Jeff Kushner, PhD

• Associate Professor of ISAT
• College of Integrated Science and Technology
• James Madison University
• Harrisonburg, Virginia

Laparoscopic splenopexy for wandering spleen: case report and review of the literature herbals for blood pressure buy slip inn without a prescription. A meta-analysis of perioperative outcomes of laparoscopic splenectomy for hematological disorders herbals on demand coupon purchase slip inn uk. Massive splenomegaly is associated with significant morbidity after laparoscopic splenectomy herbs used for pain order slip inn amex. Laparoscopic treatment of splenomegaly: a case for hand-assisted laparoscopic surgery herbs medicinal order generic slip inn pills. Single incision versus reduced port splenectomy-searching for the best alternative to conventional laparoscopic splenectomy herbs that help you sleep buy slip inn online pills. Randomized controlled trial to investigate the impact of anticoagulation on the incidence of splenic or portal vein thrombosis after laparoscopic splenectomy herbals medicine purchase cheap slip inn. Overwhelming postsplenectomy infection syndrome in adults: a clinically preventable disease. Spleen registry may help reduce the incidence of overwhelming postsplenectomy infection in Victoria. Postsplenectomy Sepsis and its Mortality rate: actual versus percieved risks Br J Surg. Overwhelming infection in asplenic patients: current best practice preventive measures are not being followed. Perioperative outcomes of laparoscopic versus open splenectomy: a meta-analysis with emphasis on complications. Knowledge of its specific anatomic features is required for management of abdominal wall diseases or during entry into the peritoneal cavity. It is mesodermal in origin and develops as bilateral migrating sheets, which originate in the paravertebral region and envelop the future abdominal area. The leading edges of these structures develop into the rectus abdominis muscles, which eventually meet in the anterior midline. The rectus abdominis is longitudinally oriented and encased within an aponeurotic sheath, the layers of which are fused in the midline at the linea alba. The rectus insertions are on the pubic bones inferiorly and on the fifth and sixth ribs, as well as the seventh costal cartilages and the xiphoid process superiorly. The lateral border of the rectus muscles has a curved shape identifiable as the surface landmark, the linea semilunaris. These layers are derived from laterally migrating mesodermal tissues during the sixth to seventh week of fetal development. The external oblique muscle runs inferiorly and medially, arising from the margins of the lowest eight ribs and costal cartilages. The external oblique muscles originate on the latissimus dorsi and serratus anterior muscles, as well as on the iliac crest. Medially, the external obliques form a tendinous aponeurosis, which is contiguous with the anterior rectus sheath. The inguinal ligament is the inferior-most edge of the external oblique aponeurosis, reflected posteriorly in the area between the anterior superior iliac spine and pubic tubercle. The internal oblique muscle lies deep to the external oblique and arises from the lateral aspect of the inguinal ligament, the iliac crest, and the thoracolumbar fascia. Its fibers course superiorly and medially and form a tendinous aponeurosis that contributes components to both the anterior and posterior rectus sheath. The lower medial and inferior-most fibers of the internal oblique may fuse with the lower fibers of the transversus abdominis muscle (the conjoined area). The inferior-most fibers of the internal oblique muscle are contiguous with the cremasteric muscle in the inguinal canal. These relationships are of critical significance in the management of inguinal hernias. The transversus abdominis muscle is the deepest of the three lateral muscles and runs transversely from the lowest six ribs, the lumbosacral fascia, and the iliac crest, to the lateral border of the rectus abdominis. Above the arcuate line, the anterior rectus sheath is formed by the external oblique aponeurosis and the external lamina of the internal oblique aponeurosis, whereas the posterior rectus sheath is formed by the internal lamina of the internal oblique aponeurosis and the transversus abdominis aponeurosis. Below the arcuate line, the anterior rectus sheath is formed by the external oblique aponeurosis, the laminae of the internal oblique aponeurosis, and the transversus abdominis aponeurosis. There is no aponeurotic posterior covering of this lower portion of 1 the rectus muscles, although the endoabdominal, or transversalis, fascia provides contiguous coverage of the posterior aspect of the abdominal above and below the arcuate line. The superior epigastric artery arises from Key Points 1 There are important anatomic differences in the rectus sheath structures above and below the arcuate line. The laminae of the internal oblique, which contribute to both the anterior and (along with the transversus abdominis) posterior rectus above the arcuate line, only contribute to the anterior sheath below the arcuate line. There is no aponeurotic posterior covering on the lower portion of the rectus muscles. Rectus diastasis is associated with abdominal wall bulging consequent to separation of the rectus abdominis muscles in the midline. It does not represent a hernia, and surgical interventions for this condition are of questionable, if any, clinical benefit. When resection of abdominal wall desmoid tumors is undertaken, it must be recognized that failure to achieve negative margins is associated with an extremely high risk of local recurrence of the tumor. Primary repair of ventral incisional hernias is associated with unacceptably high failure rates, and repair using other approaches, such as use of prosthetic mesh, is preferred. Potential benefits of laparoscopic incisional hernia repairs compared to open repairs with mesh include shorter hospitalization, lower risk of wound complications, and better abdominal wall function. Surgical treatment of sclerosing mesenteritis is most often undertaken to confirm diagnosis and to rule out neoplasm as the cause of a mesenteric mass. Resection possibilities are limited by the extensiveness of the process as well as by the questionable benefit in most cases. Potential surgical interventions in retroperitoneal fibrosis include operative biopsy to rule out neoplasm, ureteral stent placement, open or laparoscopic ureterolysis, and endovascular interventions for iliocaval occlusion. A collateral network of branches of the subcostal and lumbar arteries also contributes the abdominal wall blood supply. The lymphatic drainage of the abdominal wall is predominantly to the major nodal basins in the superficial inguinal and axillary areas. Motor nerves to the rectus, oblique, and transversus abdominis muscles run from the anterior rami of spinal nerves at the T6 to T12 levels. Physiology the rectus muscles, external obliques, and internal obliques work as a unit to flex the trunk anteriorly or laterally. Trunk rotation is achieved by simultaneous contraction of a unilateral external oblique and the contralateral internal oblique. Linea alba is the midline aponeurotic demarcation between the bellies of the rectus abdominis muscles. The rectus abdominis muscle and its tendinous intersections on the left are shown deep to the reflected anterior rectus sheath. The three muscular layers of the abdominal wall lateral to the rectus abdominis are the external oblique, internal oblique, and transversus abdominis muscles, shown here on the low abdomen, where the lower margin of the external oblique