Search

short bowel syndrome is marked by inadequate intestinal surface area to absorb nutrients. Current treatments are focused on medical management and surgical reconfiguration of the dilated intestine. We propose the use of spring-mediated distraction enterogenesis as a novel intervention to increase intestinal length. Given our previous success lengthening intestinal segments using springs with spring constant ~7 N/m that exerts 0.46 N or higher, we sought to determine the minimal force needed to lengthen porcine small intestinal segments, and to explore effects on intestine over time.Juvenile Yucatan pigs underwent laparotomy with enterotomy to introduce nitinol springs intraluminally (n = 21 springs). Bowel segments (control, spring-distracted) were retrieved on post-operative day (POD) 7 and 14, and lengths measured. Thickness of cross-sectional intestinal layers were measured using HE, and submucosal collagen fiber orientation measured using trichrome stained sections.all pigs survived to POD7 and 14. Spring constants of at least 2 N/m exerting a minimum force of 0.10 N significantly lengthened intestinal segments (p 0.0001). The stronger the spring force, the greater the induced thickness of various intestinal layers at POD7 and 14. Collagen fiber orientation was also more disordered because of stronger springs.a spring constant of approximately 2 N/m exerting 0.10 N and greater significantly lengthens intestinal segments and stimulates intestinal structural changes at POD7 and 14. This suggests a decreased force is capable of inducing spring-mediated distraction enterogenesis.

Background Roux-en-Y gastric bypass is a proven treatment for morbid obesity and its sequelae. Gastric bypass has a safe risk profile, but postoperative complications can be seen. We report on 10 cases of postoperative bleeding causing an obstructing clot at the jejunojejunostomy (JJ) occurring over a 9-year period. Objectives The aim was to document presenting symptoms of obstructing clots at the JJ and to suggest a treatment approach to minimize complications. Setting University Hospital, United States Methods The local Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for all patients undergoing reoperation after Roux-en-Y gastric bypass, from July 2009 until December 2019. All patients who were found to have postoperative bleeding causing an obstructing clot at the JJ were selected for retrospective medical-record review. Results The most common presenting symptoms were Hematocrit drop (10 of 10), nausea (9 of 10), abdominal pain (7 of 10), and hematemesis (4 of 10). There were 12 reoperations in the 10 patients, 10 of which were completed laparoscopically. Infectious complications were the most frequent morbidity in our patients; 4 patients developed abscesses. In all of these, the operative notes described gross spillage into the peritoneal cavity. In later cases, the remnant stomach was decompressed before reoperation, reducing spillage. Conclusions Despite the low rate of obstructing clots at the JJ, without rapid recognition and reoperation, there is a risk for serious complications. Typical presenting symptoms include nausea and abdominal pain, which help differentiate it from other causes of decreased hematocrit. Diagnosis is commonly made with computerized tomographic (CT) scan. Decompression of a dilated remnant stomach before addressing the clot can prevent intraperitoneal spillage and subsequent abscess formation. Enterotomy creation and removal of clot is recommended, without fear of continued bleeding.

Highlights • Gossypiboma is a mass comprising of cotton matrix within the body left accidentally during a surgical procedure. • There have been rare case reports of Transmural migration of retained surgical swab which is a rare phenomenon. • Plain abdominal radiograph can help diagnosis, when a radio opaque marker of the swab is seen., Introduction Textiloma or Gossypiboma is a mass comprising of cotton matrix within the body left accidentally during a surgical procedure. It is estimated that retained surgical foreign bodies occur one in every 5,500–18,760 inpatient operations but the incidence may be as high as one out of every 1,000–1,500 abdominal cavity operations, and even more common during emergency surgeries. There have also been rare case reports of Transmural migration of retained surgical swab which is a rare phenomenon. But even rarer is the incidence of retention of swab inside the small intestine in the previous procedure. Presentation of case A 29-year-old female coming with chief complaints of pain in abdomen since 1 year which was colicky in nature, present all over abdomen, non-radiating. The pain aggravated on eating food. Patient also noticed a lump in her abdomen since past 1 year. Abdomen was opened and the bowel was inspected. Enterotomy was performed and two swabs were removed from the intestine. Discussion Prevention of this condition can be achieved by meticulous count of surgical materials in addition to thorough exploration of surgical site at the conclusion of operations and also by routine use of surgical textile materials impregnated with a radio opaque marker. Conclusion Although rare, a diagnosis of retention of swab or surgical instruments must be considered in cases of vague lumps in abdomen or in cases of intestinal obstruction, especially if the patient has had previous history of laparotomy.

Background Patients undergoing ventral hernia repair (VHR) are at risk of an inadvertent enterotomy during surgery. Inadvertent enterotomies potentially contaminate the surgical field presenting a management dilemma for the surgeon. The aim of our study was to define the incidence and risk factors for a recognized inadvertent enterotomy and determine its impact on short-term outcomes after ventral hernia repair. Methods Using a nationwide hernia registry, the Americas Hernia Society Quality Collaborative, we reviewed all ventral hernia repair performed between 2013 and 2017. Patients were assessed for full-thickness inadvertent enterotomies at the time of surgery. Patients with inadvertent enterotomies and without enterotomies were compared to assess differences in 30-day outcomes, using regression modeling. Results A total of 5,916 patients were included. The incidence of inadvertent enterotomy was 1.9%, with no difference between open and laparoscopic approaches. Inadvertent enterotomies did not increase surgical site occurrences but there were more surgical site infections (OR: 2.20 [95% CI: 1.24–3.90], P = .007). Patients were less likely to receive mesh if there was an enterotomy. Inadvertent enterotomies led to higher rates of reoperations, readmission, enterocutaneous fistulas, and mortality. Conclusion Inadvertent enterotomies are more common in complex cases of ventral hernia repair and have an overall incidence of 1.9%. These patients are at increased risk of surgical site infections, reoperations, readmission, and mortality. Although definitive hernia repair with mesh can be safely performed, surgeons should consider multiple factors, including type of mesh and location of mesh in the abdominal wall, before proceeding with definitive repair in any case of an enterotomy.

Highlights • To highlight a forgotten cause of bowel occlusion due to cholecystoduodenal fistula. • Importance of knowledge of this rare entity and its clinical manifestation. • Familiarity of its radiological findings can lead to early diagnosis and better outcome. • Choice of surgical option must be tailored according to patient's medical condition., Introduction Gallstone ileus is a rare sequela of cholelithiasis. The pathology occurs as a result of bilioenteric fistula due to erosion by the offending gallbladder stone. It is most commonly encountered in elderly females and CT imaging is diagnostic in the majority of cases. Surgical intervention aims to promptly relief the obstruction by removing the gallstone and dealing with the fistula. Morbidity and mortality are usually high since it usually occurs in elderly patients. Presentation of case An 88-year-old lady with multiple chronic medical problems and no history of biliary manifestation presented with acute small bowel obstruction. Abdominal CT imaging revealed a bilioenteric fistula and an impacted gallstone in the jejunum causing occlusion. Laparotomy was performed and the stone was removed via enterolithotomy. Manipulation of the cholecystoduodenal fistula was not attempted due to severe inflammatory adhesions. The patient had uneventiful postoperative course and remained symptom free on one year follow-up. Discussion and conclusion Management of gallstone ileus is mainly surgical. Delay in detection and treatment of gallstone ileus may result in significant morbidity and mortality. The choice of surgical option is influenced by the preoperative medical status of the patient. A literature review generally supports the employment of enterolithotomy in high-risk patients and reserving cholecystectomy and resection of the fistula for less comorbid patients with feasible anatomy.

