Herniation through a defect of the uterine broad ligament is a rare internal hernia that is difficult to diagnose definitively. Common hernia contents contain ileal loops. Herein, we report a rare case of internal herniation of both the ileum and fallopian tube through a defect of the broad ligament. A 52-year-old woman presented to our hospital with suprapubic pain and vomiting. She had a history of bowel obstruction following cesarean section. On abdominopelvic computed tomography, we suspected a closed-loop obstruction associated with bowel herniation in the right broad ligament. However, we could not identify an area of poor enhancement adjacent to distended small intestines. Emergency laparoscopic exploration revealed a viable ileal loop and incarcerated organ. Therefore, we switched to laparotomy that revealed the right fallopian tube as the ischemic organ. We reduced the hernia, resected necrotic right fallopian tube, and closed the defect of the broad ligament. The patient had an uneventful postoperative course. Rare hernia contents might complicate preoperative clinical diagnosis. Laparoscopy is useful for establishing a definitive diagnosis and treating broad ligament hernias.

/pdf/rare-contents-of-an-internal-hernia-through-a-defect-of-the-4ffr36djve.pdf

Rare Contents of an Internal Hernia through a Defect of the Broad Ligament of the Uterus

(1) Background: Gastroduodenal perforation (GDP) is a life-threatening condition caused by a spontaneous or traumatic event. Treatment should be based on the mechanism of damage, timing, location, extent of the injury, and the patient’s clinical condition. We aimed to examine several etiologic factors associated with gastroduodenal perforation and to search for the best method(s) for its prevention and treatment. (2) Methods: We conducted extensive literature reviews by searching numerous studies obtained from PubMed, Science Direct, and Cochrane for the following keywords: gastroduodenal perforation, Helicobacter pylori, NSAIDs’ use, side effects of GDP, laparoscopy, and surgery. The primary outcome was the reported occurrence of GDP. (3) Results: Using keywords, 883 articles were identified. After applying the inclusion and exclusion criteria, 53 studies were eligible for the current analyses, with a total number of 34,692 gastroduodenal perforation cases. Even though the risk factors of gastroduodenal perforation are various, the prevalence of H. pylori among patients with perforation is considerably high. As technology develops, the treatment for gastric perforation will also improve, with laparoscopic surgery having a lower mortality and complication rate compared to open surgery for GDP treatment. (4) Conclusions: H. pylori infection plays the most significant role in GDP, more than NSAIDs, surgery, chemotherapy, or transplantation. Treatment of H. pylori infection is essential to decrease the prevalence of GDP and speed up its recovery. However, urgent cases require immediate intervention, such as laparoscopic or open surgery.

The Prevalence, Etiology and Treatment of Gastroduodenal Ulcers and Perforation: A Systematic Review

Although the classical surgical treatment of adhesive ileus is performed using the open method, laparoscopic surgery has recently been performed in some centers. This study aimed to discuss the feasibility and role of laparoscopic surgery in the treatment of adhesive small bowel obstruction. In this retrospective study, the data of 830 patients who were operated for ileus in Başkent University Faculty of Medicine, Ankara Hospital, Department of General Surgery between January 2011 and September 2022 were analyzed. Missing data and intraabdominal cancer-related ileus were accepted as exclusion criteria and 648 patients were excluded from the study. The development of adhesion-related ileus and completeness of the data were accepted as inclusion criteria. Data were compared between the 2 groups [open group (OG; 152 cases) and laparoscopic group (LG; 30 cases]). When the patient characteristics were evaluated, it was found that the history of previous abdominal surgery (P < .001) and the number of previous abdominal surgery (P < .001) were statistically significantly higher in OG. Operation time was significantly longer in the LG (P = .022). There were no statistically significant differences between the groups in terms of intraoperative bowel injury (P = .216), bowel resection (P = .284), and stoma creation (P = .331). OG had a significantly higher rate of Clavien-Dindo grade ≥ 3 serious complications (P < .001) and mortality rate (P = .045). The first gas out occurred significantly earlier in the LG (P = .014). Oral intake was initiated earlier in the LG (P = .004). The length of hospital stay was significantly shorter in the LG (P < .001). There was no significant difference between the groups in terms of postoperative ileus, readmission, and reoperation. Laparoscopic surgery can be safely performed for the treatment of selected patients with adhesive small bowel obstruction. In addition, it is advantageous in terms of postoperative recovery.

Is laparoscopic surgery safe and feasible in acute adhesive ileus?

