Intestinal Strangulation Research Articles

A Surgical Perspective of the Outcome of a Multidisciplinary Intestinal Rehabilitation Program for Children With Short Bowel Syndrome in the Netherlands

AimIn 2001, a multidisciplinary intestinal rehabilitation program, prompted by a nationwide collaboration on intestinal failure (Dutch Registry for Intestinal Failure and Intestinal Transplantation), was started for children who have short bowel syndrome (SBS). This study evaluates this program, focusing on children who have SBS after extensive bowel resection. DesignThis is a retrospective cohort study. MethodDemographic data, general information on disease status, and outcome of intestinal rehabilitation of patients treated between 2001 and 2009 were collected. Outcome measures were intestinal autonomy, intestinal and/or liver transplantation, and survival. ResultsTen boys and 9 girls, median gestational age 36 weeks, were treated. Eight were referred, 3 times as many as in the period 1991–2000. Causes of SBS were intestinal atresia (3), gastroschisis (2), volvulus (9), necrotising enterocolitis (3), and strangulation (2). The median remaining small-intestinal length was 35 cm (range, 10 to 70 cm). In 14 patients the ileocecal valve was still present. In all patients at least 25% of colon was still present. The median follow-up was 25 months (range, 50 days to 9 years). After a median of 138 days (range, 41 days to 11 years) on total parenteral nutrition, 16 patients (84%) reached intestinal autonomy. Central venous catheter–related complications occurred in all; there were liver function disorders in 68%, and a failure to thrive in 26%. One patient underwent intestinal lengthening. No patient needed intestinal transplantation, but one underwent liver transplantation for intestinal failure–associated liver disease. Overall mortality was 11%: those 2 patients died of abdominal sepsis. ConclusionThis specialized intestinal rehabilitation program led to intestinal autonomy in 84% of the patients who had SBS. None of the patients underwent an intestinal transplantation.

Mesenteric haemangiopericytoma as a cause of ileal strangulation in a horse

A case of ischaemic strangulation of the small intestine caused by a haemangiopericytoma in a 12-year-old horse is reported. An encapsulated, 4-cm diameter mass was located in the mesentery adjacent...

Long‐term survival in horses with strangulating obstruction of the small intestine managed without resection

Although many studies have described results after small intestinal resection and anastomosis in horses, few have described the outcome in horses with strangulating lesions managed without resection. To examine short- and long-term recoveries in horses with strangulated small intestine that was judged to be viable during surgery and not resected. Retrospective analysis of case records. Data were reviewed from all cases (35 horses) with colic caused by small intestinal strangulation that underwent surgery between 1996 and 2011 at 2 university hospitals and that were managed without resection by 2 surgeons who used a clinical grading system to assess intestinal viability. Kaplan-Meier analyses were used to examine long-term survival. Survival to discharge from the hospital was 100%, and post operative complications developed in 11 horses (31%). Three horses (8.6%) required repeat coeliotomy because of persistent pain with or without reflux, and they responded favourably to decompression of distended intestine. Ten horses died after discharge, and 12 were still alive at follow-up from 20 to 192 months after surgery. Information was available on 13 horses after discharge, but these were eventually lost to follow-up. Kaplan-Meier analyses yielded a median survival probability of 120 months. A subjective method of assessing small intestinal viability in strangulated small intestine in horses, as used in this study, could reduce the need for resection and anastomosis, with the associated complications and costs. Also, the favourable post operative course in these horses provides strong evidence that early referral could avoid the need for resection and improve survival. The numbers of horses with the most severe changes that were not resected were too small to allow a conclusion that such segments should be left in place, and additional criteria might be needed to guide that decision in such cases.