Highlights • An enterolith occurring in the duodenal afferent loop after distal gastrectomy, leading to obstructive jaundice and ileus is rare. • Although afferent loop enterolith formation is uncommon, it should be considered when a patient with a history of B-II gastrectomy or Roux-en-Y reconstruction presents with fever, abdominal pain, or other symptoms suggesting acute cholangitis. • Surgical treatment should be considered for afferent loop obstruction or intestinal obstruction that is refractory to conservative treatment., Introduction Afferent loop obstruction is an uncommon complication associated with Billroth II reconstruction or Roux-en-Y reconstruction after gastrectomy. Moreover, cases where the obstruction is caused by enterolith are rare. Here, we report a rare case of afferent loop obstruction caused by an enterolith after Roux-en-Y reconstruction of gastrectomy; subsequently, leading to ileus in the ileum. Presentation of case An 84-year-old man who received a Roux-en-Y distal gastrectomy for gastric cancer presented with symptoms of fever and jaundice 14 months later. Computed tomography (CT) scan revealed an enterolith in the duodenal afferent loop and a dilated intrahepatic bile duct. Although the obstructive jaundice and fever disappeared with conservative therapy, ileus occurred due to the movement of the enterolith into the ileum, which was refractory to conservative therapy. Therefore, enterotomy was performed to remove the enterolith, and the patient had an uneventful recovery. Histologically, the enterolith derived from food residue. No postsurgical sign of recurrence has been noted for 6 months. Conclusion We report a rare case where an enterolith in a duodenal afferent loop after distal gastrectomy led to obstructive jaundice, and subsequently, caused ileus by its movement into the ileum.

Introduction Fecaloma is an accumulation of feces that has formed a mass and has failed to be expelled spontaneously. Because fecal matter is harder and firmer in the left side of colon, and the diameter of the bowel is smaller compared to the right, fecalomas mostly form in recto-sigmoid area. Small bowel fecaloma formation is an extremely rare condition. Case presentation We report a 49 years old man who presented with small bowel obstruction due to ileal fecalomas for whom enterotomy and removal of fecaloma was done with good outcome. Discussion Fecal matter can accumulate in the intestinal lumen to form a mass separate from other intestinal contents which eventually becomes fecaloma. Formation is usually related to chronic constipation, conditions causing intestinal motility disorder, or in psychiatric patients who could have ingested extraordinary substances. Fecaloma can present as abdominal mass, stercoral colitis, urinary retention or intestinal obstruction. Treatment options include conservative management with bowel rest, laxatives, endoscopic removal, laparotomy and removal via enterotomy. Conclusion Fecaloma can be considered in patients who present with small bowel obstruction without any risk factors. Initial noninvasive management should be considered. Failed conservative treatment can be followed by laparotomy and fecaloma removal., Highlights • Fecaloma is an accumulation of feces that has formed a mass and has failed to be expelled spontaneously. • Most patients have risk factors in form of intestinal motility disorder, constipation or psychiatric disorder. • Small bowel fecaloma is extremely rare without such risk factors. • Spontaneous formation of fecaloma in small bowel can present with intestinal obstruction.

The laparotomy surgical procedure allows for the identification and correction of intestinal lesions associated with acute abdomen in horses. The clinician relies on various laparotomy techniques to diagnose and treat this syndrome, and to date, the postsurgical effects of these techniques have not been clarified. The aim of this study was to evaluate the effects of jejunal manipulation during three laparotomy techniques through physical and clinical parameters and echography. Fifteen healthy horses were randomly assigned to three groups: animals in G1 (n = 5) were subjected to an exploratory laparotomy, animals in G2 (n = 5) to a laparotomy with an enterotomy, and animals in G3 (n = 5) to a laparotomy with an enterectomy. Degree of pain, jejunal wall thickness, and clinical parameters were evaluated before and after surgery. Horses in G3 had higher heart rates, respiratory frequency, degree of pain, and jejunal wall thickness compared with G1. Clinical variables during the postsurgical period were compared among the laparotomy techniques, and higher values of erythrocytes, leucocytes, neutrophils, and proteins were found in horses belonging to G3 compared to those in G1. Intestinal manipulation during the surgical procedure altered the physical and clinical parameters, as well as the results of the echography evaluation, with more significant effects from laparotomy with enterectomy. In the postsurgical period, the heart rate of horses in G3 was higher (P = .02) than the values obtained in G1 and G2. Upon the evaluation of degree of pain, statistically significant differences (P = .04) were identified between horses in G1 versus G3. G3 animals presented a higher degree of pain. Regarding the erythrocytes (L/L), higher values were measured in G3 (P = .001) in comparison with G1 and G2. These results suggest that meticulous tissue handling is essential to minimize intestinal trauma and inflammation.

A 13-year-old mare presented for evaluation of recurrent colic episodes. The horse was diagnosed with a mass within the spleen at the ultrasound examination of the abdomen; the levels of Serum Amyloid A and the fibrinogen were high and so a presumptive diagnosis of an abscess involving the spleen was made base on clinical, ultrasonographic and laboratory findings and it was decided to perform n exploratory laparotomy for a definitive diagnosis and possible treatment. Upon abdominal exploration a mass involving the spleen, the lateral wall of the ventral colon adherent to the left abdominal wall was diagnosed and with an intraoperative ultrasound examination a linear hyperechoic foreign body was diagnosed within the mass. It was removed through an enterotomy of the left ventral colon that allowed the digital exploration of the mass without spilling of pus within the peritoneal cavity. The horse was discharged and the long term follow-up revealed no complications and no more signs of abdominal pain.

Background Gallstone ileus is caused by the exit of a gallstone from the gallbladder or bile duct into the small intestine, resulting in bowel obstruction if this stone becomes lodged in a small bowel loop. Clinical case The case is presented of a 78 year-old woman with an episode of intestinal obstruction. After studying the main cause of the obstruction, it was decided to perform a laparotomy where a gallstone located in the terminal ileum was causing the obstruction. No fistula was observed between the gallbladder and the bile duct and the intestinal tract. It is important to note the history of an endoscopic retrograde cholangiopancreatography performed a few months earlier, as it would probably be the cause of the passage of the gallstone to the small bowel. Conclusion Few reports of gallstone ileus have been described in the literature after performing an endoscopic retrograde cholangiopancreatography. In these cases, the intestinal obstruction usually occurs several months after the endoscopic retrograde cholangiopancreatography, so the diagnosis is often delayed. Surgery is usually the definitive treatment and it consists of the removal the stone by enterotomy and performing a cholecystectomy. Biliary enteric fistula repair is not necessary since this does not form.

Highlights • Rectal impalement injuries are infrequently encountered in surgeons’ practice. They pose a diagnostic challenge to surgeons and put them in demanding circumstances for successful extraction. • High index of suspicion of perforations should be there in all rectal foreign bodies. Iatrogenic bladder injuries give excellent results when repair suitably. • Prompt diagnosis and immediate intervention to remove the foreign bodies are quintessential in all rectal foreign bodies with evidence of perforation., Introduction and importance Rectal perforations due to foreign body impalement are infrequently encountered in practice. Accidental or intentional foreign body insertions pose a diagnostic challenge to surgeons and put them in demanding circumstances for successful extraction. Case presentation We report a case of a 60-year-old male with alleged history of accidental foreign body insertion into the rectum. Radiographs showed a linear metallic foreign body with crooked end. Computed Tomography (CT) with rectal contrast revealed contrast extravasation indicating anterior wall perforation of upper rectum. Patient was taken urgently for exploration and foreign body removal. Intra-operatively, bladder was injured inadvertently. Primary repair of enterotomy and loop sigmoid-ostomy was done besides bladder repair. Patient tested positive for COVID-19. Patient was observed in critical care unit for two days. Post-operative period was unremarkable apart from midline abdominal wound gape for which secondary closure was done. Patient was discharged with urinary catheter in-situ. Patient followed-up with a normal cystourethrogram and a well-functioning stoma. Stoma closure after two months was uneventful. Clinical discussion A thorough history and clinical examination is required and one should raise a high index of suspicion of perforation in patients with rectal foreign bodies, which should be managed appropriately and promptly to prevent sepsis and multi-organ dysfunction. Inadvertent bladder injuries are common with lower-midline incisions. However, give good results when repaired suitably. Conclusion The rationale behind this report is to explicate the complexity and hurdles in the surgical management of rectal foreign bodies causing impalement injury.

Small intestinal foreign bodies can often be manually manipulated orad into the stomach, or aborad into the colon during exploratory laparotomy. While the former allows for gastrotomy in lieu of enterotomy, the latter obviates need for incision in the gastrointestinal tract altogether. In this report, we provide novel description of a technique to remove foreign material from the stomach per os following extraluminal manipulation during surgery. This is achieved using a grasping instrument introduced via orogastric tube. The described laparotomy-assisted transoral foreign body retrieval is an effective alternative to gastrotomy in certain cases. This technique is less invasive and may be associated with shorter operative time and decreased morbidity compared to procedures requiring incision into the gastrointestinal tract.

