Endoscopic retroperitoneal repair of superior lumbar hernia (Grynfeltt hernia) using self-fixating mesh to prevent nerve injury: a case report.

BACKGROUND: The primary superior lumbar hernia, also called the Grynfeltt Hernia, is a rare entity; hence, a standard surgical repair method has not been established. It is important for this repair procedure not only to prevent recurrence by placing an adequate size of mesh but also to avoid nerve injury. The endoscopic retroperitoneal approach is considered a useful technique for this procedure, requiring no mobilization of the colon and providing good visibility of the surrounding nerves. A self-fixating mesh does not require a traumatic fixation, which is considered advantageous for nerve preservation. CASE PRESENTATION: A 72-year-old woman, complaining of left lumbar swelling, was diagnosed with a primary left superior lumbar hernia and underwent endoscopic retroperitoneal hernia repair. With the patient in the right lateral decubitus position, five small ports were inserted, and the retroperitoneal space was dissected. The 2.0 × 1.0-cm hernial orifice was found, and the 12th subcostal nerve above the hernial orifice and the iliohypogastric and the ilioinguinal nerves below the hernial orifice were identified. A 15 × 10-cm self-fixating mesh was placed in the retroperitoneal space without mesh tacking. The postoperative course was uneventful, and the patient was discharged on the first postoperative day. Two years after surgery, there was no sign of recurrence, and chronic pain and neuropathic symptoms were absent. CONCLUSIONS: Endoscopic retroperitoneal repair of primary superior lumbar hernia using a self-fixating mesh seems to be useful for nerve preservation.

Surgeons' involvement in COVID-19 treatment: a practice by a regional core hospital in Japan to avoid physician burnout.

BACKGROUND: To prevent task accumulation on certain divisions, our institution developed a unique system of allocating inpatient treatment of COVID-19 patients to doctors who were not specialized in respiratory infections. The objective of this study was to investigate whether surgeons can be involved in the COVID-19 inpatient treatment without negatively affecting patient outcome, and how such involvement can affect the wellbeing of surgeons. METHODS: There were 300 patients diagnosed with COVID-19 and hospitalized from January to June 2021, and 160 of them were treated by the redeployed doctors. They were divided into 3 groups based on the affiliation of the treating doctor. Patient characteristics and outcomes were compared between the groups. In addition, the impact of COVID-19 duty on participating surgeons was investigated from multiple perspectives, and a postduty survey was conducted. RESULTS: There were 43 patients assigned to the Department of Surgery. There were no differences in the backgrounds and outcomes of patients compared with other groups. The surgeon's overtime hours were significantly longer during the duty period, despite no change in the number of operations and the complication rate. The questionnaire revealed that there was a certain amount of mental and physical burden from the COVID-19 duty. CONCLUSION: Surgeons can take part in inpatient COVID-19 treatment without affecting patient outcome. However, as such duty could negatively affect the surgeons' physical and mental wellbeing, further effort is needed to maintain the balance of fulfilling individual and institutional needs.

Is Palliative Gastrojejunostomy for Malignant Gastric Outlet Obstruction an Optimal Choice for Very Elderly Patients? A Report from a Long-Lived Country.

BACKGROUND: Gastrojejunostomy (GJ) is a surgical option for malignant gastric outlet obstruction (mGOO). Confronting an aging society, the demand to treat elderly cancer patients with unresectable malignancies is increasing; however, the benefit of GJ to the very elderly (≥ 80 years of age) has never been investigated. METHODS: This multicenter, retrospective review included 108 patients who had undergone GJ for mGOO from two medical centers in Japan, one of the most long-lived countries. Patients were divided into two groups, with 80 years of age as the cut-off. Various factors, including surgical complications and patient survival, were compared. RESULTS: GJ in the very elderly (aged ≥ 80 years) was associated with a higher incidence of surgical complications (p = 0.049), such as delayed gastric emptying (DGE; p < 0.001), aspiration pneumonia (p = 0.029), and consequent mortality (p = 0.016). Age ≥80 years was also identified as an independent predictor of DGE (odds ratio 6.444, p = 0.005) and survival after GJ (hazard ratio 7.767, p = 0.016). In particular, the median survival time after GJ in the population aged ≥80 years with gastric cancer was only < 2 months. About the surgical procedure, antiperistaltic anastomosis with partial stomach partitioning (PSP) yielded the lowest occurrence rate of DGE (3.4%) and aspiration pneumonia (1.7%). CONCLUSIONS: GJ does not seem to be the optimal choice for very elderly patients, particularly those with gastric cancer. If performed, antiperistaltic anastomosis with PSP should be employed to reduce the surgical complications.

