Groin Exploration Research Articles

Isolated spermatic cord metastasis of prostate cancer after radiotherapy detected with 18F-PSMA PET/CT: a case report and literature review.

We report the case of a 65year-old male with prostate cancer previously treated with external beam radiotherapy and 2years of androgen deprivation therapy. His nadir PSA reached undetectable level but gradually increased to 0.89ng/dL. 18F-PSMA PET/CT demonstrated a PSMA-avid lesion at left spermatic cord. Left groin exploration revealed an 8mm left vas deferens mass. Mass excision was performed and pathology result showed prostatic adenocarcinoma. The metastatic route is unknown but the possible routes are intraluminal route via ejaculatory duct, hematogenous route and lymphatic route. This case also highlights the role of 18F-PSMA PET/CT to detect a recurrent lesion at an atypical site in biochemical failure patients even at the low PSA level.

Implementing Contralateral Surgical Exploration during Hernia Repair in Children with Unilateral Inguinal Hernia: A Dutch Qualitative Study.

A total of 10-15% of children undergoing unilateral inguinal hernia repair develop a metachronous contralateral inguinal hernia (MCIH) that necessitates second anesthesia and surgery. Contralateral exploration can be performed to prevent MCIH development. This study investigates (1) factors that promote or hinder the adoption and (de-)implementation of contralateral groin exploration in children ≤ 6 months undergoing unilateral hernia repair and (2) strategies to overcome these barriers. A qualitative interview study was conducted using 14 semi-structured interviews and two focus groups involving healthcare professionals, stakeholders involved from a patients' perspective and stakeholders at the organizational/policy level. The results show that the effectiveness of surgical treatment and stakeholders' motivation and attitudes towards the intervention were reported as barriers for implementation, whereas patient and family outcomes and experience and strategies to overcome these barriers were identified as facilitating factors for future implementation. This study is unique in its contributions towards insights into facilitators and barriers for (de-)implementation of contralateral groin exploration in children with a unilateral inguinal hernia. In case the HERNIIA trial shows that contralateral exploration is beneficial for specific patient and family outcomes or a subgroup of children, the results of this study can help in the decision-making process as to whether contralateral exploration should be performed or not.

A Case Report: Ruptured Testicular Seminoma in a Female with Ambiguous Genitalia, Dr. Sulman Alamin Medical Center, Elhassaheisa, Gezira State, Sudan; 2023

Background: Ambiguous genitalia represent a sequel of sexual development disorders where the external genitalia don’t have a typical resemblance to that of male or female. Methods: This was a female case of ambiguous genitalia, her age was twenty-eight years, ultrasound examination revealed atrophied uterus and bilateral undescended testes. She complained of gradual size increase of her left testicle in the last 6 months. Due to sudden trauma, she developed severe pain and swelling in her left groin. On examination: patient looked unwell, in pain, afebrile, locally there was swelling about 10 cm in size with shiny and red looking, it was very tender, otherwise it was unremarkable. So, this was considered as a case of left testicular trauma that need urgent left groin exploration. The patient was counselled and consented about possible orchidectomy. Intra-operative note: under spinal anesthesia patient was put on supine position, skin painted by yamidin, left inguinal incision was made and hematoma was evacuated, the left testicle was found to be hugely enlarged and ruptured. The spermatic cord was clamped and orchidectomy was done. No intra operative complications. Result: Histological examination of the testicular specimen confirmed that it was a germ cell tumor [Seminoma]. Patient was recommended to for: (1) Chemotherapy at the Oncology Department, (2) Laparoscopic search for her right undescended testis to confirm whether it is a testis or an ovary, (3) Buccal biopsy for sex determination and (4) Surgery, for the right side, if needed. Conclusion and recommendation: Neglected cases of undescended testis may have a serious outcome. Screening for ambiguous genitalia, and early exploration and management was highly recommended.

