Occult contralateral inguinal hernias: what is their true incidence and should they be repaired?

BACKGROUND: The true incidence of occult contralateral inguinal hernia is unknown; however, when found, there exists controversy as to whether or not they should be repaired. The aim of our study is to identify the incidence of contralateral incidental inguinal hernias in our surgical population, compare our results to previous studies timelining occult hernia identification to repair need, and generate debate as to whether incidental contralateral hernias should be repaired at the index operation. METHODS: We reviewed the charts of 297 consecutive patients undergoing robotic inguinal hernia repair between October 2014 and April 2018 at a single facility. By comparing preoperative physical examination to intraoperative findings, we determined the number of occult contralateral inguinal hernias in our patient population. RESULTS: Of 297 patients, 158 (53.2%) presented with a right inguinal hernia, 90 (30.3%) presented with a left inguinal hernia, and 49 (16.5%) presented with bilateral inguinal hernias. Forty-seven of the 297 patients (15.8%) were found to have an incidental contralateral inguinal hernia. Excluding patients with known bilateral inguinal hernias, 20% of patients with a left inguinal hernia were found to have an occult right inguinal hernia and 18.4% of patients with a right inguinal hernia were found to have an occult left inguinal hernia. CONCLUSIONS: The true incidence of occult contralateral inguinal hernia may be higher than originally thought. When inguinal hernia repair is performed through a transabdominal approach, these occult hernias may be easily addressed during the same operation without additional skin incisions. This may ultimately prevent the morbidity of developing a metachronous hernia that requires repair.

Symptomatic right-sided diaphragmatic hernia in the third trimester of pregnancy.

BACKGROUND: Laparoscopic repair of incarcerated diaphragmatic hernias is widely recognized as both safe and effective. However, symptomatic diaphragmatic hernias encountered in the setting of pregnancy, while rare, present a significant surgical challenge. Furthermore, right-sided diaphragmatic hernias account for only 13% of cases. Here, we present a case in which a symptomatic, posterior right-sided diaphragmatic hernia, presenting in the later stages of pregnancy, was successfully repaired using a laparoscopic approach. METHODS: Our patient is a 42-y-old gravid woman who, at 27 wk gestation, was admitted to the gynecology service with a 2-d history of right upper quadrant abdominal pain, right shoulder pain, abdominal distension, and obstipation. RESULTS: Computed tomography of the chest demonstrated an incarcerated right diaphragmatic hernia. Surgical consultation was obtained, and the patient was taken to the operating room urgently for repair. Intraoperatively, the cecum was reduced and the diaphragm repaired primarily using a laparoscopic approach. The patient recovered well and was discharged home on postoperative day 8 with no complications to the patient or the pregnancy. CONCLUSION: Laparoscopic reduction and repair of symptomatic incarcerated diaphragmatic hernia can be safely performed in the third trimester of pregnancy.

Patient-reported outcomes after single-incision versus traditional laparoscopic cholecystectomy: a randomized prospective trial.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) is a newer approach that may be a safe alternative to traditional laparoscopic cholecystectomy (TLC) based on retrospective and small prospective studies. As the demand for single-incision surgery may be driven by patient perceptions of benefits, we designed a prospective randomized study using patient-reported outcomes as our end points. METHODS: Patients deemed candidates for either SILC or TLC were offered enrollment in the study. After induction of anesthesia, patients were randomized to SILC or TLC. Preoperative characteristics and operative data were recorded, including length of stay (LOS). Pain scores in recovery and for 48 h and satisfaction with wound appearance at 2 and 4 weeks were reported by patients. We used the gastrointestinal quality of life index (GIQLI) survey preoperatively and at 2 and 4 weeks postoperatively to assess recovery. Procedural and total hospital costs per case were abstracted from hospital billing systems. RESULTS: Mean age of the study group was 44.1 years (±14.8), 87% were Caucasian, and 77% were female, with no difference between groups. Operative times were longer for SILC (median = 57 vs. 47 min, p = 0.008), but mean LOS was similar (6.8 ± 4.2 h SILC vs. 6.2 ± 4.8 h TLC, p = 0.59). Operating room cost and encounter cost were similar. GIQLI scores were not significantly different preoperatively or at 2 or 4 weeks postoperatively. Patients reported higher satisfaction with wound appearance at 2 weeks with SILC. There were no differences in pain scores in recovery or in the first 48 h, although SILC patients required significantly more narcotic in recovery (19 mg morphine equivalent vs. 11.5, p = 0.03). CONCLUSIONS: SILC is a longer operation but can be done at the same cost as TLC. Recovery and pain scores are not significantly different. There may be an improvement in patient satisfaction with wound appearance. Both procedures are valid approaches to cholecystectomy.