Highlights • Elipse™ IGB is a novel procedureless device for weight loss. • We represent a successful laparoscopic management of a small bowel obstruction caused by Elipse™ IGB migration. • This is the first reported adverse event in literature regarding Elipse™ IGB device., Introduction The Elipse™ intragastric balloon (IGB) for weight loss is a swallowable capsule that is filled with 550 mL of fluid and resides in the stomach for four months before being excreted from the gastrointestinal tract. Although initial data showed that use of this device is safe and free from serious complications, we report for the first time the successful management of an Elipse™ IGB-related adverse event. Presentation of case A 41-year-old woman presented to our emergency department following two days of abdominal pain, vomiting, and constipation. Her medical history included four caesarean sections and insertion of the Elipse™ IGB 16 weeks prior to presentation. The patient was vitally stable at presentation and abdominal examination revealed a mildly distended abdomen. Plain X-ray revealed a small bowel obstruction (SBO), and a double contrast computed tomography scan showed a dilated small bowel with mild free fluid proximal to a transition zone at the distal jejunum. Laparoscopic enterotomy was performed just proximal to the obstruction site, and the balloon was visualized and extracted after it had been incised and emptied. The enterotomy incision was closed with an intracorporeal continuous absorbable suture. The patient’s recovery was uneventful and she was discharged on postoperative day 4. Discussion We discuss the possible etiologies of SBO following Elipse™ IGB insertion, and present a brief literature review regarding surgical and nonsurgical management options for such cases. Conclusion Although initial data showed the Elipse™ IGB to be safe, complications can occur and be managed successfully.

Background The main objective was to identify predictive factors associated with prosthesis infection and mesh explantation after abdominal wall hernia repair (AWHR). Methods This is a retrospective review of all patients who underwent AWHR from January 2004 to May 2014 at a tertiary center. Multivariate analysis identified predictors of mesh infection and explantation after AWHR. Results From 3,470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. Steroid or immunosuppressive drugs use (odds ratio [OR] 2.22; confidence interval [CI] 1.16 to 3.95), urgent repair (OR 5.06; CI 2.21 to 8.60), and postoperative surgical site infection (OR 2.9; CI 1.55 to 4.10) were predictive of mesh infection. Predictors of mesh explantation were type of mesh (OR 3.13; CI 1.71 to 5.21), onlay position (OR 3.51; CI 1.23 to 6.12), and associated enterotomy in the same procedure (OR 5.17; CI 2.05 to 7.12). Conclusions Immunosuppressive drugs use, urgent repair, and postoperative surgical site infection are predictive of mesh infection. Risk factors of prosthesis explantation are polytetrafluoroethylene mesh, onlay mesh position, and associated enterotomy in the same procedure.

Highlights • A case report of postoperative ileo-ileal intussusception with a sutured enterotomy site as a lead point is described. • This is a rare postoperative complication in the adult. • A review of the relevant literature is presented., Introduction Postoperative small bowel obstruction due to intussusception is a rare entity but can lead to severe morbidity and even mortality. We present a case of this rare complication produced by an unusual cause. Case report A 22 year old male, who is a fruitarian, presented to the E.R on day 6 after laparotomy due to obstructing fetobezors that were removed via gastrotomy and enterotomy. In his readmission, he had severe, diffuse abdominal pain, distended abdomen and diffuse peritonitis. Abdominal computed tomography (CT) showed a large amount of fluid in the abdomen, distended small bowel loops, a small amount of free air around the stomach and a suspected ileo-ileal intussusception. The patient underwent emergent laparotomy which revealed an ileo-ileal intussusception with the sutured enterotomy site from the previous operation as the lead point. In addition, a minor dehiscence of the gastrotomy site was identified. A reduction of the intussusception was performed with resection of the enterotomy site and side to side anastomosis. The gastrotomy site was debrided and re-sutured. Recovery was uneventful. Conclusion Postoperative intussusception, although rare, is potentially a dangerous complication, often not involving the site of the primary operation. To our knowledge this is the first report of an intussusception with a sutured enterotomy site as the lead point. Clinicians should be aware of this entity when assessing a patient with abdominal pain and distention after surgery with enterotomy or resection of bowel.

Background Early identification of serious adverse events following ventral hernia repair (VHR) could result in improved patient outcomes. Establishment of clinical markers that correlate with serious adverse events following VHR would help facilitate a more timely diagnosis of such events. We investigated the clinical utility of postoperative tachycardia to predict serious adverse events in patients undergoing VHR. Methods Consecutive patients undergoing VHR at the Cleveland Clinic Comprehensive Hernia Center from September 2013 through June 2015 were identified within the Americas Hernia Society Quality Collaborative database. Tachycardia was classified according to frequency and duration. Sustained tachycardia was defined as >8 consecutive hours of tachycardia on any postoperative day. Serious adverse events were defined as cardiac events, venous thromboembolism, infection, bleeding, and anastomotic leak or missed enterotomy. Association between tachycardia class and serious adverse events was investigated using the Pearson χ2 test. Results A total of 377 patients underwent VHR during the study period. A total of 119 (31.6%) patients experienced at least 1 episode of tachycardia. There were 26 (6.9%) patients with a serious adverse event. Tachycardia was present in 21 (80.7%) of these patients. Sustained tachycardia had a significant association with serious adverse events (P = .007). The presence of postoperative tachycardia was associated with the occurrence of a serious adverse event, having a positive likelihood ratio of 2.9 (95% confidence interval 2.2–3.7). Conclusion Postoperative tachycardia is common following VHR. Nevertheless, sustained tachycardia is associated with a significant risk for serious postoperative adverse events and mandates further investigation.

Study Objective To demonstrate the safe and effective excision of an ovarian remnant in the face of extensive pelvic adhesion. Design Surgical video presentation. Setting Academic tertiary care center. Patients or Participants This is a 46 year old patient G7P5025 patient with a history of chronic pelvic pain. Her past surgical history is significant for a total abdominal hysterectomy followed by a right salpingo-oophorectomy 8 years later for an ovarian cyst. Her right salpingo-oophorectomy surgery was complicated by an enterotomy with injury to the sigmoid colon due extensive pelvic adhesive disease. Interventions Preoperative pelvic ultrasound and MRI revealed a large left sided cystic pelvic mass as well as aright adnexal mass suspicious for an ovarian remnant. Intraoperatively, extensive pelvic adhesions were noted as well as the large cytic pelvic mass and an ovarian remnant attached to the right pelvic side wall. A left oophorectomy was performed and the right ovarian remnant was excised after extensive ureterolysis. Measurements and Main Results After the above interventions normal anatomy was restored to the pelvis. Pathologic evaluation confirmed right ovarian cortical tissue. At her 6 months follow up visit the patient had significant resolution of her pelvic pain. Conclusion Surgical removal of an ovarian remnant can be quite challenging and has risks of injury to the ureters, bladder and bowel. With good surgical technique using the laparoscopic/robotic platform, safe and effective excision of ovarian remnant can be achieved; affording a favorable outcome for patients.

Study Objective To evaluate laparoscopic sacrocolpopexy operative times, complication rates and long-term surgical outcomes at one academic institution with significant trainee involvement. Design This is a retrospective chart review of laparoscopic sacrocolpopexy cases. Setting Cases took place in an operating room at a large academic medical center. Patients were in dorsal lithotomy position with five abdominal laparoscopic trocar sites. Patients or Participants A series of 181 consecutive laparoscopic sacrocolpopexy cases (with or without concomitant procedures) were examined between February 2014 and August 2019. Interventions None. Measurements and Main Results Descriptive statistics were used to compare primary outcomes with published literature. The average operative time was 139.9 minutes, compared to 180-190 minutes noted in other studies. Four cases of intraoperative cystotomy (2.2%) and one enterotomy (0.6%) were noted compared to 5-6% and 1.4% respectively in the literature (Sheyn et al 2019). There were 16 cases of postoperative urinary tract infection (8.8%). At their most recent postoperative visit, which occurred on average at postoperative day 278, recurrent prolapse was noted in 11.7% of patients and 3.9% of those patients underwent a subsequent repair to correct their prolapse. Other complications included 0.6% small bowel obstruction, 1.1% mesh erosion and 7.7% de-novo stress urinary incontinence; all of these were less than those documented in the literature. The overall complication rate was 15.4% compared to 18% in the literature (Nosti et al 2014). Conclusion This institutional demonstrates short operative times, low complication rates and favorable outcomes with resident involvement in laparoscopic sacrocolpopexy. This indicates advanced urogynecology procedures can be performed with significant resident involvement without compromising operative time and surgical outcomes.