The Case Files

A patient presented after a cardiac cath with a football-sized mass in her groinFigure 1.: Axial CT angiography demonstrating right anterior thigh hematoma measuring 11.9 cm by 15.4 cm by 21 cm with active arterial extravasation (arrow).FigureFigureFigureA 56-year-old woman presented with shortness of breath and a cough she had had for a month. She also had associated orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion. A workup revealed an NSTEMI and new systolic heart failure, dilated cardiomyopathy (estimated ejection fraction 18%), and a sizable left ventricular apical thrombus on echocardiogram. Cardiac catheterization was performed and complicated by stable focal dissection of the right femoral artery and external iliac artery. She was discharged home on warfarin and enoxaparin for the LV thrombus. The patient returned to the ED one week later with symptoms of right groin pain and generalized lethargy, and she was in hypovolemic shock and had a massive right groin mass. Bedside ultrasound of the mass revealed a large hyperechoic fluid collection prompting resuscitation with two units of packed red blood cells to treat suspected hemorrhagic shock. She was also started on norepinephrine infusion for blood pressure and MAP support. Anticoagulation reversal was administered with 10 mg of vitamin K and one unit of FFP. CT angiography of the mass was obtained (Figures 1 and 2), and the patient was immediately taken to the OR for right femoral groin exploration for suspected right femoral artery injury with active arterial extravasation.Figure 2.: Coronal CT angiography demonstrating right anterior thigh hematoma with active arterial extravasation (arrow).Massive Hematoma The patient was diagnosed with post-catheterization femoral artery dissection with massive hematoma and active hemorrhage. She presented with hypotension, progressing to hypovolemic shock requiring aggressive fluid resuscitation, blood transfusion, vasopressors, and anticoagulation reversal. CT angiography showed a mixed density hematoma measuring 11.9 cm by 15.4 cm by 21 cm, and a small central focus of contrast blush. The patient was taken to the OR, where the surgeon found a hematoma the size of a football, which is roughly 17 cm in diameter and roughly 28 cm long. The hematoma was evacuated, and the femoral artery and external iliac arteries were repaired. Hematomas are the most common complication after cardiac catheterization. One review found that the incidence of femoral hematomas was 2.8 percent while active femoral and retroperitoneal bleeds were even lower at 0.6 percent and 0.3 percent, respectively. Dissection of the femoral or iliac arteries is also extremely rare, with an incidence of 0.46 percent. (Glob J Health Sci. 2012;4[1]:65; https://bit.ly/42TUAv5.) A large multicenter cohort study investigating vascular complications following endovascular cardiac procedures found that the incidence of major vascular complications was only 1.6 percent, defined as major hematoma (>10 cm), unstable bleeding, retroperitoneal hematoma, pseudoaneurysm, and arteriovenous fistula within a 48-hour periprocedural window. (Rev Lat Am Enfermagem. 2018;26:e3060; https://bit.ly/3lXFhRx.) The study also found that most vascular complications took place within six hours of surgery, making this patient's prolonged presentation even more unexpected. Most hematomas are self-limited, but larger ones with bleeding can cause hemodynamic instability. This patient was on anticoagulation for an LV thrombus, which likely complicated the bleeding. This case highlighted the importance of physician awareness of an emergent, rare presentation of a common hospital procedure—the cardiac cath. Clinical suspicion, especially in the periprocedural setting, rapid identification of the bleeding source, and immediate imaging make the diagnosis. Patients who continue to deteriorate despite resuscitative efforts require operative management. (StatPearls. Jan. 16, 2023; http://bit.ly/3nnkmaL.) Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

SJLA_2024_A16: Unusual Complications of Open Preperitoneal Tension-Free Inguinal Hernia Repair

Background: The purpose of this study is to report two patients referred to our hospital after developing unusual complications attributed to prior open preperitoneal tension-free inguinal hernia repair. Methods: Case # 1 A 75-year-old male developed a left proximal thigh abscess requiring incision and drainage 5 years after open prosthetic, preperitoneal inguinal hernia repair with single-layer mesh. A pelvic computed tomography (CT) scan demonstrated an abscess in the left inguinal preperitoneal space as well as diverticulosis but no diverticulitis. A colonoscopy was negative for any additional findings. The patient underwent groin exploration, debridement of the inguinal canal and sinus tract, and mesh resection followed by JP drain placement. The inguinal defect was repaired utilizing the should ice technique. Intraoperative cultures revealed penicillin-resistant Staphylococcus aureus. The drain was removed on postoperative day nine, and his recovery remains uneventful without hernia recurrence or infectious complications at 11-month follow-up. Case # 2 An 82-year-old man developed progressive left lower extremity edema and disabling claudication 1 month after open prosthetic inguinal hernia repair with a bilayer disc mesh. Venous duplex imaging revealed compression of the left common femoral and external iliac veins. A CT angiogram demonstrated left external iliac and common femoral artery thrombosis and a 5.2 cm fluid collection consistent with hematoma. An inferior vena cava filter was placed. The common femoral artery was controlled after initial exploration revealed a common femoral artery pseudoaneurysm. The mesh was densely adherent to the external iliac vein and was thus not resected. The common femoral artery pseudoaneurysm was repaired and the profunda femoris artery over sewn. An external iliac to superficial femoral artery 8 mm Polytetrafluoroethylene bypass graft was placed. The patient was discharged on systemic anticoagulation without claudication on postoperative day thirteen. Results: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Discussion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Conclusion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available.

