Giant epiphrenic diverticulum: a challenging case / Divertículo epifrénico gigante: un caso desafiante

A diverticulum is a limited saccular protrusion of the esophageal wall, communicating with its lumen. Anatomically, esophageal diverticula are classified into pharyngoesophageal, median, and epiphrenic. Treatment of esophageal diverticula is based on several basic pathophysiological principles. Small and asymptomatic diverticula do not require specific treatment. Large and symptomatic diverticula require surgical intervention, consisting of diverticulectomy combined with myotomy. Operations for symptomatic epiphrenic diverticula make up no more than 2% of all operations on the esophagus. We describe a case of an epiphrenic diverticulum with the dimensions 88x60x90 mm in a 54-year-old patient. Surgical treatment of this disease was performed according to the Lewis method. The article also describes methods of dealing with concomitant postoperative complications and a brief review of the literature on epiphrenic diverticula (AU)

Un divertículo es una protuberancia sacular limitada de la pared esofágica, que se comunica con su luz. Anatómicamente, los divertículos esofágicos se clasifican en faringoesofágicos, medianos y epifrénicos. El tratamiento de los divertículos esofágicos se basa en varios principios fisiopatológicos básicos. Los divertículos pequeños y asintomáticos no requieren tratamiento específico. Los divertículos grandes y sintomáticos requieren intervención quirúrgica, que consiste en diverticulectomía combinada con miotomía. Las operaciones por divertículos epifrénicos sintomáticos representan no más del 2% de todas las operaciones en el esófago. Describimos un caso de divertículo epifrénico de dimensiones 88x60x90 mm en un paciente de 54 años. El tratamiento quirúrgico de esta enfermedad se realizó según el método de Lewis. El artículo también describe métodos para tratar las complicaciones posoperatorias concomitantes y una breve revisión de la literatura sobre divertículos epifrénicos (AU)

Análisis comparativo de 2 técnicas quirúrgicas en el tratamiento de la hernia incisional subxifoidea. Estudio observacional / Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study

Introducción: La hernia incisional subxifoidea presenta complejidad en su solución quirúrgica por las características de la región anatómica donde aparece. El objetivo de nuestro estudio fue el análisis de los resultados obtenidos con las diferentes técnicas realizadas en nuestro centro durante 9 años, incidiendo en las complicaciones postoperatorias y la tasa de recidiva. Métodos: Estudio observacional, retrospectivo desde enero de 2011 hasta enero de 2019 de los pacientes intervenidos de hernia incisional subxifoidea en nuestra Unidad. Se analizaron las comorbilidades, técnicas quirúrgicas empleadas (eventroplastia preperitoneal o TP, y técnica de doble malla ajustada) y variables postoperatorias, incidiendo en la recidiva herniaria. Las complicaciones se recogieron según la clasificación de Clavien-Dindo. Resultados: Se intervinieron un total de 42 pacientes: 22 (52,4%) mediante una TP, y 20 (47,6%) mediante técnica de doble malla ajustada. Todas las complicaciones registradas fueron leves (grado i) y aparecieron mayoritariamente en el grupo de la TP (p=0,053). El seguimiento medio postoperatorio fue 25,8±15,1 meses; no existieron diferencias estadísticamente significativas en cuanto a recidiva comparando los 2 grupos de tratamiento (p=0,288). Conclusiones: Según nuestros resultados, la TP fue la técnica ideal para reparar una hernia incisional subxifoidea. La técnica de doble malla ajustada puede representar un abordaje eficaz con un bajo índice de complicaciones, aunque analizando globalmente la tasa de recidiva, el cierre fascial por encima de la prótesis preperitoneal conlleva un menor impacto en la misma. (AU)

Introduction: The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate. Methods: It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification. Results: 42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P=.053). The average follow up was 25.8±15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P=.288). Conclusions: According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it. (AU)

Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study.

INTRODUCTION: The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate. METHODS: It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification. RESULTS: 42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P = .053). The average follow up was 25.8 ± 15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P = .288). CONCLUSIONS: According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it.

