Laparoscopic Repair of Extraperitoneal Ureteral Inguinal Hernia With Mesh Placement.

Ureteral inguinal hernias are a well-described entity, within the spectrum of sliding hernias, with over 140 cases described since 1880. Though herniation of the ureter is relatively rare and complete ureteric obstruction is infrequent, a massive herniation may cause complete obstruction, leading to hydronephrosis. Management of these hernias is challenging and poses a significant danger of inadvertent injury and entrapment of a tortuous ureter. When faced with this type of hernia, extreme care should be taken to perform the appropriate preoperative workup and thoroughly plan the surgical approach. The present case describes a patient with a known ureteral inguinal hernia, who underwent a laparoscopic repair of the hernia with mesh placement.

The Role of Minimally Invasive Surgery in Appendectomy Within a Hernia.

We present three cases where an inflamed incarcerated appendix was in a femoral, inguinal, and an umbilical hernia. All three patients underwent an appendectomy laparoscopically. The hernias in two of the patients (femoral and inguinal) were left unrepaired as the primary goal was to relieve the patients' symptoms and achieve source control. The hernia was repaired primarily in the patient with an umbilical hernia intraoperatively. At three months follow-up, none of the patients had a clinically visible hernia.

Laparoscopic Approach for Gallstone Ileus in Geriatric Patients.

We report two patients who presented with small bowel obstruction secondary to gallstones in the ileum. Both patients were geriatric women with multiple comorbidities. The first patient was a 73-year-old woman who presented with a gallstone eroding and obstructing the duodenum (Bouveret's syndrome) secondary to gallbladder cancer with diffuse metastatic spread to the liver. The stone was disimpacted endoscopically using lithotripsy. The patient presented two days later after the stone had migrated downstream into the small bowel causing obstruction requiring surgical intervention. Second patient was an 81-year-old woman who presented with small bowel obstruction caused by a gallbladder stone impacted in the distal ileum. Both patients were managed laparoscopically with a mini laparotomy to extract the affected segment of bowel loop via small incision on the anterior abdominal wall at the port site with enterolithotomy. Both patients were discharged by postoperative day four with no complications. We conclude that, in elderly patients with multiple comorbidities presenting with gallstone ileus, laparoscopic approach provides early recovery with minimal pain.

Amyand's Hernia: Perforated Appendix in an Incarcerated Inguinal Hernia.

Amyand's hernia is an unusual condition characterized by the presence of a normal or inflamed appendix located within an inguinal hernia. We present a rare situation wherein a 56-year-old male patient presented with an incarcerated inflamed appendix in a right inguinal hernia. He was emergently taken to the operating room, with diagnostic laparoscopy changed to open, due to incarcerated cecum and terminal ileum. The incarcerated segment had to be resected with primary anastomosis. The inflamed and purulent contents were washed out, and the hernia defect was left unrepaired due to the presence of abscess in the inguinal canal.

Asynchronous Bilateral Obturator Hernias: A Suggested Approach to Reduce Morbidity of Obturator Hernias.

Obturator hernias (OHs) are rare pelvic hernias that involve the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator foramen. Risk factors for OH patients include female gender, chronic disease, age, malnourishment, history of multiple pregnancies, anatomical enlargement of obturator foramen, increased intraabdominal pressure, and defective collagen metabolism. Since OHs have the highest mortality rate of all abdominal hernias, prompt diagnosis and treatment are critical. Prior research has demonstrated an increased likelihood of bilateral OHs relative to unilateral. We present the case of a 79-year-old female who presented with an obstructed OH six months after an operation for an OH on the contralateral side. Due to the potential morbidity and mortality associated with OHs and delay in discovery, we suggest evaluation and treatment of the contralateral side in patients who present with unilateral OHs.

A rare case of perianal granular cell tumor: case report and literature review.

Granular cell tumor (GCT) is a rare submucosal neoplasm most commonly localized in the oral mucosa; with one-third of all cases found in the tongue, with less than 30 cases of perianal GCT reported in the literature, making it a rare anal neoplasm. Wide local excision is the gold standard of treatment and follow-up includes annual colonoscopy due to the high incidence of reoccurrence. Here we describe a rare case of benign perianal GCT in a 29-year-old female who presented asymptomatically; however, pathology report revealed a S100 positive immunostaining pattern. GCT is an important differential to be included when evaluating a patient with an asymptomatic perianal submucosal lesion. Since GCT and Squamous Cell Carcinoma present with similar pseudoepitheliomatous hyperplasia of the epithelium it is important that a biopsy and immunohistochemical analysis be performed to allow for accurate diagnosis and appropriate treatment.

Silastic ring vertical gastric bypass: evolution of an open surgical technique, and review of 1,588 cases.