PSUN259 A Severe Case of Fournier's Gangrene Associated With Dapagliflozin

Abstract Background SGLT2 inhibitors have gained popularity in treatment of Type 2 Diabetes, and recently in lowering the risk of major adverse cardiovascular events (MACE). Genitourinary infections are well known side effects of SGLT2 inhibitors. Fournier's gangrene is a necrotizing fasciitis of the perineum which can be rarely associated with SGLT2 inhibitors. Between 2013 to 2018, the FDA received 12 case reports of Fournier's gangrene in patients taking SGLT2 inhibitors. Glucosuria from the medication creates a milieu which increases the chances of developing Fournier's gangrene. The annual incidence of Fournier's gangrene in the general population is 1.6/100,000 males in the US. Here, we present a case of Fournier's gangrene within few months of starting Dapagliflozin. Clinical case A 62-year-old male with history of poorly controlled Type 2 DM was brought to the ED after being found down at his residence covered in feces. He reportedly had nausea, vomiting and diarrhea for 3 days prior to his presentation. His diabetes home regimen consisted of metformin 1000 mg BID, oral semaglutide 14 mg daily, glimepiride 8 mg daily, pioglitazone 45 mg daily and dapagliflozin 10 mg daily. Of note, dapagliflozin was started 3.5 months prior to presentation. Workup revealed WBC count 14.2 k/ul with left shift, sodium 132 mmol/L, HCO3 15 mmol/L, anion gap 26 mmol/L, glucose 432 mg/dL, Cr 3.27 mg/dL (Baseline 1.18 mg/dL), Lactic acid 2.7 mmol/L, AST 131 u/l, CK 905 u/l and A1c 9.2%. CT abdomen and pelvis with contrast showed necrotizing infection of the scrotum and perineum, consistent with Fournier's gangrene. Gas was seen tracking into the mesorectal fascia layer in the extraperitoneal spaces of the pelvis. He was given IV antibiotics and IV fluids per sepsis protocol. Urology and General Surgery consultations were obtained with the patient taken emergently to the operating room and underwent exploration of groin with debridement of genitals, right gluteal and perianal debridement, and bilateral orchiectomy. The patient had an extensive hospital stay with gradual improvement in clinical status. He later underwent extensive reconstructive plastic surgery. All oral diabetes medications were discontinued, and he was ultimately discharged on an insulin regimen consisting of insulin glargine 20 units BID, insulin lispro 5 units before meals and insulin lispro correction scale. Conclusion SGLT2 inhibitors remain valuable drugs in treating Type 2 Diabetes. Fournier's gangrene is a rare but serious possible adverse effect of SGLT2 inhibitors that requires a high index of suspicion to recognize. Time to onset of Fournier's gangrene after initiation of SGLT2 inhibitor therapy can be variable. Patients on SGLT2 inhibitors should be alerted to seek medical attention if they develop fever associated with pain, redness, or swelling in the genital or perineal area. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

OC-038 RISK FOR CONTRALATERAL INGUINAL HERNIA REPAIR FOLLOWING PRIMARY UNILATERAL HERNIA REPAIR – A REGISTER-BASED STUDY

Abstract Aim To investigate the incidence as well as the factors predictive for a subsequent hernia repair on the contralateral side following a primary unilateral hernia repair. Material & Methods Prospective population-based study of data from the Swedish Hernia Register based on 151,297 patients operated with an index unilateral inguinal hernia mesh repair using open and endo-laparoscopic technique, during 2007–2019. Incidence, predictive factors and time to a contralateral hernia repair was analysed. Results There were 7.4% registered contralateral hernia repairs with a median time of 2.7 years to a subsequent contralateral repair following the index unilateral hernia repair. Median follow-up time was 7.5 years. Significant predictors for a subsequent contralateral hernia were, male sex (HR 1.78, 95% CI 1.61–1.97), high age (HR 1.01 95% CI 1.006–1.009), medial inguinal hernia (HR 1.05, 95% CI 1.003–1.098), combined inguinal hernia (HR 1.10, 95% CI 1.03–1.18), hernia defect size 1.5–3.0 cm (HR 1.10, 95% CI 1.03–1.17), hernia defect size > 3 cm (HR 1.36, 95% CI 1.27–1.45) and a repair on the left side (HR 1.30, 95% CI 1.25–1.35). Endo-laparoscopic repairs and obesity were associated with a lower incidence of a later contralateral repair. Conclusion If the relevant risk factors, i.e., male sex, high age, large hernia defect size, medial or combined hernia, are present at a unilateral endo-laparoscopic groin hernia repair and the decision has been shared with the patient, exploration of the contralateral groin and prophylactic mesh placement may be considered.