reflects posteriorly as the inguinal ligament. Abdominal musculature contraction that occurs when the diaphragm is relaxed will result in expiration of air from the lungs, or a cough if this contraction is forceful. If the diaphragm is contracted when the abdominal musculature is contracted (Valsalva maneuver), the increased abdominal pressure aids in processes such as micturition, defecation, and childbirth. Abdominal Anatomy and Surgical Incisions Surgeons must deal with the abdominal wall to access pre-, intra-, and retroperitoneal sites. Incisions for open surgery are generally located in proximity to the principal operative targets. Laparoscopic port site incisions might be remote from the site of interest and are carefully planned based on the instrument approach angles and working distances both to the operative site and between ports. Orientation of any incision may be determined based on expected quality of exposure, closure considerations including cosmesis, avoidance of previous incision sites, and surgeon preference. Modifications are numerous and can consist of various extensions to optimize exposure in specific clinical situations. Cross-sectional anatomy of the abdominal wall above and below the arcuate line of Douglas. The lower right abdominal wall segment shows clearly the absence of an aponeurotic covering of the posterior aspect of the rectus abdominis muscle inferior to the arcuate line. Superior to the arcuate line, there are both internal oblique and transversus abdominis aponeurotic contributions to the posterior rectus sheath. The superior and inferior epigastric arteries form an anastomosing network of vessels in and around the rectus sheath, with collateralization to subcostal and lumbar vessels situated more laterally on the abdominal wall. Incising the fused midline aponeurotic tissue of the linea alba is simple and does not injure skeletal muscle. Paramedian incisions through the rectus abdominis sheath structures have largely been abandoned in favor of midline or nonlongitudinal incisions. Incisions lateral to the midline made with transverse or oblique orientations can either divide the successive muscular layers or bluntly separate the fibers. This latter muscle-splitting approach, exemplified by the classic McBurney incision for appendectomy, may be less destructive to tissue but offers more limited exposure. Subcostal incisions on the right (Kocher incision for cholecystectomy) or left (for splenectomy) are archetypal muscle-dividing incisions that result in transection of intervening musculoaponeurotic tissues, including a portion of the rectus abdominis. These incisions are closed in two layers, the more superficial one incorporating the anterior aponeurotic sheath of the rectus medially, transitioning to external oblique muscle and aponeurosis laterally. The posterior, deeper layer consists of internal oblique and transversus abdominis muscle. Similar anatomic considerations are guide closure of transversely oriented muscle-dividing incisions. The Pfannenstiel incision, used commonly for pelvic procedures, is distinguished by transverse skin and anterior rectus sheath incisions, followed by rectus muscle retraction and longitudinal incision of the peritoneum. Irrespective of the incision type, suture apposition of abdominal wall tissues during closure is accomplished without significant tension and with great precision. Abdominal incisions can lead to short- and long-term complications and patient disability. In general, it is prudent to make incisions no larger than necessary to safely accomplish the operative goals. Laparoscopic and other minimally invasive surgical methods owe their development in large pelvic position. Persistence of urachal remnants can result in cysts as well as fistulas to the urinary bladder with drainage of urine from the umbilicus. These are treated by urachal excision and closure of any bladder defect that may be present. Rectus abdominis diastasis (or diastasis recti) results from a separation of the two rectus abdominis muscle pillars. This results in the characteristic bulging of the abdominal wall in the epigastrium that is sometimes mistaken for a ventral hernia despite the fact that the midline aponeurosis is intact and no hernia defect is present. Diastasis may be congenital, as a result of a more lateral insertion of the rectus muscles to the ribs and costochondral junctions, but is more typically an acquired condition with advancing age, obesity, or following pregnancy. In the postpartum setting, rectus diastasis tends to occur in women of advanced maternal age, after multiple or twin pregnancies, or in women who deliver high-birth-weight infants. Surgical correction of rectus diastasis by plication of the broad midline aponeurosis has been described for cosmetic indications and for disability of abdominal wall muscular function. However, 2 these approaches introduce the risk of an actual ventral hernia and are of questionable value in addressing any actual pathology. Devices of this type are valuable exposure aids that reduce the physical demands on personnel in the operating room and allow more complete focus on the surgical site of interest. Hemorrhage from the network of collateralizing vessels within the rectus sheath and muscles can result in a rectus sheath hematoma. Although a history of trauma might be elicited, other less obvious events including sudden contraction of the rectus muscles with coughing, sneezing, or any vigorous physical activity may also cause this condition. Spontaneous rectus sheath hematomas occur most frequently in the elderly and in those on anticoagulation therapy. Patients frequently describe the sudden onset of unilateral abdominal pain that may be confused with lateralized peritoneal disorders such as appendicitis. Congenital Abnormalities the abdominal wall layers begin to form within in first weeks following conception. In early embryonic development, there is a large central defect through which pass the vitelline (omphalomesenteric) duct and allantois. During the sixth week of development, the abdominal contents grow too large for the abdominal wall to completely contain them, and the embryonic midgut herniates into the umbilical cord. While outside the developing abdomen, it undergoes a 270-degree counterclockwise rotation on the developing mesentery. In omphalocele, viscera protrude through an open umbilical ring and are covered by a sac derived from the amnion. In gastroschisis, the viscera protrude through a defect lateral to the umbilicus and no sac is present. Complete failure of the vitelline duct to regress results in a vitelline duct fistula, which is associated with drainage of small intestinal contents from the umbilicus. If both the intestinal and umbilical ends of the vitelline duct regress into fibrous cords, a central vitelline duct (omphalomesenteric) cyst may occur. Persistent vitelline duct remnants between the gastrointestinal tract and the anterior abdominal wall may be associated with small intestinal volvulus in neonates. When diagnosed, vitelline duct fistulas and cysts should be excised along with any accompanying fibrous cord. The edges of the rectus abdominis muscle, rigid with voluntary contraction, are palpable along the entire length of the bulging area. This occurred in an elderly, anticoagulated patient without a clear history of trauma. Radical resection with frozen section margins and immediate mesh reconstruction of any consequent abdominal wall defect is the most commonly recommended treatment. Extensive infiltration 3 and involvement of peritoneal structures frequently makes desmoid resection technically unfeasible.