Eventroplastia abdominal con técnica de Rives-Stoppa: reconstruyendo un abdomen / Abdominal hernia repair using the Rives-Stoppa technique: an abdominal reconstruction

Introducción: La eventroplastia con malla retromuscular de Rives-Stoppa ha demostrado en adultos tener los mejores resultados en lareparación de las grandes eventraciones de la línea media. Presentamosel primer caso pediátrico tratado exitosamente con esta técnica. Caso clínico: Varón de 9 años con eventración tras laparotomíamedia urgente. Los principios básicos de la corrección fueron: aperturadel saco herniario y adhesiolisis, incisión longitudinal sobre la vainaposterior del músculo recto y tallado del espacio retromuscular, cierrede la vaina posterior, colocación de una malla sobre este plano aloján-dola en el espacio retromuscular creado y cierre sin tensión del colgajomusculo-aponeurótico anterior, reconstruyendo así la línea media. Norecidiva tras 2 años de seguimiento. Comentarios: La técnica de Rives-Stoppa implica una reconstruc-ción por planos más anatómica que restaura las propiedades anatomo-fisiológicas de la pared abdominal. Consideramos que puede ser unaalternativa útil en el tratamiento de las eventraciones pediátricas.(AU)

Introduction: Retromuscular mesh hernia repair using Rives-Stoppatechnique has demonstrated the best results when it comes to repairinglarge midline hernias. We present the first pediatric case successfullytreated with this technique. Clinical case: This is the case of a 9-year-old male patient with her-nia following urgent midline laparotomy. Basic repair principles includedopening of the hernia sac and adhesiolysis, longitudinal incision on the posterior sheath of the rectus muscle and division of the retromuscularspace, closure of the posterior sheath, placement of a mesh on this planein the brand-new retromuscular space, and tension-free closure of theanterior musculo-aponeurotic flap, thus reconstructing the midline. Norecurrences have been noted after a 2-year follow-up. Discussion: Rives-Stoppa technique allows for a more anatomicallayered reconstruction, which helps restore the anatomical and physi-ological properties of the abdominal wall. In our view, this could be auseful alternative for pediatric hernia treatment.(AU)

Bone mesh fixation for the treatment of suprailiac hernia. Report of two cases.

Hernias of the lateral abdominal wall are a rare entity. In most cases, they occur after surgery or trauma. We present two cases of lumbar hernia: the first one after iliac bone grafting and the second one after muscular tearing by the seatbelt during a car accident. Both cases were successfully repaired using a propylene mesh with bone fixation.

Las eventraciones de la pared lateral del abdomen son poco frecuentes. Pueden ser posquirúrgicas o causadas por agentes traumáticos. Se presentan dos casos de eventración lumbar: el primero tras una resección ósea por autoinjerto de cresta ilíaca y el segundo por desinserción muscular por cinturón de seguridad secundaria a un accidente en la vía pública. Ambos fueron resueltos quirúrgicamente con colocación de una malla de polipropileno fijada a hueso.

Ulcera de Marjolin (carcinoma escamoso) sobre eventración abdominal / Marjolin ulcer (squamous carcinoma) over abdominal hernia

Introducción: Las úlceras de Marjolin son neoplasias cutáneas que asientan sobre pieles afectadas por úlceras crónicas, quemaduras, cicatrices, estasis venosa o heridas cutáneas. Generalmente se diagnostica por medio de biopsias, siendo los carcinomas escamosos la variedad más frecuente. Existe escasa información sobre su desarrollo en heridas quirúrgicas abdominales previas, y aún menos casos reportados de su aparición sobre un defecto de la pared abdominal. Objetivo: Reporte de un caso de un paciente con antecedente de múltiples cirugías abdominales que desarrolló un carcinoma escamoso sobre cicatriz de laparotomía previa. Pacientes y Métodos: Presentación de un de un paciente masculino de 61 años, con antecedente de laparotomía exploradora, que consultó por una tumoración, de 6 meses de evolución, vegetante sobre eventración de mediana suprainfraumbilical. Se realiza exéresis de lesión en bloque de pared con enterectomia, anastomosis primaria y eventroplastia con malla de reemplazo. Cursa internación prolongada y con mala evolución, falleciendo al 77 día postoperatorio. Conclusión: Los carcinomas de células escamosas que se desarrollan sobre lesiones cutáneas previas presentan una agresividad mayor a aquellos desarrollados espontáneamente, tienen alto porcentaje de recidiva y metástasis asociadas. Se propone abordajes quirúrgicos radicales para su tratamiento, aun asi presentando una morbimortalidad elevada

