Carotid occlusive disease: primary care of patients with or without symptoms.

Of the half-million strokes that occur each year in the United States, 20 to 30% can be directly linked to carotid occlusive disease. The degree of stenosis involving the carotid bifurcation is an important predictor of stroke risk. Asymptomatic disease may be diagnosed on routine physical exam or screening of the carotid bifurcation in patients with risk factors for ischemic strokes. Symptomatic disease includes transient ischemic attacks, stroke in evolution, and complete stroke. Duplex ultrasound scanning is the standard test for the initial evaluation of carotid artery disease. Patients undergoing surgery should also have magnetic resonance angiography or an angiogram of the carotid vessels. Stroke prevention includes lifestyle modification such as cessation of smoking, strict dietary and medical management of hyperlipidemia, diabetes, and hypertension. Antiplatelet, anticoagulant, and thrombolytic therapy can be used where indicated.

Small bowel obstruction as a complication of laparoscopic extraperitoneal inguinal hernia repair.

Laparoscopic hernia repair is associated with its own set of complications, such as intra-abdominal organ and vascular injury, gas embolism, penumoperitoneum, small bowel obstruction secondary to trocar site fascial defects, intra-abdominal adhesion, and reaction to synthetic mesh. With the extraperitoneal approach, the abdominal cavity is not violated, thereby eliminating the risks for these complications. However, small bowel obstruction, albeit rarely, do occur with this approach because of inadvertent violation of the peritoneal cavity, or failure to close the peritoneal opening of the hernia sac, as shown in this case presentation.