Abdominal Viscera Research Articles

Situs inversus with levocardia in a 15-year-old male adolescent: a case report

BackgroundSitus inversus with levocardia is a rare anomaly in which the heart is present in the left chest but the abdominal viscera are transposed. It is caused by a single incomplete penetration of an autosomal recessive gene. It is unclear what exactly causes situs inversus with levocardia. Even if situs inversus can be identified following a comprehensive physical examination, it is now possible to validate the results and search for further information and pathologies since medical imaging is so widely accessible.CaseA 15-year-old Oromo male child from a remote area of Bale Zone presented to the Goba Referral Hospital’s medical emergency outpatient department complaining of periumbilical pain that had persisted for 4 months. He frequently came to our hospital and was admitted three times with the same problem. Objectively, there was tenderness over the left lower quadrant and periumbilical area. The sonographic evaluation discovered the transposition of the liver and spleen with cardiac apex on the left side. He received conservative treatment with ceftriaxone 1 g intravenous twice a day and metronidazole 500 mg intravenous for 5 days, and he went home improved.ConclusionIsolated levocardia is a rare form of situs inversus in which the heart is in the traditional levo position while the abdominal organs are in the dextro position. What causes situs inversus with levocardia is unknown. Despite the fact that situs inversus can be diagnosed after a thorough physical examination, medical imaging has allowed us to confirm the findings as well as understand more about diseases. Due to the severity of an underlying heart defect, situs inversus with levocardia has a dismal prognosis.

Nonpuerperal chronic endometritis with pyometra causing systemic illness in a production sow

A second parity, late pregnant, commercial mixed-breed sow was examined on a farm with a 5-day history of inappetence and lethargy that was unresponsive to treatment with flunixin meglumine. Clinical signs were suspected due to an enlarged, fluid-filled hollow abdominal organ identified via transabdominal ultrasonography. Further characterization of abdominal viscera and fluid was limited by the sensitivity of the imaging equipment. Flunixin meglumine was discontinued and a dietary supplement was added to the feed to encourage intake. Repeat transabdominal ultrasonography was performed 4 days later due to a lack of improvement with worsening lethargy, continued inappetence, and fever. The sow was euthanized because of poor prognosis, chronicity of disease, and lack of pregnancy. On necropsy, the uterine horns measured 20 cm in diameter and occupied ~ 80% of the abdominal cavity, compressing the intestines and liver. The uterine lumen contained watery, turbid fluid. The left ovary had multiple grossly appreciable corpora lutea, and right ovary had multiple corpora albicantia. Although uterine disease is poorly defined in swine, based on the gross and histologic findings this sow was diagnosed with nonpuerperal chronic endometritis with intrauterine accumulation of purulent fluid (consistent with pyometra). Additionally, the sow was diagnosed with salpingitis, interstitial nephritis, lymphadenitis, and gastric ulceration, all likely contributing to her declining health and systemic illness.

Hemophagocytic Lymphohistiocytosis (HLH) in a Post-COVID-19 Infection: A Case Report