Background: Marjolin ulcers are skin malignancies that appear on skin affected by chronic ulcers, burns, scars, venous stasis or skin wounds. They are generally diagnosed through a biopsy and the most frequent type is the squamous cell carcinoma. There is little information on its development in existing abdominal surgical wounds, and there are even fewer cases reported in relation to its appearance upon an abdominal wall defect. Objective: To report a case of a patient with a history of multiple abdominal surgeries who developed a squamous cell carcinoma in an existing laparotomy scar in association with an incisional hernia. Patient and Methods: A 61-year-old male patient, with history of an exploratory laparotomy in 1986, presents with a 6-month-old vegetating tumor upon a supra-infraumbilical median eventration. An excision of the lesion that included the abdominal wall and an associated enterectomy, primary anastomosis, and eventroplasty with replacement mesh was performed. During his prolonged hospital stay, he underwent with many medical intercurrences and even an additional surgery was needed. Eventually, the patient dies 77 days after the surgery. Conclusion: Squamous cell carcinomas that develop in existing skin lesions tend to be more aggressive than those that develop spontaneously. They have a high percentage of recurrence and associated metastases. Radical surgical approaches are suggested for its treatment, although it has a high morbidity and mortality rate.

Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study. / Análisis comparativo de 2 técnicas quirúrgicas en el tratamiento de la hernia incisional subxifoidea. Estudio observacional.

INTRODUCTION: The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate. METHODS: It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification. RESULTS: 42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P=.053). The average follow up was 25.8±15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P=.288). CONCLUSIONS: According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it.

Extended Totally Extraperitoneal (eTEP) Approach for Ventral Hernia Repair: Initial Results. / Vía totalmente extraperitoneal extendida (eTEP) para la corrección de hernias ventrales: resultados preliminares.

INTRODUCTION: Since the first laparoscopic incisional hernia repair, several minimally invasive procedures have been developed in abdominal wall repair. In 2017, the extended totally extraperitoneal (eTEP) approach for abdominal wall repair was published. We present the results from eTEP implementation at two medical centers by one surgeon. METHODS: Prospective descriptive study of the implementation of the eTEP approach, with transversus abdominis release (TAR) when needed. The surgical technique was initiated by accessing the space between the rectus abdominis muscle and posterior rectus sheath, connecting this space with the fatty preperitoneal space at the midline and the contralateral retrorectal space. Identification and dissection of the hernia sac is performed in the created cavity. Additionally, posterior component release in a TAR fashion could be done. Finally, closure of posterior plane and linea alba is completed and mesh prosthesis is deployed along the whole dissected space. RESULTS: Forty patients underwent an eTEP procedure with 20 supraumbilical defects, 10 infraumbilical and 10 lateral hernias. Sixteen cases required a TAR technique. Mean operative time was 126minutes. Median pain reported the first postoperative day was 3 on the visual analogue scale. Median length of stay was 1 day and mean follow-up was 10 months. Only one patient developed recurrence, and two patients underwent reoperation. CONCLUSIONS: Implementation of eTEP in abdominal wall repair is safe. Preliminary outcomes of the eTEP approach in ventral hernia repair show good pain control with less hospital stay.

