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We present an 87-year-old woman who presented to the emergency department with a 7-day history of severe abdominal pain at her ileostomy parastomal hernia site. Prior to presentation, her general practitioner had started her on a reducing steroid dose for suspected Crohn’s disease exacerbation. On examination, she had a distended abdomen with localised guarding and tenderness over her hernia site. A CT scan demonstrated an incarcerated perforated gallbladder within her parastomal hernia. Successful surgical management was performed involving an enterotomy, refashioning her ileostomy and an open cholecystectomy. The patient recovered well with a short postoperative stay. This report is intended as a guide for clinicians in the differential diagnoses for acute abdominal pain and an unusual presentation of a gallbladder perforation.

Gastrointestinal foreign bodies (GFB) in cats and dogs are among the life-threatening surgical diseases that require invasive surgery. This study aimed to evaluate the cases of GFB in 32 cats and dogs diagnosed and treated in Hatay Mustafa Kemal University Veterinary Health Practice and Research Hospital. Information regarding the type, breed, age, sex, clinical symptoms, characteristics of foreign bodies (FB) localization, prognosis, type of treatment administered, and conditions determined in postoperative controls was collected. The cases were aged between 1 and 7 years and adult animals were also included. The rate of FB incident was the same in male and female cats, whereas male dogs had a higher rate of FB incident. Strings/ ropes and metallic objects were the most common foreign objects found in animals. Early diagnosis and treatment were important in preventing complications in the cases, FB was usually found in the stomach, and vomiting was the most common clinical symptom. Further, surgical intervention (gastrostomy/enterotomy) was the most common treatment method with a rate of 53.13 % for treating FB in the gastrointestinal system that yielded successful results. Thus, to avoid complications and for a good prognosis, owners must be conscious and seek for diagnosis and treatment as soon as they notice the incidence of swallowing a FB, so as to ensure early diagnosis and treatment. Los cuerpos extraños gastrointestinales (CEG) en perros y gatos se encuentran entre las enfermedades quirúrgicas potencialmente mortales que requieren cirugía invasiva. Este estudio tuvo como objetivo evaluar los casos de CEG en 32 gatos y perros diagnosticados y tratados en el Hospital de Investigación y Práctica de Salud Veterinaria de la Universidad Hatay Mustafa Kemal. Se recogió información sobre el tipo, raza, edad, sexo, clínica, características de los cuerpos extraños (CE), localización del CE, pronóstico, tipo de tratamiento administrado y condiciones determinadas en los controles postoperatorios. Los casos tenían edades comprendidas entre 1 y 7 años y también se incluyeron animales adultos. La tasa de incidentes con CE fue la misma en gatos machos y hembras, mientras que los perros machos tuvieron una mayor tasa de incidentes con CE. Las cuerdas / mecates y los objetos metálicos eran los objetos extraños más comunes que se encontraban en los animales. El diagnóstico y tratamiento precoces fueron importantes para prevenir complicaciones en estos casos, habitualmente se encontraban CE en el estómago y el vómito era el síntoma clínico más común. Además, la intervención quirúrgica (gastrostomía / enterotomía) fue el método de tratamiento más común con una tasa del 53,13 % para el tratamiento de CE en el sistema gastrointestinal que arrojó resultados exitosos. Así, para evitar complicaciones y para un buen pronóstico, los propietarios deben estar conscientes y buscar el diagnóstico y tratamiento tan pronto como se percaten de la incidencia de la ingestión de un CE, a fin de asegurar un diagnóstico y tratamiento precoces. 1-8 cafer.isler@gmail.com