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper inflammatory process caused by extensive immune activation and characterized by multi organ dysfunction. During COVID-19 pandemic secondary hemophagocytic lymphohistiocytosis has been reported in acute phase of COVID-19 infection, but HLH in recovered post-COVID-19 patients is rare. We report a case of HLH following of COVID infection. Case Description: 72-year-old female with well-controlled rheumatoid arthritis and COVID infection 2 months prior presented with progressive shortness of breath. She was diagnosed with acute on chronic heart failure, acute kidney injury, worsening anemia and thrombocytopenia. She progressively got worse during hospitalization and on day 9 developed fever and multiorgan failure (pancytopenia, acute liver injury, respiratory failure requiring mechanical ventilation, renal failure requiring hemodialysis). Labs included hemoglobin of 7.9 g/dL, platelets 50 Th/uL, ANC 1.38 Th/uL, LDH 6000 IU/L, ferritin >10,000 ng/ml, fibrinogen 136 mg/dL, triglycerides 656 mg/dL. HLH was suspected and a bone marrow biopsy showed occasional macrophages with hemophagocytosis without evidence of lymphoproliferative disorder (Figure 1). Interleukin-2 receptor soluble was elevated at 57026.9 pg/mL. HLH diagnosis was established, and patient was started on HLH-94 protocol with etoposide and dexamethasone. She improved quickly with treatment and was extubated in a few days. After 4 weeks, there was continued clinical improvement with improving liver function, LDH was down to 373, ferritin 3586 but she remained cytopenic needing transfusion support. By week 6, she was off dialysis and repeat Interleukin-2 receptor soluble was 2500 pg/ml and ferritin was 2500 ng/ml. A positron emission tomography (PET) scan did not show any evidence of lymphoma. Patient was not considered to be suitable candidate for stem cell transplant and was monitored. Within 6-8 weeks, she was noted to have worsening LDH, ferritin, liver function and patient was started on ruxolitinib 5 mg twice a day and dexamethasone 2 mg daily. Patient continued to have worsening anemia, thrombocytopenia, LDH and ferritin. Patient was readmitted around week 6 of ruxolitinib treatment with progressive shortness of breath. Patient was re-treated with dexamethasone and etoposide. On day 10 of 2nd hospitalization, she developed acute respiratory failure needing mechanical ventilation and was diagnosed with abdominal viscus perforation. After discussion with family, she was transitioned to best supportive care given poor prognosis. Discussion: Few cases of HLH in post-covid-19 patients have been reported in the literature, but this entity may be likely under diagnosed given the delayed presentation, absence of definitive clinical, laboratory, or histopathological criteria. Immune dysregulation and macrophage activation due to subclinical inflammation following post-COVID-19 infection is postulated to underlie the pathogenesis of HLH in post-COVID-19 patients. The hyperinflammatory situation results in multi-organ failure and high mortality rates. The HLH2004 has been recommended as the diagnostic criteria of choice for HLH among post-COVID-19 patients. Immunosuppressive therapies with steroids, and etoposide are the conventional first-line agents based on the HLH94 protocol; however, refractory cases have been shown to respond to other immunosuppressive agents and biologics including ruxolitinib, alemtuzumab, and emapalumab. Figure 1: A. Hemophagocytosis (Macrophage ingesting lymphocyte) B. Hemophagocytosis, more specifically-erythrophagocytosis (macrophage ingesting red blood cell).

Improvement of graphene induced pulmonary edema by graphene exfoliator NaCl with KCl solution

89-year-old man with left basal ganglia internal capsule post limb infarct to our hospital with a history of sputum, fever (37.8oC), dyspnea combined with nasal cannula oxygen therapy, vital signs: blood pressure 120 (systolic) / 60 (diastolic), heart rate 82, respiratory rate 21, O2 saturation 78%, total leukocyte count of 11200/cmm, Lactate Dehydrogenase (LDH) 330 IU/l, alkaline phosphatase 360 u/l, Blood Urea Nitrogen (BUN) 23.7 mg/dl and erythrocyte sedimentation rate (ESR) 50 mm in the first hour using Westergren method, C-reactive protein (CRP) 28.71 mg/dl. The intravenous infusion of a solution consisting of 250 mL normal saline with of potassium chloride (KCl) over 6 h , vitamin C intake with supportive care resulted in recovery of O2 saturation 94%, intramuscular injections of the graphene previously [1-4]. Congestive heart failure (CHF) is the result of insufficient output because of cardiac failure, high resistance in the circulation or fluid overload. Left ventricle (LV) failure is the most common and results in decreased cardiac output and increased pulmonary venous pressure. In the lungs LV failure will lead to dilatation of pulmonary vessels, leakage of fluid into the interstitium and the pleural space and finally into the alveoli resulting in pulmonary edema. Right ventricle (RV) failure is usually the result of long standing LV failure or pulmonary disease and causes increased systemic venous pressure resulting in edema in dependent tissues and abdominal viscera [5]. Abnormal left ventricular structure and function as in, for example, left ventricular hypertrophy or chronic heart failure, is associated with sudden cardiac death and, when the ejection fraction is depressed, with prolongation of the QT interval [6].

