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Urology Sep 2020Pelvic organ prolapse is an increasingly reported complication following anterior pelvic exenteration and usually consists of an anterior enterocele. We present the...
OBJECTIVE
Pelvic organ prolapse is an increasingly reported complication following anterior pelvic exenteration and usually consists of an anterior enterocele. We present the surgical management of a peritoneal-vaginal fistula in a woman who presented with an acute enterocele 16 months following vaginal sparing, robot-assisted laparoscopic anterior pelvic exenteration.
METHODS
Our patient is an 85-year-old female with history of upper tract urothelial carcinoma who underwent a left nephroureterectomy in 2008, and vaginal sparing robot-assisted laparoscopic anterior pelvic exenteration for BCG-refractory carcinoma in situ of the bladder in August 2016. She presented in November 2017 with new onset vaginal bleeding and discharge. On physical examination, she had a dehisced vaginal cuff apex with a bulging enterocele. There were no signs of active evisceration or strangulation. The patient was no longer sexually active and desired surgical treatment. At the time of surgery, a mature peritoneal-vaginal fistula was identified, and the fistula and prolapse were surgically managed with colpectomy and colpocleisis.
RESULTS
Intraoperatively found to have a partial vaginal cuff dehiscence covered with granulation tissue, resulting in a 5 mm peritoneal-vaginal fistula. The granulation-covered enterocele sac was trimmed, dissected free, closed, and reduced with serial purse-string sutures. In this fashion, the sutures were used to not only reduce the fistula, but to also perform a colpocleisis and colpectomy. The colpocleisis and colpectomy were performed due to lack of supportive apical vaginal structures and patient desire. The serial purse-string sutures not only provided additional apical support, but also reduced the likelihood of fistula recurrence by covering the peritoneum.
CONCLUSION
Transvaginal peritoneal-vaginal fistula repair with serial purse-string sutures and partial colpectomy provides a technique for repair in patients who do not have supportive apical tissue following exenterative surgery. The ideal prevention of this problem at the time of cystectomy and management for when it occurs remains unclear.
Topics: Aged, 80 and over; Female; Fistula; Gynecologic Surgical Procedures; Humans; Peritoneal Diseases; Vagina; Vaginal Fistula
PubMed: 32502605
DOI: 10.1016/j.urology.2020.05.029 -
American Journal of Obstetrics and... Aug 2020Laparoscopic or robotic procedures involving extensive dissection of the posterior cul-de-sac and pelvic sidewalls often require the surgeon and assistants to manipulate...
Laparoscopic or robotic procedures involving extensive dissection of the posterior cul-de-sac and pelvic sidewalls often require the surgeon and assistants to manipulate the uterus and adnexa to optimize intraoperative visualization and access pathology. This is especially true during excision of endometriosis surgeries. Temporary oophoropexy and uteropexy improve intraoperative visualization and decrease the necessity for additional ports and surgical assistants. These procedures can be efficiently completed by using a Keith needle and suture passed suprapubically (uteropexy) or through the bilateral lower quadrants (oophoropexy) (Figure), through the target viscera, and back through the abdominal wall. The suture is then secured at the level of the abdominal wall. A video was included to describe and demonstrate these procedures. Temporary oophoropexy and uteropexy free the assistant to provide countertraction, irrigation, and removal of specimens rather than limiting the assistant to the sole duty of retraction. This can in turn improve operating room efficiency and safety.
Topics: Endometriosis; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Ovary; Peritoneal Diseases; Robotic Surgical Procedures; Uterus
PubMed: 32360845
DOI: 10.1016/j.ajog.2020.04.027 -
Revista de La Facultad de Ciencias... Sep 2021The finding of a vermiform appendix within the peritoneal sac of an indirect inguinal hernia occurs in approximately 1% of cases. However, the presence of appendicitis...
INTRODUCTION
The finding of a vermiform appendix within the peritoneal sac of an indirect inguinal hernia occurs in approximately 1% of cases. However, the presence of appendicitis within an inguinal hernial sac is found only in 0.08% of the general population.
CASE REPORT
We present the case of a 58-year-old male patient that was admitted with abdominal pain associated with a small non-reducible right groin mass.
DISCUSSION
To establish the correct diagnosis preoperatively, an abdominal and pelvic CT scan is mandatory.