Early Diagnosis and Treatment of Traumatic Diaphragmatic Injuries

Introduction: Early diagnosis and treatment of injuries of the diaphragm are important both because of high incidence of concomitant injuries and since they may lead to life-threatening intestinal and gastric strangulation in the late term. Herein, cases with diaphragmatic injury that have been diagnosed and operated in the early period after injury or during surgery were presented. Methods: Data of 14 cases, which have been diagnosed with diaphragmatic injury after trauma or during surgical procedure that was performed because of concomitant abdominal or intra-thoracic injury between January 2008 and April 2013, were retrospectively reviewed. Results: Of the traumatic diaphragmatic injuries, 10 (71.4%) have occurred due to penetrating trauma, whereas 4 (28.5%) have occurred due to blunt trauma. Diagnosis was made using I.V. contrast-enhanced whole abdominal and thoracic tomography in all 3 pediatric cases (21.4%) and during surgery in the others (78.5%). Conclusion: All of the diaphragmatic injuries have been accompanied by intra-abdominal or intra-thoracic organ injury that requires surgery. In these cases, the diagnosis was made on suspicion of diaphragmatic injury in the course of surgical procedure performed for concomitant organ injury. Computed tomography was diagnostic for diaphragmatic injuries in the pediatric cases.

Anesthetic management of a case of spontaneous rupture of diaphragm.

Sir, A 58-year-old male patient presented with a history of sudden onset of the left upper quadrant pain and vomiting from 6 days following the lifting of bucket filled with water. He also had a history of the left lower chest pain on inspiration, dyspnea on lying supine, decrease appetite and constipation. Vitals were almost normal at admission. Oxygen saturation was 90%. On auscultation air entry was absent over left lower hemithorax. Routine blood tests were normal. Arterial blood gas showed respiratory alkalosis with mild hypoxemia (pH 7.50, pCO2 30 mmHg and pO2 64 mmHg). Electrocardiogram showed “t” wave inversion in leads V1, V2 and V3. A plain erect chest radiograph showed upward shifting of the left side of hemidiaphragm, air filled shadow of stomach occupying lower half of left hemithorax, compression of the left lung, shifting of the trachea and mediastinal structures to the right side [Figure 1]. In the operating room, standard anesthesia monitors were attached. A rapid sequence induction (RSI) of anesthesia was done with thiopentone, succinylcholine, and fentanyl. Due to nonavailability of double lumen tube trachea was intubated with number 8.0 standard endotracheal tube (ETT) that was intentionally inserted in the right main bronchus and was fixed at 26.0 cm. A pressure controlled mode was initiated. Anesthesia was maintained on oxygen in the air and isoflurane. Laparotomy via midline approach revealed a tear of approximately 5 cm at the lateral side of left hemidiaphragm. Stomach was pulled down through the rent along with gangrenous part of omentum. Gastropexy was done and diaphragm tear was repaired. Gangrenous part of omentum was resected out. ETT was withdrawn to 22 cm at upper incisor and bilateral air entry was confirmed. Chest drain was placed. At the end of surgery, patient was extubated in the operating room with acceptable vital parameters. Figure 1 X-ray chest posteroanterior view showing left diaphragmatic hernia Spontaneous rupture of the diaphragm is extremely rare with limited literature. Spontaneous rupture can be due to violent cough,[1,2] during vaginal delivery[3] physical activity,[2] violent vomiting and defecation.[4] Sudden and violent Valsalva maneuver with increased intraabdominal pressure is main denominator in these cases.[5] Diagnosis is difficult due to nonspecific clinical presentation such as upper quadrant abdominal pain, vomiting, and constipation.[6] This is mostly associated with dyspnea, tachycardia and hypotension. Chest radiograph may help in diagnosis, but has poor sensitivity and specificity. Radiographic finding includes herniation of abdominal viscera into the thoracic cavity, compression of ipsilateral lung and displacement of mediastinum to the opposite side. “Collar sign” is the presence of a large bulla between the abdomen and the chest, with a constriction at the diaphragmatic level is specific of a diaphragmatic defect.[5] Early complications may include strangulation of intestine that can terminate in rupture and gangrene formation. Peritonitis and pleural effusion may be the sequel. Early intervention includes oxygenation, correction of fluid deficit, gastric decompression etc. Emergent surgical intervention is usually required in view of high mortality and morbidity. The causative factor for diaphragm rupture would be the raised intraabdominal pressure during lifting of a heavy object. Other possible etiologies like congenital diaphragmatic hernia or ischemic process was ruled out by intraoperative findings. Anesthetic management of these patients is quite challenging in view of an emergency nature of surgery with inadequate time to patient optimization, unstable hemodynamics, high probability of hypoxemia and rapid desaturation, full stomach, fluid deficit, electrolyte imbalance and need for one lung ventilation. These patients often require the securing of wide bore intravenous access or central venous cannulation, beat to beat blood pressure monitoring if hemodynamically unstable. RSI in these patients may cause rapid desaturation because of already decreased functional residual capacity. During mechanical ventilation, lung protective strategy should be applied with low tidal volume and positive end expiratory pressure. Postoperatively, patient can be extubated in the operating room if vital parameters allow. Grossly ruptured and hemodynamically unstable patient should be allowed to ventilate postoperatively. Adequate analgesia (epidural analgesia) in the postoperative period can help in early recovery. Patient controlled analgesia can be used if epidural was placed.