P-055 LAPAROSCOPIC EXPLANTATION OF GROIN MESH WITH STAPLED EXCISION OF COLO CUTANEOUS FISTULA

Abstract Aim Groin mesh explantation is a challenging situation and a multidisciplinary approach at index explantation surgery can avoid a long term catastrophic situation for the patient . Material & Method The history of the patient started a decade back with bilateral laparoscopic TAPP, following which he had swelling in both groin area with high grade fever . He was advised open bilateral groin exploration and explant of the mesh. Post procedure he was kept on antibiotics for few weeks and he was asymptomatic, he developed swelling again and started on anti mycobacterial treatment He presented four years with foul smelling discharge from the suprapubic area . CT Scan with sinogram revealed a communication with sigmoid colon and tacker from index surgery We planned laparoscopic approach, stapled excision of sigmoid-cutaneous fistula was performed . Removal of residual mesh and tacker from index under fluoroscopy guidance with skin tract excision .Intra op flexible sigmoidoscopy revealed no lumen compromise . Histopathology showed granulomatous inflammation for which he was started on atypical mycobacterial treatment for 9 months .He remains uneventful after 2 years of surgery . Conclusion Mesh infection should be avoided at index surgery with utmost care to aseptic precautions. Mesh explantation should be a part of multidisciplinary approach, radiology and colonoscopy were key investigations in this case . One should plan for a complete removal of mesh and tacker/s at index explantation surgery for safe long term outcomes .

EP-70 Gangrenous appendix with an abscess in femoral hernia cavity-a rare case of De Garengeot's hernia

Abstract Background De Garengeot's hernia (DGH) is a Femoral Hernia that contains an appendix and has been named after Rene De Garengeot, a French surgeon in 1731. It is a rare entity that is mostly identified as an incidental finding during exploration of an incarcerated Femoral Hernia and even rarer is the incidence of a gangrenous appendix in these cases. Case An 81 years-old female patient presented to Accident & Emergency complaining of a progressively tender enlarging mass in the right groin region, associated with local inflammation. CT scan of abdomen and pelvis (CTAP) performed showed suspected perforated caecum with large groin abscess. She underwent groin exploration which confirmed femoral hernia sac containing a gangrenous appendix with a surrounding abscess. The abscess cavity extended from the right groin to medial aspect of thigh. Appendectomy was performed, abscess cavity drained and washed with normal saline/ Betadine followed by suture repair of the femoral hernia defect . She made an uneventful recovery following the surgery. Discussion DGH itself is rare surgical pathology with an incidence of about 0.18% to 0.13%, however, the presentation like our case is even rarer. Emergency surgery is the definitive treatment of DGH to avoid any complications. During surgery, appendectomy and femoral hernia repair are performed consecutively. In conclusion, appendicitis within a femoral hernia often lacks a classical presentation. CTAP can be helpful in diagnosis, however there can be limitations. Appendectomy with mesh-free hernia repair is an acceptable treatment for DGH. Keywords De Garengeot hernia, Incarcerated femoral hernia

Management of Hand Injuries: a Six-year Experience from Komfo Anokye Teaching Hospital, Kumasi, Ghana

Background: Hand injuries can ruin patients’ ability to work with their hands. This could lead to depression and social isolation. It is imperative that hand injuries be reconstructed to as near normal as possible.Patients and Method: A prospective study was undertaken from January 2005 to December 2010 at the Komfo Anokye Teaching Hospital, Kumasi, Ghana to document the pattern of hand injuries, and the outcome of management. The patients were evaluated clinically. Wound debridement was done; the defects were repaired using reconstructive techniques matched to the type of injury.Result: Ninety-five patients (71 males) were treated. Male: female ratio was about 3:1. Their ages ranged from 2 to 60 years with mean (± SD) of 29.5 (± 12.9). Of the 102 hands injured, 52 were right. The right was the dominant hand in 65%. Both dominant and nondominant hands were injured equally. 5% of the injuries were isolated; 95% were combined. The distribution of mechanisms of injuries was as follows: avulsion, sustained through road traffic accidents (37%), crush injuries (25. 3%), sharp injuries (including spaghetti wrists) (19%) machine mangling (11%), burns (8.4%), blunt injuries (15%), human bites (2.1%), snake bite (1.1%), gunshot (4.2%), and injection injuries (2.1%). Patients’ occupations were: farmers 23%, mechanics (20%), traders (11%), factory workers (5%), followed by 2% each of teachers, electricians and civil servants, and 1% each of drivers and pastors; 5% were unemployed. Ofthe remainder, 16 % were children and 11% students. Surgical procedures performed were groin flap (30%), exploration and repair (24%), skin grafting (21%), debridement alone (13%) cross finger flap (7%). decompression of carpal tunnel,(3%) and terminalisation(2%)Conclusion: Severe hand injuries requiring reconstructive surgery were sustained through road traffic accidents Farmers, traders, mechanics and children are at risk of severe combined hand injuries.

