Sigmoid perforation by broken nitinol memory frame after inguinal hernia repair.

INTRODUCTION: For an inguinal hernia repair, meshes with a continuous memory frame made it more easy to position the mesh in the preperitoneal space by anterior approach. We present a case of a sigmoid perforation caused by a fractured nitinol ring of a Rebound HRD Shield mesh. PATIENTS AND METHODS: A 29-years old sports instructor presented to the Emergency Department (ED) with a gnawing abdominal pain in the left lower quadrant. His past medical history noted an inguinal hernia repair on this side. A computed tomography scan showed a broken metal ring of the inguinal mesh perforating the sigmoid, so a laparoscopy was performed. The sigmoid was attached to the abdominal wall partially overlying the preperitoneal mesh and a part of the broken nitinol frame was found perforating the colon. RESULTS: The memory ring of the Rebound mesh is made of nitinol. An alloy well-known in vascular surgery for stenting arteries with high bending and compression forces. In this setting, fracture due to fatigue has already been described, but it is not known in abdominal wall reconstruction. Our patients groin was subject to daily bending and compression forces resulting in breakage of the nitinol ring. CONCLUSION: Particularly in young athletic patients the nitinol ring will be subject to bending forces in the groin and prone to breakage. This can have potentially severe consequences given its location near abdominal organs and neurovascular structures. In our opinion, patients should be informed about the possibility of ring breakage and doctors should consider the risk-benefits well.

Laparoscopic appendectomy combined with TEP for de Garengeot hernia: case report.

INTRODUCTION: A de Garengeot hernia is defined as a femoral hernia containing the vermiform appendix. De Garengeot hernia is a rare condition, reported to occur in only 0.8% of all femoral hernias. Acute appendicitis presenting within a femoral hernia is even rarer, occuring in 0.08-0.13% of all cases of acute appendicitis. CASE REPORT: We present the case of a 64-year-old woman with the diagnosis of incarcerated groin hernia. An urgent laparoscopy was performed showing the distal part of the appendix passing through a small right-sided femoral hernia. A laparoscopic appendectomy was performed, followed by TEP-procedure for femoral hernia repair. DISCUSSION: To our knowledge, this is the first report of this type of approach for a de Garengeot hernia.

Risk adjusted benchmarking of clinical anastomotic leakage rate after total mesorectal excision in the context of an improvement project.

AIM: Anastomotic leakage (AL) after total mesorectal excision (TME) is a major adverse event. This study evaluates variability in AL between centres participating on a voluntary basis in PROCARE, a Belgian improvement project, and how further improvement of the AL rate might be achieved. METHOD: Between January 2006 and March 2011, detailed data on 1815 patients (mean age 65.5 years, 63% male) who underwent elective TME with colo-anal reconstruction for rectal cancer were registered by 48 centres. Variability in early clinical AL rate was analysed before and after adjustment for gender, age > 60 years, American Society of Anesthesiologists score of 3 or more and body mass index > 25 kg/m(2). RESULTS: The overall AL rate was 6.7% (95% CI 5.6%-7.9%). Early AL required reoperation in 86.8% of patients. It increased length of hospital stay from 14.7 days to 32.4 days and in-hospital mortality from 1.1% to 4.8%. Statistically significant variability in AL rate between centres was not observed, either before or after risk adjustment. Nonetheless, further improvement may be achievable in some centres by targeting the adjusted performance of better performing centres. These centres used neoadjuvant treatment, rectal irrigation, mobilization of the splenic flexure, resection of the sigmoid colon, side-to-end colo-anastomosis with or without pouch and defunctioning stoma at primary surgery in a significantly higher proportion of patients than less well performing centres. CONCLUSION: The overall AL rate was low but needs to be interpreted with caution because of incomplete registration. Further improvement might be achieved by adopting the approach of better performing centres.

Quality of care indicators in rectal cancer.

Quality of health care is a hot topic, especially with regard to cancer. Although rectal cancer is, in many aspects, a model oncologic entity, there seem to be substantial differences in quality of care between countries, hospitals and physicians. PROCARE, a Belgian multidisciplinary national project to improve outcome in all patients with rectum cancer, identified a set of quality of care indicators covering all aspects of the management of rectal cancer. This set should permit national and international benchmarking, i.e. comparing results from individual hospitals or teams with national and international performances with feedback to participating teams. Such comparison could indicate whether further improvement is possible and/or warranted.