BACKGROUND: Silastic ring vertical gastric bypass (SRVGBP) has evolved from a stapled (SSRVGBP) to a transected (TSRVGBP), and finally to a transected pouch with jejunal interposition (TSRVGBP with J-I). The creation of the gastroenterostomy evolved from a hand-sewn to a stapled and finally to a combined stapled and hand-sewn anastomosis. The circumference of the ring was increased from 5.5 to 6.0 cm. We address the effect of these modifications on surgical outcome. METHOD: The records of 1,588 consecutive patients (mean BMI of 44.5) since 1990 who had a SRVGBP were indentified from a prospective data-base of all patients undergoing bariatric operations. 205 patients with a prior bariatric operation were excluded from the review, leaving 1,383 patients who had a primary SRVGBP. RESULTS: In the 193 SRVGBP patients, there was 1 gastric leak (0.5%) and 64 gastrogastric fistulas (33.2%). In the 165 TSRVGBP patients, there were 4 gastric leaks (2.4%) and 14 gastrogastric fistulas (8.5%). In the 1,025 patients with TSRVGBP with JI, there were 8 gastric leaks (0.8%) and no gastro-gastric fistulas. In the TSRVGBP with J-I, 367 patients had a hand-sewn, 16 a stapled, and 642 a combined stapled and hand-sewn anastomosis. Stricture rate was 3.8%, 31%, and 2.6% respectively. There were 7 ring migrations (0.7%), all in the totally hand-sewn group. Ring removal was necessary in 20 (5%) with a 5.5-cm and 4 (0.74%) with a 6.0-cm ring. CONCLUSION: TSRVGBP with J-I with a combined stapled and hand-sewn gastrojejunal anastomosis using a 6.0-cm ring decreased the incidence of complications, and is our current technique.

Colorectal malignancies in HIV-positive patients.

Due to the development of more effective medications, those infected with HIV are living longer. Consequently, more tumors and infections have been added to the AIDS-defining criteria in the last decade. Our aim was to review the occurrence and clinical course of colorectal (CR) malignancies in HIV infected/AIDS patients from a single institution. A retrospective review of HIV/AIDS patients with colorectal malignant tumors was undertaken. We included adult patients, with ELISA and Western blot test positive for HIV, and primary malignant tumors located in the colon or rectum. Malignant neoplasms of the anus were excluded for the purposes of this study. Twelve patients (9 males and 3 females), mean age 41 years, were identified with the following neoplasm: 6 adenocarcinomas (ACA), 5 non-Hodgkin lymphomas (NHL), and 1 small-cell carcinoma. Intravenous drug abuse was the main risk factor for HIV. No patient had identified risk factors for colorectal neoplasm. Five out of six patients with ACA had metastatic disease at the time of diagnosis. One patient with stage II ACA developed early liver metastases after colonic resection. Seven out of 12 patients underwent surgery. Six (85.7%) of these sustained postoperative complications, primarily wound infection. The overall survival in our series was dismal, averaging 20 months. For NHL average survival was 29 months, and 12 months for CR-ACA. This is the largest series of cases of colorectal cancer in the HIV/AIDS patient population published in the English language and the largest number of colorectal ACA reported in this unique population. Early in our experience, tumors frequently found in immunoincompetent patients were detected (NHL). More recently, we have only treated patients with colorectal ACA; none of them had no risk factors for colorectal cancer (family history, IBD, FAP, HNPCC). These patients developed tumors at earlier ages and were diagnosed at an advanced stage. Therefore, these tumors may be associated with the grade of immunosuppression induced during the course of the HIV infection and with a tumorigenic effect of the HIV on the colonic epithelium. Consequently, a high index of suspicion when evaluating chronic abdominal complaints in such patients is warranted. The use of the new antiretroviral therapy regimens should be further evaluated to know its impact in the survival.

Hepatocarcinoma y embarazo: presentación de un caso / Hepatocellular carcinoma: case of presentation

La asociación entre hepatocarcinoma y embarazo es rara. Presentamos un caso de una paciente de 32 años sin antecedentes de importancia, quien consulta con un embarazo a término en trabajo de parto. Se encuentra una masa en epigastrio e hipocondrio derecho, de consistencia dura y, posteriormente el parto en el que se obtuvo un récien nacido a término en buenas condiciones, signos de sangrado activo. Durante la laparotomía se encuentra un tumor hepático con vaso sangrando activamente. Se comenta la literatura

Apendicitis aguda en hernia inguinal por deslizamiento / Acute appendix in sliding inguinal hernia

Se presenta un caso inusual de hernia inguinal atascada y por deslizamiento, cuyo saco se encontraba formado en su pared posterior por el apéndice cecal con un proceso de apendicitis aguda. El paciente fue intervenido quirúrgiicamente practicándose apendicectomía más herniorrafia inguinal bilateral, evolucionando satisfactoriamente. Se realiza una revisión bibliográfica de tan infrecuente asociación de entidades patológicas

Sarcoma uterinos: a propósito de dos casos y revisión de la literatura / Uterine sarcoma: on purpose of two cases and revision of the literature

Reportamos dos casos de sarcoma uterinos tratados en la práctica privada. El primero, una mujer de 54 años, quien consultó a la emergencia por dolor abdominal, en shock hipolémico por hemorragia interna debido a erosión tumoral de una arteria uterina. Después de practicar histerectomía abdominal subtotal, el estudio anatomopatológico muestra un leiomiosarcoma bien diferenciado del istmo con metástasis al fondo uterino y siembras peritoneales. La paciente se niega a recibir tratamiento coadyuvante, y fallece al año de la operación. El segundo caso, una paciente de 67 años con sangramiento postmenopáusico y tumor uterino por ecosonografía. La biopsia endometrial reporta tumor mixto mesodérmico tipo Mülleriano heterólogo. Se realiza histerectomía total, ooforosalpingectomía y radioterapia postoperatoria, falleciendo pocos meses después de identificarse metástasis y agresiva neoplasia ginecológica