A case of small bowel evisceration through the rectum and anus.

A 46-year-old man presented with a small bowel prolapsing through the anus after straining on the toilet, which was starting to become ischaemic. He admitted to inserting a plastic object in his rectum about half an hour before straining. The bowel was kept moist by placing an intravenous drip line with saline dripping onto a wet swab. In theatre, the bowel was found to be prolapsing through a hole in the upper rectum and out through the anus. It was reduced back into the abdominal cavity through the same perforation, which was 4 cm long, without needing to extend it. This was sutured with polydioxanone (PDS) 2-0 as there was no contamination with faeces or pus. Due to improvement in the appearance of a small bowel and an extremely bruised mesentery, a re-look was planned in 24 hours. At the re-look the small bowel appeared healthy, therefore no resection was performed. However, a loop colostomy was fashioned to protect the upper rectal perforation repair. This shows that resection is not always required in such cases.

Comparison of Omental Patch Closure Versus Simple Closure for Laparoscopic Repair of Perforated Peptic Ulcer: A Systematic Review and Meta-Analysis.

AIMS: To evaluate comparative outcomes of laparoscopic repair of perforated peptic ulcer with omental patch versus without omental patch. METHODS: A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic repair of perforated peptic ulcer (PPU) with and without omental patch were included. Operative time, postoperative complications, re-operation and mortality were the evaluated outcome parameters for the meta-analysis. Revman 5.3 was used for data analysis. RESULTS: Four observational studies reporting a total number of 438 patients who underwent laparoscopic repair of PPU with (n = 268) or without (n = 170) omental patch were included. Operative time was significantly shorter in no-omental patch group (NOP) when compared to omental patch group (P = .02). There was no significant difference in the risk of postoperative ileus (Odd ratio (OR) .76, P = .61), leakage (OR 1.17, P = .80), wound infection (OR 1.89, P = .34), intra-abdominal abscess (OR 1.17, P = .87), re-operation (OR .00, P = .94) and mortality (OR .55, P = .48). Moreover, length of hospital stay was comparable between the two groups (P = .81). CONCLUSION: Laparoscopic repair of PPU with or without omental patch have comparable postoperative complications and mortality rate. However, considering the shorter operative time, no-omental patch approach is an attractive and more favourable choice. Well-designed randomized controlled trials are needed to investigate this comparison.

A Spontaneous Groin Collection Masquerading as an Irreducible Inguinoscrotal Hernia.

This case report details a clinically rare presentation in which a middle-aged man was diagnosed clinically with a large irreducible inguinoscrotal hernia. However, intraoperatively, a large volume of old blood/clots was seen and aspirated, without a definite hernia being identified. Inguinal hernias remain a clinical diagnosis, and imaging is used only in equivocal cases. Owing to the number of differential diagnoses associated with groin swelling, careful clinical assessment is critical in differentiating between the various causes. Rupture of the inferior epigastric vessels was suspected, and although rare, it should be considered as a differential diagnosis as this may alter ongoing management.

Meta-Analysis of Spinal Anesthesia Versus General Anesthesia During Laparoscopic Total Extraperitoneal Repair of Inguinal Hernia.

OBJECTIVES: To evaluate comparative outcomes of spinal anesthesia (SA) and general anesthesia (GA) during laparoscopic total extraperitoneal (TEP) repair of inguinal hernia. METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Postoperative pain assessed by visual analogue scale (VAS), individual and overall perioperative morbidity, procedure time and time taken to normal activities, were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models. RESULTS: We identified 5 comparative studies reporting a total of 1518 patients (2134 hernia) evaluating outcomes of laparoscopic TEP inguinal hernia repair under SA (n=1277 patients, 1877 hernia) or GA (n=241 patients, 257 hernia). SA was associated with significantly lower post-operative pain assessed by VAS at 12 hours [mean difference (MD): -0.32; 95% confidence interval (CI), -0.45 to -0.20; P<0.0001] and shorter time to normal activities (MD: -0.30; 95% CI, -0.48 to -0.11; P=0.002) compared with GA. However, it significantly increased risk of urinary retention [odds ratio (OR): 4.02; 95% CI, 1.32-12.24; P=0.01], hypotension (OR: 3.97; 95% CI, 1.57-10.39; P=0.004), headache (OR: 7.65; 95% CI, 1.98-29.48, P=0.003), and procedure time (MD: 3.82; 95% CI, 1.22-6.42; P=0.004). There was no significant difference in VAS at 24 hours (MD: 0.06; 95% CI, -0.06 to 0.17; P=0.34), seroma (OR: 1.54; 95% CI, 0.73-3.26; P=0.26), wound infection (OR: 1.03; 95% CI, 0.45-2.37; P=0.94), and vomiting (OR: 0.84; 95% CI, 0.39-1.83; P=0.66) between the 2 groups. There was a nonsignificant decrease in overall morbidity in favor of GA (OR: 1.84; 95% CI, 0.77-4.40; P=0.17) which became significant following sensitivity analysis (OR: 2.59; 95% CI, 1.23-5.49; P=0.01). CONCLUSIONS: Although TEP inguinal hernia repair under SA may reduce pain in early postoperative period, it seems to be associated with increased postoperative morbidity and longer procedure time. It may be an appropriate anesthetic modality in selected patients who are considered high risk for GA. Higher level of evidence is needed.

Meta-analysis of laparoscopic groin hernia repair with or without mesh fixation.

OBJECTIVES: To evaluate comparative outcomes of laparoscopic repair of groin hernia with and without mesh fixation. METHODS: MEDLINE; EMBASE; CINAHL; CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists were systematically checked. Combination of free text and controlled vocabulary search adapted were applied to thesaurus headings, search operators and limits in each of the above databases. Post-operative pain, procedure time, conversion rate, length of hospital stay, time taken to normal activities, overall complications, seroma formation, cost and recurrence were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models. The work has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. This protocol was registered at the International Prospective Register of Systematic Reviews (registration number: CRD42019139564). RESULTS: We identified 13 randomized controlled trials reporting a total of 1731 patients (2021 groin hernia) evaluating outcomes of laparoscopic hernia repair with mesh fixation using stapler or tacker (n = 853 patients, 999 hernia) and without mesh fixation (n = 878 patients, 1022 hernia). Mesh Fixation was associated with significantly higher post-operative pain assessed by visual analogue scale (VAS) (MD: 0.59; 95% CI, 0.05-1.13, P = 0.03) and longer procedure time (MD: 2.00; 95% CI, 0.98-3.02, P = 0.0001), compared to no fixation technique. However, there was no significant difference in length of hospital stay (MD:0.09; 95% CI, -0.05-0.23, P = 0.19), time to normal activities, (MD: 0.12; 95% CI, -0.37-0.61, P = 0.69), overall complications (OR: 1.05; 95% CI, 0.77-1.43, P = 0.76), seroma formation (OR: 0.63; 95% CI, 0.39-1.00, P = 0.05) and recurrence rate (RD: 0.00; 95% CI, -0.01-0.01, P = 0.84) between two groups. CONCLUSIONS: Avoiding mesh fixation with a stapler or tacker during laparoscopic groin hernia repair may reduce postoperative pain and procedure time. Future studies are encouraged to evaluate cost effectiveness of each approach.