Abnormal obturator artery with ipsilateral inferior epigastric artery passed behind the femoral vein / Arteria obturatriz anómala con arteria epigástrica inferior ipsilateral que cruza posterior a la vena femoral

SUMMARY: Clear awareness of the vascular variations is critical in surgeries, which may cause massive hemorrhage during surgical procedures. During educational dissection of a male cadaver, we encountered a combined variation of the left obturator artery and ipsilateral aberrant inferior epigastric artery. The left obturator artery originated from the external iliac artery, then coursed inward, adherent to the superior pubic ramus. The left inferior epigastric artery originated from the femoral artery, and coursed behind the femoral vein. These anatomical variations shown in one person were extremely rare. This is particularly true with regard to these variations while performing pelvic and inguinal region surgeries.

El conocimiento claro de las variaciones vasculares es fundamental en las cirugías, ya que pueden causar una hemorragia masiva durante los procedimientos quirúrgicos. Durante la disección educativa de un cadáver de sexo masculino, encontramos una variación combinada de la arteria obturatriz izquierda y la arteria epigástrica inferior ipsilateral aberrante. La arteria obturatriz izquierda se originaba en la arteria ilíaca externa, luego discurrió hacia medial, adhiriéndose a la rama púbica superior. La arteria epigástrica inferior izquierda se originaba en la arteria femoral y discurría por detrás de la vena femoral. Estas variaciones anatómicas mostradas en una sola persona son extremadamente raras. Esto es importante de conocer estas variaciones cuando se realizan cirugías de las regiones pélvica e inguinal.

Robotic re-TAPP: a minimally invasive alternative for the failed posterior repair / re-TAPP robótico: uma alternativa minimamente invasiva para falha da via posterior

ABSTRACT Objective: to describe the use of the robotic platform in inguinal hernia recurrence after a previous laparoscopic repair. Methods: patients with recurrent inguinal hernias following a laparoscopic repair who have undergone robotic transabdominal preperitoneal between December 2015 through September 2020 were identified in a prospectively maintained database. Outcomes of interest included demographics, hernia characteristics, operative details and rates of 30-day surgical site occurrence, surgical site occurrences requiring procedural interventions, surgical site infection and hernia recurrence were abstracted. Results: nineteen patients (95% male, mean age 55 years, mean body mass index 28) had 27 hernias repaired (N=8 bilateral). Average operative time was 168.9 ± 49.3min (range 90-240). There were two intraoperative complications all of them were bleeding from the inferior epigastric vessel injuries. Three SSOs occurred (N=2 seromas and N=1 hematoma. After a median 35.7 months follow-up (IQR 13-49), no recurrence has been diagnosed. One patient developed chronic postoperative inguinal pain. Conclusions: on a small number of selected patients and experienced hands, we found that the use of the robotic platform for repair of recurrent hernias after prior laparoscopic repair appears to be feasible, safe and effective despite being technically demanding. Further studies in larger cohorts are necessary to determine if this technique provides any benefits in recurrent inguinal hernia scenario.

RESUMO Objetivo: descrevemos nossa experiência com uso da plataforma robótica no tratamento das recidivas operadas previamente por laparoscopia, mantendo assim uma proposta minimamente invasiva a esses pacientes, apesar de haver uma predileção pela via anterior e aberta nestes casos. Métodos: foram incluídos pacientes submetidos a hernioplastia inguinal robótica transabdominal pré-peritoneal como tratamento de recidiva e que foram operados previamente por laparoscopia, entre dezembro de 2015 e setembro de 2020 e mantidos em uma base de dados ambulatorial prospectiva. Variáveis de interesse incluíram dados demográficos, características herniárias, detalhes operatórios, ocorrências do sítio cirúrgico em 30 dias (com ou sem necessidade de intervenção), infeção do sítio cirúrgico, tempo de seguimento e taxa de recidiva. Resultados: dezenove pacientes (95% masculino, média de idade de 55 anos, média de índice de massa corporal 28kg/m2) e 27 hérnias operadas (N=8 bilaterais). Média de tempo cirúrgico 168.9±49.3 min (variando 90-240). N=2 complicações intraoperatórias por lesão de vasos epigástricos inferiores. N=2 seromas e N=1 hematoma foram identificados no pós-operatório; N=1 paciente apresentou dor crônica pós operatória. Após um tempo de seguimento médio de 35.7 meses (intervalo entre quartis 13-49), nenhuma recidiva foi diagnosticada. Conclusões: o uso da plataforma robótica parece ser seguro e efetivo no tratamento das recidivas operadas previamente laparoscopia, nesse pequeno grupo de pacientes selecionados, apesar de requerer expertise em cirurgia robótica. Outros estudos com maiores casuísticas são necessários para estabelecer o papel desta técnica no cenário das hérnias inguinais recidivadas.