Intact peritoneum in a child with ileal perforation from a firearm injury

Introduction Indirect intra-abdominal injury with an intact peritoneum following close passage of highly energized projectiles is an uncommon but clearly described phenomenon; likewise delayed gastrointestinal perforation hours or days after passage of a high-energy stress wave from primary blast injury is uncommon. Awareness of these two rare occurrences is required to ensure delayed perforations are diagnosed and managed in a timely manner. Case report An 8-year-old male child sustained a shotgun injury to the right elbow and the abdominal wall only of the right hypochondrium. Due to a non-salvageable joint injury, he underwent amputation of the right upper limb above the elbow, but on the third day of admission, he developed peritonitis and an X-ray revealed pneumoperitoneum. On abdominal exploration, two small ileal perforations were found without penetration of the peritoneum or diaphragm. The ileal injuries were primarily repaired and the postoperative course was uneventful. Conclusion Indirect injury to abdominal viscera from the primary blast effect of close passage of high-energy projectiles resulting is rare and can have significant consequences if not diagnosed and managed early.

Use of self-extendable mesh in the minimally invasive treatment of posterolateral diaphragmatic hernia, a novel device

BackgroundCongenital diaphragmatic hernia (CDH) is a pathology found in neonates, though it can affect individuals of various ages. The definitive treatment for this condition is surgical, either through an open or minimally invasive approach. Hernial defects not allowing primary closure must be corrected with a mesh. There is no specific mesh for this pathology. We describe the use of a self-extendable mesh based on a market-available mesh for the closure of a CDH that facilitates its placement and suture to the diaphragm using a minimally invasive technique. MethodsWe conducted a retrospective longitudinal study from January 2019 to January 2023. The study included patients under the age of 18 with a confirmed diagnosis of CDH who underwent minimally invasive surgery with the placement of a self-extendable mesh. A minimum follow-up period of six months was established. Descriptive statistics were applied to analyze various variables, including age at diagnosis, associated pathologies, hernia classification, surgical time, and postoperative parameters, such as complications, respiratory and gastrointestinal symptoms, recurrence, and thoracic alterations. ResultsWe included five patients with CDH. Two patients were diagnosed in the neonatal period, two between 28 days of life and one year, and one after the first year of life. All patients had posterolateral hernias; three were left-sided, and two were right-sided. Four had a type C defect, and one had a type B defect. All patients were treated by minimally invasive surgery, through thoracoscopy, with a surgical time between 89 and 120 min. There were no intraoperative complications or conversions to open surgery. Short and medium-term follow-up was performed in the remaining patients, the shortest follow-up period being 19 months and the longest reaching 36 months. No recurrence of the defect or thoracic or vertebral deformities were reported. ConclusionsThe modified self-extendable mesh is a device that offers a safe and effective way of correcting CDH, facilitating the placement and suture process to the native tissue while reducing the risk of injury to the abdominal viscera. Although we cannot definitively conclude that the surgical time decreases based on our limited number of cases, the mesh shows promise as a valuable tool in treating CDH. Further research and a larger sample are necessary to determine the effects on surgical time.

Inguinal Hernia: Diagnosis and Management

The inguinal hernia is the subcutaneous part of the peritoneum containing the abdominal viscera that exits through the inguinal canal or directly through the abdominal wall. Most patients do not realize they have an inguinal hernia until swelling arises in the thigh fold area or pain in the groin area. The purpose of this literature review is to provide an update regarding the diagnosis and management of inguinal hernias. The diagnosis of an inguinal hernia is largely based on the history and physical examination, whereas imaging is rarely performed unless there is a certain suspicion. Surgical management can be performed on patients with symptoms, while asymptomatic patients can be subjected to conservative therapy.