CONCLUSION
Acute appendicitis in an Amyand's hernia is a very rare entity that can be easily misdiagnosed preoperatively. CT is extremely useful in reaching the correct preoperative diagnosis.
Topics: Acute Disease; Appendicitis; Appendix; Hernia, Inguinal; Humans; Male; Middle Aged; Tomography, X-Ray Computed
PubMed: 34617710
DOI: 10.31053/1853.0605.v78.n3.30705 -
Annals of Surgery Open : Perspectives... Mar 2023Postoperative seroma and pain are common problems following laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernias. These adverse outcomes may be...
INTRODUCTION
Postoperative seroma and pain are common problems following laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernias. These adverse outcomes may be avoided by dissecting and using the peritoneum in the hernial sac to bridge the hernia defect.
METHODS
This was a patient- and outcome assessor-blinded, parallel-design, randomized controlled trial comparing nonclosure and peritoneal bridging approaches in patients scheduled for elective midline ventral hernia repair. The primary endpoint was seroma volume on ultrasonography. The secondary endpoints were postoperative pain, recurrence, and complications.
RESULTS
Between November 2018 and December 2020, 112 patients were randomized, of whom 60 were in the nonclosure group and 52 were in the peritoneal bridging group. The seroma volume in the nonclosure and peritoneal bridging groups were 17 cm (6-53 cm) versus 0 cm (0-26 cm) at 1-month follow-up ( = 0.013). The median volume was zero at the 3-, 6-, and 12-month follow-ups in both groups. No significant differences were observed in early postoperative pain ( = 0.447) and in recurrence rate ( = 0.684). There were 4 (7%) and 1 (2%) perioperative complications that lead to reoperations in simple IPOM (sIPOM) and IPOM with peritoneal bridging (IPOM-pb), respectively.
CONCLUSIONS
Seroma was less prevalent after IPOM-pb at 1-month follow-up compared with sIPOM, with similar postoperative pain 1 week after index surgery in both groups. At subsequent follow-ups, the differences in seroma were not statistically significant. Further studies are required to confirm these results. Trial registration (NCT04229940).
PubMed: 37600866
DOI: 10.1097/AS9.0000000000000257 -
Clinical Kidney Journal Jun 2020The kidney is not typically the main target of severe acute respiratory syndrome coronavirus 2, but surprisingly, acute kidney injury (AKI) may occur in 4-23% of cases,...
The kidney is not typically the main target of severe acute respiratory syndrome coronavirus 2, but surprisingly, acute kidney injury (AKI) may occur in 4-23% of cases, whereas the dialysis management of AKI from coronavirus 2019 has not gained much attention. The severity of the pandemic has resulted in significant shortages in medical supplies, including respirators, ventilators and personal protective equipment. Peritoneal dialysis (PD) remains available and has been used in clinical practice for AKI for >70 years; however, it has been used on only a limited basis and therefore experience and knowledge of its use has gradually vanished, leaving a considerable gap. The turning point came in 2007, with a series of sequential publications providing solid evidence that PD is a viable option. As there was an availability constraint and a capacity limit of equipment/supplies in many countries, hemodialysis and convective therapies became alternatives. However, even these therapies are not available in many countries and their capacity is being pushed to the limit in many cities. Evidence-based PD experience lends support for the use of PD now.
PubMed: 32695319
DOI: 10.1093/ckj/sfaa102 -
Hernia : the Journal of Hernias and... Apr 2022Repair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in...
BACKGROUND
Repair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in the context of lifelong immunosuppression. The peritoneal flap hernioplasty addresses this problem by using flaps of the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space, exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. We report our short and long-term results of 26 consecutive liver transplant cases with incisional hernias undergoing repair with the peritoneal flap technique.
METHODS
Post-OLT patients undergoing elective peritoneal flap hernioplasty for incisional hernias from Jan 1, 2010-Nov 1, 2017 were identified from the Lothian Surgical Audit system (LSA), a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in Feb 2020.
RESULTS
A total of 517 liver transplantations were performed during the inclusion period. Twenty-six of these (18 males, 69%) developed an incisional hernia and underwent a peritoneal flap repair. Median mesh size (Optilene Elastic, 48 g/m, BBraun) was 900 cm (range 225-1500 cm). The median time to repair following OLT was 33 months (range 12-70 months). Median follow-up was 54 months (range 24-115 months) and median postoperative stay was 5 days (range 3-11 days). Altogether, three patients (12%) presented with postoperative complications: 1 with hematoma (4%) and two with chronic pain (8%). No episodes of infection or symptomatic seroma were recorded. No recurrence was recorded within the follow-up period.