Predictors of prolonged hospitalization and perioperative complications following mid-urethral sling mesh removal.

To assess preoperative and perioperative characteristics associated with increased length of stay and major complications after mid-urethral sling mesh removal. We performed an IRB-approved retrospective analysis of patients who underwent mid-urethral sling mesh removal. Demographic data and baseline surgical characteristics were collected. Operative reports and hospital/clinic notes were reviewed for complications which were categorized using the Clavien-Dindo Classification scheme. Length of stay was deemed abnormal if greater than 1day. Complications were assessed using multivariate regression analysis. A total of 468 patients were identified as having undergone mid-urethral sling mesh removal. Mean age was 56 (± 11.1). 431 patients had either retropubic or transobturator slings. 241 patients underwent retropubic or groin exploration as a part of their mesh removal. A prolonged length of stay was noted in 73 patients (15.6%) and 13 patients (2.8%) experienced a Clavien Grade 3 complication. Pre-operative narcotic/benzodiazepine use, concomitant surgical procedure, bladder injury, increased ASA class, and major complications had an increased odds of a prolonged length of stay. Patients who experienced a bladder injury, groin/suprapubic incision, and estimated blood loss of over 400mL had an increased odds of Clavien Grade 3 complications. Patient characteristics and perioperative factors are associated with increased length of stay and major complications after mid-urethral sling mesh removal.

Assessment of recurrence rate and risk factors of relapse in stage in IA vulvar carcinoma

ObjectiveTo evaluate recurrence rates and risk factors of relapse in stage IA vulvar squamous cell carcinoma (VSCC) patients. Material and methodsPopulation-based prospectively collected data on stage IA VSCC was retrieved through the Danish Gynecological Cancer Database (DGCD) during 2011–2017. A central pathology review was performed on tumors from women with recurrent disease. Results62 women diagnosed and treated for stage IA VSCC were identified. Nine (14.5%) of the included cases relapsed within the observation period. The recurrences were in the vulva, groins or both in 5 (8.1%), 3 (4.8%) and 1 (1.6%) of the women, respectively. At central pathology review, including all recurrent cases (n = 9), 5 out of 21 reviewed patients were upstaged to stage IB due to depth of invasion >1 mm and two were downstaged to Carcinoma in situ. Two of the upstaged women developed an isolated groin recurrence and one an isolated vulvar relapse. After exclusion of the seven cases the overall recurrence rate decreased to 10.9% (n = 6).Among these cases (n = 55) resection margin <8 mm and tumor size were associated with cancer recurrence. ConclusionPathological assessment of stage IA VSCC (depth of invasion ≤1 mm) may be difficult. This may result in under-staging, which impact the choice of treatment and possibly the prognosis. This suggests a need for further clarification of the FIGO measurement and may require a more radical approach when it comes to treatment and groin exploration in stage IA VSCC.Resection margins <8 mm and tumor size were associated with relapse of the disease.

Surgical management of colocutaneous fistulae in diverticulitis.

A 70-year-old female presented to the emergency department with a painful left inguinal mass along with intermittent nausea and vomiting but no constipation or obstipation. Her last bowel motion was on the morning of presentation. Her medical background was significant for gastro-oesophageal reflux disease, hysterectomy, a bowel containing reducible left inguinal hernia seen on ultrasound 3 months earlier for which the patient was awaiting surgical review and an episode of diverticulitis 4 years ago complicated by a 3.6 cm perisigmoid abscess. The previous episode of diverticulitis was treated successfully with intravenous (IV) antibiotics only as the abscess was not drainable. During this presentation, examination revealed a soft abdomen with the tender firm left inguinal mass with overlying erythema. Bowel sounds were present. The patient was afebrile, heart rate was 110 beats per minute and systolic blood pressure was 160 mmHg. Initial blood tests revealed a pH of 7.39, lactate of 1.1 mmol/L and a white cell count of 10.7 × 109/L. Attempts were made to reduce the left inguinal mass, but this was unsuccessful. After surgical review, a provisional diagnosis of an incarcerated left inguinal hernia was made. The patient proceeded to the operating theatre without imaging for an open groin exploration ± washout. Upon entering the inguinal canal, an abscess cavity was encountered unexpectedly (Fig. 1(a)). Laparoscopy was performed for concerns of bowel necrosis, revealing inflamed sigmoid bowel consistent with sigmoid diverticulitis as well as adherent bowel to the anterior abdominal wall and the bladder (Fig. 1(b)).