Introduction: The present study aims to bridge this gap by providing an extensive comparative analysis of totally extraperitoneal (TEP) versus transabdominal preperitoneal (TAPP) techniques to correct bilateral inguinal hernias, focusing on their efficiency, safety levels, and complication rates. Materials and Methods: We used a retrospective cohort study design that compared TEP with TAPP results among adult patients who underwent bilateral inguinal hernia repair from January 2021 to December 2023 at our institution. Exclusion criteria were recurrent hernias, emergency procedures, or patients who were not suitable for the minimally invasive approach. Surgical results, including complication rates, recovery outcomes, and operative details, were analyzed systematically. Results: A total of 144 patients, 51 with TAPP and 93 with TEP, were included in the study. There was no statistical difference between the groups in terms of mean age, body mass index, and length of hospital stay. The mean VAS scores in pain assessment the morning after surgery were 3.1±1.5 (TAPP) and 2.9±1.4 (TEP) respectively, and there was no significant difference between the two methods (p=0.346). Complications and readmission rates did not show significant differences between the two approaches. Conclusion: Both TEP and TAPP are effective laparoscopic methods that can be applied in bilateral inguinal hernia surgery. This is because no major complications are observed in either surgical procedure. Patient characteristics and surgical experience are the main determinants of the procedure to be chosen.

Which technique is used in laparoscopic bilateral inguinal hernia surgery ?

A multi-analysis of nomogram model for the identification of banded adhesions and matted adhesions in adhesive small bowel obstruction.

Background: Laparotomy (open surgery) is considered the standard approach for acute small bowel obstruction (ASBO). However, with the advent of minimally invasive surgery, the laparoscopic approach is gaining popularity. There is no consensus on the appropriate setting for laparoscopic therapy for small bowel obstruction (SBO).

Aim and objectives: The purpose of this study is to evaluate the outcomes of laparoscopic surgery for ASBO.

Patients and methods: We retrospectively evaluated the prospectively collected data of all the 38 patients who had undergone laparoscopy for ASBO, performed by a single surgeon at our institution, due to adhesions (30 patients), internal hernias (five patients), midgut malrotation (one patient), ileo-ileal intussusception (one patient), and superior mesenteric artery (SMA) syndrome (one patient) from 2012 to 2020. Data were extracted from the hospital electronic medical records (EMR) for the following parameters of each individual patient: age, sex, clinical presentation, preoperative investigation findings, final diagnosis, surgical details, operating time, time to postoperative oral feeds, length of hospital stay, complications, recurrences, and time taken to resume normal activity. A preoperative abdominal contrast-enhanced computed tomography (CECT) was performed in all the cases. Patients with peritonitis and septic shock were excluded from the study. 

Results: The mean age of the 38 patients was 58 years (ranged between 33 and 83 years) with a standard deviation (SD) of 16.5. The mean age of the female patients in the study was 60.5 years with an SD of 16.6, while the mean age of the male patients was 54.9 years (SD = 16.2). The age difference between male and female patients in the study was not statistically significant (p = 0.36). The mean operating time was 74.4 minutes (range: 60-90 minutes, with an SD of 7.2). The mean time to oral liquid/soft diet was 2.5 days. The mean postoperative stay was 5.7 days. Three patients (8%) underwent conversion to open surgery, out of which two patients had multiple complex bowel-to-bowel and bowel-to-parietes adhesions, and in one patient, massive distension of small bowel caused technical difficulties.

Conclusion: Laparoscopic management of ASBO is feasible, effective, and safe. Optimum surgical techniques, the surgeon's experience with the procedure, and stringent patient selection criteria enable a high probability of success.

Role of Laparoscopy in the Surgical Management of Acute Small Bowel Obstruction: Fact or Fiction?

