Objective: Spigelian hernia is an uncommon abdominal wall defect. We present our series of patients with Spigelian hernia and a literature review.Patients: We carried out a retrospective review of patients operated on from 2001 to 2008. Epidemiological aspects, diagnostic methods, surgical technique characteristics, morbidity, hospital stay, recurrences and follow up are analyzed.Results: We have treated 39 patients, 25 female and 14 male, with a mean age of 70 years. Left side was the most frequent location. Risk factors were present in 74% of patients. Diagnosis was made clinically in 72% of cases. Open hernioplasty followed by laparoscopic hernioplasty are the most frequent techniques performed. Emergency operation was needed in 20% of patients. Postoperative morbidity is very low.Conclusions: Diagnosis of Spigelian hernia is basically clinic. The gold standard is TC in doubtful cases. An important percentage of patients will present with an acute complication of the Spigelian hernia as their first symptom. Surgical technique depends on patient characteristics, type of hernia and surgeon experience.Key words: Spigelian hernia. Ventral hernia. Laparoscopy. Mesh. RESUMENObjetivo: la hernia de Spiegel es una variedad poco frecuente de defecto de la pared abdominal. Presentamos nuestra serie de pacientes intervenidos con éste diagnóstico, así como una revisión de la literatura.Pacientes: se realiza un estudio retrospectivo de los pacientes intervenidos por hernia de Spiegel en nuestro centro entre los años 2001 y 2008. Se analizan factores epidemiológicos, forma de diagnóstico, características de la técnica quirúrgica, morbilidad, estancia hospitalaria, recidivas y seguimiento.Resultados: han sido intervenidos 39 pacientes, 25 mujeres y 14 hombres, con una edad media de 70 años. La localización más frecuente es la izquierda. El 74% de los pacientes presenta 1 o más factores de riesgo. El diagnóstico fue clínico en el 72% de los casos. La técnica más empleada es la hernioplastia seguida de la hernioplastia laparoscópica y en el 20% de los casos la intervención tuvo que realizarse de forma urgente. La morbilidad postoperatoria es escasa.Conclusiones: el diagnóstico de la hernia de Spiegel es fundamentalmente clínico. En caso de duda diagnóstica el TAC es la prueba de elección. En un porcentaje importante de pacientes la primera manifestación es la incarceración. La técnica quirúrgica dependerá de las características del paciente, la hernia y la experiencia del cirujano Palabras clave: Hernia de Spiegel. Hernia ventral lateral. Laparoscopia. Malla.

Cardiac injuries caused by knives and firearms are slightly increasing in our environment. We report the case of a 43-year-old male patient with a transmediastinal gunshot wound (TGSW) and a through-and-through cardiac wound who was hemodynamically stable upon his admission. He had an entrance wound below the left clavicle, with no exit wound, and decreased breath sounds in the right hemithorax. Chest X-ray showed the bullet in the right hemithorax and large right hemothorax. The ultrasound revealed pericardial effusion, and a chest tube produced 1500 cc. of blood, but he remained hemodynamically stable. Considering these findings, a median sternotomy was carried out, the through-and-through cardiac wounds were suture-repaired, lung laceration was sutured, and a pacemaker was placed in the right ventricle. The patient had uneventful recovery and was discharged home on the twelfth postoperative day. The management and prognosis of these patients are determined by the hemodynamic situation upon arrival to the Emergency Department (ED), as well as a prompt surgical repair if needed. Patients with a TGSW have been divided into three groups according to the SBP: group I, with SBP >100 mmHg; group II, with SBP 60–100 mmHg; and group III, with SBP <60 mmHg. The diagnostic workup and management should be tailored accordingly, and several series have confirmed high chances of success with conservative management when these patients are hemodynamically stable.

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Purpose:Hypocalcaemia after total thyroidectomy (TT) has been effectively avoided with the routine calcium supplementation, but this strategy implies collateral effects and a high overtreatment rate. Levels of intact intra-operatory paratohormone (iPTHio) have been successfully used to predict hypopathyroidism after TT (HypoPTH-TT).This study was designed aiming to assess an easy, universal and reliable method, based on iPTHio determinations to predict HypoPTH-TT in patients undergoing surgery irrespectively of etiology or kind of limphadenectomy. Results after prospective application of selective prophylactic postoperative supplementation (SPPS) are also described.Method: Two-phased observational study. In phase I, percentage decline of iPTHio (ΔiPTHio) and iPTHio at skin closure (iPTHio-SC) of 53 TT and 16 thyroid lobectomy (TL) cases were recorded. Receptive Operative Curves (ROC) were used to calculate the ability of both iPTHio assays to predict hypoPTH-TT. Best cut-off points were calculated and evaluated. In phase II, SPPS was implemented on 202 TT cases guided by cut-off point of Δ-iPTHio. Hypocalcaemia and readmission rates were recorded.Results:ΔiPTHio and iPTHio-SC showed an area under the curve of 0.96 and 0.97 respectively. Best cut-off points were 70% for ΔiPTHio (Sensitivity:0.957; Negative predictive value: 96.6) and 21.50 pg/ml for iPTHio-SC (Sensivity: 0.913; Negative predictive Value: 93.5). All iPTHio-SC were above 14pg/ml when ΔiPTHio < 70%. After implement SPPS based on ΔiPTHio criteria, 110 TT cases (54.5%) were discharged without supplementation, and none were readmitted.Conclusion:ΔiPTHio is an easy, universal and accurate method to predict hypoPTH-TT risk. ΔiPTHio < 70% (whenever iPTHio-SC>14pg/ml) allows SPPS to be applied safely and avoids unnecesary treatment in 54,5 % of the patients.

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