Dolor de cadera en adolescentes: estudio y tratamiento / Hip pain in adolescent: assessment and treatment

En adolescentes que consultan por dolor de cadera o pelvis, es crucial una adecuada historia clínica para orientarnos sobre la etiología del dolor y comprender los mecanismos que lo generan. Es importante conocer y realizar un exhaustivo examen físico, con especial énfasis en la cadera, incluyendo pruebas específicas para diferentes patologías, además de comprender las indicaciones de los diferentes estudios de imágenes, para así lograr un correcto diagnóstico.Entre las causas más frecuentes de coxalgia en adolescentes debemos considerar la epifisiolisis, el pinzamiento femoroacetabular con o sin roturas del labrum, las lesiones avulsivas de la pelvis, la coxa saltans, entre otras. Aunque son poco frecuentes, patologías sistémicas como reumatológicas y oncológicas también deben ser descartadas en adolescentes. Un diagnóstico de certeza nos permitirá realizar una adecuada estrategia de tratamiento, a fin de lograr una rehabilitación precoz y evitar futuras complicaciones.

In adolescents presenting with hip or pelvis pain, an adequate medical history is crucial to guide the etiology and understand the mechanisms that generate it. It is important to know and carry out an exhaustive physical examination, with special attention to the hip, including specific tests for different pathologies, in addition to understand the indications of the different imaging studies, in order to achieve a correct diagnosis. Among the most frequent causes of hip pain in adolescents, we must rule out slipped capital femoral epiphysis, femoroacetabular impingement with or without labral tears, avulsion lesions of the pelvis, snapping hip, among others. Although rare, systemic pathologies such as rheumatologic and oncologic diseases must also be ruled out in adolescents. An accurate diagnosis will allow us to carry out an adequate treatment strategy, in order to achieve early rehabilitation and avoid future complications.

Irreducible Indirect Inguinal Hernia Caused by Sigmoid Colon Cancer Entering Right Groin:A Case Report / 中国医学科学院学报

We reported a case of irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.The patient complained about a right groin mass for more than 60 years with progressive enlargement for 3 years and pain for half a month.Abdominal CT examination at admission showed rectum and sigmoid colon hernia in the right inguinal area and thickening of sigmoid colon wall.Electronic colonoscopy and pathological diagnosis showed sigmoid colon cancer.Therefore,the result of preliminary diagnosis was irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.We converted laparoscopic exploration to laparotomy followed by radical sigmoidectomy and employed end-to-end anastomosis of descending colon and rectum in combination with repair of right inguinal hernia.The patient recovered well after operation and was discharged.

Femoral hernia: uncommon, but associated with potentially severe complications / Hérnia femoral: incomum, mas associada a complicações potencialmente graves

ABSTRACT Background: Although the laparoscopic access is becoming the preferable treatment for femoral hernia, there are only few studies on this important subject. Aim: To assess the outcomes of the totally extraperitoneal laparoscopic (TEP) access in the treatment of femoral hernia. Methods: Data of 62 patients with femoral hernia who underwent herniorrhaphy were retrospectively reviewed. The diagnosis of femoral hernia was established by clinical and/or imaging exams in 55 patients and by laparoscopic findings in seven. Results: There were 55 (88.7%) females and 7 (11.3%) males, with female to male ratio of 8:1. The mean age was of 58.9±15.9 years, ranging from 22 to 92 years. Most patients (n=53; 85.5%) had single hernia and the remaining (n=9; 14.5%) bilateral, making a total of 71 hernias operated. Prior lower abdominal operations were recorded in 21 (33.9%) patients. Conversion to laparoscopic transabdominal preperitoneal procedure was performed in four (6.5%). Open herniorrhaphy was needed in two (3.2%), one with spontaneous enterocutaneous fistula in the groin region (Richter's hernia) and the another with incidental perforation of the adjacent small bowel that occurred during dissection of hernia sac. There was no mortality. Conclusion: Femoral hernia is uncommon, and it may be associated with potentially severe complications. Most femoral hernias may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