Incisional Hernia Case Management in a Local Cat

Background: An incisional hernia is a condition where the sutures on the abdominal wall rupture while the sutures on the skin remain intact. This causes abdominal viscera to protrude through the surgical incision hole, resulting in a visible lump. Purpose: Literature reports regarding incisional hernias in animals are very rarely reported; therefore, this case report aims to provide information about incisional hernias. Case: An eight month old female cat weighing 1.7 kg was presented at the Veterinary Surgery Laboratory, Veterinary Medical Faculty of Udayana University, with clinical signs of a lump on the ventral side of the abdomen, with visible stitch scars in the lump area. Upon pressing the lump, it could be reinserted, leading to a diagnosis of incisional hernia. Case Management: The cat underwent herniorrhaphy to return the visceral organs to the abdominal cavity and close the hernial opening. Post-operative care included administering cefotaxime 20 mg/kg BW intravenously twice a day for three days, followed by cefixime 5 mg/kg BW orally twice a day for four days, and non-steroidal anti-inflammatory drugs tolfenamic acid of 4 mg/kg BW subcutaneously once a day for three days. The wound area was covered with 1% framycetin sulfate tulle gauze (Daryant-Tulle®), and the stitches were removed on the 14th postoperative day. Conclusion: The wound appears dry, with well-approximated edges and no visible protrusion. It can be concluded that treatment with herniorrhaphy in this case was successful.

Laparoscopic Mesh Repair Of Diaphragmatic Morgagni Hernia

Diaphragmatic hernias of Morgagni were first described in 1769 as anatomical defects in the anterior diaphragm that allow herniation of abdominal viscera into the thorax by Giovanni Battista Morgagni, an Italian anatomist and pathologist. Patients reported to have previous normal radiographs suggest that these hernias may be acquired through a congenital defect in the diaphragm 4. Most hernias of Morgagni are diagnosed late because patients can be asymptomatic or present with vague gastrointestinal and respiratory symptoms and signs. USG has been shown to be useful in assessing diaphragmatic hernias but CT is the most sensitive as it gives excellent anatomical detail on the contents of the hernia and its complications such as strangulation Once diagnosed, the requirement for surgery is largely dependent upon the presentation Repair avoids further complications but it is the timing which is important. Emergency intervention is not always necessary unless there is evidence of strangulation. Laparoscopy is an excellent way to confirm diagnosis and to repair non-complicated hernia of Morgagni. The hernia sac can be easily viewed through the laparoscope. The hernia contents can then be easily reduced once the peritoneum at the perimeter of the defect is incised. The sac is usually not removed; as this may result in massive pneumomediastinum with potential respiratory and circulatory complications.

A retrospective study of Kaposi's sarcoma in Hotan region of Xinjiang, China.

Kaposi sarcoma (KS) is the most common cancer in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (AIDS). In 1994, Chang and Moore discovered Kaposi sarcoma associated herpesvirus for the first time in KS lesions in AIDS patients. KS is a low-grade mesenchymal neoplasm of blood and lymphatic vessels that primarily affects the skin, although the disease may become disseminated to the lymphatic system, lungs, airways, or abdominal viscera. In this research, clinical characteristics and treatment of patients of Kaposi sarcoma were retrospectively analyzed in Hotan District, Xinjiang China. We look into the clinical traits, prognosis, and therapy of Kaposi sarcoma. From May 2017 to August 2022, 32 patients were treated in the People's Hospital of Hotan District, Xinjiang Uygur Autonomous Region, China. Twenty-two of these were classic Kaposi sarcomas (cKS), and 10 of these were Kaposi sarcomas linked to AIDS (AIDS-KS). The majority of KS patients were Uyghur. In terms of age at onset, AIDS-KS patients were younger than cKS patients. cKS and AIDS-KS are most frequently manifested in the feet and lower limbs. Ten patients with AIDS-KS have treated with combination antiretroviral therapy (combination antiretroviral therapy) combination chemotherapy, 5 of 10 patients had a complete response, 2 patients achieved partial response, the overall effective rate was 70%, and CD4 + T cells were greater than before. For cKS and AIDS-KS, the median overall survival was 56 and 50.8 months, respectively (P > .05). As a result, antiviral combination chemotherapy can also improve the prognosis of AIDS-KS patients.

Inefficiency in Delivery of General Surgery to Black Patients: A National Inpatient Sample Study.