Separación de componentes con liberación del músculo transverso (TAR) para el tratamiento de grandes defectos de la pared abdominal / Component separation with transverse abdominis muscle release (TAR) for the treatment of large abdominal wall defects

Antecedentes: numerosas técnicas han sido descriptas para el tratamiento de defectos complejos de la pared abdominal. La técnica de separación de componentes con liberación del músculo transverso (TAR) permite la movilización de colgajos miofasciocutáneos y cierre de la línea media, con baja tasa de complicaciones. Objetivo: evaluar los resultados del tratamiento de eventraciones complejas con técnica TAR. Material y métodos: se incluyó una serie de pacientes en los que se realizó TAR entre marzo de 2013 y abril de 2017, con seguimiento mínimo de 6 meses. Se analizaron variables demográficas y clínicoquirúrgicas. Los resultados fueron expresados en medianas. Resultados: se realizaron 14 eventroplastias con técnica TAR. Diez (70%) correspondieron a hombres. La edad fue 60 (35-81) años y el IMC fue: 28,2 kg/m². El 70% tenía al menos dos cirugías previas. Se solicitó tomografía computarizada preoperatoria en todos los pacientes. El índice de Tanaka fue 24,5%. En 7 (50%) pacientes el riesgo quirúrgico fue ASA < III. El tamaño del defecto fue 480 (224-720) cm² y el de la malla 900 (500-1050) cm². El tiempo operatorio fue 248 (180-341) minutos, y la estadía hospitalaria, 3 (2-4) días. Dos pacientes tuvieron infección del sitio quirúrgico. El seguimiento posoperatorio fue de 20 (6-48) meses, y no se detectaron recidivas. Conclusión: la técnica TAR es un método seguro y fiable para la reparación de grandes defectos de la pared abdominal con baja morbimortalidad y recidiva, por lo que debería considerarse dentro del armamentario quirúrgico.

Background: several strategies have been described for the treatment of complex abdominal wall defects. The component separation technique with transversus abdominis muscle release (TAR) allows adequate fasciomiocutaneos flaps mobilization to close the middle line and has low morbidity. Objective: to evaluate outcomes of TAR technique for the treatment of large incisional hernias. Material and methods: in the period between March 2013 and April 2017, all consecutive patients with TAR procedures with a minimum follow-up of 6 months were included. Demographics, operative and postoperative variables were analyzed. Results were expressed in medians. Results: a total of 14 TAR procedures were performed. Ten patients were men. The age was 60 (35-81) years and BMI was 28,2 kg/m². Seventy percent of the patients had at least two previous surgeries. CT scan was performed before surgery in all patients. Tanaka index was 24,5%. Seven patients had ASA < III. The defect size was 480 (224-720) cm² and mesh size 900 (500 - 1050) cm². Operative time was 248 (180 -341) minutes and hospital stay 3 (2-4) days. Two patients had surgical site infection. Postoperative follow-up was 20 (6-44) months. There was no recurrences. Conclusion: TAR technique is safe and reliable for the repair of large abdominal wall defects with low morbidity and recurrence rates. Therefore it should be taken into account in the surgical armamentarium.

Alternativas quirúrgicas en hernias y eventraciones diafragmáticas crónicas / Surgical alternatives for chronic diaphragmatic hernias and eventrations

Introducción: las eventraciones y las hernias diafragmáticas crónicas son dos afecciones que en ocasiones se confunden; tienen una frecuencia relativamente baja y su estrategia quirúrgica varía. Objetivo: mostrar la experiencia del Hospital Universitario Clínico Quirúrgico Comandante Manuel Fajardo en la atención de enfermos con hernias y eventraciones diafragmáticas. Métodos: se presentan 11 pacientes atendidos desde 1998 hasta 2015 por afecciones del diafragma como eventraciones y hernias diafragmáticas crónicas. Del total, 7 fueron operadas con anillos de hasta 10 cm y dos con más de 10 cm. Resultados: se operaron 9 pacientes con hernias diafragmáticas y 2 con eventraciones. Ocho hernias fueron del lado izquierdo y una derecha. En 8 de las hernias el contenido era multivisceral. La hernia derecha tenía un anillo de más de 10 cm y con el hígado en su contenido. Cinco fueron reparadas mediante superposición de colgajos y en cuatro se necesitó una malla protésica. Las eventraciones se presentaron en dos mujeres, ambas parciales, una derecha y otra izquierda, tratadas con plicatura del hemidiafragma en dos planos. Conclusiones: las hernias y las eventraciones diafragmáticas son entidades parecidas con particularidades y terapéutica diferentes. En las eventraciones, la plicatura del diafragma es la técnica de elección, por vía abierta o de preferencia por toracoscopia. En las hernias diafragmáticas, la reparación depende del tamaño del anillo, hasta 10 cm se prefiere la reparación con superposición de colgajos y en defectos mayores el uso de mallas protésicas, preferentemente por una toracotomía(AU)