RESUMO Racional: Embora o acesso laparoscópico esteja se tornando o tratamento preferencial para a hérnia femoral, poucos são os estudos sobre esse importante assunto. Objetivo: Avaliar os resultados do acesso laparoscópico totalmente extraperitoneal no tratamento da hérnia femoral. Métodos: Os dados de 62 pacientes com hérnia femoral que foram submetidos a herniorrafia foram revisados ​​retrospectivamente. O diagnóstico foi estabelecido por exames clínicos e/ou de imagem em 55 pacientes e por achados laparoscópicos em sete. Resultados: Havia 55 (88,7%) mulheres e 7 (11,3%) homens, com proporção feminino/masculino de 8: 1. A média de idade foi de 58,9±15,9 anos (22-92). A maioria (n=53, 85,5%) apresentava hérnia única e o restante (n=9, 14,5%) bilaterais, perfazendo um total de 71 hérnias femorais operadas. Operações prévias no abdome inferior foram registradas em 21 (33,9%) pacientes. A conversão para procedimento pré-peritoneal transabdominal laparoscópico foi realizada em quatro (6,5%). Herniorrafia aberta foi necessária em dois pacientes (3,2%), um com fístula enterocutânea espontânea na região da virilha (hérnia de Richter) e o outro com perfuração incidental do intestino delgado adjacente que ocorreu durante a dissecção do saco herniário. Não houve mortalidade. Conclusão: A hérnia femoral é incomum e pode estar associada a complicações potencialmente graves. A maioria das hérnias femorais pode ser tratada com sucesso através do acesso laparoscópico totalmente extraperitoneal, com baixas taxas de conversão e complicações.

Abordaje multidisciplinario del dolor inguinal crónico luego de hernioplastia inguinal / Multidisciplinary approach to chronic postoperative inguinal pain

RESUMEN Antecedentes: el dolor inguinal crónico posoperatorio representa una complicación que altera la ca lidad de vida después de la hernioplastia inguinal. Su incidencia es variable con informes de hasta el 16%. Objetivo: describir el tratamiento y los resultados en pacientes con dolor inguinal crónico luego de una hernioplastia inguinal con malla. Material y métodos: estudio descriptivo, observacional y retrospectivo. Se definió como dolor ingui nal crónico posoperatorio la presencia de dolor inguinal por daño nervioso o afectación del sistema somatosensorial tisular que persiste por más de 6 meses luego de la cirugía inicial. Se revisaron las historias clínicas de los pacientes que cursaban el posoperatorio de hernioplastia inguinal convencio nal y laparoscópica en el período 2010-2018. Se realizó la encuesta EuraHS Quality of life score antes y después del abordaje terapéutico multidisciplinario para evaluar cambios en el dolor y restricción de la actividad física. Los resultados fueron analizados y comparados. Resultados: se identificaron 8 pacientes con dolor inguinal crónico posoperatorio grave. El 100% fue evaluado por el Servicio de tratamiento del dolor y requirieron 3 o más fármacos para manejo del do lor. Posteriormente requirieron bloqueo guiado por tomografía computarizada a causa de la persisten cia de los síntomas. Se realizaron 3 (50%) exploraciones quirúrgicas con retiro de material protésico y 2 triples neurectomías. Se observó una disminución estadísticamente significativa (p < 0,05) en el dolor en reposo, dolor durante la actividad y dolor que experimentaron en la última semana. Conclusión: el abordaje multidisciplinario y escalonado permitiría seleccionar a los pacientes que se beneficiarán con el tratamiento quirúrgico.

ABSTRACT Background: Chronic postoperative inguinal pain represents a complication that alters the quality of life after inguinal hernioplasty. Its incidence is variable with reports of up to 16%. Objective: To describe the treatment and results in patients with chronic inguinal pain after an inguinal hernioplasty with mesh. Material and methods: Descriptive, observational and retrospective study. The postoperative chronic inguinal pain was defined as the presence of inguinal pain due to nerve damage or involvement of the somatosensory tissue system that persists for more than 6 months after the initial surgery. The medical records of patients in the postoperative period of conventional and laparoscopic inguinal hernioplasty in the period 2010-2018 were reviewed. The EuraHS Quality of life score pre and post multidisciplinary therapeutic approach was used to evaluate changes in pain and restriction of physical activity. The results were analyzed and compared. Results: 8 patients with severe chronic postoperative inguinal pain were identified. 100% were eva luated by the pain management service and required 3 or more drugs for pain management. Sub sequently, they required block guided by computed tomography due to persistence of symptoms. 3 (50%) surgical examinations were performed with removal of prosthetic material and 2 triple neurec tomies. A statistically significant decrease (p <0.05) was observed in pain at rest, pain during activity and pain experienced in the last week. Conclusion: The multidisciplinary and step up approach would allow selecting the patients who will benefit from the surgical treatment.