The syndromic craniosynostoses not only include bicoronal synostosis but also involve the midface herbals importers generic slip inn 1pack with amex, with resulting exorbitism and midface hypoplasia herbals on wholesale buy slip inn 1pack with visa. Multilevel airway anomalies herbals in the philippines buy discount slip inn online, obstructive sleep apnea herbals india purchase 1pack slip inn with amex, corneal exposure herbals good for the heart slip inn 1pack otc, intracranial hypertension herbs collision purchase genuine slip inn on line, feeding difficulties, and severe malocclusion are some of the associated anomalies found in children with syndromic craniosynostoses. Pierre Robin sequence is characterized by three pathognomonic findings: microretrognathia, glossoptosis, and respiratory distress. It is thought by some to occur secondary to a fixed and flexed fetal head position that inhibits mandibular growth and results in micrognathia. The micrognathia prevents the natural caudal migration of the tongue from between the clefted palatal shelves, and the resulting deformity as described earlier. The functional consequences include intermittent respiratory obstruction and obstructive sleep apnea that may affect feeding, growth, and safety of the airway. Treatment of a child mildly affected with Pierre Robin sequence may include simply positioning the child prone until the child "grows out" of the condition. However, if the child is severely affected and unable to feed adequately or has an unsafe airway, surgical intervention is required. For decades, tracheotomy was the initial and definitive treatment of choice; however, today many initially attempt a tongue-lip adhesion, treating the glossoptosis and alleviating respiratory obstruction by suturing the tongue tip to the lower lip. Most believe treatment should be delayed until at least 1 year after the process of atrophy has ceased. The categories of craniofacial hyperplasia, hypertrophy, and neoplasia encompass a wide variety of conditions affecting the craniofacial skeleton. These include vascular anomalies (discussed later in this chapter), neurofibromatosis, hemifacial hypertrophy, and bony conditions such as osteomas and fibrous dysplasia. Fibrous dysplasia can be monostotic, affecting a single location, or polyostotic, affecting more than a single location in the skeleton; it may be associated with skin pigmentation abnormalities and endocrine involvement, and be termed polyostotic or McCune-Albright syndrome. Treatment of fibrous dysplasia of the craniofacial skeleton includes block resection and reconstruction with bone grafts. If extensive involvement exists and block resection is not possible or feasible, partial resection and contouring of the affected bone is possible, as long as there is the understanding that long-term outcomes and the behavior of the disease are unpredictable. Vascular anomalies are vascular birthmarks that all appear similar: flat or raised, in various shades of red and purple. Today these vascular birthmarks have been biologically classified as either hemangiomas or vascular malformations. The Greek suffix -oma means "swelling" or "tumor" and today connotes a lesion characterized by hyperplasia. Hemangiomas are congenital vascular anomalies that undergo a phase of rapid growth followed by slow regression, based on endothelial cell kinetics. Malformations are abnormal vascular channels lined with quiescent endothelium, usually are seen at birth, never regress, and have the potential to expand. The differential diagnosis of vascular anomalies is routinely made by a detailed accurate history and clinical examination. Biopsy is used if the diagnosis is uncertain or there is concern over the potential of malignancy. Lateral view of a child with Pierre Robin sequence and mandibular microretrognathia. Intraoperative photo of a submandibular incision and planning for the placement of a buried mandibular distractor. Lateral view of the child after mandibular distraction with slight overcorrection of retrognathia. The distractor is still in place as evident from the activating rod seen exiting the skin retroauricularly. In children with multiple (more than three) cutaneous hemangiomas, abdominal ultrasound is suggested to rule out hemangiomatosis with visceral involvement. Hemangiomas do not cause bleeding disorders; however, more invasive lesions such as kaposiform hemangioendothelioma can result in Kasabach-Merritt syndrome, characterized by platelet trapping and disordered bleeding. Hemangiomas are usually first noted around 2 weeks of life as a flat pink spot, often confused with a superficial scratch. Around the second month of life, they enter the proliferating phase in which rapid growth is seen caused by plump, rapidly dividing endothelial cells. If the hemangioma is superficial, the skin becomes crimson and raised; if the lesion is deep, a dark blue or purple color is noted with less superficial swelling. Hemangioma growth frequently peeks before the first year, and then the lesions enter the involuting phase in which growth is commiserate with the child. The involuting phase is characterized by diminishing endothelial activity and luminal enlargement. The lesion begins to "gray," losing its intense reddish color and taking on a purple-gray shade with overlying "crepe paper" skin. The involuted phase begins in 50% of children by 5 years of age and in 70% by 7 years. The treatment of hemangiomas is largely observational, with reassurance of parents that regression and involution will occur. Cutaneous ulceration secondary to a proliferating hemangioma occurs in 5% of cases and more frequently with lip or urogenital lesions. Local wound care, topical application of lidocaine for pain, and laser cauterization may be beneficial treatment modalities. The firstline treatment for problematic hemangiomas is systemic corticosteroid therapy, which is particularly effective (85% response rate). Second-line therapies include interferon and vincristine, each with its own attendant effectiveness and morbidity. Laser therapy has been claimed by some to be effective in the treatment of early hemangiomas; however, there has been no conclusive proof that laser therapy either diminishes lesion bulk or induces involution. Surgery for hemangiomas in the proliferating phase is largely limited to treatment of problematic lesions. Hemangioma surgery usually is reserved for the treatment of secondary deformities and residual fibro-fatty depositions, among other indications. Vascular malformations are subclassified by vessel type, such as lymphatic, capillary, venous, or arterial, and by rheologic characteristics, such as slow flow and fast flow. Although surgery rarely removes the entire lesion, surgical resection is the only possibility for cure. Surgical treatment includes arterial embolization to temporarily occlude the nidus 24 to 72 hours before surgical extirpation. The nidus and overlying affected skin must be widely excised, and reconstruction can be performed afterward. Neurocutaneous melanocytosis carries a lifetime nonreducible risk of central nervous system melanoma and other morbidity and mortality from seizures, hydrocephalus, and other central nervous system conditions. Dermabrasion, chemical peels, and laser therapy have been reported to improve the appearance; however, none of these modalities completely removes nevus cells. To address malignant potential, only complete excision is a possible solution, and this is difficult, because nevus cells may extend beyond the skin and into the deep subcutaneous tissue and even the underlying muscle. Treatment options have particular indications with respect to the location of the nevus. Tissue expansion is associated with increased morbidity in lower extremity reconstruction, and therefore excision and grafting, even with previously expanded full-thickness skin grafts, is often the treatment of choice. As technologic advances raise the level of energy involved in modern systems of transportation, recreation, and weaponry, so follow increases in the degree of maxillofacial destruction related to misadventures with this technology. The first phase of care for the patient with maxillofacial trauma is activation of the advanced trauma life support protocol. The most common life-threatening considerations in the facial trauma patient are airway maintenance, control of bleeding, identification and treatment of aspiration, and identification of other injuries. Physical examination of the face with attention to lacerations, bony step-offs, instability, tenderness, ecchymosis, facial asymmetry, and deformity guides the examiner to underlying hard tissue injuries. Coronal, sagittal, and three-dimensional reconstructions of images further elucidate complex injuries. Lesions are frequently light to dark brown and round or oval, and vary greatly in size, pattern, and anatomic location. Frequently, larger lesions are associated with multiple smaller satellite lesions. Over time, these lesions may become less (or sometimes more) pigmented and develop hypertrichosis and a variegated texture, including nodularity. Mandibular fractures are common injuries that may lead to permanent disability if not diagnosed and properly treated. Fractures are frequently multiple, and disturbances in dental occlusion reflect the forces of the many muscles