Background Racial disparities in outcomes among patients in the United States are widely recognized, but disparities in treatment are less commonly understood. This study is intended to identify treatment disparities in delivery of surgery and time to surgery for diagnoses managed by general surgeons-appendicitis, cholecystitis, gallstone pancreatitis, abdominal wall hernias, intestinal obstructions, and viscus perforations. Methods The National Inpatient Sample (NIS) was used to estimate and analyze disparities in delivery of surgery, type of surgery received, and timing of surgery. Age-adjusted means were compared by race/ethnicity and trends in treatment disparities were evaluated from 1993 to 2017. Linear modeling was used to measure trends in treatment and outcome disparities over time. Mediation analysis was performed to estimate contributions of all available factors to treatment differences. Relationships between treatment disparities and disparities in mortality and length of stay were similarly evaluated. Results Black patients were less likely to receive surgery for appendicitis, cholecystitis, pancreatitis, and hernias, and more likely to receive surgery for obstructions and perforations. Black patients experienced longer wait times prior to surgery, by 0.15 to 1.9 days, depending on the diagnosis. Mediation analysis demonstrated that these disparities are not attributable to the patient factors available in the NIS, and provided some insight into potential contributors to the observed disparities, such as hospital factors and socioeconomic factors. Conclusion Treatment disparities are present even with common indications for surgery, such as appendicitis, cholecystitis, and gallstone pancreatitis. Black patients are less likely to receive surgery with these diagnoses and must wait longer for surgery if it is performed. Surgeons should plan institution-level interventions to measure, explain, and potentially correct treatment disparities.

Heterotaxy Syndrome In A Middle-Aged Pakistani Male

Background: Heterotaxy syndrome (or situs ambiguous) is an extremely rare disorder in which the viscera are arranged in an abnormally asymmetrical pattern around the midline along with cardiac and spleen abnormalities. The management of this disorder depends upon the extent and variability of the organ involvement and a multi-disciplinary approach is often required.
 Case presentation: A middle-aged male presented in pulmonology OPD with with complaint of hemoptysis and shortness of breath for 3 weeks. He had a history of cyanotic spells since childhood. His HRCT chest revealed dextrocardia, generalized mild centrilobular emphysema of the lungs with fibrotic bands and mild cylindrical bronchiectasis and his echocardiography showed dextrocardia along with ventricular septal defect and pulmonary hypertension. He was found to have abnormally positioned abdominal viscera along with multiple spleens and he was diagnosed as a case of heterotaxy syndrome with left isomerism. His respiratory symptoms were treated conservatively and the patient was referred to the cardiology unit for management of cardiac defects.
 Conclusion: This manuscript describes a case of heterotaxy syndrome which is a rare disorder with significant mortality and morbidity. The patient may present with vague symptoms. Early involvement of all the relevant specialities might help in a prompt diagnosis and timely management, which may improve the disease outcome.

Assessment of Silver Sulfadiazine Dressing in the Non-Operative Management of Omphalocele

Background: Non-operative management of omphalocele, a congenital abdominal wall defect involving abdominal viscera protrusion through the umbilical cord base, poses significant neonatal care challenges. Silver sulfadiazine dressing, renowned for its antimicrobial and wound-healing properties, is emerging as a potential adjunctive therapy for omphalocele. Aim of the study: This study aimed to assess the effectiveness of silver sulfadiazine dressing in the non-operative management of omphalocele. Methods: This prospective interventional study was carried out at Dhaka Medical College and Hospital (DMCH), Dhaka, Bangladesh, from March 2018 to June 2020. The study included 10 neonates with omphalocele who received silver sulfadiazine dressing. Random sampling was employed for participant selection, and data were collected using a pre-designed data collection sheet. Analysis and presentation of data were done using the MS Office suite. Results: The average age of the participants was 1.0±1.15 years, and 60% of them were male. Participants with omphaloceles showed diverse sac sizes, with 10% having sacs ≤5 cm, and 90% >5 cm (mean 7.30 cm ± 2.58 cm). Eschar formation took 7.70±2.62 days. Initial hospital stays averaged 9.10±1.91 days. Epithelization commenced in 18.90±3.60 days. Full epithelization across participants averaged 103.30±16.74 days. Conclusion: Eschar formation and initial hospital stays are as expected, but complete epithelization is significantly prolonged, highlighting the need for ongoing care. Our recommendation for medical practitioners is to tailor care to omphalocele patients, especially regarding epithelization management, considering individual needs and optimizing the process.