Herniation of the gravid uterus through a mesoduodenal defect and concurrent omental hernia in a cow

To describe surgical treatment of herniation of the gravid uterus through the mesoduodenum, displacement of the descending duodenum around the gravid uterus, and concurrent herniation of the small and large intestines into the omental bursa in a cow. Clinical report. Three-year-old, five-month-pregnant Swiss Braunvieh cow. Repositioning of the displaced uterus and descending duodenum without transection and anastomosis of the duodenum was performed through a right flank laparotomy. Concurrent displacement of a large portion of the small and large intestines into the omental bursa was not associated with intestinal strangulation and was corrected manually. The defects in the omentum and mesoduodenum were sutured. There were no postoperative complications, and the cow was healthy at discharge from the clinic 1 week after surgery. Telephone follow-up revealed that the cow had delivered a live calf and was producing a normal amount of milk. The cow was slaughtered 14 months after the surgery because of an udder problem. Herniation of the gravid uterus through a tear in the mesoduodenum with subsequent displacement of the descending duodenum around the uterus combined with internal omental herniation caused nonspecific clinical signs and no ileus. Exploratory laparotomy in an early stage of pregnancy facilitated reduction of the displaced uterus without transection of the descending duodenum.

English

Caecal volvulus is a rare condition and caecal bascule, a variant of caecal volvulus is even rarer. Despite similar clinical presentation, initial vigil during clinical examination helps in furthering the diagnosis. The objective of treatment in case of caecal volvulus is to avoid any complication such as gangrene with resection being the only choice if gangrene has already developed. The present case of a 53 year old male, is a typical representation of a caecal volvulus complicated by presence of gangrene confirmed on laparotomy. Resection of 5.7 cm of involved gangrenous part averted any further complication. Follow-up and reversal of ileostomy was done after 6 weeks with an ileo-ascending anastomosis. No complication was reported during the follow up. INTRODUCTION: Cecal volvulus is a rare condition, and its incidence is reported to range from 2.8 to 7.1 per million people per year [1]. It is characterised anatomically by the axial twisting that occurs involving the caecum, terminal ileum, and ascending colon [2, 3]. Caecal bascule is a variant of this condition associated with the upward and anterior folding of the ascending colon and accounts for about 10% of all caecal volvulus case sp [3]. Despite anatomical differentiation, the clinical profile of caecal volvulus and caecal bascule is very similar and is often manifested in terms of intestinal obstruction and strangulation [2, 3]. Clinical presentation of volvulus cases is very diverse and is characterized by intermittent episodes of abdominal pain to unbearable pain leading to medical emergencies [3, 4]. Owing to its rare occurrence, it is difficult to diagnose. In this paper, we report a case of cecal volvulus with extremely rare caecal bascule variant seen in a 55-year-old man, diagnostic method, treatment planning and management of the case is discussed CASE REPORT: A 55 year old male presented with complaints of pain for the last 5 days followed by distension of abdomen for the last 2 days. He was also vomiting for the past 24-hours. On examination, generalized distension with tenderness was felt. Tympanic note over left upper quadrant was noticed. There were no bowel sounds and no evidence of sepsis. Erect X-Ray of abdomen showed dilated small bowel loops with a large gas-filled loop with haustrations placed obliquely which are characteristic of caecal bacsule. On exploratory laparotomy, caecum & appendix were found to be gangrenous and lying over splenic flexure of colon. Resection of gangrenous segment 5.7 cm in length was done with exteriorization of ileum & ascending colon. Patient recovered and was discharged with ileostomy in situ on day ___. Follow-up and reversal of ileostomy was done after 6 weeks with an ileo-ascending anastomosis.