CONCLUSION
Repair of incisional hernias in patients following liver transplantation with the Peritoneal Flap Hernioplasty is a safe procedure associated with few complications and a very low recurrence rate. We propose this technique for the reconstruction of incisional hernias following liver transplantation.
Topics: Female; Hernia, Ventral; Herniorrhaphy; Humans; Incisional Hernia; Liver Transplantation; Male; Postoperative Complications; Recurrence; Surgical Mesh
PubMed: 33884521
DOI: 10.1007/s10029-021-02409-5 -
Morphologie : Bulletin de L'Association... Jun 2017Hernia is described as the protrusion of an organ into the wall of its normal containing cavity. Internal hernia (IH) involves protrusion of viscera through: a...
Hernia is described as the protrusion of an organ into the wall of its normal containing cavity. Internal hernia (IH) involves protrusion of viscera through: a peritoneal or mesentery defect, a normal or abnormal compartment of the peritoneal cavity. Hernias occurring in the pelvis cavity are usually classified according to the fascial margins breached and include sciatic, obturator and those through the rectouterin pouch: elytrocele and enterocele. Those hernias are defined by the protrusion of a viscus through the wall of the pelvis due to weakness of the pelvic fascia and/or muscles. Pelvic hernia through the pouch of Douglas (PD) involves the genital tract in female (elytrocele and enterocele). Sometimes described in the literature as Douglas hernia, this type of hernia must be distinguished from the conventional IH. As defined before, the borders to be considered for IH is the peritoneal membrane, which is not a real solid wall but delimitates the peritoneal cavity; and there is no peritoneal defect in elytrocele or enterocele. A PubMed search for IH through a defect in the peritoneal PD revealed only five female cases, making this an extremely rare condition. To our knowledge, we have presented here the only published case in a male. This probably congenital and morphologic anomaly (defect) of pouch of Sir Douglas must be distinguished as the real "Douglas IH". Authors discuss the concept of a new and more detailed classification of IH.
Topics: Abdominal Pain; Anastomosis, Surgical; Bandages; Constipation; Digestive System Surgical Procedures; Douglas' Pouch; Hernia; Humans; Ileal Diseases; Ileum; Intestinal Obstruction; Male; Middle Aged; Peritoneal Diseases; Surgical Wound Infection; Sutures; Tomography, X-Ray Computed; Vomiting
PubMed: 28528186
DOI: 10.1016/j.morpho.2017.04.002 -
Journal of Immunology (Baltimore, Md. :... Dec 2021Tissue-resident macrophages (TRMΦ) are important immune sentinels responsible for maintaining tissue and immune homeostasis within their specific niche. Recently, the...
Tissue-resident macrophages (TRMΦ) are important immune sentinels responsible for maintaining tissue and immune homeostasis within their specific niche. Recently, the origins of TRMΦ have undergone intense scrutiny, in which now most TRMΦ are thought to originate early during embryonic development independent of hematopoietic stem cells (HSCs). We previously characterized two distinct subsets of mouse peritoneal cavity macrophages (MΦ) (large and small peritoneal MΦ) whose origins and relationship to both fetal and adult long-term (LT) HSCs have not been fully investigated. In this study, we employ highly purified LT-HSC transplantation and in vivo lineage tracing to show a dual ontogeny for large and small peritoneal MΦ, in which the initial wave of peritoneal MΦ is seeded from yolk sac-derived precursors, which later require LT-HSCs for regeneration. In contrast, transplanted fetal and adult LT-HSCs are not able to regenerate brain-resident microglia. Thus, we demonstrate that LT-HSCs retain the potential to develop into TRMΦ, but their requirement is tissue specific in the peritoneum and brain.
Topics: Animals; Brain; Cell Lineage; Embryonic Development; Female; Hematopoietic Stem Cells; Macrophages; Mice; Organ Specificity; Peritoneum; Pregnancy; Regeneration
PubMed: 34810224
DOI: 10.4049/jimmunol.2100344 -
Biomedicine & Pharmacotherapy =... Apr 2022Cardiorenal syndrome (CRS) remains the leading cause of death in hospitalized patients for all disease entities. Sacubitril/Valsartan (Sac/Val) therapy has been proved...