518 Testicular Mass: A Rare Presentation of Richter’s Syndrome

Abstract A 72-year-old male patient who presented with a painless right sided scrotal swelling for few months. History of stage A Chronic Lymphocytic Leukemia (CLL) since 2015- under surveillance by hematology team. On examination; 10 X 10 cm hard non-tender right-sided scrotal mass, normal left testicle, no peripheral lymphadenopathy or organomegaly. WBC count = 17.5 × 109 /L with neutrophils of 4.39 × 109 /L & lymphocytes of 11.16 × 109 /L. Testicular tumour marker; within normal CT chest, abdomen, and pelvis (CAP); some borderline enlarged left para-aortic and aorto-caval lymph nodes and unremarkable abdominal viscera. Right inguinal orchiectomy Histopathology and immunohistochemistry profile were consistent with a high-grade Richter’s transformation to diffuse large B cell lymphoma. MDT plan with hematologist: 6 cycles of R-CHOP and IV as well as intrathecal Methotraxate for CNS prophylaxis. Patient was given the option testicular radiotherapy vs orchidectomy and he opted for orchidectomy. After more than 24 months follow up, the patient had no relapse. Richter’s syndrome (RS) is the transformation of CLL to an aggressive form of lymphoma mostly represented by diffuse large B cell lymphoma (DLBCL) in 2 -10% of CLL patients. RS is clinically characterized by development of B symptoms (fever, night sweats and weight loss), rapid clinical deterioration and a rapid increase in the size of lymphadenopathy and /or splenomegaly. RS commonly arises in lymph nodes or bone marrow and disseminates to other organs. Presenting as a testicular mass, as in this case, is quite rare and our patient represents the 4th case reported in the literature.

HIATAL HERNIA, PANORAMIC REVIEW OF DIAGNOSIS AND MANAGEMENT

Introduction: Hiatal hernia (HH) occurs frequently in the population, characterized by various non-specific symptoms, however most of these symptoms are found to be related to gastroesophageal reflux disease. A hiatal hernia is said to be a medical condition in which the upper portion of the stomach or other internal organ protrudes through an opening in the diaphragm. Objective: to detail current information related to hiatal hernia, description, etiology, classification, diagnosis, differential, prognosis, management and complications. Methodology: a total of 38 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 27 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: hiatal hernia, hiatal repair, diagnosis, management. Results: The incidence of symptomatic cases of hiatal hernia is related to the diagnosis of gastroesophageal reflux disease (GERD). The incidence of hiatal hernias increases with age. About 55%-60% of individuals over 50 years of age have a hiatal hernia. However, approximately 9% have symptoms and it depends on the type and competence of the lower esophageal sphincter (LES). The largest percentage of these hernias are type I sliding hiatal hernias. Type II, paraesophageal hernias, represent approximately 5% of hiatal hernias in which the LES remains stationary, with the stomach protruding superiorly to the diaphragm. There is also a high prevalence in women, attributable to increased intra-abdominal pressure during pregnancy. The estimated overall 30-day mortality rate in relation to antireflux surgery is approximately 0.19%. Conclusions: Hiatal hernia (HH) is relatively common in the general population. It is caused by increased intra-abdominal pressure, leading to protrusion of the stomach and other abdominal viscera into the mediastinum. Hiatal hernias can be congenital or acquired. The current anatomical classification of hiatal hernias consists of four types or categories, each with its different characteristics. Diagnosis of hiatal hernia can be challenging because of the change in the anatomy of the esophagogastric junction on swallowing, breathing and movement. The pre-surgical study of the individual supports the diagnosis and the exclusion of other pathologic entities to properly direct the surgical intervention. The success of hiatal hernia surgery can be measured by the improvement of symptoms, such as esophageal acid exposure, complications and the requirement for reoperation. Complications of surgery are usually mild and are not directly linked to the surgery itself. KEY WORDS: surgery, hernia, hiatus, diagnosis, management.

Transition ofResuscitative Endovascular Balloon Occlusion ofthe Aorta from Zone 3 to Zone 1 to Treat Hemodynamic Collapse during Continued Hemorrhage.