Small intestinal anastomoses are commonly performed in veterinary medicine following resection of diseased or devitalized intestinal tissue. Traditionally, suture has been employed to anastomose intestinal ends. However, use of intestinal staplers has become increasingly popular due to the ability to produce a rapid anastomosis with purported superior healing properties. Under normal conditions, intestinal healing occurs in three phases: inflammatory, proliferative, and maturation. Dehiscence, a devastating consequence of intestinal anastomosis surgery, most often occurs during the inflammatory phase of healing where the biomechanical strength of the anastomosis is almost entirely dependent on the anastomotic technique (suture or staple line). The resulting septic peritonitis is associated with a staggering morbidity rate upwards of 85% secondary to the severe systemic aberrations and financial burden induced by septic peritonitis and requirement of a second surgery, respectively. Intraoperative and postoperative consideration of the multifactorial nature of dehiscence is required for successful patient management to mitigate recurrence. Moreover, intensive postoperative critical care management is necessitated and includes antibiotic and fluid therapy, vasopressor or colloidal support, and monitoring of the patient's fluid balance and cardiovascular status. An understanding of anastomotic techniques and their relation to intestinal healing will facilitate intraoperative decision-making and may minimize the occurrence of postoperative dehiscence.

Background: There has been a recent widespread performance of and publication on robotic ventral hernia repair (RVHR). A national database study demonstrated decreased hospital stay with RVHR compared to laparoscopic repair (LVHR). However, no randomized controlled trial (RCT) has evaluated RVHR. We hypothesized that RVHR compared to LVHR is associated with fewer days in the hospital 90-days post-operative. Methods: In this blinded, multicenter RCT, patients scheduled to undergo elective VHR were randomized to RVHR or LVHR and stratified by surgeon. Primary outcome was days in hospital within 90-days post-operative. Secondary outcomes included emergency room visits, operating room time, wound complications, hernia recurrence, reoperation, quality of life (QOL), and costs from the healthcare system perspective. Outcomes were assessed through frequentist (negative binomial, generalized linear or logistic regression) and Bayesian analyses. Findings: A total of 124 patients were enrolled and randomized: 65 underwent RVHR and 59 LVHR. Patients from both groups were similar at baseline. Ninetyday follow-up was completed in 123 patients (99·2%). There was no difference in days in hospital between the two groups (median 0 vs 0 days; RR=0·90 [95%CI=0·37-2·19]; p=0·822). On secondary outcomes, no differences were noted in emergency room visits, wound complications, hernia recurrence, or reoperation. However, RVHR had longer operative duration (141 vs 77 minutes; coefficient=62·89 [95%CI=45·75-80·01]; p=

Study Objective To determine the feasibility of measuring hydrogen sulfide (H2S) gas in the insufflated abdomen during laparoscopic surgery after transmural bowel injury as a marker of unrecognized bowel injuries. Design This is a feasibility study performed on swine models during a robotic training course. We aimed to determine baseline H2S levels and subsequent elevations in H2S levels after enterotomy of the large and small intestine. Setting University based robotic training lab. Patients or Participants N/A Interventions During initial insufflation of the swine abdominal cavity, baseline H2S levels were recorded over 15 second intervals for 10 minutes using the Analytical Technology, Inc. PortaSens II Portable Gas Leak Detector Model C16. The same values were recorded in separate studies after transmural transection of the small intestine and large intestines using laparoscopic shears with and without monopolar electrosurgery. Measurements and Main Results Baseline H2S level over the initial 10 minutes of insufflation were 0 ppm. H2S levels after small and large bowel enterotomy without monopolar electrosurgery failed to show any elevation in H2S levels. H2S levels after small and large bowel enterotomy with monopolar electrosurgery both showed increases to 4 ppm with a duration of elevation measuring 3:45 minutes and 4:15 minutes respectively. Conclusion Our study demonstrates that H2S cannot be utilized as a detection method for unrecognized bowel injury during laparoscopic surgery. While our study did show elevations in H2S after transection with monopolar electrosurgery, this was later determined to be the result of cross contamination with carbon monoxide which was an unexpected and confounding factor. Further testing of other gases produced by the gastrointestinal tract or use of alternative detection methods may provide more clinically relevant results.

This article summarizes the available information on different soft tissue surgical procedures in rabbits, based on the literature and the authors' experiences, emphasizing the differences between rabbits and the more familiar dogs and cats. The major surgical principles in rabbits are discussed, and common surgical procedures, such as abdominal exploration, gastrotomy, enterotomy, liver lobectomy, nephrectomy, cystotomy, cystectomy, ovariohysterectomy, ovariectomy, orchidectomy, are described.

Background The aim of this study was to assess the impact of previous abdominal surgery (PAS) on single-port laparoscopic colectomy (SPLC). Methods We studied 429 consecutive patients who underwent SPLC in our department from May 2009 to December 2013. Patients were divided into 2 groups: those with PAS (PAS group) and those with NPAS (NPAS group). Operative parameters and outcomes were analyzed between the 2 groups retrospectively. Results SPLC was performed in 152 PAS patients and 277 NPAS patients. Eight patients in the PAS group and 6 patients in the NPAS group were converted to multiport laparoscopic colectomy (5.3% vs 2.2%, respectively; P = .077). Three patients in the PAS group and 2 patients in the NPAS group had inadvertent enterotomy (2.0% vs .7%, respectively; P = .352). No patients were converted to open surgery. There were no significant differences between the 2 groups in terms of blood loss, operative time, and postoperative outcomes. Conclusion Our experience has demonstrated the safety and feasibility of SPLC in patients with PAS.

Highlights • Bezoar-induced small bowel obstruction remains an uncommon diagnosis accounting for 0.4–4% of all mechanical bowel obstruction that poses a diagnostic and management challenge. • It should be suspected in patients with an increased risk of bezoar formation, such as in the presence of previous gastric surgery, poor dentition or a history suggestive of increased fiber intake, or patient with psychiatric disorders. • The presence of well-defined intraluminal mass with mottled gas pattern on CT scan is suggestive of an intestinal bezoar., Introduction Bezoar is an unusual cause of small bowel obstruction accounting for 0.4–4% of all mechanical bowel obstruction. The common site of obstruction is terminal ileum. Case report A 28-year-old male with no past surgical history, known to have severe mental retardation presented with anorexia. CT scan demonstrated dilated small bowel loops and intraluminal ileal mass with mottled appearance. At exploratory laparotomy, a bezoar was found impacted in the terminal ileum 5–6 inches away from the ileocecal valve and was removed through an enterotomy. Discussion Bezoars are concretions of fibers or foreign bodies in the alimentary tract. Small bowel obstruction is one of common clinical symptoms. The typical finding of well-defined intraluminal mass with mottled gas pattern in CT scan is suggestive of an intestinal bezoar. The treatment option of bezoar is surgery including manual fragmentation of bezoar and pushing it toward cecum, enterotomy or segmental bowel resection. Thorough exploration of abdominal cavity should be done to exclude the presence of concomitant bezoars. Recurrence is common unless underlying predisposing condition is corrected. Conclusions Bezoar-induced small bowel obstruction remains an uncommon diagnosis. It should be suspected in patients with an increased risk of bezoar formation, such as in the presence of previous gastric surgery, a history suggestive of increased fiber intake, or patient with psychiatric disorders. CT scan is helpful for preoperative diagnosis.

