the natural history and arteriographic findings of these patients, treatment has not been well delineated. We report a young female patient who presented with severe peripheral arterial insufficiency and underwent an unusual clinical course associated with protein S deficiency.

Isolated Gallbladder Injury after Blunt Abdominal Trauma

An isolated injury of the gallbladder rarely occurs after blunt abdominal trauma and is usually associated with damage to other intra-abdominal organs, which clearly necessitating surgical intervention. Blunt abdominal trauma is often overlooked because there may be no visible signs on the abdominal wall. It is important to closely follow up patients and look for early signs of organ damage as an isolated injury of the gallbladder often follows a vague and insidious clinical course. A combination of special investigations, including a contrast enhanced computed tomographic scan, may be required to confirm the diagnosis of this relatively rare, but serious injury, and if a lesion is suspected, a laparoscopy can be successfully used to confirm the diagnosis and treat this condition without the usual requirement of open exploration. Unfortunately, in our case, a laparoscopy could not be performed due to the patient having undergone previous surgery for early gastric cancer. Herein, the case of a 56-year-old male presenting with an isolated gallbladder injury immediately after violent blunt abdominal trauma, diagnosed on the basis of a computed tomographic scan, which was treated successfully, is reported.