A Canine Model for Lymphangiography and Thoracic Duct Access

OBJECTIVE: To evaluate the technical feasibility of intranodal lymphangiography and thoracic duct (TD) access in a canine model.MATERIALS AND METHODS: Five male mongrel dogs were studied. The dog was placed in the supine position, and the most prominent lymph node in the groin was accessed using a 26-gauge spinal needle under ultrasonography (US) guidance. If the cisterna chyli (CC) was not opacified by bilateral lymphangiography, the medial iliac lymph nodes were directly punctured and Lipiodol was injected. After opacification, the CC was directly punctured with a 22-gauge needle. A 0.018-in microguidewire was advanced through the CC and TD. A 4-Fr introducer and dilator were then advanced over the wire. The microguidewire was changed to a 0.035-in guidewire, and this was advanced into the left subclavian vein through the terminal valve of the TD. Retrograde TD access was performed using a snare kit.RESULTS: US-guided lymphangiography (including intranodal injection of Lipiodol [Guerbet]) was successful in all five dogs. However, in three of the five dogs (60%), the medial iliac lymph nodes were not fully opacified due to overt Lipiodol extravasation at the initial injection site. In these dogs, contralateral superficial inguinal intranodal injection was performed. However, two of these three dogs subsequently underwent direct medial iliac lymph node puncture under fluoroscopy guidance to deliver additional Lipiodol into the lymphatic system. Transabdominal CC puncture and cannulation with a 4-Fr introducer was successful in all five dogs. Transvenous retrograde catheterization of the TD (performed using a snare kit) was also successful in all five dogs.CONCLUSION: A canine model may be appropriate for intranodal lymphangiography and TD access. Most lymphatic intervention techniques can be performed in a canine using the same instruments that are employed in a clinical setting.

Primary abandon-of-the-sac (pas) technique: preliminary results of a novel minimally invasive approach for inguinoscrotal hernia repair / Técnica do abandono primário do saco herniário (pas): resultados preliminares de uma nova técnica na cirurgia minimamente invasiva de hérnias inguinoescrotais

ABSTRACT Background: Laparoscopic best approach of repairing inguinoscrotal hernias are still debatable. Incorrect handling of the distal sac can possibly result in damage to cord structures and negative postoperative outcomes as ischemic orquitis or inguinal neuralgia. Aim: To describe a new technique for a minimally invasive approach to inguinoscrotal hernias and to analyze the preliminary results of patients undergoing the procedure. Methods: A review of a prospectively maintained database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias. Patient´s demographics, as well as intraoperative variables and postoperative outcomes were also analyzed. Results: Twenty-six male were submitted to this modified procedure. Mean age of the case series was 53.8 years (range 34-77) and body mass index was 26.8 kg/m2 (range 20.8-34.2). There were no intraoperative complications or conversion. Average length of stay was one day. No surgical site infections, pseudo hydrocele or neuralgia were reported after the procedure and two patients presented seroma. No inguinal hernia recurrence was verified during the mean 21.4 months of follow up. Conclusion: The described technique is safe, feasible and reproducible, with good postoperative results.

RESUMO Racional: A melhor maneira laparoscópica do reparo de hérnias inguinoescrotais permanece ainda aberta a discussão. O manuseio incorreto do saco herniário pode resultar em danos às estruturas do cordão e resultados pós-operatórios indesejados, como orquite isquêmica ou neuralgia inguinal. Objetivo: Descrever uma nova técnica de abordagem minimamente invasiva das hérnias inguinoescrotais e analisar os resultados preliminares de pacientes submetidos ao procedimento. Métodos: Foi realizada na série de casos a análise retrospectiva de um banco de dados mantido prospectivamente em pacientes submetidos a reparo minimamente invasivo usando a técnica "abandono primário do saco" (PAS) para hérnias inguinoescrotais. Dados demográficos dos pacientes, bem como variáveis intraoperatórias e resultados pós-operatórios são descritos. Resultados: Vinte e seis homens foram submetidos ao procedimento. A idade média foi de 53,8 anos e o índice de massa corpórea de 26,8 kg/m2. Não houve complicações intraoperatórias ou conversão para operação aberta. A duração média da estadia hospitalar foi de um dia. Não foram relatadas infecções de sítio cirúrgico, hematomas ou neuralgia após o procedimento e a presença de seroma ocorreu em dois pacientes. Nenhuma recorrência de hérnia inguinal foi verificada durante média de 21,4 meses. Conclusão: A técnica descrita é segura e replicável, apresentando bons resultados pós-operatórios.

Inguinodynia: review of predisposing factors and management / Inguinodinia: revisão sobre fatores predisponentes e manejo

ABSTRACT Herniorrhaphy is one of the most common surgical procedures, with an estimated 20 million operations performed annually worldwide. One of the common complications associated with this procedure is inguinodynia, defined as pain beyond three months after inguinal hernia surgery. In this review, we have addressed the main aspects of this complication with current articles, published in the last five years. Inguinodynia has a multifactorial nature and studies have shown that its development is related to the surgical technique and intrinsic factors of the patient that imply greater predisposition to this phenomenon. In this regard, it has been discussed which surgical techniques imply a lower incidence of this complication. Many studies have focused on understanding intrinsic features of each patient, both in physical and cognitive aspects, and how the approach of these factors can favor a better post-surgical recovery. The treatment of this condition is still challenging, and there are no established universal guidelines. We believe that due to its multifactorial nature, the treatment is hampered due to the individuality inguinodynia presentations.