Intracorporeal reinforcing sutures reduce anastomotic leakage in double-stapling anastomosis for laparoscopic rectal surgery.

Introduction: In rectal surgery, double-stapled anastomosis is one of the most common techniques. However, the crossing of the staple line is considered a weakness of this method and could lead to anastomotic leakage (AL), which is one of the major complications of rectal cancer surgery. Aim: To investigate the usefulness of laparoscopic intracorporeal reinforcement suturing for preventing AL in laparoscopic rectal surgery. Material and methods: A total of 153 patients with rectal cancer underwent laparoscopic rectal resection with anastomosis using the double-stapling technique between January 2015 and December 2018. Patient characteristics, surgical data, and outcomes were recorded and retrospectively analysed. Patients who received intracorporeal reinforcing sutures (n = 72) were compared with those who did not receive the reinforcing sutures (n = 81). Results: AL was observed in 11 (7.2%) cases overall and in only 1 case in the group with intracorporeal reinforcing sutures. There were no associations between clinicopathological factors and the use of reinforcing sutures. Multivariate analysis revealed that a distance from the anal verge of less than 6.5 cm, diabetes mellitus, and the non-use of reinforcing sutures were independent risk factors for AL. Conclusions: Laparoscopic intracorporeal reinforcing sutures reduced the incidence of AL. Therefore, laparoscopic reinforcing sutures for double-stapled anastomoses seem useful for the prevention of AL.

Enhanced-view totally extraperitoneal repair in a patient with incisional hernia after robot-assisted laparoscopic radical prostatectomy: a case report.

BACKGROUND: Although laparoscopic incisional hernia repair, especially laparoscopic intraperitoneal onlay mesh, is a widely used technique, it can cause serious complications, including mesh erosion, adhesive bowel obstruction, and chronic pain. The enhanced-view totally extraperitoneal (eTEP) technique has been reported to prevent such complications by placing the mesh in the retrorectus space. Here, we report the case of a patient with post-robot-assisted laparoscopic radical prostatectomy (RARP) incisional hernia repaired using the eTEP technique. CASE PRESENTATION: A 67-year-old man, who underwent RARP for prostate cancer 4 years ago developed an incisional hernia. Abdominal computed tomography showed the presence of an epigastric incisional hernia measuring 4 cm long and 3.7 cm wide. We performed an eTEP repair. We closed the hernia defect using a 0 barbed suture and placed a self-gripping mesh measuring 20 cm long and 15 cm wide in the developed retrorectus space with no fixation. There were no postoperative complications, and the patient was discharged on postoperative day 2. CONCLUSIONS: eTEP repair is considered an extremely effective surgical treatment option for incisional hernias because of its few resulting postoperative mesh-and-tacker-related complications.

Laparoscopic Surgery for Colorectal Cancer in Super-Elderly Patients: A Single-Center Analysis.

BACKGROUND: Super-elderly patients with colorectal cancer are being encountered with increasing frequency in Japan. Laparoscopic surgery is considered a less invasive surgery in these patients; however, it is difficult to conduct controlled clinical trials in this super-elderly population. This study assessed the feasibility and safety of laparoscopic colorectal surgery in patients over 85 years old. MATERIALS AND METHODS: Open and laparoscopic surgeries for colorectal cancer in super-elderly patients (aged 85 y and older) were performed under general anesthesia in a single medical center. Records were retrospectively reviewed, and the clinicopathologic features of each patient and the surgical time and outcomes were recorded and analyzed. RESULTS: Records of colorectal surgery were reviewed for 108 super-elderly patients. Twenty-six open surgeries and 82 laparoscopic surgeries were performed. The mean operation times were 215 and 228 minutes in open and laparoscopic surgeries, respectively. Intraoperative bleeding in laparoscopic surgery was lesser than that in open surgery. There were 2 cases with major postoperative complications in open surgery, and mortality occurred in one case within 1 month after surgery. No major complications were observed in laparoscopic surgery. In survival analysis, disease-free survival did not differ between the 2 groups. The oldest patient was a man aged 102 years and 6 months who underwent laparoscopic anterior resection with lymph node dissection. CONCLUSION: Laparoscopic surgery in super-elderly patients with colon cancer is feasible and safe. The authors report the success of laparoscopic colectomy for rectosigmoid colon cancer in the oldest known patient and the positive outcomes of laparoscopic colectomy in super-elderly patients.