Background Small bowel anastomoses can present a technical challenge during laparoscopic procedures, particularly gastric bypass procedures. Early small bowel obstruction (SBO) rates associated with such procedures occur in .7%–5.2% of patients. Herein, we describe how a bidirectional stapling technique moves the enterotomy to the center of the anastomosis, decreasing the chances of an afferent limb obstruction. Methods A prospectively collected cohort of 2263 consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass with bidirectional stapling of the small bowel anastomosis was evaluated for early SBO. All patients met the National Institutes of Health criteria for bariatric surgery. Results Overall, 3 patients’ perioperative courses were complicated by perioperative, early SBO (.13%). These instances were all attributable to intraluminal blood clots and not from inadvertent narrowing of the afferent limb. One was diagnosed on postoperative day 1 by upper gastrointestinal study (UGI); 2 were diagnosed on postoperative day 2 by computed tomography (CT) scan with oral contrast. All 3 patients’ complications were managed with a laparoscopic operation. Conclusion The bidirectional stapling technique for small bowel anastomoses, with our modifications, is a rapid, well-tolerated, and effective technique that offers potential advantages over standard laparoscopic anastomotic techniques by reducing perioperative SBO complications.

Enterotomy is a significant complication of laparoscopic ventral or incisional hernia repair (LVHR) and can be devastating if missed. Enterotomy occurs in 2.6% of patients undergoing LVHR and is missed 21.8% of the time. Controversy exists regarding the management of known or potential enterotomies. Approaches for managing recognized enterotomies during hernia repair are usually employed immediately; in a nonstaged fashion; and include laparoscopic enterotomy repair with immediate LVHR, laparotomy for repair of enterotomy with concomitant LVHR, or conversion to laparotomy for both enterotomy and hernia repair. The staged approach for managing recognized or potential enterotomies is less commonly employed and involves lapa- roscopic repair of enterotomy, admission, and delayed but definitive laparoscopic hernia repair in the same hospitaliza- tion. The presence of known or potential enterotomies during LVHR presents a difficult problem and may be a contraindication for immediate placement of prosthetic because of increased risks posed for abdominal infection, reopera- tion, prosthetic removal, hernia recurrence, and death. The staged approach—with a 2- to 5-day delay—represents a safe solution to this challenging problem. We present 4 cases managed via staged approach due to an enterotomy, risk factors, and suspicion for missed or delayed enteroto- mies augmented by a review of the literature.

Background Gastrojejunostomy is important for palliation of malignant gastric outlet obstruction and surgical obesity procedures. A less-invasive endoscopic technique for gastrojejunostomy creation is conceptually attractive. Our group has developed a compression anastomosis technology based on endoscopically delivered self-assembling magnets for endoscopy (SAMSEN) to create an instant, large-caliber gastrojejunostomy. Objective To develop and evaluate an endoscopic means of gastrojejunostomy creation by using SAMSEN. Setting Developmental laboratory and animal facility. Design Animal study and human cadaveric study. Subjects Yorkshire pigs (7 cadaver, 5 acute); human (1 cadaver). Interventions A transoral procedure for SAMSEN delivery was developed in porcine and human cadaver models. Subsequently, gastrojejunostomy creation by using SAMSEN was performed in 5 acute pigs. The endoscope was advanced into the peritoneal cavity through the gastrotomy, and a segment of the small bowel was grasped and pulled closer to the stomach. An enterotomy was created, and a custom overtube was advanced into the small bowel for deployment of the first magnetic assembly. Next, a reciprocal magnetic assembly was deployed in the stomach. The 2 magnetic systems were mated under fluoroscopic and endoscopic guidance. Contrast studies assessed for gastrojejunostomy leak. Immediate necropsies were performed. Main Outcome Measurements Technical feasibility and complications. Results Gastrojejunostomy creation by using SAMSEN was successful in all 5 animals. Deep enteroscopy was performed through the stoma without difficulty. No leaks were identified on contrast evaluation. At necropsy, the magnets were properly deployed and robustly coupled together, resistant to vigorous tissue manipulation. Limitations Acute animal study. Conclusions Endoscopic creation of immediate gastrojejunostomy by using SAMSEN is technically feasible.

In the last 15 years, gynecologic oncologists have increasingly used laparoscopic-assisted vaginal hysterectomy for the treatment of endometrial cancer. In a large randomized trial, no difference was found between the laparoscopic approach and laparotomy in oncologic outcomes among patients with endometrial cancer. The procedure has not been widely adopted, because the nontraditional surgical skills required result in a steep learning curve and reliance on highly-skilled surgical assistants. In recent years, robotic-assisted surgical approaches have been developed for gynecologic surgery that may provide an alternative to traditional laparoscopy. Its use appears to eliminate several technical problems associated with traditional laparoscopy. The robotic approach has been investigated for complex gynecologic procedures, including surgical staging for endometrial cancer. Several small series comparing the robotic method with traditional laparoscopy suggest a number of advantages that may allow for a quicker recovery, including reduced estimated blood loss and shorter operative time. The present study was a 2-year retrospective chart review comparing intraoperative complication rates, perioperative morbidity, staging, and pathological outcomes for surgical staging of endometrial cancer between 2 cohorts of patients: those receiving robotic-assisted surgery, and those treated with the traditional laparoscopic approach. The major intraoperative complications identified included vascular injuries, enterotomy, cystotomy, and conversion to laparotomy. Secondary outcomes examined included operative time, estimated blood loss, need for transfusion, total number of lymph nodes retrieved, and the length of hospital stay. Among the 275 cases identified, 102 were patients with robotic-assisted staging and 173 were patients with traditional laparoscopic staging. No significant difference was found between the groups in the rate of intraoperative (P = 0.71), intra-hospital (P = 0.41), and major late complications (P = 0.14). Although the mean operative time was longer with robotic-assisted staging compared with the traditional laparoscopic approach (237 minute vs. 178 minute, P < 0.0001), the estimated blood loss was significantly lower (109 mL vs. 187 mL, P < 0.0001). Similar numbers of lymph nodes were retrieved from the 2 groups (P = 0.32). No significant differences were found in the length of the hospital stay, or rates of readmission or reoperation. These findings show that the robotic-assisted approach to surgical staging and treatment of women with endometrial cancer is a safe and feasible alternative to traditional laparoscopy.

Intestinal obstruction due to foreign body ingestion is one cause of colic in horses. Although it occurs more frequently in juveniles, adult horses also may be affected. The small colon is a common location in which foreign bodies can be found. Depending on the location of the obstruction in the small colon, different techniques to dislodge the foreign body toward areas where it can be safely exteriorized and removed can be attempted. Alternatively, different approaches to the abdomen can be performed to facilitate exteriorization of the obstructed segment and removal of the foreign body. This paper describes a case of large and small colon obstruction in an adult horse caused by two distinct foreign bodies. The large colon obstruction was removed through a pelvic flexure enterotomy using the ventral midline approach, and the small colon obstruction was removed through a small colon enterotomy using a paramedian approach. Information regarding signalment, history, clinical signs, surgical treatment, and follow-up status of the horse are described.

Background Laparoscopic suprapubic hernia repair (LSHR) is frequently a technically difficult procedure. This is often due to extensive adhesions from multiple previous operations, the necessary wide pelvic dissection, and adequate mesh coverage with transfascial suture fixation. The aim of the current study was to document the complications and morbidity associated with the repair of suprapubic hernias. Methods A retrospective review of patients with complex suprapubic ventral hernias undergoing laparoscopic repair between 2003 and 2007 at 2 university-based practices by 1 surgeon at each facility was conducted. The operative techniques were similar and included dissection into the space of Retzius to mobilize the dome of the bladder, intraperitoneal onlay of mesh using a barrier mesh, careful tack fixation to the pubic bone and Cooper's ligaments, and extensive transfascial suture fixation of the mesh. Results A total of 47 patients were reviewed, 29 women and 18 men, with a mean age of 54 years. Patients averaged 3.5 previous abdominal surgeries (SD ±2.3) and had a mean body mass index (BMI) of 35.1 (SD ±7.5). Previous ventral hernia repairs had been performed in 57% of patients. Average defect size was 139.8 cm2 (SD ±126) and average mesh size was 453.8 (SD ±329.0), with an average hernia-to-mesh ratio of 3.2. Median length of stay was 3 days with a mean follow-up of 2.6 months (SD ±3.1). There were 18 complications (38%): symptomatic seroma (n = 4), prolonged ileus (n = 2), chronic pain (n = 2), postoperative urinary retention (n = 2), enterotomy (n = 1), intraoperative bladder injury (n = 1), postoperative urinary tract infection (n = 1), mesh infection (n = 1), rapid ventricular rate (n = 1), small bowel obstruction (n = 1), pulmonary embolism (n = 1), and pneumonia (n = 1). One patient required conversion to open ventral hernia repair, no injury was identified. Recurrence occurred in 3 patients (6.3%). The mechanisms of recurrence included reherniation at the level of the pubic tubercle, a lateral mesh recurrence in a patient with a high BMI and small abdominal excursion, and in a pregnant patient who developed a fixation suture hernia. Conclusions Laparoscopic suprapubic hernia repair is safe and effective with a relatively low recurrence rate, considering the complexity of the repair.