Intra-Operative Vascular Injury and Control During Laparoscopic and Robotic Mesh Explantation for Chronic Post Herniorrhaphy Inguinal Pain (CPIP)

Chronic postherniorrhaphy inguinal pain (CPIP) is common following inguinal hernia repair. As even primary minimally-invasive inguinal hernia repairs carry a risk of significant intra-operative bleeding, it is unsurprising that reoperative groin exploration and mesh explantation for chronic post-inguinal herniorrhaphy pain confers an even higher risk of arteriotomy or venotomy due to a distorted anatomy and the presence of adhesions. In this report, we present a single institution's experience with the management of intra-operative vascular injury encountered during minimally invasive groin exploration and mesh explantation for CPIP. We performed a retrospective consecutive case series study at a single academic center of patients with CPIP who underwent minimally invasive groin exploration and mesh removal during which an iatrogenic arteriotomy or venotomy occurred from September 2015 to September 2020. Descriptive statistics were collected for age, laterality of hernia repair, mean follow-up time, surgical approach (robotic vs. laparoscopic), type of intra-operative vascular injury, vascular control technique, and post-operative complications. Of 196 minimally invasive groin exploration and mesh removal cases, 46 were performed with robotic assistance and 150 were performed using traditional laparoscopy. The overall incidence of intra-operative vascular injury was 43 (22%). Fifteen of 46 (32%) robotic groin exploration and mesh removal cases and 28 of 150 (19%) laparoscopic cases involved vascular control. Three of 15 (20%) robotic cases and 23 of 28 (82%) laparoscopic cases involved a hybrid open inguinal approach to address anterior pathology (neurectomy, anterior mesh removal, hernia repair) or facilitate exposure for vascular repair. The most common site of injury was the inferior epigastric vessels. Other sites included the iliac vein, iliac artery, corona mortis, and accessory obturator vessels. Vascular control techniques included ligation with an energy device or suture, primary suture repair of injured vessel, or bovine pericardium patch angioplasty. All were managed without intra-operative vascular surgery intervention except for one case with extensive calcification that required endarterectomy and angioplasty to improve patency. No cases required conversion to midline laparotomy. Ninety three percent of the cases with large vessel bleeding during laparoscopic-assisted procedures were repaired via an open groin incision, whereas all cases of large vessel bleeding during robotic-assisted procedures were repaired robotically. None of the patients required transfusion. Postoperative complications occurred in 3 patients (7%), 2 (5%) developed hematoma formation requiring surgical evacuation, and 1 (2%) developed ipsilateral iliofemoral deep vein thrombosis (DVT) and underwent peripheral angiography and thrombolysis. Although minimally invasive groin exploration and mesh explantation for CPIP is technically challenging, it is a safe and effective operation when performed at experienced centers. Iatrogenic vascular injury should be anticipated but can be effectively controlled laparoscopically, robotically, or via a hybrid open inguinal incision without conversion to a midline laparotomy and with low post-operative complication rates.