RESUMO A herniorrafia é um dos procedimentos cirúrgicos mais realizados, com estimativa de 20 milhões de operações feitas anualmente em todo o mundo. Uma das complicações comuns associadas a esse procedimento é a inguinodinia, definida como dor inguinal crônica, com duração superior a três meses após herniorrafia inguinal. Nesta revisão, abordamos os principais aspectos dessa complicação com base em artigos sobre o tema, publicados nos últimos cinco anos. A inguinodinia tem natureza multifatorial e estudos mostram que está relacionada à técnica cirúrgica e aos fatores intrínsecos do paciente, que implicam maior predisposição a esse fenômeno. Nesse sentido, têm sido discutidas quais técnicas cirúrgicas implicam menor incidência dessa complicação. Muitos estudos têm se concentrado em compreender características inerentes a cada paciente, tanto no aspecto físico, quanto cognitivo, e como a abordagem desses fatores pode favorecer a melhor recuperação pós-cirúrgica. O tratamento dessa condição ainda é desafiador e não há diretrizes universais estabelecidas. Acreditamos que, devido à natureza multifatorial, o tratamento é dificultado em razão da individualidade das apresentações da inguinodinia.

Femoral hernia containing the right fallopian tube: a rare finding / Hérnia femoral contendo a trompa de falópio direita: um achado raro

Abstract Femoral hernias comprise a small proportion of all groin hernias. They are more common in women and have a high rate of incarceration and strangulation, leading to emergency repair. A 61-year-old female patient was admitted to the emergency department complaining of a 2-day painful lump in the right groin, that had become more intense in the last 24 hours. Physical examination suggested the presence of a strangulated femoral hernia, and the patient underwent emergency surgical repair. Intraoperatively, the right fallopian tube was observed in the hernia sac. Since there were no signs of ischemia, the tube was reduced back into the pelvic cavity and the hernia was repaired. The postoperative period was uneventful, and the patient was discharged without complications, 3 days after surgery.

Resumo As hérnias femorais representamuma pequena fração de todas as hérnia da região inguinal. Elas são mais comuns entre as mulheres e estão associadas a elevadas taxas de complicações, como encarceramento e estrangulamento, com necessidade de cirurgia urgente. Uma paciente do sexo feminino, de 61 anos, recorreu ao serviço de emergência por quadro de dor e tumefação da região inguinal direita com 2 dias de evolução e agravamento nas últimas 24 horas. O exame objetivo sugeria a presença de uma hérnia femoral encarcerada, e a paciente foi submetida a cirurgia urgente. Intraoperatoriamente, confirmou-se o diagnóstico de hérnia femoral encarcerada, que continha a trompa de falópio direita no interior do saco herniário. Uma vez que a que a trompa não apresentava sinais de isquemia, o conteúdo da hérnia foi reduzido, e procedeu-se à sua reparação. O período pós-operatório decorreu sem intercorrências, e a paciente teve alta no 3° dia após a cirurgia.

Imaging Assessment of the Pubis in Soccer Players / Avaliação por imagem do púbis em jogadores de futebol

Abstract Objective To compare the accuracy of ultrasound (US) with that of magnetic resonance imaging (MRI) in the detection of aponeurosis lesions of the rectus abdominis/adductor longus muscles, to study the characteristics of the athletes and imaging findings associated with pubalgia, and to demonstrate the importance of each method in evaluating this condition. Materials and methods The present study was conducted from 2011 to 2016 with 39 professional soccer players: 15 with pubalgia and 24 without pubalgia. Age, field position, bodymass index (BMI), weekly training load, career length, and history of thigh/knee injury and lower back pain were recorded. The following tests were performed: radiographs (anteroposterior view of the pelvis in standing and flamingo positions) to evaluate hip impingement, sacroiliac joint, and pubic symphysis instability; US to analyze the common aponeurosis of the rectus abdominis/adductor longus muscles and inguinal hernias; and MRI for pubic bone degenerative alterations and edema, and lesions in the adductor and rectus abdominis muscles and their aponeurosis. Results There was an association between pubalgia, high BMI (p = 0.032) andmuscle alterations (p < 0.001). Two patients with pubalgia had inguinal hernias and one patient with pubalgia and two controls had sports hernias. Pubic degenerative changes were frequent in both groups. Aponeurosis lesions weremore frequent in patients with pain. The US detection had 44.4% sensitivity and 100% specificity. Conclusion The evaluation of athletic pubalgia should be performed with radiography, US, and MRI. High BMI, muscle injuries, geodes, and osteophytes are findings associated with pubalgia; US has low sensitivity to detect injuries of the common aponeurosis of the rectus abdominis/adductor longus muscles.