Background Various techniques have been used for laparoscopic gastric bypass. This study was performed to survey American Society for Bariatric Surgery practicing surgeons on how they perform laparoscopic gastric bypass. Methods An Internet-based survey was sent to all practicing surgeons in the American Society for Bariatric Surgery database by way of e-mail. The survey was divided into sections, including experience, pouch, limbs, gastrojejunostomy (GJ), jejunojejunostomy, and band. The survey results were collected from the Internet site after 4 months. Results A total of 215 surgeons responded; 98% stated they performed laparoscopic gastric bypass. The surgeons had performed an average of 423 cases in their career and 95 cases during the past 12 months. The average pouch size was 25 cm 3 and approximately one half of the surgeons (49%) measured the pouch size by the distance for the gastroesophageal junction. Almost all surgeons (99.5%) performed Roux-en-Y and not loop GJ. The average biliopancreatic limb length was 48 cm, and the average Roux limb was 114 cm. About one half of the surgeons (46%) measured the limb length with an open grasper, and few (7%) used a suture or umbilical tape. The antecolic and antegastric approaches were the more common. The percentage of those using the circular stapler, linear stapler, and hand sewing was 43%, 41%, and 21% for the GJ technique. Most surgeons (93%) routinely tested the GJ intraoperatively. The percentage of those using staple anastomosis and hand-sewn common enterotomy, double stapling, triple stapling, and hand sewing was 53%, 36%, 13%, and 1% for the jejunojejunostomy technique. Most surgeons (94%) closed at least one mesenteric defect. Also, most surgeons (95%) did not place a band around the pouch. Conclusion Technical variations exist in how laparoscopic gastric bypass procedures are performed by American Society for Bariatric Surgery practicing surgeons. Additional research is needed to explore the links between the technical variations and outcomes.

Incisional hernias are common. Optimal repair is one of the most analyzed and debated topics; however, there is no consensus as to the appropriate surgical technique.An Institutional Review Board-approved protocol was designed using an Internet-based survey site (www.surveymonkey.com) to assess practices and opinions regarding incisional hernia repair.Of 766 surgeons, 204 (27%) responded. Most respondents practice in an academic, urban hospital, and 85% to 96% perform basic laparoscopic procedures. The median percentage of laparoscopic versus total hernia repair was10%. Use of the laparoscopic technique was associated with a higher volume of hernia repair (r(Spearman's) = .315, P = .001), concurrent advanced laparoscopic experience (z(Wilcoxon rank sum) = -2.348, P = .019), and completion of a laparoscopic fellowship (z(Wilcoxon rank sum) = -3.317, P = .001). When asked how many would start to perform laparoscopic hernia repair, 81% indicated "no." In that group, 52% indicated that a lack of improved results was the main reason, followed by risk of enterotomyoperative timecostexperience. Those who would start indicated that the main reason was patient request (54%). Among those that use the laparoscopic technique, 85% indicated that they would perform more of these surgeries. The main reason for this was a lower recurrence rate (42%).There continues to be a lack of consensus on the most appropriate method of repairing incisional hernias. Surgeons having experience with advanced laparoscopic techniques, laparoscopic fellowship training, and higher volume of hernia repair are more likely to use the laparoscopic approach.

Background Gastric bypass is an established bariatric procedure that has undergone multiple modifications to improve its effectiveness. The side-to-side stapled technique is well recognized, but closure of the gastrotomy/enterotomy by the stapler can potentially narrow the Roux limb. Because of this, many surgeons will hand suture the closure of the gastrotomy/enterotomy. To obviate this difficulty, we inserted the linear stapler from the stomach's greater curvature, using a double-stapled anastomosis that minimized the need for hand suturing. Methods We performed a retrospective analysis of 307 patients undergoing this technique for laparoscopic gastric bypass. The weight loss and 30-day morbidity and mortality were tabulated and compared with those in other published series. Results Of the 307 patients, none died postoperatively. The overall 30-day morbidity rate was 15%. Two leaks from the gastrojejunostomy and 2 from the jejunojejunostomy (1.2%) developed. The mean percentage of excess weight loss was 34% at 3 months, 52% at 6 months, 73% at 1 year, 71% at 2 years, and 69% at 3 years. Conclusion The greater curve approach avoids Roux limb obstruction, minimizes the need for hand suturing, and uses standard trocar incisions. Our short-term follow-up results are similar to those of series of other techniques.

OBJECTIVES To assess the efficacy, reliability, and performance of the LapraTy clip (LTc) as a substitute for knot tying during reconstructive surgery in a porcine model. METHODS Twenty-four farm pigs were divided in two groups, each undergoing two surgical procedures: group A, transperitoneal laparoscopic cavotomy and small-bowel enterotomy with repair, and group B, laparoscopic partial nephrectomy and cystotomy with repair. In all animals LTc were used to replace knot tying. Tissue specimens were harvested and examined at 2, 4, and 8 weeks postoperatively to assess success of reconstruction and tissue reaction. RESULTS There were no major complications. Animals in group A showed no clinical signs of caval obstruction. No intraperitoneal collections or significant narrowing were noted at the enterotomy sites. Animals in group B showed no evidence of fluid collections around the partially resected kidneys or the cystotomy sites, and all repairs were intact. Pathologic examination revealed that all LTc were encapsulated by fibroblasts and giant cells typical of a foreign body-type granulomatous reaction. No evidence of clip migration into the epithelium was noted in any of the tissues examined. CONCLUSIONS In an animal model, the LTc is a safe and efficient alternative to knot tying during laparoscopic reconstructive surgery. We are currently evaluating the clinical applicability of the LTc in a variety of urologic conditions. We believe that other surgical specialties should evaluate this device as well.

Background Objective analysis methods of surgical performance are now available so comparison between surgeons is available. One such method is by direct observation using the Objective Structured Assessment of Technical Skills (OSATS), but this is a time-consuming process; therefore, a simple screening tool for the ability to detect errors (previously validated) was analyzed and considered as a predictor of qualitative performance. Methods Thirty-eight volunteer surgeons were recruited to the skills laboratory to undertake 3 exercises. Two were bench-top surgical tasks that were scored using the global rating of the OSATS technique. The third task was the ability to detect simple errors in 22 synthetic models of common surgical procedures, some of which contained purposefully made errors. P Results The scores (interquartile ranges in parentheses) for the 3 sections were excision of sebaceous cyst = 21 (19,24), closure of small bowel enterotomy = 23 (21,27), and identification of errors = 31 (27,34). Three scorers blinded to the operative models exhibited an interobserver reliability of .9 and .91 for the video tasks, respectively. Spearman’s rank correlations between the error examination and performance on the 2 tasks were both statistically significant at .69 (cystectomy) and .54 (enterotomy). Conclusions The ability to detect simple surgical errors is a predictor of technical skill and performance of bench tasks. What must be answered is whether the use of such models and principles can shorten the qualitative surgical learning curve.

We report a rare case of primary small intestinal trichobezoar in a 5-year-old girl presenting as subacute intestinal obstruction. Clinical, radiological, endoscopic, and laparoscopic investigations suggested the diagnosis. Most reported cases use diagnostic or laparoscopic assisted removal mainly in the adults. We describe the complete laparoscopic removal of a primary intestinal trichobezoar without significant spillage. A retrieval bag allowed the trichobezoar to be removed via a small umbilical incision before closing the enterotomy.