Small Intestinal Strangulation Due to a Rare Type of Primary Internal Hernia

Internal hernias in which the gate is located in the paracolic gutter are rare. A 75-year-old man was admitted to our hospital with severe epigastric pain without past history of laparotomy and/or trauma. He was diagnosed with strangulation of the ileum by the findings of computed tomography, and the operation was performed. During laparotomy, the small intestine was found to be strangulated and to enter the retroperitoneum from the right paracolic gutter near the hepatic flexure. The patient was diagnosed with an internal hernia, which differed from a pericecal hernia in that the hernia gate was located along the paracolic gutter near the hepatic flexure far from the cecum. Hence, it was considered to be a rare type of internal hernia. We report the clinical presentation and imaging findings of this rare internal hernia.

Evaluation of neutrophil apoptosis in horses with acute abdominal disease

To quantify peripheral blood neutrophil apoptosis in equine patients with acute abdominal disease (ie, colic) caused by strangulating or nonstrangulating intestinal lesions and compare these values with values for horses undergoing elective arthroscopic surgery. 20 client-owned adult horses. Peripheral blood was collected from horses immediately prior to and 24 hours after surgery for treatment of colic (n = 10) or elective arthroscopic surgery (10), and neutrophils were counted. Following isolation by means of a bilayer colloidal silica particle gradient and culture for 24 hours, the proportion of neutrophils in apoptosis was detected by flow cytometric evaluation of cells stained with annexin V and 7-aminoactinomycin D. Values were compared between the colic and arthroscopy groups; among horses with colic, values were further compared between horses with and without strangulating intestinal lesions. Percentage recovery of neutrophils was significantly smaller in preoperative samples (median, 32.5%) and in all samples combined (35.5%) for the colic group, compared with the arthroscopy group (median, 66.5% and 58.0%, respectively). No significant differences in the percentages of apoptotic neutrophils were detected between these groups. Among horses with colic, those with strangulating intestinal lesions had a significantly lower proportion of circulating apoptotic neutrophils in postoperative samples (median, 18.0%) than did those with nonstrangulating lesions (66.3%). The smaller proportion of apoptotic neutrophils in horses with intestinal strangulation suggested that the inflammatory response could be greater or prolonged, compared with that of horses with nonstrangulating intestinal lesions. Further investigations are needed to better understand the relationship between neutrophil apoptosis and inflammation during intestinal injury.

Intra-abdominal adhesions in ultrasound. Parts I and II.