Resumo Objetivo Comparar a acurácia da ultrassonografia em relação à ressonância magnética na detecção de lesões da aponeurose do reto abdominal/adutor longo, estudar características dos jogadores e achados de imagem associados à pubalgia e demonstrar a importância de cada método. Materiais e métodos Estudo realizado de 2011 a 2016 com 39 jogadores profissionais de futebol, 15 deles com e 24 sem pubalgia. Foram registrados idade, posição, índice de massa corporal (IMC), carga de treino semanal, tempo de profissão e lesão prévia na coxa/joelho e lombalgia. Os seguintes exames de imagem foram realizados: radiografias (anteroposterior da bacia e flamingo) para avaliar sinais de impacto do quadril, articulações sacroilíacas e instabilidade da sínfise púbica; ultrassonografia para analisar a aponeurose comum do reto abdominal/adutor longo e hérnias inguinais e do esporte; ressonância magnética buscando alterações degenerativas e edema no púbis, lesões musculares dos adutores e retos abdominais e na sua aponeurose. Resultados Observou-se uma associação entre pubalgia e IMC elevado (p = 0,032) e alterações musculares (p < 0,001). Hérnia inguinal foi encontrada em dois casos e hérnia do esporte, em um caso e dois controles. Alterações degenerativas do púbis foram frequentes nos dois grupos. Lesões da aponeurose foram mais comuns nos pacientes com dor e a ultrassonografia teve sensibilidade de 44,4% e especificidade de 100% na detecção. Conclusão A avaliação da pubalgia atlética deve ser realizada com radiografias, ultrassonografia e ressonância magnética. Índice de massa corporal elevado, lesões musculares, geodos e osteófitos são achados associados à pubalgia; a ultrassonografia tem baixa sensibilidade para detectar lesões da aponeurose comum do reto abdominal/ adutor longo.

Cementless Bipolar Hemiarthroplasty for Low-energy Intracapsular Proximal Femoral Fracture in Elderly East-Asian Patients: A Longitudinal 10-year Follow-up Study / 대한고관절학회지

PURPOSE: Short-term outcomes following cemented and cementless hemiarthroplasties (HAs) are reported to be comparable, however, long-term outcomes of cementless HA—especially among Asian patients—is limited. We aimed to assess long-term outcomes in elderly East-Asian patients with intracapsular proximal femoral fractures treated with cementless HA. MATERIALS AND METHODS: We enrolled 135 patients treated with cementless HA who met our inclusion criteria. We documented bone/implant-related complications (e.g., incidences of revision hip surgery, femoral stem subsidence, dislocation, intraoperative and postoperative periprosthetic fractures, contralateral hip fractures). We included those patients who are still alive 10 years after the index surgery in the final functional analysis of the existence of pain, ambulatory status, and residential status. RESULTS: The mean age at injury was 78.3 years (range: 60–85 years). At the 10-year follow-up, 26 of the original patients (19.3%) had survived. During follow-up, revision hip surgery was conducted in two patients (1.5%). We recorded the incidence of intraoperative fractures, postoperative periprosthetic fractures, and contralateral fractures in two (1.5%), eight (5.9%), and six patients (4.4%), respectively. Among the 10-year survivors, six patients (23.1% of the survivors) complained of groin pain, but generally reported the pain to be tolerable. CONCLUSION: Among elderly East-Asian patients, the incidence of revision surgery after cementless HA may be lower than that in their European counterparts, whereas the incidence of periprosthetic fractures can still be considerably higher. For patients undergoing cementless HA, prevention of such secondary fractures is of critical importance.