Introduction: Chronic diaphragmatic hernias and eventrations are two conditions sometimes mistaken for each other. They have a relatively low frequency and their surgical strategy varies. Objective: To show the experience at Comandante Manuel Fajardo Clinical Surgical University Hospital in the caring for patients with diaphragmatic eventrations and hernias. Methods: 11 patients attended from 1998 to 2015 were presented for diaphragmatic conditions, such as hernias and chronic diaphragmatic eventrations. Of the total, 7 were operated with rings of up to 10 cm. Two were operated for rings of more than 10 cm. Results: 9 patients with diaphragmatic hernias and 2 with incisional hernias were operated. Eight hernias were on the left side. One hernia was on the right side. In 8 of the hernias, the content was multivisceral. The right hernia had a ring of more than 10 cm, and had the liver in its content. Five hernias were repaired by flaps. Four hernias required a prosthetic mesh. The eventrations were presented in two women, both partial: one was on the right and the other was on the left, and both were treated with plication of the hemidiaphragm in two planes. Conclusions: Diaphragmatic hernias and eventrations are similar entities with different characteristics and therapeutics. In eventrations, the plication of the diaphragm is the technique of choice, either openly or preferably by thoracoscopy. In diaphragmatic hernias, repair depends on the size of the ring, up to 10 cm, flap repair is preferred, and in larger defects, it is the use of prosthetic meshes, preferably by thoracotomy(AU)

Alternativas quirúrgicas en hernias y eventraciones diafragmáticas crónicas / Surgical alternatives for chronic diaphragmatic hernias and eventrations

Introducción: las eventraciones y las hernias diafragmáticas crónicas son dos afecciones que en ocasiones se confunden; tienen una frecuencia relativamente baja y su estrategia quirúrgica varía. Objetivo: mostrar la experiencia del Hospital Universitario Clínico Quirúrgico Comandante Manuel Fajardo en la atención de enfermos con hernias y eventraciones diafragmáticas. Métodos: se presentan 11 pacientes atendidos desde 1998 hasta 2015 por afecciones del diafragma como eventraciones y hernias diafragmáticas crónicas. Del total, 7 fueron operadas con anillos de hasta 10 cm y dos con más de 10 cm. Resultados: se operaron 9 pacientes con hernias diafragmáticas y 2 con eventraciones. Ocho hernias fueron del lado izquierdo y una derecha. En 8 de las hernias el contenido era multivisceral. La hernia derecha tenía un anillo de más de 10 cm y con el hígado en su contenido. Cinco fueron reparadas mediante superposición de colgajos y en cuatro se necesitó una malla protésica. Las eventraciones se presentaron en dos mujeres, ambas parciales, una derecha y otra izquierda, tratadas con plicatura del hemidiafragma en dos planos. Conclusiones: las hernias y las eventraciones diafragmáticas son entidades parecidas con particularidades y terapéutica diferentes. En las eventraciones, la plicatura del diafragma es la técnica de elección, por vía abierta o de preferencia por toracoscopia. En las hernias diafragmáticas, la reparación depende del tamaño del anillo, hasta 10 cm se prefiere la reparación con superposición de colgajos y en defectos mayores el uso de mallas protésicas, preferentemente por una toracotomía(AU)