Diaphragm disease associated with nonsteroidal anti-inflammatory drugs mimicking intestinal tumor: A case report.

INTRODUCTION: Diaphragm disease is rare and caused by intestinal obstruction due to nonsteroidal anti-inflammatory drugs (NSAIDs). Given the availability of video capsule endoscopy (VCE) and balloon enteroscopy (BE) this disease will be diagnosed more often. PRESENTATION OF CASE: A 73-year-old man was presented to our hospital for persistent nausea and vomiting. Abdominal ultrasound and computed tomography revealed small-bowel thickening, stricture in the terminal ileum, and dilation of the proximal small intestine. Differential diagnosis included ileal lymphoma and multiple ileal adenocarcinomas, and a diagnostic laparoscopy was performed. Twenty-centimeter of ileum was resected by primary ileo-ileal anastomosis. On pathological examination, fibrosis of the submucosa was identified, and erosions and numerous inflammatory cells reaching the submucosa were also identified from the specimen. DISCUSSION: The preoperative diagnosis of diaphragm disease is sometimes challenging due to its uncharacteristic symptoms; moreover, radiological findings are usually indefinite and distinctive. Currently, the main treatment for diaphragm disease is surgery. CONCLUSION: We have documented a case of intestinal obstruction by NSAIDs. However, it is desirable to determine the course of treatment based on small bowel endoscopic dilatation cases in the future.

Internal hernia of the stomach associated with colostomy after laparoscopic surgery for rectal cancer: a case report.

BACKGROUND: Colostomy via the intraperitoneal route is often performed during laparoscopic Hartmann's operation or abdominoperineal resection. Internal hernia of the small intestine often occurs after colostomy. This report shows a rare case of internal hernia of the stomach associated with sigmoid colostomy after laparoscopic abdominoperineal resection for rectal cancer. CASE PRESENTATION: The patient was a 79-year-old woman with a sigmoid colostomy. Computed tomography scan showed a markedly distended stomach in the space between the lifted sigmoid colon and the lateral abdominal wall. Laparoscopy revealed that the body of the stomach had passed through a hernia orifice located between the lifted sigmoid colon and the left lateral abdominal wall. The dislocated stomach was restored to its normal position, and the lateral defect was closed with the lateral peritoneum and the lifted sigmoid colon laparoscopically. CONCLUSIONS: Internal hernia associated with colostomy can lead to not only obstruction of the small intestine, but also obstruction of the stomach. We reported a successful case of the suture repair for the internal hernia of the stomach associated with colostomy.

Transperineal abdominoperineal resection for anorectal melanoma: A case report.

INTRODUCTION: Anorectal melanoma is a rare type of cancer characterized by frequent metastasis. We report our experience with a case of anorectal melanoma resected via transperineal abdominoperineal resection and total mesorectal excision. PRESENTATION OF CASE: A 77-year-old woman visited our hospital with the complaint of melena. Colonoscopic examination revealed a black type 1 tumor measuring 5 mm in size on the dentate line of the anal canal circumference. Tumor biopsy revealed malignant melanoma, and positron emission tomography-computed tomography showed tracer accumulation within the mass but not at other sites. We performed a two-stage abdominoperineal resection surgery with lymphadenectomy via transperineal abdominoperineal resection, and pathological diagnosis indicated submucosal tumor depth. The patient was diagnosed with T2 N0 M0 stage I malignant melanoma and was followed on an outpatient basis. A 24-month follow-up computed tomography revealed multiple liver metastases. DISCUSSION: Anorectal melanoma is associated with a very poor prognosis because of its association with early lymph node metastasis and distant metastasis. The tumor may spread beyond the main lesion and involve the surrounding mucosa and draining lymph nodes. Transperineal abdominoperineal resection is a minimally invasive procedure that can be used to achieve curative tumor resection with lymphadenectomy. CONCLUSION: Transperineal abdominoperineal resection appears to be a feasible approach for the treatment of anorectal melanoma.