of mastication on the fracture segments. Dental occlusion is perhaps the most important basic relationship to understand about fracture of the midface and mandible. The Angle classification system describes the relationship of the maxillary teeth to the mandibular teeth. Class I is normal occlusion, with the mesial buccal cusp of the first maxillary molar fitting into the intercuspal groove of the mandibular first molar. Nonsurgical treatment may be used in situations in which there is minimal displacement, preservation of the pretraumatic occlusive relationship, and normal range of motion. The goals of surgical treatment include restoration of pretraumatic dental occlusion, reduction and stable fixation of the fracture, and repair of soft tissue. Operative repair involves seating of the 1854 Condyle Coronoid process Ramus postoperative objectives is release from maxillary-mandibular fixation and resumption of range of motion as soon as possible to minimize the risk of ankylosis. Other potential complications include infection, nonunion, malunion, malocclusion, facial nerve branch injury, infra-alveolar or mental nerve injury, and dental fractures. Treatment of all but the simplest orbital injuries should include evaluation by an eye specialist to assess visual acuity and rule out globe injury. Orbital fractures may involve the orbital roof, floor, or lateral or medial walls. The most common orbital fracture is the orbital floor blow-out fracture caused by direct pressure to the globe and sudden increase in intraorbital pressure. Because the medial floor and inferior medial wall are made of the thinnest bone, fractures occur most frequently at these locations. These injuries may be treated expectantly if they are sufficiently small and without complication. However, larger blow-out fractures and those associated with enophthalmos (increased intraorbital volume), entrapment of inferior orbital tissues, or diplopia lasting >2 weeks generally require surgical treatment. All provide access to the orbital floor and allow for repair with a multitude of different autogenous and synthetic materials. Late complications include persistent diplopia, enophthalmos, ectropion, and entropion. Lateral and inferior orbital rim fractures also are not uncommon and are often associated with the zygomaticomaxillary complex fracture pattern, as discussed later. Special mention should be made of two uncommon complications after orbital fracture. Superior orbital fissure syndrome results from compression of structures contained in the superior orbital fissure in the posterior orbit. Compression of these structures leads to symptoms of eyelid ptosis, globe proptosis, paralysis of the extraocular muscles, and anesthesia in the cranial nerve V1 distribution. Both of these syndromes are medical emergencies, and steroid therapy and surgical decompression are considered. Regardless of the stabilization approach, one of the I Zygoma and Zygomaticomaxillary Complex Fractures. Isolated arch fractures manifest as a flattened, wide face with associated edema and ecchymosis. Nondisplaced fractures may be treated nonsurgically, whereas displaced and comminuted arch fractures may be reduced and stabilized indirectly (Gilles approach) or, for more complicated fractures, directly through a coronal incision. The fracture segment tends to rotate laterally and inferiorly, creating an expanded orbital volume, limited mandibular excursion, an inferior cant to the palpebral fissure, and a flattened malar eminence. Class I: the mesial buccal cusp of the maxillary first molar fits into the intercuspal groove of the mandibular first molar. Telecanthus is produced by splaying apart of the nasomaxillary buttresses to which the medial canthal ligaments are attached. Treatment typically involves plating or wiring all bone fragments meticulously, potentially with primary bone grafting, to restore their normal configuration. If comminution is severe, this may be achievable using transnasal wiring of the ligaments. The region of the frontal sinus is a relatively weak structural point in the upper face. The paired sinuses each have an anterior bony table that determines the contour of the forehead and a posterior table that separates the sinus from the dura. Each sinus drains through the medial floor into its frontonasal duct, which empties into the middle meatus within the nose. The nose is the most common facial fracture site due to its prominent location, and such fracture can involve the cartilaginous nasal septum, the nasal bones, or both. It is important to perform an intranasal examination to determine whether a septal hematoma is present. If present, a septal hematoma must be incised, drained, and packed to prevent pressure necrosis of the nasal septum and long-term midvault collapse. Closed reduction of nasal fractures may be performed under local or general anesthesia. Unfortunately, many, if not most, show some deformity upon final healing, requiring rhinoplasty if airway obstruction is present or if improved appearance is desired. These include the upper eyelid incision (zygomaticofrontal buttress and lateral orbital wall), the subtarsal or transconjunctival incision (orbital floor and infraorbital rim), and the maxillary gingivobuccal sulcus incision (zygomaticomaxillary buttress).

A survey of American Association for the Surgery of Trauma member practices in the management of blunt splenic injury herbals that lower cholesterol buy slip inn online. Novel computed tomography scan scoring system predicts the need for intervention after splenic injury herbs used for anxiety order slip inn 1pack amex. Multivariate analysis of clinical herbs pictures order cheapest slip inn and slip inn, anatomic herbals dario bottineau purchase slip inn master card, and pathologic features after 3D reconstruction of the spleen herbs contraindicated for pregnancy order slip inn 1pack without prescription. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization herbs uses purchase 1pack slip inn free shipping. Partial splenic embolization in the treatment of patients with portal hypertension: a review of the English language literature. Evidence-based mini-review: is indiumlabeled autologous platelet scanning predictive of response to splenectomy in patients with chronic immune thrombocytopenia Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy. Splenic artery embolization as a treatment option for chronic pancytopenia secondary to hypersplenism: a case report and review of literature. Intra-abdominal splenosis: how clinical history and imaging features averted an invasive procedure for tissue diagnosis. Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura: study of clinical and laboratory data. Short-term and long-term failure of laparoscopic splenectomy in adult immune thrombocytopenic purpura patients: a systematic review. Guidelines for the diagnosis and management of hereditary spherocytosis-2011 update. Risks and benefits of splenectomy versus no splenectomy for hereditary spherocytosis-a personal view. Hereditary spherocytosis and partial splenectomy in children: review of surgical technique and the role of imaging. Glucose-6-phosphate dehydrogenase Guadalajara-a case of chronic non-spherocytic haemolytic anaemia responding to splenectomy and the role of splenectomy in this disorder. Classification and therapeutic approaches in autoimmune hemolytic anemia: an update. Laparoscopic splenectomy for autoimmune hemolytic anemia in patients with chronic lymphocytic leukemia: a case series and review of the literature. Indications and complications of splenectomy for children with sickle cell disease. Splenectomy: a strong risk factor for pulmonary hypertension in patients with thalassaemia. Prevention of overwhelming postsplenectomy infection in thalassemia patients by partial rather than total splenectomy. Sequence of treatments for adults with primary immune thrombocytopenia Am J Hematol. Treatment practices in adults with chronic immune thrombocytopenia-a European perspective. Rituximab before splenectomy in adults with primary idiopathic thrombocytopenic purpura: a meta-analysis. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Analysis of outcome of laparoscopic splenectomy for idiopathic thrombocytopenic purpura by platelet count. Case series: splenectomy: does it still play a role in the management of thrombotic thrombocytopenic purpura Historical treatments of in hairy cell leukemia, splenectomy and interferon: past and current uses. Casaccia M, Torelli P, Cavaliere D, et al: Laparoscopic lymph node biopsy in intra-abdominal lymphoma: high diagnostic accuracy achieved with a minimally invasive procedure. Splenic marginal zone lymphoma proposals for a revision of diagnostic, staging and therapeutic criteria. Polycythemia vera and essential thrombocythemia: 2012 update on diagnosis, risk stratification, and management. Symptomatic splenomegaly in polycythemia vera: a review of the indications for splenectomy and perioperative considerations. Palliative goals, patient selection, and perioperative platelet management: outcomes and lessons from three decades of splenectomy for myelofibrosis with myeloid metaplasia at the Mayo Clinic. Laparoscopic approach for isolated splenic metastasis: comprehensive literature review and report of 6 cases. Management of non-neuronopathic Gaucher disease with special reference to pregnancy, splenectomy, bisphosphonate therapy, use of biomarkers and bone disease monitoring. Combined medical treatments and the addition of imatinib have been used with some success in small numbers of patients; radiation therapy has been used in both adjuvant and palliative roles with high response rates. Pain typically increases with contraction of the rectus muscles, and a tender mass may be palpated. The ability to appreciate an intra-abdominal mass is ordinarily degraded with contraction of the rectus muscles. Bilateral or large hematomas will likely require hospitalization, as well as potential resuscitation. Transfusion or coagulation factor replacement may be indicated in some situations. Angiographic embolization is required infrequently, but may be necessary if hematoma enlargement, free bleeding, or clinical deterioration occurs. Surgical therapy is used in the rare situations of failed angiographic treatment or hemodynamic instability that precludes any other options. The operative goals are evacuation of the hematoma and ligation of any bleeding vessel identified. Mortality in this condition is rare, but has been reported in patients requiring surgical treatment and in the elderly. The abdominal wall may be the site of various benign neoplasms including lipomas and neurofibromas. Surgical treatment is not always mandatory, but local excision is recommended for symptomatic or enlarging lesions. Primary abdominal wall malignancies are exceedingly rare and include subtypes of sarcomas (leiomyosarcoma, malignant fibrous histiocytoma, fibrosarcoma, liposarcoma, and rhabdomyosarcoma), dermatofibrosarcoma protuberans, schwannoma, and melanoma. These studies define the extent of the tumor and involvement of contiguous structures in anticipation of surgical treatment. Prior to surgery for abdominal wall sarcomas, a core needle biopsy is generally obtained (with image guidance if needed). Once the diagnosis is established, treatment consists of resection with tumor-free margins, applying the same general principles used for extremity sarcoma resection. Meticulous dissection avoiding violation of tumor capsule and maintaining margins greater than 2 cm, if possible, are essential considerations. Extensive resection may leave a considerable abdominal wall defect that will have to be reconstructed. Immediate reconstruction with mesh and/or wound coverage with rotational or free myocutaneous flaps are the best options if primary closure is not feasible. Although these tumors are frequently described as radiationand chemotherapy-resistant, both modalities have been used in advanced cases in both adjuvant and palliative settings. The very limited experience in these rare conditions makes commentary on the effectiveness of these therapies difficult. Abdominal wall resection may also be required with contiguous involvement of gastrointestinal or gynecologic malignancies. Primary closure may be feasible, but prosthetic mesh use (even in the setting of bowel resection), absorbable or biologic mesh reinforcement, and myocutaneous flap reconstruction are also options. Desmoid tumors of the abdominal wall are fibrous neoplasms originating from the musculoaponeurotic structures of the anterior abdomen. They are also referred to collectively as aggressive fibrosis, a term that describes their aggressive and infiltrative local behavior. They do not have metastatic potential, and although there is marked cellularity in biopsy specimens, there are no specific histologic characteristics that suggest malignancy, per se. Hernias of the anterior abdominal wall, or ventral hernias, represent defects in the parietal abdominal wall fascia and muscle through which intra-abdominal or preperitoneal contents can protrude. Acquired hernias may develop via slow architectural deterioration of the musculoaponeurotic tissues, or they may develop from failed healing of an anterior abdominal wall incision (incisional hernia). The most common finding is a mass or bulge, which may increase in size with Valsalva. Ventral hernias may be asymptomatic or cause a considerable degree of discomfort and will generally enlarge over time. Physical examination reveals a bulge on the anterior abdominal wall that may reduce spontaneously, with recumbency, or with manual pressure. A hernia that cannot be reduced is described as incarcerated and generally requires surgical correction. Incarceration of an intestinal segment may be accompanied by nausea, vomiting, and significant pain, and is a true surgical emergency. If the blood supply to the incarcerated bowel is compromised, the hernia is described as strangulated, and the localized ischemia may lead to infarction and perforation. Primary ventral hernias (nonincisional) are generally named according to their anatomic location. Epigastric hernias are located in the midline between the xiphoid process and the umbilicus. They are generally small and may be multiple, and at elective repair, they are usually found to contain omentum or a portion of the falciform ligament. These may be congenital and due to defective midline fusion of developing lateral abdominal wall elements. Umbilical hernias occur at the umbilical ring and may be present at birth or develop later in life. Umbilical hernias are present in approximately 10% of all newborns and are more common in premature infants. Surgical treatment is offered if a hernia is observed to enlarge or is associated with symptoms, or if incarceration occurs. Surgical treatment can consist of primary sutured repair or placement of prosthetic mesh for larger defects (>2 cm) using open or laparoscopic methods. Patients with advanced liver disease, ascites, and umbilical hernia require special consideration. Enlargement of the umbilical ring usually occurs in this clinical situation as a result of increased intra-abdominal pressure from uncontrolled ascites. First line of therapy is aggressive medical correction of the ascites and paracentesis for tense ascites with respiratory compromise. These hernias are usually filled with ascitic fluid, but omentum or bowel may enter the defect after large-volume paracentesis. Uncontrolled ascites may lead to skin breakdown on the protuberant hernia and eventual ascitic leak, which can predispose the patient to bacterial peritonitis. Spigelian hernias can occur anywhere along the length of the Spigelian line or zone-an aponeurotic band of variable width at the lateral border of the rectus abdominis. However, the most frequent location of these rare hernias is at or slightly above the level of the arcuate line. These are not always clinically evident as a bulge and may come to medical attention because of pain or incarceration. The largest review of surgical management of these hernias suggests that the risk of incarceration is as high as 17% at the time of diagnosis. This has been cited as a justification for mandatory repair of Spigelian hernias after they have been diagnosed. As many as 10% to 20% of patients may eventually develop hernias at incision sites following open abdominal surgery. The etiology of any given case of incisional hernia can be difficult to determine. Obesity, primary wound healing defects, multiple prior procedures, prior incisional hernias, and technical errors during repair may all be contributory. Repair of incisional hernias can be technically challenging, and a myriad of methods have been described. The most important distinctions in surgical management of incisional hernias are primary versus mesh repair and open versus laparoscopic repair. Primary repairs of incisional hernia include both simple suture closure and components separation. Primary repair by simple suture approximation, even for small hernias (defects <3 cm), is associated with high reported hernia recurrence rates. In a randomized prospective study of open primary and open mesh incisional hernia repairs in 200 patients, investigators from the Netherlands found that after 3 years, recurrence rates were 43% and 24%, respectively. Risk factors for recurrence were primary suture repair, postoperative wound infection, pros4 tate problems, and surgery for abdominal aortic aneurysm. In an effort to decrease suture line tension associated with primary repair, Ramirez described the components separation technique in 1990. This procedure entailed creation of large subcutaneous flaps lateral to the fascial defect followed by bilateral incision of the external oblique aponeuroses and, if necessary, incision of the posterior rectus sheaths bilaterally. The net effect is up to 10 cm of medial mobilization of the rectus muscles allowing for primary apposition of the fascia. Early reports of components separation demonstrated a high wound infection rate (20%) and an 18. However, as the technique evolved, an improved understanding of key operative elements, including maximal preservation of the rectus perforator vessels and minimal dissection of the subcutaneous tissues, has led to fewer postoperative wound complications. In recent years, further modifications have included the endoscopic components separation technique as well as the addition of mesh reinforcement to primary fascial edge closure. Using the former closed technique with videoscopic control, effective external oblique division is achieved without creation of extensive subcutaneous flaps.