Femoral hernias: A paediatric surgical enigma

PurposeIn the paediatric population, femoral hernia (FH) represents an uncommon and often misdiagnosed pathology. This study aimed to review our experience with the management of FH in children. MethodsMedical records were retrospectively reviewed for all patients presenting to the paediatric surgical service in Ireland over a 15-year period (2004–2019), who were operated on for FH. Collected data included demographics, preoperative diagnosis, operative details, complications and follow-up. ResultsDuring the study period, n = 26 patients (n = 18 males) underwent FH repair, with a median age at surgery 6.9 years (range 3–16 years). During the same period n = 5693 patients underwent inguinal herniotomy, resulting in a FH to inguinal hernia (IH) ratio of 1:219 and a FH incidence of 0.45% of all groin hernias. The right side was affected in n = 18 (69.2%) cases and all cases were unilateral. A correct preoperative diagnosis was established in n = 16 (61.5%) cases, n = 8 (30.8%) cases were misdiagnosed as IH and the diagnosis was equivocal in 2 cases (7.7%). All operations were performed on an elective basis. In 3 patients from the misdiagnosed group, FH was found at first operation following negative groin exploration for IH. The remaining 5 patients underwent previous groin exploration for suspected IH and represented with clinical picture of groin hernia recurrence. All patients with a correct preoperative diagnosis underwent a FH repair via an inguinal or infra-inguinal approach. The content of the hernia sac was preperitoneal fat in n = 18 cases, lymph nodes in n = 2 cases, omentum in n = 1 and an empty sac in n = 1. There were no postoperative complications or recurrences. Median follow-up time was 6 weeks (range 0–2.5 years). ConclusionIn the paediatric population, FH is a rare pathology and can be a challenging diagnosis. FH is commonly misdiagnosed as IH and may require more than one operation to correctly identify and treat. A high index of suspicion of FH should be maintained in patients who have a negative groin exploration for IH in the setting of a clear pre-operative diagnosis of a groin hernia. FH should also be considered in the differential diagnosis when an IH appears to recur.

Duplicated vas deferens identified in post-mortem analysis

The identification of a duplicated Vas Deferens is significant during common operations such as vasectomies, groin explorations and hernioplasties. The reports are rare and incidental. Consequences of failure to identify this anomaly may yield effects such as sperm granulomas and vasovenous fistulas. We present the first publication of a duplicated vas from an Australian cadaveric dissection.

A Retrospective Review of the Management of Vascular and Soft Tissue Complications in People Who Inject Drugs at a Tertiary Vascular Surgical Unit

Introduction - In the UK hospital admissions associated with skin,soft tissue and vascular infections (SSTVI) secondary to illicit opiod use have increased in the last 5 years. People who inject drugs (PWID) utilise a significant amount of secondary care resources and the extent of this has not been fully evaluated in the contemporary literature. The utilisation of femoral vessels for injection is indicative of long-term intravenous drug use as more easily accesible vessels in the hand and antecubital fossa become thrombosed. This study evaluates the demographics, presentation, subsequent management and outcomes of PWID presenting to a tertiary vascular unit in the UK with SSVTI. The region this work was undertaken experiences the highest number of PWID related admissions to hospital in the UK. Methods - Admissions to our hospital from Jan 2014 to Dec 2017 were collected for retrospective analysis. A total of 202 patients were admitted with a SSTVI in this time period. Presenting complaint, in-patient length of stay (LOS), receiving speciality, imaging modalities, microbiology, blood borne virus (BBV) status along with subsequent medical and surgical management were reviewed. Results - 69.3% of patients admitted with a SSTVI were male with the majority being in the age range of 40-60 (55.9%). Median LOS was 6 days (IQR 2-12.75), with 49.5% of patients being treated by the Vascular Surgical team, the rest being managed across medical, orthopaedic and general surgical teams. 30.7% of patients had USS of the SSVTI, 28.7% had a CT angiogram, 10.4% had a plain x-ray and 13.9% had both CT angiogram and USS. 48% of the patients tested positive for the Hepatitis C core antigen indicating current or recent exposure to the Hepatitis C virus. 16.3% of the patients had detectable levels of Hepatitis C viraemia on ribonucleic acid. 1% of patients were positive for HIV-1. 67 patients underwent groin exploration and drainage of an abscess with 27 also requiring ligation of a femoral pseudoanueysm. No patients underwent reconstruction of the femoral artery following ligation and there were 3 above knee amputations performed during the same in-patient episode. Conclusion - We have noted a significant increase in the number of patients presenting with SSVTI over the period of our study. This has had a significant impact on resources given the LOS and multidisciplinary input required to ensure a safe and timely discharge from hospital when dealing with PWID. All patients in whom a SSVTI is suspected in the groin should undergo a CT angiogram as the imaging modality of choice as this accurately identifies any vascular complications as well as the presence of foreign bodies which may potentially cause a needle stick injury to the surgical team. Ligation of femoral pseudoaneurysms generally does not result in patients requiring amputation, however, they are often claudicants as a result.