The technical feasibility of laparoscopically assisted radical vaginal hysterectomy has been well described, but its advantages over the open technique remain largely unproven. We reviewed and compared our experiences with both approaches.All patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) between 1996 and 2003 were identified and matched for age, FIGO stage, histological subtype and nodal metastases using a control group of women who underwent radical abdominal hysterectomy (RAH) during the same time period.Fifty-seven women were listed for LARVH, resulting in five conversions. Fifty cases were matched successfully using the criteria above. The majority of cases were FIGO stage 1B1. Statistically significant differences (P0.05) were present when the following were compared for LARVH vs. RAH: duration of surgery (median 180 vs. 120 min), blood loss (median 350 vs. 875 ml), hospital stay (median 5 days vs. 8 days) and duration of continuous bladder catheterisation (median 3 days vs. 7 days). There were no statistically significant differences with regard to nodal yield, completeness of surgical margins or perioperative complication rate. Four major complications (8%, three cystotomies and one enterotomy) occurred in the LARVH group and three in the RAH group (6%, one pulmonary embolism, one ureteric injury and one major haemorrhage). Three women in LARVH group had seen a specialist regarding postoperative bladder dysfunction, versus 12 in the RAH group (P = 0.04). No patients in the LARVH group reported constipation requiring regular laxatives, versus six in the RAH group (P = 0.03). Median follow-up was 52 months for LARVH and 49 months for RAH. There was no significant difference between recurrence rates or overall survival (94% for LARVH vs. 96% for RAH).Despite the inherent limitations of LARVH and its associated learning curve, the procedure conveys many advantages over the open technique in terms of blood loss, transfusion requirement and hospital stay. In addition, the incidence of postoperative bladder and bowel dysfunction appears low-suggesting improved quality of life-without compromising survival.

Background Phytobezoar-induced small bowel obstruction is an uncommon clinical entity accounting for 2–4.8% of all mechanical intestinal obstructions. In addition, presentation with features of acute surgical abdomen is extremely rare, accounting for only 1% of the patients. Objectives The aim of this report is to present a very rare case of a phytobezoar-induced small bowel obstruction in a male patient who presented with acute surgical abdomen. A correct preoperative diagnosis was made based on the patient’s history and characteristic imaging features on the emergency computed tomography (CT) scan. Case Report A 55-year-old man with previous gastrectomy presented with typical manifestations of acute abdomen. CT scan demonstrated dilatated small bowel loops and an intraluminal ileal mass with a mottled appearance. At exploratory laparotomy, a phytobezoar was found impacted in the terminal ileum and was removed through an enterotomy. Conclusions Phytobezoar should be considered in patients with previous gastric outlet surgery who present with bowel obstruction and features of acute surgical abdomen. The presence of a well-defined intraluminal mass with a mottled gas pattern on emergency CT scan is suggestive of an intestinal phytobezoar.

Introduction Laparoscopic surgery for the treatment of gastroesophageal reflux disease has been established as being safe, effective, and the best alternative to continuous life-long medical therapy. Antireflux surgery is not, however, devoid of complications and failures. Treatment of these patients represents a major challenge, especially when reoperation is indicated. Patients One-hundred consecutive patients had a reoperation in our clinic. Previous antireflux procedures were laparoscopic (52 patients), laparotomy (39 patients), and thoracotomy (9 patients). Results Peri- or postoperative complications occurred in 30 patients (30%). Operative complications were stomach perforation (14), significant bleeding (6), esophageal mucosal perforation (4), gastrocutaneous fistula (2), small bowel enterotomy followed by fistula (1), and tension pneumothorax (1). Reoperation was required in only 2 patients because of a missed stomach perforation or persistent chest leak. The conversion rate (from laparoscopic to open procedure) was 17% overall. Conclusion Laparoscopic reoperation after a failed antireflux procedure is a major surgical challenge, and it is not devoid of morbidity. The surgeon must have extensive experience in laparoscopic surgery and should be able to perform reoperative open surgery through the abdomen and chest. Laparoscopic redo surgery is feasible with good results. Many patients in whom previous open surgery has failed enjoy the advantages of a laparoscopic redo procedure.

Background/Purpose: Distal intestinal obstruction syndrome (DIOS) occurs in 15% of patients with cystic fibrosis (CF). The authors reviewed their experience to determine the incidence, risk factors, and natural history of adhesive intestinal obstruction and DIOS after lung transplantation. Methods: Eighty-three bilateral transplants were performed in 70 CF patients between January 1990 and September 1998. All were on pancreatic enzymes preoperatively, and none had preoperative bowel preparation. Fifty-six patients (80%) had prior gastrostomy (n = 54) or jejunostomy (n = 2). Eighteen patients (25.7%) had a previous laparotomy for meconium ileus (n = 8), fundoplication (n = 4), liver transplant (n = 1), jejunal atresia (n = 1), Janeway gastrostomy takedown (n = 1), pyloromyotomy (n = 1), free air (n = 1), or appendectomy (n = 1). Results: After lung transplantation, 7 patients (10%) required laparotomy for bowel obstruction (6 during the same hospitalization, and 1 during a subsequent hospitalization). The causes of obstruction were adhesions only (n = 1), DIOS only (n = 2), and a combination of DIOS and adhesions (n = 4). Adhesiolysis was performed in the 5 patients with adhesions, and a small bowel resection was also performed in 1 patient. DIOS was treated by milking secretions distally without an enterotomy (n = 3) with an enterotomy and primary closure (n = 1) or with an end ileostomy and mucus fistula (n = 2). Five had recurrent DIOS early postoperatively. One resolved with intestinal lavage, 2 were treated successfully with hypaque disimpaction, and 2 underwent reoperation; 1 required an ileostomy. The most important risk factor for posttransplant obstruction was a previous major abdominal operation. Obstruction occurred in 7 of 18 (39%) who had undergone a prior laparotomy versus 0 of 52 who had not ( P χ 2 ). Conclusions: (1) The incidence of intestinal obstruction is high after lung transplantation in children with CF. (2) Previous laparotomy is a significant risk factor. (3) Recurrent obstruction after surgery for this condition is common. (4) Preventive measures such as pretransplant bowel preparation and early postoperative bowel lavage may be beneficial in these patients.

Summary Meconium impactions are only rarely refractory to medical therapy. The purpose of this paper is to examine the outcome of 8 foals that required an exploratory celiotomy to correct a meconium impaction. Between 1984 and 1992, 24 foals were referred with a primary diagnosis of meconium impaction. All foals were treated medically prior to and following referral. Of the 24 foals, 8 had impactions requiring surgical intervention. Exploratory celiotomies were performed, and the impaction was reduced manually or by enterotomy. Follow up information was available on 7 foals. All survived surgery and were discharged. Four of the 8 foals matured and raced. Two foals were euthanatized due to extensive serosal adhesions and one foal was euthanatized due to an unrelated orthopedic condition. Our results support the decision for an exploratory surgery only after aggressive medical therapy has failed. Several treatment options have been developed in recent years that have reduced the number of foals that may require surgery.

Markedly premature infants may present with intestinal obstruction and perforation secondary to inspissated meconium in the absence of cystic fibrosis. Between 1990 and 1994, 13 patients were treated for intestinal obstruction secondary to inspissated meconium. The average birth weight was 760 g. Prenatal and postnatal risk factors were identified, and included intrauterine growth retardation, maternal hypertension, prolonged administration of tocolytics, patent ductus arteriosus, hyaline membrane disease, and intraventricular hemorrhage. Stooling was absent or infrequent during the first 2 weeks of life. Surgical presentation consisted of distension and/or perforation between days 2 and 17 of life. Twelve patients required operative intervention. Findings invariably included one or more obstructing meconium plugs with proximal distension and frequent necrosis of the dilated segments. Surgical options consisted of resection or enterotomy, accompanied by primary closure or by distal irrigation and exteriorization. Irrigation led to iatrogenic bowel injury in two patients. One patient was managed successfully with oral and rectal gastrograffin and oral acetylcysteine. Ten patients were discharged, all of whom had normal stooling patterns and tested negatively for cystic fibrosis. Three patients died, two from the primary disease. The markedly premature infant is at risk for obstruction and eventual perforation secondary to meconium plugs, presumably formed in conjunction with intestinal dysmotility. Prompt diagnosis and timely intervention require a high index of suspicion, attention to stooling patterns and abdominal examinations, and screening radiographs when indicated.