Patient perception of single-incision laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Single-incision laparoscopic cholecystectomy (SILC) is gradually being adopted into general surgical practice. The potential risks and benefits are still being studied, and little is known about how patients perceive this new surgical technique. METHODS: After providing patients with basic educational materials on laparoscopic cholecystectomy (LC) and SILC, we administered a questionnaire exploring patients' perspectives of the importance of postoperative pain, scar appearance, risk of complications, and cost regarding their preference for SILC versus LC. RESULTS: Among 100 patients (mean age, 43.3 years), the majority were women (85%), white (85%), college educated (77%), and privately insured (85%). Indications included biliary dyskinesia (43%), biliary colic (48%), and acute cholecystitis (9%). Patients stated that they would be somewhat or very interested in SILC if recommended by their surgeon (89%), although 35% were somewhat or very concerned about the lack of long-term results. The majority would accept no additional risk to undergo SILC. Scar appearance was somewhat or very important to <40% of patients, whereas pain was somewhat or very important to 79%. Only 27% of patients would spend >$100 to undergo SILC. When asked to rank pain, appearance, symptom resolution, personal cost, and risk of complications, 52% ranked symptom resolution, 20% ranked pain, and 19% ranked risk of complications as most important. CONCLUSIONS: Safety and relief of symptoms are most important to patients with gallbladder disease, whereas postprocedural esthetics was relatively unimportant and few would be willing to pay more for SILC versus LC. However, if the surgeon recommends SILC, most patients would trust this recommendation.

Single-incision laparoscopic cholecystectomy: a comparison with the gold standard.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) may be a comparable alternative to conventional multiport laparoscopic cholecystectomy (LC). This study compared procedural outcomes and costs between SILC and LC. METHODS: A retrospective review of patients undergoing SILC over an 8-month period was performed. A cohort of LC patients from the same surgeons over the preceding 8 months was used as historic controls. Demographics, comorbidities, diagnosis, operative data, pain control in the recovery room, complications, length of hospital stay, and cost were compared between the two groups. RESULTS: Of the 285 patients, 177 underwent LC and 108 underwent SILC. The mean age was 49.7 years for the LC patients and 48.2 years for the SILC patients (p = 0.44). Two of the LC patients underwent conversion to open surgery. None of SILC patients were converted to open procedure, although nine had additional ports placed. After multivariate adjustment, SILC was associated with a 15% longer operative time (p = 0.053) and a 66% shorter hospital stay (p = 006) than LC. Biliary dyskinesia and biliary colic were independently associated with shorter operative times and a reduced hospital stay. No significant differences were noted in pain score, narcotics used in the postanesthesia care unit (PACU), 30-day complication rates (1.7 vs 1.9%; p = 1), hospital charges, or cost between the two groups. CONCLUSIONS: Single-incision LC is safe, significantly reduces the hospital stay, and is an acceptable alternative to traditional LC. Although further study is warranted, initial results indicate that SILC may offer the most benefit for outpatient procedures.

Is trauma centre care helpful for less severely injured patients?