Introduction: Chronic diaphragmatic hernias and eventrations are two conditions sometimes mistaken for each other. They have a relatively low frequency and their surgical strategy varies. Objective: To show the experience at Comandante Manuel Fajardo Clinical Surgical University Hospital in the caring for patients with diaphragmatic eventrations and hernias. Methods: 11 patients attended from 1998 to 2015 were presented for diaphragmatic conditions, such as hernias and chronic diaphragmatic eventrations. Of the total, 7 were operated with rings of up to 10 cm. Two were operated for rings of more than 10 cm. Results: 9 patients with diaphragmatic hernias and 2 with incisional hernias were operated. Eight hernias were on the left side. One hernia was on the right side. In 8 of the hernias, the content was multivisceral. The right hernia had a ring of more than 10 cm, and had the liver in its content. Five hernias were repaired by flaps. Four hernias required a prosthetic mesh. The eventrations were presented in two women, both partial: one was on the right and the other was on the left, and both were treated with plication of the hemidiaphragm in two planes. Conclusions: Diaphragmatic hernias and eventrations are similar entities with different characteristics and therapeutics. In eventrations, the plication of the diaphragm is the technique of choice, either openly or preferably by thoracoscopy. In diaphragmatic hernias, repair depends on the size of the ring, up to 10 cm, flap repair is preferred, and in larger defects, it is the use of prosthetic meshes, preferably by thoracotomy(AU)

Incisional hernia prevention and use of mesh. A narrative review. / Profilaxis de la hernia incisional y utilización de mallas. Revisión narrativa.

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.

Reparación protésica en una paciente con hernia incisional catastrófica / Prosthetic repair in a patient with catastrophic incisional hernia

Se presenta el caso clínico de una paciente de 66 años de edad, blanca, con antecedentes de hipertensión arterial, diabetes mellitus de tipo II y sobrepeso, quien fue operada en el Hospital General Universitario Dr Juan Bruno Zayas Alfonso de Santiago de Cuba por presentar una eventración gigante en la pared abdominal anterior, que no le permitía deambular sin apoyo. Se realizó la reparación protésica que resultó eficaz y segura, con 13 años sin recurrencia

The case report of a 66 years white patient with a history of hypertension, type II diabetes mellitus and overweight is presented, who was operated on at Dr Juan Bruno Zayas Alfonso University General Hospital in Santiago de Cuba due to a considerable eventration in the front abdominal wall that didn't allow her wandering around without support. The prosthetic repair which was effective and safe, was carried out with no recurrence during 13 years

Reparación protésica en una paciente con hernia incisional catastrófica / Prosthetic repair in a patient with catastrophic incisional hernia

Se presenta el caso clínico de una paciente de 66 años de edad, blanca, con antecedentes de hipertensión arterial, diabetes mellitus de tipo II y sobrepeso, quien fue operada en el Hospital General Universitario Dr Juan Bruno Zayas Alfonso de Santiago de Cuba por presentar una eventración gigante en la pared abdominal anterior, que no le permitía deambular sin apoyo. Se realizó la reparación protésica que resultó eficaz y segura, con 13 años sin recurrencia(AU)

The case report of a 66 years white patient with a history of hypertension, type II diabetes mellitus and overweight is presented, who was operated on at Dr Juan Bruno Zayas Alfonso University General Hospital in Santiago de Cuba due to a considerable eventration in the front abdominal wall that didn't allow her wandering around without support. The prosthetic repair which was effective and safe, was carried out with no recurrence during 13 years(AU)

Preoperative preparation of «loss of domain¼ hernia. Progressive pneumoperitoneum and botulinum toxin type A. / Preparación preoperatoria de la hernia con pérdida de domicilio. Neumoperitoneo progresivo y toxina botulínica tipo A.

Preoperative progressive pneumoperitoneum and botulinum toxin type A are useful tools in the preparation of patients with loss of domain hernias. Both procedures are complementary in the surgical repair, especially with the use of prosthetic techniques without tension, that allow a integral management of these patients. The aim of this paper is to update concepts related to both procedures, emphasizing the advantages that take place in the preoperative management of loss of domain hernias.

The use of an algorithm for prophylactic mesh use in high risk patients reduces the incidence of incisional hernia following laparotomy for colorectal cancer resection. / Un algoritmo para la colocación de malla profiláctica en pacientes de riesgo reduce la incidencia de hernia incisional tras laparotomía por cáncer colorrectal.