Introduction The aim of this study was to develop a reliable objective structured assessment of technical skills (OSATS) score for linear-stapled, hand-sewn closure of enterotomy intestinal anastomoses (A-OSATS). Materials and methods The Delphi methodology was used to create a traditional and weighted A-OSATS score highlighting the more important steps for patient outcomes according to an international expert consensus. Minimally invasive novices, intermediates, and experts were asked to perform a minimally invasive linear-stapled intestinal anastomosis with hand-sewn closure of the enterotomy in a live animal model either laparoscopically or robot-assisted. Video recordings were scored by two blinded raters assessing intrarater and interrater reliability and discriminative abilities between novices (n = 8), intermediates (n = 24), and experts (n = 8). Results The Delphi process included 18 international experts and was successfully completed after 4 rounds. A total of 4 relevant main steps as well as 15 substeps were identified and a definition of each substep was provided. A maximum of 75 points could be reached in the unweighted A-OSATS score and 170 points in the weighted A-OSATS score respectively. A total of 41 anastomoses were evaluated. Excellent intrarater (r = 0.807–0.988, p p Conclusion With the weighted and unweighted A-OSATS score, we propose a new reliable standard to assess the creation of minimally invasive linear-stapled, hand-sewn anastomoses based on an international expert consensus. Validity evidence in live animal models is provided in this study. Future research should focus on assessing whether the weighted A-OSATS exceeds the predictive capabilities of patient outcomes of the unweighted A-OSATS and provide further validity evidence on using the score on different anastomotic techniques in humans.

Rationale Superabsorbent polymers are marketed as toys, and cases of ingestion in children are increasingly reported. Even if these cases are usually considered benign, bowel obstruction has been reported. Objective To investigate the exposure characteristics, clinical presentation, management, and outcome of patients who developed bowel obstruction following ingestion of superabsorbent polymer-made products. Methods Databases were searched (no start date - 2020/01/31) using the following keywords: ("superabsorbent" OR "polymer" OR "hydrogel" OR "crystal" OR "jelly" OR "Orbeez" OR "beads") AND ("ingestion" OR "obstruction" OR "perforation") AND ("intestinal" OR "bowel"). All cases of bowel obstruction following superabsorbent polymer-made product ingestion were included. Results Report selection: We found 25 reports reporting 43 cases of bowel obstruction following superabsorbent polymer-made product ingestion. All the reports were retrospective, including 20 case reports and 4 case series. Patient characteristics and clinical presentation: Age ranged from 6 to 36 months, and the female/male sex ratio was 1.3. The median delay between the ingestion of the product and the onset of the first symptoms (available in only four reports) was 1.0 [0.7;1.8] day (from 15 h to 2 days). The median delay between the onset of gastrointestinal symptoms and hospital admission, available for all but 15 patients, was 3 [2;4] days (from 15 h to 30 days). The reported symptoms were persistent vomiting in all cases, associated with constipation (11/43), diarrhea (1/43), abdominal pain (1/43), and clinically assessed dehydration (14/43). Abdominal palpation found abdominal tenderness or distension in 11/43 and 28/43 patients, respectively. An abdominal mass was palpated in 3/43 patients. Two patients presented with fever, and three patients developed seizures. Characteristics of exposure: Ingestion of superabsorbent polymer-made products was reported by relatives on hospital admission in only 10/43 cases. Based on imaging and/or surgically/endoscopically removed products, all were bead-shaped objects. The median number of beads removed (available in 27/43) was 1 [1-2] (range from 1 to 6). Their median diameter (available in 21/43 patients) at the time of the diagnosis of bowel obstruction - i.e., at hydrated state - was 30 [30;36] mm (range from 25 to 65 mm). Imaging findings: Abdominal radiography, performed in 31/43 patients, never showed evidence of foreign body ingestion Abdominal computed tomography scanning, performed in 10/43 patients, visualized an intraluminal mass in 5/10 cases. Abdominal ultrasound performed in 34/43 patients allowed visualization of a rounded intraluminal image that corresponded to a bead in 28/34 patients but led to a correct diagnosis of foreign body-induced bowel obstruction in only 15/34 cases. One case reported the contributory use of abdominal MRI. Beads were always located in the small bowel (from the duodenum to the terminal ileum). Removal of beads: Bead removal required endoscopy in 2/43 cases and surgery in 41/43 cases (enterotomy or resection in 36/43 and 5/43 cases, respectively). In 3/36 cases, additional enterotomy was performed to remove beads that had not been found during the first surgery. The delay between the onset of gastrointestinal symptoms and removal procedures ranged from 1 to 7 days. Outcome: Except for two fatal cases, the outcome was favorable. Conclusions Ingestion of superabsorbent polymer-made beads can be responsible for fatal bowel obstruction in children related to the increase in bead size within the intestinal tract. Diagnosis is made difficult by the radiolucent properties of the beads. The management of bowel obstruction probably most often requires endoscopic or surgical procedures. Children under 4 years of age are probably the most at risk of developing bowel obstruction.

