Despite extensive experience and significant reduction of complications in recent years, laparoscopic treatment of complex abdominal hernias is a challenge even for the experienced endoscopic surgeon. Patients with severe incisional hernias or symptomatic rectus diastasis benefit from the closure of the linea alba as a morphological and physiological reconstruction of the abdominal wall followed by mesh implantation. Occasionally, an additional component separation is necessary. In open surgery, this is associated with very large wound areas, postoperative seromas, poor wound healing and, in the worst case, mesh infections. To avoid these complications, we operate these complex reconstructions completely endoscopically. Our concept is based on a laparoscopic closure of the linea alba through an ongoing, barbed non-resorbable 1–0 suture (polybutester) and final reinforcement by an intraperitoneal-onlay mesh (IPOM-Plus). For the treatment of complex abdominal hernias with a width of more than 10 cm, we performed an endoscopic anterior bilateral component separation. This allows the surgeon to combine the advantages of the open abdominal wall reconstruction with those of laparoscopic hernia repair. Between May 2015 and June 2017, we treated 42 patients with abdominal hernias by laparoscopic continuous hernia defect closure and complementary mesh implantation, whereby a complex reconstruction with additional endoscopic anterior component separation was performed in five patients. In this article, we will present this innovative technique of endoscopic/laparoscopic hernia repair in complex abdominal hernias.
Isolated inflammatory alterations of the greater omentum are rare diseases. Since the preoperative diagnosis is difficult these changes are usually ascertained upon laparotomy. Between 1999 and 2001 four patients (44-88-years-old, 2 males) underwent laparotomy for an inflammatory tumor mass or an acute abdomen, respectively. C-reactive protein was elevated in all cases. In two cases a primary torsion of the greater omentum was found, in the other two a paracolic pseudotumorous omentitis. Resection of the diseased omental parts led to complete recovery. Torsion of the greater omentum and omentitis cause abdominal symptoms with an inflammatory component that often mimics other more common diseases such as acute appendicitis and urges laparotomy. Partial omentectomy is the therapy of choice.
The incidence of parastomal hernias after a permanent stoma is between 50% and 80% depending on the type of stoma, the definition of the hernia (clinical or radiological), and the length of the follow-up. Surgical therapy is complex and involves several techniques with different recurrence rates. We present three cases where we have closed the hernia gap with continuous, non-resorbable, self-retaining sutures with subsequent use of the sandwich technique ('Sandwich-plus-technique'). There were pronounced parastomal hernias in three female patients (mean age was 72 years and the range was 63-78 years) with permanent colostomata. After laparoscopic adhesiolysis, the closure of the hernia defect was completed with ongoing, barbed non-resorbable 1-0 sutures (polybutester) followed by the sandwich technique. There were no intraoperative complications and currently no clinical or radiological evidence for recurrences of the parastomal hernia. Closure of the hernia gap leads to the additional reconstruction of the lateral abdominal wall, resulting in a larger contact surface for integration of the keyhole mesh and thus prior to implantation of the Sugarbaker mesh. The laparoscopic augmentation of large parastomal hernias using the 'Sandwich-plus-technique' is technically complex but achieves very good results in our case series. Further studies and long-term results should prove that the low recurrence rate of the sandwich technique can be further reduced.
We report the case of a 12-year-old boy who presented after a bicycle accident with handlebar injury of the epigastrium with clinical signs of hollow visceral injury and elevated pancreatic enzymes. Upon emergency laparotomy, a complete rupture of the pancreatic isthmus and a nearly total transsection of the postpyloric duodenum were encountered (Grade IV according to Lucas). Reconstruction consisted of reanastomosis of the proximal duodenum, closure of the distal end of the pancreatic head and internal drainage of the left pancreas into a Roux-en-Y jejunal loop. The postoperative course was uneventful. For rare traumatic pancreaticoduodenal lesions only individual surgical concepts are promising depending on the extent of damage. However, effort should be made to preserve as much pancreatic tissue as possible.
The separation of laryngology and rhinology from the medical field and of otology from the surgical field in the 1850s led to the development of an independent field: the ear, nose and throat diseases, head and neck surgery. Therefore, oto-rhino-laryngology (ORL) has its roots in surgery. Concerning this and considering common anatomic circumstances, ORL medical aspects should be relevant to the surgeon. This concerns traumatological cases, the problem of difficult intubation and the common treatment of a series of illnesses of the upper aerodigestive tract, in particular problems of the major tumour surgery.
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