Background Recently, laparoscopic totally extraperitoneal (TEP) inguinal hernia repair has been considered one of the most effective and widely performed techniques for repairing inguinal hernias by avoiding entry into the peritoneal cavity. Its indications have evolved and expanded to almost encompass the entire range of groin hernias. This retrospective study aims to determine the outcomes and postoperative complications in patients undergoing TEP inguinal hernia repair performed by a single surgeon for groin hernias at a single center. Methodology We retrospectively evaluated the prospectively collected data of 900 patients who underwent elective TEP repair over 18 years at a single center performed by a single surgeon from April 2004 to February 2023. Patients were evaluated for age, sex, type of hernia, time taken for surgery, open from laparoscopy, intra and postoperative complications, hospital stay, and days taken to resume regular activity. Results The mean age of the 900 patients was 59 years (range = 21-83 years). The mean age of males and females was 59 and 56 years, respectively. The mean operative time was 40 and 55 minutes for a unilateral and bilateral hernia, respectively. In total, 369 (41%) patients had a right-sided groin hernia, 382 (42%) patients had a left-sided groin hernia, and 149 (16.5%) patients had bilateral groin hernias. A total of 121 (13%) patients had occult hernias, and 17 patients underwent concurrent TEP and transurethral resection of the prostate. Of the 900 patients, 20 (2.2%) had a recurrent hernia after a previous open inguinal hernia repair. Seven (0.8%) patients had a recurrence of hernias post-TEP and subsequently underwent open inguinal hernia repair. Seven (0.7%) patients needed conversion from TEP to the transabdominal pre-peritoneal approach. Only minor complications were noted intra and postoperatively. The average time of hospitalization was 24 hours. The time to resume normal activities was five (±1) days. Conclusions Our experience suggests that TEP repair with mesh fixation is a safe and effective procedure with a marginal recurrence rate. Apart from the obvious cosmetic benefits of minimal tissue invasion, a significant advantage of TEP is the visualization of the contralateral groin along with the surgical repair of a hernia, if required, in the same sitting and without the insertion of any extra trocars. 

/pdf/laparoscopic-groin-hernia-repair-using-the-totally-84yf93tx.pdf

Laparoscopic Groin Hernia Repair Using the Totally Extraperitoneal Approach: A Retrospective Study and Our Experience

AIM This prospective study aimed to determine the outcomes and postoperative complications of hemorrhoid disease (HD) treated by hemorrhoidal laser procedure (HeLP). BACKGROUND We, herein report the results of 18 months of methodical use of mini-invasive laser procedures in 100 patients with grades 2 and 3 hemorrhoids and minimum to a mild degree of rectal prolapse. The surgical technique is called HeLP. METHODS Data were collected on the duration of the procedure, intraoperative complications, postoperative pain, the declivity of hemorrhoids, persistency or complete resolution, and recurrence of hemorrhoids were collected prospectively. RESULTS No evidence of intraoperative complications occurred. The median follow-up was nine months. Postoperative pain was not significant or null in most patients. There was no rectal tenesmus or alteration of defecation habits. Plateau of hemorrhoid symptoms and downgrading of hemorrhoid size reached approximately three to seven months post-procedure. The frequency of pain, bleeding, pruritus ani, and acute hemorrhoidal syndrome decreased by 75-80%. There was a significant reduction in hemorrhoids with the rate of recurrence being 7% over 12 months of follow-up. CONCLUSION Our study evaluated and demonstrated that HeLP is an effective, safe, and non-painful procedure for the management of patients with the symptomatic second or third degree of hemorrhoid with mild to the minimum degree of rectal mucosal prolapse. It is a suitable ambulatory treatment.

The Laser Therapy for Hemorrhoidal Disease: A Prospective Study.

Appendiceal mucinous neoplasms are rare and account for just 0.6 percent of gastrointestinal malignancies and approximately 0.7-1 percent of appendicectomy specimens. Most of the appendicular malignancies are detected incidentally. We, herein, report images of a case of a 76 years old male patient who presented with dull pain in the lower abdomen and a palpable lump in the right lower abdomen. A contrast enhanced computed tomography scan of the abdomen revealed an ileo-colic intussusception. He underwent a laparoscopic quarter colectomy with ileo-colic anastomosis followed by an uneventful post-operative recovery. The histopathology report revealed a low grade appendiceal mucinous neoplasm with clear resecton margins.

A Rare Case of Low-grade Appendicular Mucinous Neoplasm Presenting as Ileocolic Intussusception

Broad ligament hernia (BLH) is a rare clinical entity. It is a potentially life-threatening, yet often neglected and sometimes misdiagnosed surgical condition. We, herein report a case of acute small bowel obstruction in a 42-year-old female caused by internal herniation of the small bowel through a defect in the left broad ligament, which was successfully managed laparoscopically. We also reviewed the literature on BLH and present our recommendation on the diagnosis and management of BLH.

/pdf/broad-ligament-hernia-as-a-rare-cause-of-acute-small-bowel-5dmjlne4rd.pdf

Broad ligament hernia as a rare cause of acute small bowel obstruction: A wolf in sheep’s clothing – A case report with review of the literature

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