Unilateral versus Bilateral Groin Puncture for Atrial Fibrillation Ablation: Multi-Center Prospective Randomized Study

PURPOSE: Catheter ablation for atrial fibrillation (AF) requires heavy anticoagulation and uncomfortable post-procedural hemostasis. We compared patient satisfaction with and the safety of unilateral groin (UG) puncture-single trans-septal (ST) ablation with conventional bilateral groin (BG) puncture-double trans-septal (DT) ablation in paroxysmal AF patients. MATERIALS AND METHODS: We enrolled 222 patients with paroxysmal AF (59.4±10.7 years old) who were randomized in a 2:1 manner into UG-ST ablation (n=148) and BG-DT ablation (n=74) groups. If circumferential pulmonary vein isolation could not be achieved after three attempts of touch-up ablation in the UG-ST group, the patient was crossed over to BG-DT by performing a left groin puncture. RESULTS: Ten patients in the UG-ST group (6.8%) required crossover to the BG-DT approach. There were no significant differences in procedure time (p=0.144) and major complications rate (p>0.999) between the UG-ST and BG-DT groups. Access site pain (p=0.014), back pain (p=0.023), and total pain (p=0.015) scores were significantly lower for the UG-ST than BG-DT group as assessed by the Visual Analog Scale. Over 20.2±8.7 months of follow up, there was no difference in AF recurrence free-survival rates between the two groups (Log rank, p=0.984). CONCLUSION: UG-ST AF ablation is feasible and safe, and was found to significantly reduce post-procedural hemostasis-related discomfort, compared to the conventional DT approach, in patients with paroxysmal AF.

Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial

OBJECTIVE: To determine whether an active rehabilitation program that involves repetitive effortful muscle contractions, including core stability, balancing exercises, progressive resistance exercises, and running activities, after a sports hernia, is effective. METHODS: Forty soccer players with sports hernias were randomly divided into two equal groups: group A (active rehabilitation program) and group B (conventional treatment). The methods of assessment included a visual analog scale (VAS) and hip internal and external range of motion assessments. Group A received conventional treatment (heat, massage, transcutaneous electrical nerve stimulation, and mobilization) plus an active rehabilitation program, while group B received only conventional treatment. Three treatment sessions were given each week for 2 months. Evaluations were performed pre- and post-treatment. RESULTS: A decrease in VAS was seen in both groups at the end of treatment, 80.25% in group A and 41.93% in group B. The difference between the two groups was statistically significant (p=0.0001), whereas there were no statistical differences in internal and external rotation between the groups at the end of treatment (p>0.05). After treatment, an improvement in outcome measures of group A compared to group B (p=0.01) was seen. Thirteen patients in group A and only three patients in group B returned to sports activities without groin pain. CONCLUSION: Active rehabilitation was effective for sports hernia management measured by a decrease in pain and the return to sports.

Outcomes of Elective Endovascular Aneurysmal Repair for Abdominal Aortic Aneurysms in Jordan

PURPOSE: The outcomes of endovascular aneurysmal repair (EVAR) for infrarenal abdominal aortic aneurysms (AAAs) in the Middle East have rarely been reported. We analyzed the outcomes of EVAR in a Jordanian population.MATERIALS AND METHODS: We conducted a retrospective review of the medical records of patients with infrarenal AAA who were treated with elective EVAR between January 2004 and January 2017 at a single center in Jordan. Patient characteristics, anatomical characteristics, procedural details, and early and late postoperative outcomes were analyzed.RESULTS: A total of 288 patients (mean age, 70 years; 77.8% males) underwent EVAR for infrarenal AAA (median aneurysm size, 64 mm). Bifurcated endografts were used in 265 patients, and aorto-uni-iliac devices were used in 22 patients. Successful endograft deployment was achieved in all patients with no open conversion. Early complications included localized groin hematoma in 15, femoral artery dissection in 4, wound infection in 3, and seroma in 3 patients. With a mean follow-up of 60 months, 50 endoleaks were detected, including 9 type I, 38 type II, and 3 type III. Seven patients had unilateral graft limb occlusion. The 30-day mortality was 1.7%, and long-term mortality was 7.0%, mostly due to non-AAA-related causes.CONCLUSION: EVAR was safely performed in Jordanian patients with minimal complications. However, long-term surveillance is important due to the risk of endoleaks and consequent intervention.

Varicocele and Testicular Pain: A Review

Varicocele is the dilatation of the scrotal portion of pampiniform plexus and the internal spermatic venous system. About 15% of men suffer from scrotal varicocele and 2% to 10% of them complain of pain. The probable mechanisms for pain include compression of the surrounding neural fibers by the dilated venous complex, elevated testicular temperature, increased venous pressure, hypoxia, oxidative stress, hormonal imbalances, and the reflux of toxic metabolites of adrenal or renal origin. Testicular pain associated with varicoceles is typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin; rarely, it can be acute, sharp, or stabbing. The management of testicular pain associated with varicocele starts with a conservative, non-surgical approach and a period of observation. Varicocelectomy in carefully selected candidates with clinically palpable varicocele resolves nearly 80% of all cases of testicular pain. Microsurgical techniques for varicocelectomy have gained popularity with minimal complication rates and favorable outcomes. The grade of varicocele, the nature and duration of pain, body mass index, prior conservative management, and the type of surgical method used, are predictors for the success of varicocelectomy.