A 67-YEAR-OLD MAN was admitted to the hospital with a 48-hour history of vomiting, crampy periumbilical abdominal pain, and obstipation. Clinical examination revealed a reducible hernia at the site of a previous right flank incision and some mild periumbilical tenderness. A laboratory examination revealed an elevated white blood cell count. The patient’s medical history included operation for metastatic renal cell carcinoma. Three years before the current admission, the patient underwent a right radical nephrectomy with excision of an inferior vena caval thrombus through a venotomy. One year later, abdominal ultrasound identified a 3.2-cm mass in the infrahepatic inferior vena cava (IVC) consistent with tumor recurrence. The IVC was surgically resected from below the hepatic veins to the level of the left renal vein and reconstructed with a 19-mm polytetrafluoroethylene (PTFE) graft. One month later, a right leg deep vein thrombosis developed in the patient that extended from the right superficial femoral vein proximally through the right common femoral and iliac veins and into the IVC. Despite coumadin therapy, a computed tomography (CT) scan subsequently showed that the PTFE IVC graft had collapsed with the lumen filled with air and low attenuation material that appeared consistent with thrombus. The air in the graft, and surrounding inflammation, suggested a fistula with the adjacent duodenum (Fig 1). The distal venous system appeared to drain through the hemiazygous system. At the current admission 2 years after IVC graft insertion, the abdominal CT revealed the presence of a small bowel obstruction. The vascular graft was seen to be within the lumen of the distal ileum at the transition point between the distended proximal small bowel and the distal collapsed ileum (Fig 2). The site of the obstruction appeared to be in a loop of small bowel within the right flank hernia. The patient underwent laparotomy through the previous right flank incision and, as suggested by the CT scan, the graft represented the obstructing foreign body. It was removed through a transverse enterotomy in the ileum (Fig 3). The patient recovered and was discharged home 5 days after the surgical procedure.

s Vol 30, No 2 (2010) 115 Recent evidence has suggested that exercise decreases insulin resistance in obese horses; this laminitis treatment is unique because exercise is prescribed before complete recovery if certain criteria are met. The success of this system may be dependent on owner compliance with diet and exercise recommendations. CLINICAL RELEVANCE This treatment method may provide an effective method of restoring soundness and normal hoof anatomy in certain populations of laminitic horses. In this small population, hoof health was restored without surgical techniques. CONCLUSION Further investigation with more cases is warranted. Neutrophil Gelatinase-Associated Lipocalin and Matrix Metalloproteinases in Laminar Tissue From Horses Subjected to Intestinal Obstruction and Treated With Hydrocortisone Luciane M. Laskoski, MSc, Carlos A.A. Valadao, DVM, Rosemeire O. Vasconcelos, DVM, Rafael Resende Faleiros, DVM, Danilo Ferrucci, MSc, Juliete A.F. Silva, MSc, and Dagmar R.S. Machado, DVM, Department of Veterinary Surgery and Medicine (Laskoski, Valadao) and Department of Veterinary Pathology FCAVSao Paulo State University, Jaboticabal, SP 14884-900, Brazil (Vasconcelos); Department of Veterinary Clinics and Surgery, School of Veterinary – Federal University of Minas Gerais, Belo Horizonte, MG, 30123-970, Brazil (Faleiros); Department of Applied Immunology University of Campinas, Campinas, SP 13484-370, Brazil (Ferrucci, Silva, Machado) TAKE HOME MESSAGE Hydrocortisone treatment may be beneficial to reduce the risk of laminitis in horses subjected to intestinal surgery. INTRODUCTION Laminitis is a major complication of gastrointestinal diseases in horses and its physiopathology is connected with lamellar basement membrane degradation by matrix metalloproteinases (MMPs) and leukocyte infiltration. The objective was to study laminar MMP-2, MMP-9 and NGAL expression in horses subjected to jejunal obstruction treated or not with hydrocortisone. MATERIAL AND METHODS Zymography was performed to quantify MMP-2, MMP-9 and NGAL in laminar tissue samples obtained from horses allotted in the control group (CG, n 1⁄4 7); the sham-operated group (SG, n 1⁄4 5, jejunal enterotomy); the nontreated group (NTG, n 1⁄4 5, jejunal obstruction), and the treated group (TG, n 1⁄4 4, jejunal obstruction and hydrocortisone4mg/kg, IV). Calprotectin expression was used to confirm neutrophil laminar presence in obstructed groups. Data was analyzed by one way ANOVA followed by Tukey post-hoc test (P < 0.05). RESULTS Overexpression of MMP-2 and MMP-9 occurred in obstructed groups (NTG and GT) when compared to CG horses. NGAL/MMP-9 complex expression was increased in the SG and NTG horses, but no increase was observed in horses treated with hydrocortisone (TG). Leukocyte presence in obstructed groups was detected by immunohistochemistry. DISCUSSION Amplifying previous findings that equine intestinal obstruction can cause lung neutrophil accumulation, our study indicates that jejunal obstruction may produce neutrophil accumulation and MMP overexpression in equine laminae and that hydrocortisone can ameliorate laminar inflammation. CLINICAL RELEVANCE Hydrocortisone treatment may ameliorate laminar inflammation in horses subjected to intestinal surgery. CONCLUSION Intestinal obstruction can induce laminar MMP expression and inflammation. Leukocyte Infiltration and the Role of Interleukin-6 During the Development of Oligofructose Induced Laminitis Michelle B. Visser and Christopher C. Pollitt, Australian Equine Laminitis Research Unit, School of Veterinary Science, The University of Queensland, Brisbane, Australia TAKE HOME MESSAGE The leukocytic infiltration of carbohydrate induced laminitis is preceded by IL-6 expression.

Oral anticoagulant therapy with warfarin is commonly used to prevent thromboembolic events in patients at risk. The degree of anticoagulation is variable among individuals and is influenced by many factors; therefore, patients must be monitored frequently to assess potential adverse effects related to treatment. There is a direct relationship between excessive anticoagulation and the risk of bleeding. We present a patient who came in with an acute abdomen, anemia, and increased international normalized ratio. Gastroscopy revealed a large amount of blood in the stomach. Hemodynamic instability necessitated urgent laparotomy. The small bowel was found to be ischemic due to increased intraluminal pressure. Upon enterotomy, liters of old hematoma were evacuated and the intestine resumed its blood supply. To our knowledge, we describe the first reported case of intraluminal hematoma as a rare cause of obstructive mechanical ileus during warfarin treatment. This case highlights an unknown, but potentially lethal, manifestation of warfarin therapy.

Objective To report outcomes of laparoscopic management of patients with ovarian remnant (OR). Design Retrospective chart review. Setting Referral practice and tertiary medical center. Patient(s) Sixty-four patients with confirmed OR who underwent laparoscopic treatment between July 1989 and September 2003. Intervention(s) Laparoscopic excision of OR. Main outcome measure(s) Technical feasibility and recurrence. Result(s) Sixty-nine laparoscopies were performed to remove ovarian remnants, with five patients requiring two laparoscopies. Two cases were converted to laparotomy and one to mini-laparotomy for bowel resection. In 64% (41 out of 64), pelvic mass was diagnosed by imaging (35 by ultrasound, 5 by computerized tomography [CT], and 1 by both). The majority of ovarian remnants were found attached to one or more of the following: ureter, bowel, pelvic sidewall, bladder, rectum, and uterosacral ligament. Intraoperative complications occurred in four cases: three enterotomy and repair; one cystotomy and repair. Twelve minor postoperative complications occurred including urinary tract infection, hematuria, umbilical incision infection, and transient tachycardia. Three major postoperative complications occurred: one umbilical omental hernia, one wound abscess requiring operation, and one vesicovaginal fistula. Adhesions were present in all cases, endometriosis in 55% (35 out of 64), and fibrosis in 30% (19 out of 64). Conclusion(s) In experienced hands, laparoscopic treatment of OR results in acceptable outcomes with its associated advantages over laparotomy.