The peritoneal adhesions and their clinical consequences, such as bowel obstruction, infertility in women and increased risk of extrauterine pregnancy, still remain an unsolved problem in contemporary intra-abdominal surgery. The frequency of occurrence of adhesions following laparotomies is estimated to reach 67–97%(1, 2). The most common causes encompass a physical trauma (including surgical or thermal one, e.g. electrocoagulation), infection, ischemia and the presence of a foreign body (stitches, talc, gauze, intestinal contents). Peritoneal adhesions are the most common cause of intestinal obstruction. The presence of adhesions increases the risk of each surgery and extends its duration, in particular, the stage of opening the abdominal cavity. Adhesions increase the probability of damaging the intestine while opening the abdominal cavity by 20%(3–5). Adhesive obstruction of the bowels may occur in 5% of patients who underwent a surgery(6). The adhesions which cause intestinal obstruction most frequently form after surgeries involving the large intestine as well as urologic and gynecological procedures. After laparoscopic procedures, adhesions appear more rarely and their preparation is easier(7–9). The methods that help decrease the risk of intra-abdominal adhesions include: non-traumatic surgeries, minimally invasive surgery, usage of gloves without talc, removal of drains and remains of dead tissues from the peritoneal cavity, restraining from suturing the defects in the peritoneum as well as administering pharmacological agents such as non-steroidal anti-inflammatory drugs, anticoagulants, vitamin E, statin, medicines with topical anesthetizing effect, dextran derivatives (Adept – 4% icodextrin solution) and Seprafilm (a biological barrier that prevents adhesions; composed of two polysaccharides: hyaluronic acid, carboxymethylcellulose). Seprafilm is very hydrophilic and does not require suturing. The differentiation between simple mechanical obstruction and strangulation obstruction constitutes a difficult clinical problem. Strangulation and necrosis of the bowel are the cause of a high perioperative mortality rate which in these cases equals 8–28%(7, 10). When diagnosing adhesive obstruction, the most valuable methods comprise: repeated physical examinations, plain abdominal x-ray, computed tomography and bowel passage with water soluble contrast agent (gastrografin). Gastrografin is a hyperosmolar agent (1900 mOsm/L) which increases the amount of water in the bowel and stimulates its peristalsis. The bowel passage of gastrografin is then both a diagnostic and therapeutic method(11–13). To prevent adhesive obstruction, it is proposed to perform internal intestinal splinting for the period of 7–14 days(14). The relevant literature relatively seldom mentions the value of ultrasound examination (US) in assessing the number and localization of intra-abdominal adhesions. It is a shame since there are more and more specialists in clinical sonography who use more and more advanced US equipment. Therefore, abdominal examinations performed to assess adhesive disease of the peritoneal cavity should be encouraged. In 1994, Duffy and diZerega proposed the application of abdominal US examination prior to laparoscopic management of adhesive obstruction in order to localize the first trocar(15). I know Professor Andrzej Smereczynski personally. I have always admired him for his stubbornness in research, consistent actions, enthusiasm and motivation. The Professor has vast experience in clinical sonography. He constantly verifies his studies and findings in the operation theatre. He checks himself and his actions. This is a rare and exceptional feature among diagnosticians. I have read both papers with huge interest(16, 17). Despite my limited, not to say, scarce knowledge and experience in the field of sonography, I recognize the diagnostic significance and value of the examination that is performed well and properly. I can think of numerous clinical situations in which sonographic assessment of adhesions would be of enormous significance, namely: The selection of the best site to perform a surgical cut or insert the first trocar in the patients with the history of surgeries (laparotomies). Such a procedure would surely reduce the risk of damaging the bowel when opening the abdomen. The help to differentiate between simple intestinal obstruction and strangulation of the mesentery that may cause bowel necrosis and requires urgent surgical intervention. Diagnosis of so-called aggressive fibromatosis of the peritoneum in the course of multiple, familial polyposis of the large intestine. The more common application of US examination in intra-abdominal adhesions would reduce the number of computed tomography examinations which are expensive and burden the patient with a high dosage of radiation. I can imagine that learning sonographic diagnosis of intraabdominal adhesions requires a long training. Nonetheless, with such a distinguished center, where Professor Smereczynski works, we might hope that more and more radiologists and other specialists, necessarily including surgeons, will take an interest in this diagnostic method. With all my heart, I wish you all the best and many successes in developing intra-abdominal adhesion sonography.