BACKGROUND: Trauma centres have been shown to reduce the number of preventable deaths from serious injuries. This is due largely to the rapid response of surgeons and health care teams to resuscitate, evaluate, and operate if necessary. Less is known about the effectiveness of trauma centre care on those patients who have not incurred immediate life-threatening problems and may not be as critically injured. The purpose of this study was to review the use of physician and hospital resources for this patient population to determine whether trauma team and trauma centre care is helpful or even needed. METHODS: This was a retrospective study of consecutive trauma patients (n=1592) admitted from 1998 to 2002 to the trauma service of an urban level I trauma centre and recorded in the hospital trauma registry. Patients were triaged in a tiered response to more or less severely injured. All patients' care was directed by trauma surgeons. RESULTS: Of the 1592 patients, 398 (25%) received a full trauma team response (Class I), 1194 were less seriously injured (Class II). The ISS for the Class I patients was 19+/-18 and for Class II patients 10+/-10. Nineteen percent of Class II patients had an ISS>15. Overall mortality in Class II patients was 2% including 20 unexpected deaths. Four hundred and three Class II patients (34%) had multisystem injuries. Of the Class II patients 423 (35%) were sent to the ICU or OR from the ED, 106 of whom required an immediate operation and 345 required an operation prior to discharge. Complications developed in 129 patients (11%), the majority of which were pulmonary. CONCLUSIONS: A large proportion of those patients thought initially to be less severely injured required resources available in a trauma centre, including specialty care, intensive care, and operating room accessibility. Over one-third of these patients had multisystem injuries and almost 20% were considered major trauma, needing prioritisation of care and expertise ideally found in a trauma centre environment. Complications developed in a sizable number of patients. This patient population, because of its heterogeneity and propensity for critical illness, deserves the resources of a trauma centre.

Partial hepatectomy with or without endotoxin does not promote apoptosis in the rat liver.

BACKGROUND: Liver insufficiency and failure has been described following subtotal hepatectomy. The cause is poorly understood but may be because of attrition of hepatocytes through enhanced cell death pathways such as apoptosis. The trigger for this could be reduction beyond a critical mass of liver tissue or the influence of endotoxin (LPS) on cytokine activation. The experiment was designed to answer these questions. MATERIALS AND METHODS: Rats were subjected to either 30% or 70% hepatectomy. Sacrifice occurred on either postoperative day 2 or 4. At sacrifice remnant livers were examined for apoptosis through the direct Tunel immunoperoxidase method (apoptotic index) and soluble histone ELISA. A second group of rats underwent 30% or 70% hepatectomy and were given either saline or endotoxin (LPS). Sacrifice occurred on postoperative day 1, 2, or 4. Liver samples were analyzed for apoptosis by Tunel immunoperoxidase, histone-associated DNA, TNF-alpha, and caspase-3. Mitotic activity and evidence of hepatocellular necrosis were also determined. RESULTS: By comparison to prehepatectomy values, rats subjected to hepatectomy alone failed to disclose any effect of resection on apoptotic activity. By comparison to sham operated controls there was a modest but significant increase in apoptotic activity at day 4 in the 30% and 70% hepatectomized rates by apoptotic index but not the soluble histone ELISA. Injection of LPS without hepatectomy produced an increase in apoptotic activity by apoptotic index and soluble histone ELISA methods on day 1 and 2. The addition of 30% or 70% hepatectomy produced a sporadic, but not sustained, increase in apoptotic activity which may have been because of LPS injection alone. Tissue TNF-alpha levels increased with LPS but changed little with addition of hepatectomy. Mitotic activity remained essentially unchanged with or without LPS injection. No evidence of hepatocellular necrosis was detected with LPS and extended hepatectomy. CONCLUSIONS: Apoptosis does not appear to be a prominent feature in the posthepatectomy liver, with or without addition of LPS. Even with accelerated TNF-alpha production from LPS, the mitotic pathways continue to take precedent. Apoptosis, except for occasional sporadic bursts, is effectively suppressed. It is not likely that apoptosis contributes to depletion of functional hepatocytes and liver insufficiency.

Trauma in the elderly.

As technology and medical care improve, older patients will be more active and productive at later ages. Falls and motor vehicle crashes will remain major mechanisms of injury in the elderly. Treatment of the elderly trauma patient must focus on their complex acute medical needs, their rehabilitation and social needs post trauma, and most of all prevention.