Transinguinal laparoscopic evaluation of contralateral side during unilateral inguinal hernia repair for children

Inguinal hernia repair is a common procedure in daily pediatric surgical practice. The present study was planned to find out whether transinguinal laparoscopic exploration (TILE) of the contralateral groin is effective in reducing the need of operation for contralateral metachronous inguinal hernia (CMIH) in children. Charts of 1103 children who underwent inguinal hernia repair between 2006 and 2016were retrospectively analyzed. Eighty-eight children with bilateral hernia at the presentation were excluded, and 705 patients whose parents could be contacted by phone to get the latest information about children's condition were included in the study. Of the 705 children with unilateral inguinal hernia repair, 362 (51.4%) and 343 (48.6%) of them had right-sided and left-sided inguinal hernia, respectively. Transinguinal laparoscopic exploration was performed in 479 of the 705 children with unilateral hernia and a hernia or contralateral patent processus vaginalis (PPV) was found and ligated in %28.3 (n=136) of them. Mean follow-up time was 60±36 months. Fifteen (4.3%) of 479 patients who had TILE and 31 (13.6%) of 226 the patients who did not have TILE developed CMIH. When the videos of 15 patients who developed CMIH were reviewed, overlooked PPV was found in 10 (3.3%) patients who had TILE during early phases of institutional learning curve. TILE of the contralateral side during pediatric inguinal hernia repair is a simple and effective method to evaluate contralateral PPV. This approach clearly and significantly reduces the need of operation for a metachronous hernia at a later date.

Scrotal migration of a ventriculoperitoneal shunt

We report a case of scrotal migration of a ventriculoperitoneal (VP) shunt that presented as a hydrocele in an 18‐month‐old boy. The patient had a history of congenital hydrocephalus secondary to aqueductal stenosis requiring VP shunting at 1 month of age. He subsequently presented with painless progressive right scrotal swelling for 12 months with the distal segment of the shunt's peritoneal catheter palpable within the scrotum, which was confirmed by X‐ray imaging. Groin exploration for catheter removal and high ligation of the hydrocele were performed. Postoperatively, there was no recurrence of the hydrocele. We recommend that all infant patients with an implanted VP shunt undergo regular scrotal examinations at the neurosurgical clinic, and that early surgical intervention should be considered when a hydrocele is detected.

SAT-325 Episodic Hypertension in a Young Female Due to Ectopic Adrenal Tissue: An Unusual Presentation

Introduction: Secondary hypertension due to elevated catecholamine secretion is typically seen in patients with pheochromocytomas and rarely, in those with paragangliomas. We present an unusual case of a young patient with episodic hypertension and elevated metanephrines possibly due to ectopic adrenal tissue. Case: A 31-year-old female with new-onset hypertension and uterine fibroids presented with left upper quadrant abdominal pain and high blood pressure. She had a partial hysterectomy 6 months ago and since then, had persistent abdominal and back pain. Over the past year, she also had worsening anxiety attacks with sudden sensation of flushing and lightheadedness. The episodes lasted for a few minutes several times a week, and were unresponsive to sedatives. On presentation, significant findings included: elevated blood pressure (178/114 mmHg), mild hypercalcemia, and an inappropriately elevated iPTH consistent with primary hyperparathyroidism. Plasma metanephrines were elevated; 24hr 5-HIAA was normal. CT of the abdomen showed a solid, lobulated retroperitoneal mass of 2.1cm with 170 Hounsfield units. Octreotide scan did not show abnormal areas of uptake. The mass was presumed to be a paraganglioma and she underwent surgical resection. The mass seen on imaging turned out to be a hemangioma however an additional mass removed from the area of the aortic bifurcation was found to be ectopic adrenal tissue. Post-op labs showed decreased metanephrines (from 101 to 23pg/mL) and normetanephrines (from 234 to 116pg/mL). Repeat CT scan 4 months later showed no new masses. Post-op, the patient’s symptoms improved but not completely resolved. Discussion: Ectopic adrenal tissue is an exceedingly rare finding in adults. It is more common in the pediatric population and is typically identified incidentally during pelvic surgery where groin exploration is performed. Sullivan et al. studied the prevalence of ectopic adrenal tissue and noted it was discovered in <3% of ~900 children who underwent groin exploration surgery, none of which were female1. With aging, ectopic adrenal tissue typically atrophies due to functioning adrenal glands making it an even less common entity in adults. Our case is even more unusual in that the ectopic tissue appears to be functioning by secreting catecholamines. Furthermore, given the primary hyperparathyroidism in the setting of a potential catecholamine-producing tumor, we pose whether this warrants genetic testing for multiple endocrine neoplasia (MEN), specifically MEN 2A. Reference: 1-J.G. Sullivan, M. Gohel, R.B. Kinder. Ectopic adrenocortical tissue found at groin exploration in children: incidence in relation to diagnosis, age and sex. BJU Int 2005; 95:407-410