The most significant is pulmonary hypoplasia herbals usa buy slip inn 1pack cheap, which is not survivable in the most severe cases herbals on express buy cheap slip inn 1pack online. Skeletal abnormalities include dislocation or dysplasia of the hip and pectus excavatum herbs paint and body buy slip inn with visa. The major genitourinary manifestation in prune-belly syndrome is ureteral dilation himalaya herbals wiki purchase slip inn pills in toronto. Ureteric obstruction is rarely present ridgecrest herbals cheap 1pack slip inn with mastercard, and the dilation may be caused by decreased smooth muscle and increased collagen in the ureters jeevan herbals review slip inn 1pack without a prescription. Approximately 80% of these patients will have some degree of vesicoureteral reflux, which can predispose to urinary tract infection. Despite the marked dilatation of the urinary tract, most children with prune-belly syndrome have adequate renal parenchyma for growth and development. Despite the ureteric dilation, there is currently no role for ureteric surgery unless an area of obstruction develops. The testes are invariably intra-abdominal, and bilateral orchiopexy can be performed in conjunction with abdominal wall reconstruction at 6 to 12 months of age. Despite orchiopexy, fertility in a boy with prune-belly syndrome is unlikely as spermatogenesis over time is insufficient. Deficiencies in the production An understanding of the management of pediatric inguinal hernias is a central component of modern pediatric surgical practice. Inguinal hernia repair represents one of the most common operations performed in children. The presence of an inguinal hernia in a child is an indication for surgical repair. The operation is termed a herniorrhaphy because it involves closing off the patent processus vaginalis. This is to be contrasted with the hernioplasty that is performed in adults, which requires a reconstruction of the inguinal floor. In order to understand how to diagnose and treat inguinal hernias in children, it is critical to understand their embryologic origin. Inguinal hernia results from a failure of closure of the processus vaginalis, a finger-like projection of the peritoneum that accompanies the testicle as it descends into the scrotum. When the processus vaginalis remains completely patent, a communication persists between the peritoneal cavity and the groin, resulting in a hernia. A communicating hydrocele refers to a hydrocele that is in communication with the peritoneal cavity and can therefore be thought of as a hernia. Using the classification system that is typically applied to adult hernias, all congenital hernias in children are by definition indirect inguinal hernias. Children also present with direct inguinal and femoral hernias, although these are much less common. Inguinal hernias occur more commonly in males than females (10:1) and are more common on the right side than the left. Infants are at high risk for incarceration of an inguinal hernia because of the narrow inguinal ring. The presence of an incarcerated hernia is manifested by a firm bulge that does not spontaneously resolve and may be associated with fussiness and irritability in the child. The infant who has a strangulated inguinal hernia will manifest an edematous, tender bulge in the groin, occasionally with overlying skin changes. The child will eventually develop intestinal obstruction, peritonitis, and systemic toxicity. Gentle pressure is applied on the sac from below in the direction of the internal inguinal ring. Following reduction of the incarcerated hernia, the child may be admitted for observation, and herniorrhaphy is performed within the next 24 hours to prevent recurrent incarceration. Alternatively, the child may be scheduled for surgery at the next available time slot. If the hernia cannot be reduced or if evidence of strangulation is present, emergency operation is necessary. When the diagnosis of inguinal hernia is made in an otherwise normal child, operative repair should be planned. Spontaneous resolution does not occur, and therefore, a nonoperative approach cannot ever be justified. An inguinal hernia in a female infant or child frequently contains an ovary rather than intestine. Although the gonad usually can be reduced into the abdomen by gentle pressure, it often prolapses in and out until surgical repair is carried out. In some patients, the ovary and fallopian tube constitute one wall of the hernia sac (sliding hernia), and in these patients, the ovary can be reduced effectively only at the time of operation. If the ovary is irreducible, prompt hernia repair is indicated to prevent ovarian torsion or strangulation. When a hydrocele is diagnosed in infancy and there is no evidence of a hernia, observation is proper therapy until the child is older than 12 months. If the hydrocele has not disappeared by 12 months, invariably there is a patent processus vaginalis, and operative hydrocelectomy with excision of the processus vaginalis is indicated. When the first signs of a hydrocele are seen after 12 months of age, the patient should undergo elective hydrocelectomy, which in a child is always performed through a groin incision. Aspiration of hydroceles is discouraged, since almost all without a patent processus vaginalis will resorb spontaneously, and those with a communication to the peritoneum will recur and require operative repair eventually. Transillumination as a method to distinguish between hydrocele and hernia is nonspecific. A noncommunicating hydrocele is better identified by palpation of a nonreducible oval structure that appears to have a blunt end below the external ring, indicating an isolated fluid collection without a patent connection to the peritoneum. The repair of a pediatric inguinal hernia can be extremely challenging, particularly in the premature child with incarceration. A small incision is made in a skin crease in the groin directly over the internal inguinal ring. The external oblique muscle is dissected free from overlying tissue, and the location of the external ring is confirmed. The external oblique aponeurosis is then opened along the direction of the external oblique fibers over the inguinal canal. The cremasteric fibers are separated from the cord structures and hernia sac, and these are then elevated into the wound. The hernia sac is then dissected up to the internal ring and doubly suture ligated. When the hernia is very large and the patient very small, tightening of the internal inguinal ring or even formal repair of the inguinal floor may be necessary, although the vast majority of children do not require any treatment beyond high ligation of the hernia sac. Controversy exists regarding the role for exploration of an asymptomatic opposite side in a child with an inguinal hernia. Several reports indicate that frequency of a patent processus vaginalis on the side opposite the obvious hernia is approximately 30%, although this figure decreases with increasing age of the child. Management options include never exploring the opposite side or exploring only under certain conditions such as in premature infants or in patients in whom incarceration is present. However, the presence of a patent processus vaginalis by laparoscopy does not always imply the presence of a hernia. Several authors have now reported a completely laparoscopic approach in the management of inguinal hernias in children. This technique requires insufflation through the umbilicus and the placement of an extraperitoneal suture to ligate the hernia sac. Proponents of this procedure emphasize the fact that no groin incision is used and there is a decreased chance of injuring cord structures. Inguinal hernias in children recur in less than 1% of patients, and recurrences usually result from missed hernia sacs at the first procedure, a direct hernia, or a missed femoral hernia. All children should have local anesthetic administered either by caudal injection or by direct injection into the wound. Spinal anesthesia in the preterm infant decreases the risk of postoperative apnea when compared with general anesthesia. The term undescended testicle (cryptorchidism) refers to the interruption of the normal descent of the testis into the scrotum. The testicle may reside in the retroperineum, in the internal inguinal ring, in the inguinal canal, or even at the external ring. The testicle begins as a thickening on the urogenital ridge in the fifth to sixth week of embryologic life. In the seventh and eighth months, the testicle descends along the inguinal canal into the upper scrotum, and with its progress, the processus vaginalis is formed and pulled along with the migrating testicle. At birth, approximately 95% of infants have the testicle normally positioned in the scrotum. A distinction should be made between an undescended testicle and an ectopic testicle. An ectopic testis, by definition, is one that has passed through the external