The safety of one-per-mil tumescent infiltration into tissue that has survived ischemia

BACKGROUND: The aim of this study was to assess the safety of one-per-mil tumescent injections into viable skin flaps that had survived an ischemic insult, in order to assess the potential suitability of one-per-mil tumescent injections in future secondary reconstructive procedures such as flap revision and refinements after replantation. METHODS: Forty groin flaps harvested from 20 healthy Wistar rats weighing 220 to 270 g were subjected to acute ischemia by clamping the pedicle for 15 minutes. All flaps showing total survival on the 7th postoperative day were randomly divided into group A (one-per-mil tumescent infiltration; n=14), group B (normal saline infiltration; n=13), and group C (control, with no infiltration; n=13) before being re-elevated. Transcutaneous oxygen tension (TcPO₂) was measured before and after infiltration, and changes in TcPO₂ were statistically analyzed using analysis of variance, the paired t-test, and the independent t-test. The viability of flaps was also assessed using the Analyzing Digital Images software at 7 days after the second elevation. RESULTS: Thirty-nine flaps survived to the final assessment, with the sole exception of a flap from group A that did not survive the first elevation. TcPO₂ readings showed significant decreases (P<0.05) following both one-per-mil tumescent (99.9±5.7 mmHg vs. 37.2±6.3 mmHg) and normal saline (103±8.5 mmHg vs. 48.7±5.9 mmHg) infiltration. Moreover, all groin flaps survived with no signs of tissue necrosis. CONCLUSIONS: One-per-mil tumescent infiltration into groin flap tissue that had survived ischemia did not result in tissue necrosis, although the flaps experienced a significant decrease of cutaneous oxygenation.

Phthirus pubis Infestation of the Scalp: A Case Report and Review of The Literature

Phthirus pubis usually infests the pubis, groin, buttocks and perianal region. It can sometimes infest the thighs, abdomen, chest, axillae and beard. Eyelashes and eyebrows may be involved in children. The involvement of the scalp is very rare. We describe a case of P. pubis infestation located exclusively on the scalp in an adult woman. Neither lice/nits nor skin lesions were observed elsewhere, including eyebrows, eyelashes, axillae, pubis, buttocks and perianal region (the patient was hairless in the axillae and pubis). A review of the literature is enclosed.

Primary Cutaneous Mucinous Carcinoma with Extramammary Paget’s Disease: Eccrine or Apocrine?

Primary cutaneous mucinous carcinoma (PCMC) is an uncommon tumor of the sweat gland origin. The occurrence of PCMC is mostly in middle-aged and older patients, with a slight male predominance. Most cases of PCMC arise on the head, with a preference for eyelids. The histogenesis of PCMC, whether eccrine or apocrine, remains controversial. We report a rare case of PCMC with secondary extramammary Paget’s disease in the groin of a 75-year-old man, which favored an apocrine origin. Furthermore, based on a review of the literature, we provide several histologic clues that can be used to differentiate PCMC from metastatic mucinous carcinoma.

Flow Perfusion Maintaining Long-term Viability of the Rat Groin Fat Flap: A Novel Model for Research on Large-scale Engineered Tissues / 中华医学杂志(英文版)

BACKGROUND@#Large-scale muscle tissue engineering remains a major challenge. An axial vascular pedicle and perfusion bioreactor are necessary for the development and maintenance of large-scale engineered muscle to ensure circulation within the construct. We aimed to develop a novel experimental model of a large-scale engineered muscle flap from an existing rat groin fat flap.@*METHODS@#A fat flap based on the superficial inferior epigastric vascular pedicle was excised from rats and placed into a perfusion bioreactor. The flaps were kept in the bioreactor for up to 7 weeks, and transdifferentiation of adipose to muscle tissue could have taken place. This system enabled myogenic-differentiation medium flow through the bioreactor at constant pH and oxygen concentration. Assessment of viability was performed by an immunofluorescence assay, histological staining, a calcein-based live/dead test, and through determination of RNA quantity and quality after 1, 3, 5, and 7 weeks.@*RESULTS@#Immunofluorescence staining showed that smooth muscle around vessels was still intact without signs of necrosis or atrophy. The visual assessment of viability by the calcein-based live/dead test revealed viability of the rat adipose tissue preserved in the bioreactor system with permanent perfusion. RNA samples from different experimental conditions were quantified by spectrophotometry, and intact bands of 18S and 28S rRNA were detected by gel electrophoresis, indicating that degradation of RNA was minimal.@*CONCLUSIONS@#Flow perfusion maintains the long-term viability of a rat groin engineered muscle flap in vitro, and a large-scale vascularized muscle could be engineered in a perfusion bioreactor.