Predisposing Factors for Colonic Torsion/Volvulus in Dogs: A Retrospective Study of Six Cases (1992–2010)

The purposes of this retrospective study were to review cases of colonic torsion/volvulus between July 1992 and August 2010 and to determine if any predisposing factors exist for the development of this condition. Six dogs were diagnosed with colonic torsion/volvulus during the study period. Four dogs had a history of previous gastric dilation-volvulus (GDV) with prophylactic gastropexy. Three of six dogs diagnosed with colonic torsion/volvulus had large intestinal entrapment and strangulation around the gastropexy site at the time of surgery. The history, clinical signs, physical examination, and radiologic findings were not specific for colonic torsion/volvulus in any dog. Early exploratory laparotomy was indicated to confirm the diagnosis and perform surgical correction of the affected bowel segments. Three of five dogs that underwent surgery had a left abdominal wall colopexy performed. All five dogs that underwent surgery in this study survived postoperatively. One patient was euthanized without surgical intervention. Results suggest that colonic torsion/volvulus should be considered in any large-breed dog with nonspecific gastrointestinal clinical signs and a history of previous gastropexy. Early recognition and prompt treatment of this condition may result in a good outcome.

Thoracoscopic Diaphragmatic Hernia Repair in a Warmblood Mare

To describe successful repair of a diaphragmatic hernia in a standing sedated horse using a minimally invasive thoracoscopic technique. Clinical report. Warmblood mare with a diaphragmatic hernia. An 18-year-old Warmblood mare with severe colic was referred for surgical treatment of small intestinal strangulation in a diaphragmatic defect. Twelve days after initial conventional colic surgery, left-sided laparoscopy in the standing sedated mare for diaphragmatic herniorrhaphy failed because the spleen obscured the hernia. One week later, a left-sided thoracoscopy was performed in the standing sedated horse and the hernia repaired by an intrathoracic suture technique. No long-term complications occurred (up to 4 years) and the mare returned to her previous athletic activity, followed by use as a broodmare. To avoid the high risks associated with general anesthesia, and to reduce surgical trauma and postoperative recovery, central diaphragmatic hernias are amenable to repair using a minimally invasive thoracoscopic technique in the standing sedated horse.

Huge Chronic Trauma Rupture of the Left Diaphragm Complicated with Massive Visceral Herniation and Colon Obstruction: Laparoscopic Primary Suture Repair, Sparing the Chest Tube

Introduction: In the early post-traumatic period, diaphragmatic hernias may be missed and complicated at a later time by intestinal obstruction and strangulation. In most cases, open thoracic or abdominal approach is performed. While laparoscopic approach has been established as the method of choice for hiatal hernioplasty, it can well be considered as an alternative approach to post-traumatic diaphragmatic hernias, independently of the defect size. Our case was a chronic (happened 6 months before), left diaphragmatic trauma-rupture, starting anterior to the esophageal hiatus and transversely extending for more than 10 cm along the left tendonous part of the diaphragm that was managed with total laparoscopic approach. In addition, the remnant pneumothorax was fully eliminated intraoperatively, sparing chest tube. Methods: A 50-year-old man was admitted to hospital complaining of colicky epigastric pain, shortness of breath and constipation. After a chest X-Ray and a double-contrast CT-scan, he was diagnosed with massive visceral herniation, subsequent left diaphragmatic rupture complicated with colon obstruction, left lung collapse and atelectasis. No other injury was administered. Laparoscopic management was promptly decided for the repair of the diaphragmatic rupture. The operation started with the restoration of viscera into the abdominal cavity, giving view to the collapsed left lung. Extensive adhesiolysis and meticulous dissection were performed due to chronic dense adhesions, especially between the stomach fundus and the posterior flap of the diaphragm. The left triangular liver ligament was divided in order to create adequate space for suture repair. The extended dissection and preparation of the diaphragm allowed for a tension-free, primary suture repair of the defect, using a nonabsorbable Ethibond (No. 2-0) running suture. The anesthetist recruited Valsalva maneuver with Positive End Expiratory Pressure (PEEP), aiding the elimination of remnant pneumothorax, while the surgeon was aspirating the remained air from the thoracic cavity, using a suction device, through a small diaphragmatic opening that was left unsutured for that purpose. Once the pneumothorax was fully aspirated, the opening was also sutured, sealing-up the diaphragm. Results: Despite hernia's size and chronicity, the patient was successfully managed laparoscopically with primary intracorporeal suture repair of the rupture. Operation time was 120 minutes. The pneumothorax was completely eliminated intraoperatively with the aid of the anesthetist. The lung was immediately expanded; thus, no chest tube was needed. No intraoperative complication occurred. The patient was uneventfully discharged home 2 days later. Conclusions: Laparoscopic approach to traumatic diaphragmatic hernias is feasible and safe. Beyond its well-known advantages to open surgery, its efficiency depends on the surgeon's experience in advanced laparoscopic surgery with intracorporeal suturing skills. Intraoperative elimination of remnant pneumothorax can result in reduced morbidity and hospital stay. The authors have nothing to disclose. Run time of video: 7 mins 50 secs