Noncompressible torso hemorrhage (NCTH) accounts for most potentially survivable deaths on the battlefield. Treatment of NCTH is challenging, especially in far-forward environments with limited capabilities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise in the care of patients with NCTH. REBOA involves introducing a balloon catheter into the descending aorta in a specific occlusion region (zones 1, 2, or 3) and acts as a hemorrhage control adjunct with resuscitative support. The balloon is placed in zone 3 in the infrarenal aorta for high junctional or pelvic injuries and in zone 1 proximal to the diaphragm for torso hemorrhage. Zone 1 REBOA provides more resuscitative support than zone 3; however, the potential for ischemia and reperfusion injuries is greater with zone 1 than with zone 3 REBOA placement. This study aims to determine the possible benefit of transitioning the REBOA balloon from zone 3 to zone 1 to rescue a patient with ongoing venous bleeding and impending cardiovascular collapse. Yorkshire male swine (70-90 kg, n = 6 per group) underwent injury to the femoral artery, which was allowed to bleed freely for 60 s, along with a simultaneous controlled venous hemorrhage. After 60 s, the arterial bleed was controlled with hemostatic gauze and zone 3 REBOA was inflated. Five hundred milliliters of Hextend was used for initial fluid resuscitation. The controlled venous bleed continued until a mean arterial pressure (MAP) of 30 mmHg was reached to create an impending cardiovascular collapse. The animals were then randomized into either continued zone 3 REBOA or transition from zone 3 to zone 1 REBOA. Following 30 min, a "hospital phase" was initiated, consisting of cessation of the venous hemorrhage, deflation of the REBOA balloon, and transfusion of one unit of whole blood administered along with saline and norepinephrine to maintain a MAP of 60 mmHg or higher. The animals then underwent a 2-h observation period. Survival, hemodynamics, and blood chemistries were compared between groups. No significant differences between groups were observed in hemodynamic or laboratory values at baseline, postinitial injury, or when MAP reached 30 mmHg. Survival was significantly longer in animals that transitioned into zone 1 REBOA (log-rank analysis, P = .012). The average time of survival was 14 ± 10 min for zone 3 animals vs. 65 ± 59 min for zone 1 animals (P = .064). No animals in the zone 3 group survived to the hospital phase. Zone 1-treated animals showed immediate hemodynamic improvement after transition, with maximum blood pressure reaching near baseline values compared to those in the zone 3 group. In this swine model of NCTH, hemodynamics and survival were improved when the REBOA balloon was transitioned from zone 3 to zone 1 during an impending cardiovascular collapse. Furthermore, these improved outcome data support the pursuit of additional research into mitigating ischemia-reperfusion insult to the abdominal viscera while still providing excellent resuscitative support, such as intermittent or partial REBOA.

Abstract P3112: The Effects Of Sex Hormones On Intestinal Lipoprotein Size

Larger intestinal lipoproteins are more likely to be retained in the intestinal wall, allowing their fat to be hydrolyzed and taken up by the abdominal viscera. Since men generally accumulate more abdominal visceral fat than women, we hypothesize that testosterone stimulates the release of larger intestinal lipoproteins relative to estrogen and progesterone. To test our hypothesis, the differentiated Caco-2 cells (n ≥ 12 per group) were induced to produce intestinal lipoproteins while simultaneously subjected to the physiological concentrations of sex hormones by using our semipermeable membrane system. The lipoproteins were isolated by using density gradient ultracentrifugation, and the amount of ApoB and TG were determined. Since each lipoprotein consists of only one ApoB, higher ratios of TG/ApoB suggest larger lipoproteins as shown by our previous studies. Our results indicated that while there was no dose-dependent effect of beta-estradiol (p > 0.05) and progesterone (p > 0.05), testosterone significantly (p = 0.004) increased the TG/ApoB ratio. When these hormones were combined to resemble the plasma concentrations observed in men and the different phases of the ovarian cycle (follicular, ovulatory, and luteal), both the male (p = 0.045) and the luteal phase (p = 0.043) had significantly higher TG/ApoB ratios than the ovulatory phase. The ovulatory phase secreted significantly less amount of TG than the other groups, and the follicular phase secreted significantly less amount of TG than the male (p = 0.0003). ApoB was comparable among all these four groups (p > 0.05). In conclusion, unlike beta-estradiol and progesterone, testosterone significantly increased the size of intestinal lipoproteins. The ovulatory phase secreted the least amount of TG and produced significantly smaller intestinal lipoproteins than the male and the luteal phase. These studies support our hypothesis that through their testosterone effects, men produce larger intestinal lipoproteins. Larger lipoproteins tend to stay longer in the intestinal wall, allowing their fat to be taken up preferentially by the abdominal viscera. Our studies may partly explain why men are more likely to accumulate abdominal visceral fat, which is an independent predictor of mortality.

