Study Design Retrospective analysis of prospectively collected cohort data. Objective Anterior lumbar interbody fusion (ALIF) is a commonly performed procedure for the treatment of degenerative diseases of the lumbar spine. Detailed and comprehensive descriptions of intra- and postoperative complications of ALIF are surprisingly limited in the literature. In this report, we describe our experience with a team model for ALIF and report all complications occurring in our patient series. Methods Patients were prospectively enrolled between January 2009 and January 2013 by a combined spine surgeon and vascular surgeon team. All patients underwent an open ALIF using an anterior approach to the lumbosacral spine. Results From the 227 ALIF cases, mean operative blood loss was 103 mL, ranging from 30 to 900 mL. Mean operative time was 78 minutes. The average length of stay was 5.2 days. Intraoperative vascular injury requiring primary repair with suturing occurred in 15 patients (6.6%). There were 2 cases of postoperative retroperitoneal hematoma. Three patients (1.3%) had incisional hernia requiring revision surgery; 7 (3.1%) patients had prolonged ileus (>7 days) managed conservatively. Four patients described retrograde ejaculation. Sympathetic dysfunction occurred in 15 (6.6%) patients. There were 5 (2.2%) cases of superficial wound infection treated with oral antibiotics, with no deep wound infections requiring reoperation or intravenous therapy. There were no mortalities in this series. Conclusions ALIF is a safe procedure when performed by a combined vascular surgeon and spine surgeon team with acceptably low complication rates. Our series confirms that the team approach results in short operative times and length of stay, with rapid control of intraoperative vessel injury and low overall blood loss.

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Incarcerated inguinoscrotal hernia containing sigmoid colon cancerAn 81-year-old man presented with a large left inguinoscrotal hernia, which had been present for at least 5 years, as well as a large right inguinal hernia. He reported recent weight loss, lethargy, fatigue and significant functional decline. He had no history of bleeding per rectum, malaena or significant change in bowel habit. Clinical examination revealed a soft reducible right inguinal hernia, and a large, firm irreducible left inguinoscrotal hernia. The overlying skin of the left hemiscrotum was erythematous.Investigations revealed a microcytic, hypochromic anaemia with haemoglobin 78 g/L. Serology was consistent with poor nutrition and a catabolic state, including serum albumin of 21 g/L. Serum tumour markers were raised, with CEA 16 mcg/L (normal range 0-4) and CA125 56 ku/L (0-35).Computed tomography imaging confirmed the presence of an indirect left inguinoscrotal hernia containing distal descending and proximal sigmoid colon (Fig. 1). The herniated bowel contained a complex, heterogeneous mass measuring approximately 10 cm in maximal diameter, suspicious for colon cancer. Three ill-defined, low-density lesions within the liver appeared consistent with hepatic metastases. Preoperative colonoscopy was not performed due to anticipated difficulty of accessing the incarcerated colon, and adequate diagnostic information being attained by clinical, radiological and biochemical means. Should the hernia have been reducible, then colonoscopy would have been attempted including biopsy for tissue diagnosis.The patient underwent a high anterior resection with en bloc resection of the left spermatic cord and testicle, followed by bilateral inguinal hernia repair. This was performed via a midline laparotomy with dissection of the left pre-peritoneal plane to access the inguinal canal. The neck of the hernia was incised to enable difficult reduction of its contents, and en bloc resection with the sigmoid colon and upper rectum was performed (Fig. 2). A high ligation of the inferior mesenteric artery was performed, and a standard stapled anastomosis was formed between the descending colon and the proximal rectum. The left testicle and spermatic cord were necessarily sacrificed due to dense adhesion to the hernia sac and tumour mass, and were included in order to achieve adequate oncological clearance. Posterior mesh repair of bilateral inguinal hernias was then performed, with the inguinal region accessed in the pre-peritoneal plane through the midline laparotomy wound.Tissue histopathology confirmed the diagnosis of a moderately differentiated adenocarcinoma measuring 11 cm in diameter, with surrounding abscess and extensive inflammation and fibrosis. Local invasion was beyond the muscularis propria but not through the serosal surface, and metastatic adenocarcinoma was present in one of 28 regional lymph nodes. The left testis showed significant atrophy.Incorporating surgical and radiological staging, the patient had AJCC Stage IVA colorectal cancer (T3N...

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