Small bowel lesion due to spiral tacks after laparoscopic intraperitoneal onlay mesh repair for incisional hernia

INTRODUCTIONLaparoscopic intraperitoneal onlay mesh (IPOM) repair has become a widely accepted operative technique for incisional hernias. However, tack fixation poses the risk of adhesions and injury to the intestine. We report the case of spiral tacks adherent to the small bowel after IPOM repair for incisional hernia. PRESENTATION OF CASE64 years old male patient who underwent laparoscopic IPOM repair for incisional hernia 1 year after open sigmoid resection. A laminated polypropylene mesh was fixed with titanium spiral tacks. 4 years later, elective open cholecystectomy was performed. Two spiral tacks integrated in the seromusular layer of the small bowel were encountered. Tacks were removed and bowel lesions oversewn with interrupted seromuscular stitches. DISCUSSIONAccording to the current literature, complications related to metal spiral tacks in IPOM mesh repair such as intestinal perforation or strangulation ileus seem to be rare. To our knowledge, spiral tacks adherent to the intestine have not yet been published to date. Alternative techniques for mesh fixation are transfascial sutures with single stitches, continuous sutures or fibrin glue, as already used in TAPP and TEP procedures for inguinal hernia repair. The ideal and safest technique for mesh fixation in IPOM repair for incisional hernias remains controversial. CONCLUSIONSpiral tacks used for intraperitoneal mesh fixation can lead to adhesions and bowel lesions. Sutures, absorbable tacks or fibrin glue are alternatives for mesh fixation. Further clinical trials are needed to evaluate the safest technique of laparoscopic IPOM incisional hernia repair.

Late Post Traumatic Right-sided Diaphragmatic Hernia Presenting with Acute Intestinal Obstruction and Strangulation: A Rare Presentation

We report a case of 16 year old male, who was presented to Jawaharlal Nehru Medical College, AMU, Aligarh, India as an emergency case with complaints of severe abdominal pain, difficulty in breathing and bilious vomiting. He was diagnosed as a case of late post traumatic right side diaphragmatic hernia with acute intestinal obstruction. He was successfully treated surgically by laparotomy and the defect was closed with polypropylene suture. The patient was followed for 3 months after operation and there was no complication.

Hernia incisional gigante complicada. Consecuencias de una evolución prolongada

IntroductionIncisional hernias are the most common cause of intestinal strangulation in patients presenting with intestinal obstruction, potentially complicating with intestinal gangrene, sepsis and eventually intraabdominal hypertension syndrome and its pathophysiological consequences Case reportAn obese woman with a strangulated incisional hernia is herein reported. We discuss the severe consequences and lethal risks to which this patient was exposed as a consequence of her hernia. The clinical course and treatment is reported, stressing the most important clinical and pathological aspects. ConclusionsThis gigantic incisional hernia developed because the surgical treatment was delayed due to a diverse number of factors, the most important of which was the morbid obesity and the fear of postoperative complications frequently developing in such patients. Emergency surgery in these cases represents an increased risk for the patient, the procedure is habitually bloody, and it is associated to severe postoperative morbidity.