Landmark vessel in membrane anatomy-based colorectal surgery

The theory of membrane anatomy has been widely used in the field of colorectal surgery. The key point to perform high quality total mesorectal excision (TME) and complete mesocolic excision (CME) is to identify the correct anatomical plane. Intraoperative identification of the various fasciae and fascial spaces is the key to accessing the correct surgical plane and surgical success. The landmark vessels refer to the small vessels that originate from the original peritoneum on the surface of the abdominal viscera during embryonic development and are produced by the fusion of the fascial space. From the point of view of embryonic development, the abdominopelvic fascial structure is a continuous unit, and the landmark vessels on its surface do not change morphologically with the fusion of fasciae and have a specific pattern. Drawing on previous literature and clinical surgical observations, we believe that tiny vessels could be used to identify various fused fasciae and anatomical planes. This is a specific example of membrane anatomical surgery.

Ventral Hernias in Kalyana Karnataka Teaching Hospital: A Prospective Study.

A ventral hernia is a protrusion of the abdominal viscus through the anterior abdominal wall occurring at any site other than the inguinal and femoral areas and is a common problem encountered by surgeons.
 Aims & Objective: Due to the lack of prospective cohorts to determine the natural history of untreated ventral hernias, most surgeons recommend that these hernias be repaired as soon as they are discovered. The purpose of this study was to determine the proportion of ventral hernias occurring in both sexes, various age groups, various risk factors, and complications, as well as their clinical presentations and treatment.
 Material and Methods: During the period August 2020 to August 2021 (12 months), a prospective study was conducted at our tertiary care hospital. The study included 50 cases of anterior abdominal hernias excluding groin hernias and posterior abdominal wall hernias. A detailed history and a thorough clinical examination were used to collect data. In the proforma, data was entered, tabulated, and analyzed using statistical software (SPSS 2015).
 Results: Ventral hernias accounted for 5% of surgical admissions. Among the ventral hernias, para umbilical hernias were the most prevalent (48%). An infra umbilical midline herniation accounted for 36% of cases, followed by an umbilical region herniation in 18% of cases. Constipation and obesity were found to be the major risk factors. Most defects are small (>2cm). 48% of inlay mesh repairs were made.
 Conclusion: 50 cases of ventral hernias were studied in the present study, which was conducted in our tertiary care hospital. Five percent of all admissions to the surgical ward were due to ventral hernias. The females to males ratio was 1:17, and the mean age was 41. The mean total duration for surgery in sublay group was 75.4±9.23 minutes compared to 63.7±10.58 minutes in onlay group, which was statistically significant (p<0.05).

Evidence of extraganglionic vagal mechanoreceptors in the mouse vagus nerve.

Vagal afferent neuronal somas are in the nodose and jugular ganglia. In this study, we identified extraganglionic neurons in whole-mount preparations of the vagus nerves from Phox2b-Cre-ZsGreen transgenic mice. These neurons are typically arranged in small clusters and monolayers along the cervical vagus nerve. Although infrequent, these neurons were sometimes observed along the thoracic and esophageal vagus. We performed RNAscope in situ hybridization and confirmed that the extraganglionic neurons detected in this transgenic mouse strain expressed vagal afferent markers (i.e., Phox2b and Slc17a6) as well as markers that identify them as potential gastrointestinal mechanoreceptors (i.e., Tmc3 and Glp1r). We also identified extraganglionic neurons in the vagus nerves of wild-type mice that were injected intraperitoneally with Fluoro-Gold, thereby ruling out possible anatomical discrepancies specific for transgenic mice. In wild-type mice, extraganglionic cells were positive for peripherin, confirming their neuronal nature. Taken together, our findings revealed a previously undiscovered population of extraganglionic neurons associated with the vagus nerve. Going forward, it is important to consider the possible existence of extraganglionic mechanoreceptors that transmit signals from the abdominal viscera in future studies related to vagal structure and function.