ring in the normal pathway and then has come to rest in an abnormal location overlying either the rectus abdominis or external oblique muscle, or the soft tissue of the medial thigh, or behind the scrotum in the perineum. A congenitally absent testicle results from failure of normal development or an intrauterine accident leading to loss of blood supply to the developing testicle. The incidence of undescended testes is approximately 30% in preterm infants and 1% to 3% in term infants. For diagnosis, the child should be examined in the supine position, where visual inspection may reveal a hypoplastic or poorly rugated scrotum. Usually a unilateral undescended testicle can be palpated in the inguinal canal or in the upper scrotum. Occasionally, the testicle will be difficult or impossible to palpate, indicating either an abdominal testicle or congenital absence of the gonad. If the testicle is not palpable in the supine position, the child should be examined with his legs crossed while seated. This maneuver diminishes the cremasteric reflex and facilitates identification of the location of the testicle. If there is uncertainty regarding location of a testis, repeated evaluations over time may be helpful. It is now established that cryptorchid testes demonstrate an increased predisposition to malignant degeneration. For these reasons, surgical placement of the testicle in the scrotum (orchidopexy) is indicated. It should be emphasized that this procedure does improve the fertility potential, although it is never normal. Similarly, the testicle is still at risk of malignant change, although its location in the scrotum facilitates potentially earlier detection of a testicular malignancy. Other reasons to consider orchidopexy include the risk of trauma to the testicle located at the pubic tubercle and increased incidence of torsion, as well as the psychological impact of an empty scrotum in a developing male. The reason for malignant degeneration is not established, but the evidence points to an inherent abnormality of the testicle that predisposes it to incomplete descent and malignancy rather than malignancy as a result of an abnormal environment. When the testicle is not within the scrotum, it is subjected to a higher temperature, resulting in decreased spermatogenesis. Mengel and coworkers studied 515 undescended testicles by histology and demonstrated a decreasing presence of spermatogonia after 2 years of age. Despite orchidopexy, the incidence of infertility is approximately two times higher in men with unilateral orchidopexy compared to men with normal testicular descent. Consequently, it is now recommended that the undescended testicle be surgically repositioned by 1 year of age. The use of chorionic gonadotropin occasionally may be effective in patients with bilateral undescended testes, suggesting that these patients are more apt to have a hormone insufficiency than children with unilateral undescended testicle. The combination of micro-penis and bilateral undescended testes is an indication for hormonal evaluation and testosterone replacement if indicated. If there is no testicular descent after a month of endocrine therapy, operative correction should be undertaken. A child with unilateral cryptorchidism should have surgical correction of the problem. The operation is typically performed through a combined groin and scrotal incision. The cord vessels are fully mobilized, and the testicle is placed in a dartos pouch within the scrotum. The current approach involves laparoscopy to identify the location of the testicle. If the spermatic cord is found to traverse the internal ring or the testis is found at the ring and can be delivered into the scrotum, a groin incision is made and an orchidopexy is performed. If an abdominal testis is identified that is too far to reach the scrotum, a two-stage Fowler-Stephens approach is used. In the first stage, the testicular vessels can be clipped via laparotomy or laparoscopically. Several months later, the second stage is performed during which the testis is mobilized intra-abdominally along with a swath of peritoneum with collateralized blood supply along the vas. Preservation of the gubernacular attachments with its collaterals to the testicle may confer improved testicular survival following orchidopexy in over 90% of cases. It is, nonetheless, preferable to preserve the testicular vessels whenever possible and complete mobilization of the testicle with its vessels intact. Some surgeons advocate aggressive mobilization of testicular vessels up to the renal hilum if the intra-abdominal testis is within 1 or 2 cm of the internal ring. In either case, meticulous mobilization of the intra-abdominal testis is critical for its survival and successful pexy. Congenital anomalies include a spectrum of diseases that range from simple defects (imperforate hymen) to more complex forms of vaginal atresia, including distal, proximal, and, most severe, complete. Secretions into the obstructed vagina produce hydrocolpos, which may present as a large, painful abdominal mass.

For hernias repaired via a strictly preperitoneal approach herbs like viagra order 1pack slip inn visa, prosthesis fixation may not be necessary at all herbals teas for the lungs order 1pack slip inn mastercard. Fibrin glue fixation is a successful alternative to tack fixation in hernia repair with a synthetic prosthesis herbals detox buy slip inn. Recent studies comparing fibrin glue fixation and suture fixation in open hernia repair show superior rates of chronic pain with both Lichtenstein and plug and patch techniques herbals for hair loss purchase slip inn master card. Rates of other postoperative complications and recurrence were similar between both fixation methods verdure herbals purchase slip inn toronto. Polypropylene and polyester are the most common synthetic prosthetic materials used in hernia repair herbals online cheap slip inn 1pack mastercard. These materials are permanent and hydrophobic, and they promote a local inflammatory response that results in cellular infiltration and scarring with slight contraction in size. Other synthetic mesh materials are under investigation with the goals of minimizing postoperative pain and preventing infection or recurrence. In selecting mesh material, considerations include mesh absorbability, thickness, weight, porosity, and strength. Variations in the fiber diameter and fiber count of mesh materials categorize them as heavyweight or lightweight in density. Commonly used lightweight mesh materials include -d-glucan, titanium-coated polypropylene, and polypropylenepoliglecaprone. These materials have greater elasticity and less theoretical surface area contact with surrounding tissues than their heavyweight counterparts. In settings where resources are limited, prosthetic repairs are performed using alternative materials. Polypropylene and polyethylene mosquito nets are inexpensive 1514 complications, recurrence, or length of stay between the two methods. Due to higher theoretical risk of mesh migration, repair without fixation is not recommended for anterior or transperitoneal approaches. Complications specific to herniorrhaphy and hernioplasty include hernia recurrence, chronic inguinal and pubic pain, and injury to the spermatic cord or testis. The incidence, prevention, and treatment of these complications are discussed in the ensuing section. Common medical issues associated with recurrence include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical causes of recurrence include improper mesh size, tissue ischemia, infection, and tension in the reconstruction. When a recurrent hernia is discovered and warrants re-operation, an approach through a virgin plane facilitates its dissection and exposure. Extensive dissection of the scarred field and mesh may result in injury to cord structures, viscera, large blood vessels, and nerves. After an initial anterior approach, the posterior laparoscopic approach will usually be easier and more effective than another anterior dissection. Conversely, failed preperitoneal repairs should be approached using an open anterior repair. Pain after inguinal hernia repair is classified into acute or chronic manifestations of three mechanisms: nociceptive (somatic), neuropathic, and visceral pain. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain is reproduced with abdominal muscle contraction. It may present early or late, and it manifests as a localized, sharp, burning or tearing sensation. It may respond to pharmacologic therapy and to local steroid or anesthetic injections when indicated. It is usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury. Chronic postoperative pain remains an important measure of clinical outcome that has been reported in as many as 63% of inguinal hernia repair cases. Notwithstanding, moderate-to-severe pain adversely affects physical activity, social interactions, healthcare utilization, employment, and productivity in 6% to 8% of patients. Post-herniorrhaphy inguinodynia is a debilitating chronic complication caused by a combination of nociceptive, neuropathic, and visceral elements. Its incidence is independent of the method of hernia repair; however, the original operative technique determines options for intervention and remedial surgery. Selective ilioinguinal, iliohypogastric, and genitofemoral neurolysis or neurectomy, removal of mesh and fixation material, and revision of the repair are common options for treatment. Nevertheless, anatomic variation and cross-innervation of the inguinal nerves in the retroperitoneum and inguinal canal make selective neurectomy less reliable. At greatest risk of entrapment are the ilioinguinal and iliohypogastric nerves in anterior repairs and the genitofemoral and lateral femoral cutaneous nerves in laparoscopic repairs. Clinical manifestations of nerve entrapment mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthetica, a condition characterized by persistent paresthesias of the lateral thigh. Osteitis pubis is characterized by inflammation of the pubic symphysis and usually presents as medial groin or symphyseal pain that is reproduced by thigh adduction. Avoiding the pubic periosteum when placing sutures and tacks reduces the risk of developing osteitis pubis. Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for possible bone resection and curettage. Intraoperatively, proximal ligation of large hernia sacs to avoid cord manipulation minimizes the risk of injury. In open inguinal hernia repairs, isolating the vas deferens along with the cord structures using digital manipulation may cause injury or disruption. Transections of the vas deferens should be addressed with a urologic consult and early anastomosis, if possible. Historically, surgeons and their patients speculated that synthetic material would increase the risks of mesh rejection, carcinogenesis, and inflammation; however, as mesh became used more frequently, these concerns did not manifest. Nevertheless, one study found prosthetic mesh may exert long-term deleterious effects upon the vas deferens, causing azoospermia. A recent prospective study from the Swedish Hernia Registry discovered no difference in rates of patient-reported infertility between the general population and patients who underwent either mesh or tissue-based inguinal hernia repair. Pain and burning during ejaculation are usually self-limited, and more common causes, such as sexually transmitted diseases, should be excluded. In females, the round ligament is the analog to the spermatic cord, and it maintains uterine anteversion. Injury to the artery of the round ligament does not result in clinically significant morbidity. Complications of transabdominal laparoscopy include urinary retention, paralytic ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and pneumothorax. The most common complications of laparoscopic inguinal hernia repair are presented in this section. Cord and Testes Injury Injury to spermatic cord structures may result in ischemic orchitis or testicular atrophy. Ischemic orchitis is likely caused by injury to the pampiniform plexus and not to the testicular artery. It usually manifests within 1 week of inguinal hernia repair as an enlarged, indurated, and painful testis, and it is almost certainly self-limited. It occurs in <1% of primary hernia repairs; however, this figure is larger for recurrent inguinal hernia repairs. Injury to the testicular artery also may lead to testicular atrophy, which is manifest over a protracted period. The most common cause of urinary retention after hernia repair is general anesthesia, which is routine in laparoscopic hernia repairs. Among 880 patients undergoing inguinal hernia repair with local anesthesia only, 0. Initial treatment of urinary retention requires decompression of the bladder with short-term catheterization. Patients will generally require an overnight admission and trial of normal voiding before discharge. Chronic requirement of a urinary catheter is rare, although older patients may require prolonged catheterization. The laparoscopic transabdominal approach is associated with a higher incidence of ileus than other modes of repair. This complication is self-limited; however, it necessitates sustained inpatient observation, intravenous fluid maintenance, and possibly nasogastric decompression. Abdominal imaging may be helpful to confirm the diagnosis and to exclude bowel obstruction. Prolonged absence of bowel function, in conjunction with a suspicious abdominal 1516 series, should raise concern for obstruction. Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. The presence of intraabdominal adhesions from previous surgeries may predispose to visceral injuries. In reoperative abdominal surgery, open Hasson technique and direct visualization of trocars are recommended to reduce the likelihood of visceral injury. Bowel injury may also occur secondary to electrocautery and instrument trauma outside of the camera field. If injury to the bowel is suspected, its entire length should be examined, and conversion to open repair may be necessary. Bladder injuries are less common than visceral injuries, and they are usually associated with perioperative bladder distention or extensive dissection of perivesical adhesions. As with bladder injuries encountered in open surgery, cystotomies must be repaired in several layers with 1 to 2 weeks of Foley catheter decompression. A confirmatory cystogram may be performed before catheter removal to confirm healing of the injury. Seromas are loculated fluid collections that most commonly develop within 1 week of synthetic mesh repairs. To avoid secondary infection, seromas should not be aspirated unless they cause discomfort or they restrict activity for a prolonged time. In evaluating the various available techniques, other salient signifiers of outcome include complication rates, operative duration, 5 hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various approaches to inguinal hernia repair. Among tissue repairs, the Shouldice operation is the most commonly performed technique, and it is most frequently executed at specialized centers. Meta-analysis demonstrates no significant differences in outcomes between the Lichtenstein and the plug and patch techniques; however, intra-abdominal plug migration and erosion into contiguous structures occurs in approximately 6% of cases. Nevertheless, postoperative acute pain, chronic pain, and recurrence rates are similar between the two methods. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilateral inguinal hernias as the preferred open technique. The most severe vascular injuries usually occur in iliac or femoral vessels, either by misplaced sutures in anterior repairs, or by trocar injury or direct dissection in laparoscopic repairs. Conversion to an open approach may be necessary, and bleeding should be temporarily controlled with mechanical compression until vascular control is obtained. The most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and external iliacs. Although apparent upon initial approach, these vessels may be obscured during mesh positioning, and tacks or staples may injure them. Often, due to tamponade effect, injury to the inferior epigastric vessels is not apparent until the adjacent trocar is removed. If injured, the inferior epigastrics may be ligated with a percutaneous suture passer or endoscopic hemoclips. The presentation of an inferior epigastric vein injury is often delayed because of this effect, and it may result in a significant rectus sheath hematoma. Hematomas and seromas Hematomas may present as localized collections or as diffuse bruising over the operative site. Although they are self-limited, characteristic dark blue discoloration of the entire scrotum may alarm patients. Hematomas may also develop in the incision, retroperitoneum, rectus sheath, and peritoneal cavity. Bleeding within the peritoneum or preperitoneal space may not be readily apparent on physical examination. Perhaps the most salient difference between open and laparoscopic techniques is the number of cases needed to develop technical proficiency. In a randomized controlled trial performed by the Veterans Affairs Cooperative Study, 2-year recurrence rates were 10. The authors recommend that surgeons become proficient in several techniques to address different manifestations of inguinal hernias. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. A survey of nonexpert surgeons using the open tension-free mesh patch repair for primary inguinal hernias. Patent processus vaginalis in the adult as a risk factor for the occurrence of indirect inguinal hernia. Are collagens the culprits in the development of incisional and inguinal hernia disease A systematic review and meta-analysis of the role of radiology in the diagnosis of occult hernia.

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