BACKGROUND
Cardiorenal syndrome (CRS) remains the leading cause of death in hospitalized patients for all disease entities. Sacubitril/Valsartan (Sac/Val) therapy has been proved to improve prognostic outcome in patients with heart failure or chronic kidney disease. This study tested the hypothesis that combined levosimendan and Sac/Val was superior to just one therapy on protecting the heart and kidney against simultaneous heart and kidney ischemia (I) (for 50-min)-reperfusion (R) (for 7-days) (i.e., double IR) injury (defined as CRS).
METHODS AND RESULTS
Adult-male Spraque-Dawley rats (n = 40) were equally categorized into group 1 (sham-operated control), group 2 (double IR), group 3 [double IR+levosimendan (10 mg/kg by intra-peritoneum administration at 30 min/followed by days 1-5 once daily after IR procedure)], group 4 [double IR+Sac/Val (10 mg/kg, orally at 30 min/followed by days 1-5 twice daily after IR procedure)], and group 5 (double IR+Sac/Val+levosimendan). By day 7 after double-IR, the left-ventricular-ejection fraction (LVEF)/left-ventricular-fraction-shortening (LVFS) were highest in group 1, lowest in group 2 and significantly higher in group 5 than in groups 3/4, but they showed no difference between groups 3/4, whereas the circulatory heart-failure (brain-natriuretic peptide)/proinflammatory (suppression of tumorigenicity-2) biomarkers, blood-urea-nitrogen/creatinine and ratio of urine protein to creatinine (all p < 0.0001) exhibited an opposite pattern of LVEF among the groups. The protein expressions of inflammatory (tumor necrosis factor-α/interleukin-1ß/matrix metalloproteinase-9)/oxidative-stress (NOX-1/NOX-2/NOX-4)/apoptotic (mitochondrial-Bax/caspase-3/poly-(ADP-ribose)-polymerase)/fibrotic (Smad3/transforming growth factor-ß)/mitochondrial-damaged (cytosolic-cytochrome-C)/myocardial-hypertrophic (ß-MHC) biomarkers in LV myocardium exhibited an opposite pattern of LVEF among the groups (all p < 0.0001). The cellular expressions of inflammatory (CD68)/DNA-damaged (γ-H2AX) biomarkers and infarct/fibrotic areas in LV myocardium and kidney displayed an opposite pattern of LVEF among the groups (all p < 0.0001).
CONCLUSION
Combined levosimendan and Sac/Val was superior to merely one therapy on protecting the heart and kidney as well as preserving their functions against double IR injury.
Topics: Aminobutyrates; Animals; Apoptosis; Biphenyl Compounds; Cardio-Renal Syndrome; Cardiovascular Agents; Drug Combinations; Fibrosis; Humans; Inflammation; Kidney; Male; Myocardium; Oxidative Stress; Rats; Rats, Sprague-Dawley; Reperfusion Injury; Simendan; Stroke Volume; Valsartan; Ventricular Function, Left
PubMed: 35202913
DOI: 10.1016/j.biopha.2022.112745 -
BMJ Case Reports Apr 2021Sciatic hernia is a rare pelvic floor hernia. A variety of treatment modalities were proposed, but a guideline is lacking although a mesh-based tension-free repair may...
Sciatic hernia is a rare pelvic floor hernia. A variety of treatment modalities were proposed, but a guideline is lacking although a mesh-based tension-free repair may be preferred. A 67-year-old woman with an uncomplicated sciatic hernia received primarily closing of the hernia orifice that was covered with a preperitoneal mesh in March 2019. Six months later, she developed a clinical and radiographical recurrence requiring remedial surgery. Due to the previous mesh fixation, the preperitoneal plane was obliterated. Therefore, the pouch of Douglas was closed, leaving the hernia sac in place, by folding two opposing peritoneal layers and covering it with a Ventralight ST mesh. After 9 months, the hernia had not recurred and the patient was symptom-free. It is concluded that recurrent sciatic hernia may be treated by obliterating the Douglas pouch and subsequent mesh coverage.
Topics: Aged; Female; Hernia, Abdominal; Hernia, Inguinal; Herniorrhaphy; Humans; Laparoscopy; Peritoneum; Recurrence; Surgical Mesh
PubMed: 33853813
DOI: 10.1136/bcr-2020-238755