OBJECTIVE: Incisional hernia (IH) after colorectal surgery is highly prevalent. The objective of this study is to assess the utility of an algorithm to decide on mesh augmentation after a midline laparotomy for colorectal resection to prevent IH in high-risk patients. METHODS: A prospective study was conducted including all patients undergoing a midline laparotomy for colorectal resection between January 2011 and June 2014, after the implementation of a decision algorithm for prophylactic mesh augmentation in selected high-risk patients. Intention-to-treat analyses were conducted between patients in which the algorithm was correctly applied and those in which it was not. RESULTS: From the 235 patients analysed, the algorithm was followed in 166 patients, the resting 69 cases were used as a control group. From an initial adherence to the algorithm of 40% in the first semester, a 90.3% adherence was achieved in the seventh semester. The incidence of IH decreased as the adherence to the algorithm increased (from 28 to 0%) with a time-related correlation (R2=0.781). A statistically significant reduction in IH incidence was demonstrated in high-risk groups in which the algorithm was correctly applied (10,2 vs. 46,3%; p=0,0001; OR: 7,58;95%; CI: 3,8-15). Survival analysis showed that the differences remained constant during follow-up. CONCLUSION: The implementation of the algorithm reduces the incidence of IH in high-risk patients. The adherence to the algorithm also correlates with a decrease in the incidence of IH.

Eventración diafragmática en el adulto. Reporte de un caso / Diaphragmatic eventration in adults. Case report

Resumen Introducción: El diafragma es un órgano fibromuscular cuya función fisiológica es otorgar la fuerza mecánica para la ventilación. Otra de las funciones del diafragma es dividir la cavidad torácica de la cavidad abdominal2. El diafragma se ve afectado rara vez por enfermedades. Entre las patologías primarias se encuentra la eventración diafragmática. Reporte de caso: Paciente del sexo femenino de 21 años de edad sin antecedentes de importancia quien presenta caída de su propia altura y trauma contuso en tórax. Se realiza radiografía como parte del estudio y se observa elevación del hemidiafragma izquierdo. El estudio se complementa con tomografía axial computada y se diagnostica eventración diafragmática. Ante los hallazgos, se plantea el procedimiento quirúrgico como terapia definitiva; sin embargo, la paciente no lo acepta, por lo que se ha mantenido en seguimiento por la consulta externa. Discusión: La eventración diafragmática es causada por debilidad de la parte muscular diafragmática. Se cree que es causada por la ausencia congénita o funcional de la musculatura diafragmática. El cuadro clínico generalmente es asintomático; en caso de existir sintomatología, ésta se relaciona a problemas respiratorios. El diagnóstico se corrobora con estudios radiológicos, de los cuales los más utilizados son la radiografía de tórax y la tomografía axial computada. El tratamiento puede ser conservador o quirúrgico. El pronóstico dependerá del grado de hipoplasia pulmonar y la de coexistencia de alguna otra alteración. Conclusión: La eventración diafragmática es rara vez diagnosticada en pacientes adultos asintomáticos. El manejo dependerá de la decisión del cirujano y del paciente.

Abstract Background: The diaphragm is a fibromuscular organ whose primary function is related to ventilation. It also serves as a barrier between pleural and abdominal cavities. This organ is rarely affected by pathologic entities, but eventration is among the primary diseases of this structure. Case Report: We present the case of a 21 year old female with no relevant personal history. She arrived to the emergency room with thoracic blunt trauma. Chest radiography is indicated, showing elevation of the left hemidiaphragm. This study was complemented with a computed tomography making a presumptive diagnosis of diaphragmatic eventration. As part of the treatment, we proposed surgical therapy but the patient refused and now she is under surveillance in her clinic. Discussion: Diaphragmatic eventration is caused by the weakness of the muscular part of the organ. It is thought that is caused by functional or congenital absence of the diaphragmatic musculature. The clinical presentation is variable but, in most of the cases, the patients are asymptomatic. The diagnosis is made by radiologic studies such as chest plains and computed tomography. Treatment could be conservative or surgical. The prognosis will depend on the degree of pulmonary hypoplasia and the coexistence of other malformations. Conclusion: Diaphragmatic eventration is rarely diagnosed in adults and the treatment will depend on the surgeon´s and the patient´s joined decision.