An undiagnosed left sided traumatic diaphragmatic hernia presenting as small intestinal strangulation: A case report

INTRODUCTIONPost traumatic diaphragmatic hernia is very often missed particularly in polytrauma patients. We present case of an isolated post traumatic diaphragmatic hernia with strangulation, a very rare finding. PRESENTATION OF CASEA 35 year old man presented with features of intestinal obstruction with past history of a seemingly trivial blunt thoracic injury 15 years back. Findings of X-ray abdomen and chest with high leukocyte count raised suspicion of obstructed diaphragmatic hernia which on exploration revealed obstructed diaphragmatic hernia with gangrenous bowel segment. DISCUSSIONBlunt injury of diaphragm is relatively common and is considered as a marker of severe trauma and it can clinically be occult as other violent injuries may mask and disguise its initial clinical presentation1 resulting in late presentation with obstruction and/or rarely strangulation. An early diagnosis of the condition is prudent to avoid morbidity and mortality associated with late presentations. CONCLUSIONIn a patient of intestinal obstruction with history of even trivial throraco- abdominal injury, diagnosis of diaphragmatic hernia should be kept in mind.

Femoral Hernia: A Review of the Clinical Anatomy and Surgical Treatment

Purpose: Femoral hernia is a kind of ventral hernia that surgeons commonly encounter, second in frequency only to inguinal hernia. Femoral hernias often require emergency surgery because of incarceration or strangulation of the intestine. In addition, intestinal resection may need to be considered based on intestinal viability. Definitive preoperative diagnosis and strategic planning for surgery are thus important. The surgeon should consider the operation in the context of the clinical anatomy of the abdominal cavity. Therefore the essence of the clinical anatomy and treatment of femoral hernia is described. Methods: The medical records of 38 patients who underwent femoral hernia repair between March 2006 and November 2011 were retrospectively analyzed. Results: Femoral hernioplasty was performed with original mesh repair or Ruggi’s repair plus iliopubic tract repair (or Bassini’s repair). The mean patient age was 76.7 years, and a female predominance was apparent. Twenty-four patients underwent emergency surgery with a diagnosis of incarcerated femoral hernia. Nine patients showed intestinal strangulation and underwent resection of the small intestine. Four patients developed complications. One patient died due to aspiration pneumonia. No recurrences were encountered after 6 months to 6 years of follow-up. Conclusion: Femoral hernia is an important surgical condition with high rates of incarceration/strangulation and intestinal resection. Correct preoperative diagnosis of femoral hernia and a strict operative strategy are important. The original mesh repair is effective and easy to perform.

Young Woman With Vomiting, Dyspnea, and Chest Pain

Young Woman With Vomiting, Dyspnea, and Chest Pain

Presumptive bacterial translocation in horses with strangulating small intestinal lesions requiring resection and anastomosis

To document whether presumptive bacterial translocation (PBT) occurs in horses with small intestinal strangulation (SIS). Prospective clinical cohort study. University tertiary care facility. Thirty-six adult horses with SIS (clinical cases) and 10 adult horses without gastrointestinal disease (control cases). Sterile collection and bacterial culture of samples from peripheral venous blood, mesenteric venous blood, mesenteric lymphatic tissue, and intestinal aspirates from horses with SIS and control horses without gastrointestinal disease. Five of 36 (13.8%) horses with SIS had at least 1 sample yield a positive result. Shorter SIS bowel segments were more likely to yield a positive culture result. (P < 0.01). Two of 10 of control horses had positive culture results with different bacterial species identified compared to horses with SIS. Antimicrobial usage did not influence bacterial culture status (P = 0.31). There were no differences between culture-positive and culture-negative horses with SIS regarding admission, clinical, or clinicopathologic variables. PBT occurs in normal horses and in horses with SIS. Bacterial genera differed between groups. A low incidence of PBT occurs in horses with SIS suggesting postoperative morbidity in some cases may be due to other factors.