Inguinal hernias involving the ureter, a retroperitoneal structure, is an uncommon phenomenon. It can occur with or without obstructive uropathy, the latter posing a trap for the unassuming general surgeon performing a routine inguinal hernia repair. Ureteral inguinal hernia should be included as a differential when a clinical inguinal hernia is diagnosed concurrently with unexplained hydronephrosis, renal failure or urinary tract infection particularly in a male. The present case describes a patient with a known ureteroinguinal hernia who proceeded to having a planned hernia repair and ureteric protection. The case is a reminder that when faced with an unexpected finding such an indirect sliding inguinal hernia, extreme care should be taken to ensure that no structures are inadvertently damaged and that a rare possibility is the entrapment of the ureter in the inguinal canal.
BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) has become well established as a modality for the management of common bile duct stones (CBDS), especially in the setting of associated cholangitis. Our study aims to determine the rate of long term morbidity of recurrent CBDS post ES.MethodsA retrospective analysis of patients who underwent ERCP and ES (ERCP+ES) was undertaken on a prospectively maintained database from 1998 to 2012 at the Northern Hospital, Melbourne. Primary CBDS were defined as those detected at least 6 months after complete clearance of the CBD. Prior cholecystectomy was a requirement for inclusion and patients with primary CBD stones in the setting of an intact sphincter were excluded.ResultsA total of 1148 patients underwent ERCP, of which 573 had an ES. Fifty-one patients underwent an ES prior to developing primary CBDS (8.9%). The time to recurrence ranged from 6 months to 15 years (mean 3.3 years). The number of procedures per patient ranged from 2 to 11, with 51% requiring 3 or more ERCPs. Factors associated with primary CBDS recurrence included a dilated CBD > 12 mm, stricture of the major papilla post ES to 2 - 5 mm and presence of the ampulla within or on the edge of a duodenal diverticulum.ConclusionThe results demonstrate that ERCP + ES has an inherent long-term complication of recurrent primary CBDS formation. While this can be managed with repeat ERCP, the advent of laparoscopic bile duct exploration should lead us to re-examine the role of ERCP + ES in younger patients.
Debate still exists for the management of choledocholithiasis. The purpose of this study is to quantify the rate of recurrent choledocholithiasis post choledochoscopic bile duct exploration (CBDE) in comparison to ERCP and sphincterotomy, and to demonstrate the feasibility of this approach in a busy metropolitan hospital. Data of patients undergoing CBDE from 2009–2014 at the Northern Hospital, Victoria, Australia, was collected retrospectively. Primary outcomes were bile duct clearance rate and rate of recurrent stones post-clearance. Secondary outcomes measured were post-operative complications, laparoscopic to open conversion rate and operative time. Data of patients undergoing ERCP at the same institution was collected and compared. In total, there were 4,091 cholecystectomy cases performed from 2009–2014, of which 260 (6.3%) of patients had an intraoperative cholangiography (IOC) indicating a common bile duct (CBD) stone. Two hundred and forty-eight patients (95.3%) had a CBDE. The remaining 12 patients (4.6%) had radiological clearance, which were excluded from the study. The overall clearance rate for patients undergoing CBDE was 84% (209/248). The risk of recurrent stones up to 8 years post clearance was 2% (4/209). In the same institution, and between 1998–2012, a total of 1,148 patients underwent ERCP, of which 571 had endoscopic sphincterotomy (ES). Forty-three patients required a repeat ERCP for recurrent CBD stones with a complication rate of 7.5%. Time to recurrence ranged from 6 months to 10 years with a mean of 4.5 years. The rate of recurrence was lower in the CBDE group compared to the patients who had an ERCP (8.9% vs. 2%). CBDE is a feasible and effective method for clearance of CBD stones at the time of laparoscopic cholecystectomy. This approach, although not widely used, reduces the need for ERCP, which has inherent complications. In the longer term, this series showed a significant reduction in the rate of CBD stone recurrence.
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