Management of Massive Flank Hernia After Lateral Lumbar Fusion: Preoperative Botulinum Toxin Injections and Open Repair - A Case Report.

BACKGROUND Incisional flank hernias represent a complication after lateral lumbar spine surgery. Given the increasing rate of lateral lumbar interbody fusions, the rate of incisional flank hernias will increase. Since there are no reports of open massive flank hernia repair utilizing preoperative botulinum injections, we sought to publish this technique to provide surgeons with an innovative method for preoperatively treating patients with massive flank hernias. CASE REPORT A 75-year-old man with a history of coronary artery disease, chronic kidney disease, and abdominal hernia repair presented for evaluation of left lateral abdominal and left lower back bulging for 5 months. The symptoms began after an L2-L4 lateral lumbar spinal fusion. Physical examination revealed a left posterior lateral flank bulge. Computed tomography (CT) showed a fat-containing left posterolateral abdominal hernia. The patient was scheduled for CT-guided lateral abdominal wall botulinum injections, followed by open flank hernia repair. He tolerated the surgery well, was admitted for pain control, and discharged on day 2. Repeat imaging with CT at 3 months showed no evidence of patient's prior hernia defect. CONCLUSIONS Open flank hernia repair, in conjunction with preoperative botulinum toxin injections, allows for optimal visualization and re-approximation of the myofascial components of flank hernia defects. Failure to achieve adequate myofascial and skin closure, along with mesh reinforcement, in open flank hernia repair can result in various surgical site complications, including incisional flank hernia recurrence. We recommend further investigation on the benefits of botulinum injections as an adjunct in management of massive flank hernias.

Closure of a Gastropleural Fistula Using Advanced Endoscopy.

Gastropleural fistulas are rare complications with significant mortality and morbidity. There are limited reports on the successful management of gastropleural fistulas with advanced endoscopic procedures. The following case of a 75-year-old woman with a history of recurrent pseudomyxoma peritonei secondary to ruptured low-grade appendiceal mucinous neoplasm status post cytoreductive surgery highlights the successful treatment of a gastropleural fistula with endoscopic suturing.

Low Threshold for Laparoscopic Exploration in Dementia Patients With Unexplained Abdominal Pain and Risk Factors for Acute Mesenteric Ischemia.

Acute mesenteric ischemia (AMI) is associated with a high mortality and morbidity. There are limited studies on the presentation and management of elderly dementia patients with AMI. The following case of an 88-year-old female with dementia presenting with AMI highlights the challenges in the care of elderly dementia patients with AMI, the importance of identifying risk factors and hallmarks of acute mesenteric ischemia early in the clinical course, and suggests that aggressive workup with diagnostic laparoscopy is crucial to timely diagnosis and effective care.