Abordaje fisioterapéutico en paciente con eventración compleja / Physiotherapeutic approach in patient with complex eventration

Los pacientes con hernias complejas, se caracterizan por presentar cambios sistémicos y locales. Las complicaciones respiratorias pueden ser mínimas o podrían ser evitadas con la utilización de un protocolo de atención de fisioterapia respiratoria. Se presenta el caso clínico de una paciente de 53 años con diagnóstico de eventración compleja, Obesidad Mórbida y Diabetes Mellitus tipo II. Recibe el tratamiento de fisioterapia respiratoria en las etapas pre y post operatorias, mediante la evaluación clínica kinésica se pudo comprobar la pronta mejoría, pudiendo lograr su máximo grado de dependencia funcional. Resulta interesante medir dicho avance, dado que existen escasas publicaciones sobre este tema.

Patients with complex hernias, are characterized by systemic and local changes. Respiratory complications can be minimal or could be avoided with the use of a protocol of physiotherapy care. Presented the clinical case of a 53 year old patient with diagnosis of complex eventration, morbid obesity and Diabetes Mellitus type II. Receiving physiotherapy treatment in stages pre and post operative, through evaluation clinical kinaesthetic failed to check the prompt improvement, and can achieve its maximum degree of functional dependence. It is interesting to measure such progress, given that there are little publishing on this topic.

Eventración diafragmática en pediatría: revisión de un caso y revisión de la literatura / Diaphagmatic eventration in children: a case report and review of the literature

Diaphragmatic eventration is an abnormal elevation of one of the hemidiaphragms, with deviation of the mediastinum to the contralateral side. It is usually asymptomatic. It can be either congenital or acquired. If it is asymptomatic, the patient should be kept under observation. The resolution must be surgical if the ascent of the diaphragm is pointed, if there is any symptom or recurrent pneumonia. This article describes the case of a patient with congenital diaphragmatic eventration. The difficulties the patient presented in the diagnosis are reviewed.

La eventración diafragmática es la elevación anormal de uno de los hemidiafragmas, con desviación del mediastino hacia el lado contralateral, generalmente asintomática. Se clasifica en congénita y adquirida, si es asintomática el paciente se debe mantener en observación, la resolución debe ser quirúrgica si el ascenso diafragmático es acentuado, presenta síntomas o neumonía recurrente. En este artículo se revisa el caso de un paciente con eventración diafragmática congénita, que presentó dificultades en el diagnóstico.

[Laparoscopic gastric sleeve in gastric volvulus secondary to diaphragmatic eventration in an adult patient]. / Manga gástrica laparoscópica en vólvulo gástrico secundario a eventración diafragmática en paciente adulto.

BACKGROUND: Acute gastric volvulus is a rare, but potentially life-threatening, cause of upper gastrointestinal obstruction. CLINICAL CASE: Male of 60 years old with severe epigastric pain and abdominal distension with haematemesis on two occasions. The patient was haemodynamically stable, with abdominal distension and palpable epigastric fullness. Hematic cytology showed: haemoglobin 8.2g/dl and haematocrit 27%. Abdominal X-ray showed an elevation of left diaphragm with a hugely dilated stomach. A nasogastric tube was inserted. Endoscopy was performed. There was no active bleeding, but it was impossible to reach the duodenum due to the stomach distortion. The upper gastrointestinal X-ray study showed the appearance of an inverted stomach in the chest and an organoaxial gastric torsion. The CT scans of thorax and abdomen showed a gastric ascent into the thoracic cavity. Laparoscopic surgery was performed, finding the left hemi-diaphragm elevated, and the stomach, splenic angle of the colon, the spleen and tail of the pancreas were also raised. A linear gastrectomy (gastric sleeve) was performed. The postoperative progress was satisfactory. Oral feeding was started 72 hours after surgery, and the patient was discharged, and has remained asymptomatic during the following by 8 years. CONCLUSIONS: Emergency physicians must maintain a high level of suspicion in patients that present with signs and symptoms suggesting upper digestive tract occlusion. The gastric sleeve is an excellent alternative to avoid recurrence of gastric volvulus.