AIM Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) has favourable short-term outcomes. However, NOSE is rarely adopted for left hemicolectomy procedures. This study aimed to review the feasibility, safety and short-term outcomes of transrectal NOSE in patients undergoing laparoscopic left hemicolectomy. METHOD All consecutive patients who underwent laparoscopic left hemicolectomy surgery with transrectal NOSE in a single institution between January 2018 and December 2020 were reviewed. Transrectal NOSE was performed with an enterotomy at the upper rectum. The specimen was brought out via a transanal endoscopic microsurgery scope inserted through the anus. A supplementary video demonstrates this technique. Surgical outcomes, including complications, postoperative short-term recovery and the level of pain intensity, are presented. RESULTS Twenty patients were reviewed. There were no immediate postoperative complications and no wound infections in these patients. The average time to tolerate a soft diet was 3.6 days, and the average postoperative hospital stay was 4.5 days. The average score on the numerical rating scale of postoperative pain was 3.0 on postoperative day 1. The median follow-up time was 23.5 months. CONCLUSION Laparoscopic left hemicolectomy with transrectal NOSE is a safe and feasible procedure that leads to early postoperative recovery and a short hospital stay.

BACKGROUND Intestinal ascariasis is considered as state subject in our valley of Kashmir. The aim of our study was to analyse the age, clinical presentation, diagnosis, surgical complications, and management of Ascaris lumbricoides in children and adults. METHODS Total of 312 patients above 2 years of age with definite clinical and radiological diagnosis of intestinal ascariasis and associated complications were included in our study. All our patients received anthelminthic drug (Albenzadole 400 mg stat) after termination of acute phase and attached to our Out-Patient Department for follow-up. Each patient was given second dose of antihelminthic drug at second follow-up visit. RESULTS Total of 312 subjects included 131 (41.99%) males and 181 (58.01%) females. The highest number of patients was in age group of 6-10 years (46.47%). Colicky abdomen pain was the most common presentation and present in 80.12% patients followed by vomiting (64.1%). Palpable worm bolus was a cardinal sign present in 46.47% of our subjects. Two-hundred sixty-five (84.94%) patients responded uneventfully and were relieved of colic and obstruction after conservative non-operative treatment. Twenty (6.41%) patients underwent enterotomy and evacuation of worms, 2 (0.64%) subjects underwent resection anastomosis, and 8 (2.56%) patients had laparotomy and milking of worms into colon. None of patient expired during the study period. CONCLUSION Ascaris lumbricoides is common cause of acute abdomen in our valley attributed to poor hygiene and low socioeconomic background. In patients of high clinical suspicion of worm obstruction, prompt investigations should be advised to reach a definitive diagnosis and prevent the development of complications. Significant efforts must be channelised at political and society levels for the prevention of this disease. Mass deworming programs should be adopted to overcome this menace.

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.

We developed a new technique to reduce the length of the enteric defect to be closed during intracorporeal anastomosis in laparoscopic right hemicolectomy (LRH), also avoiding the need to suture the first part of the anastomosis in a deep space with an acute angle. From January 2017, after the ileo-colic anastomosis was completed, an additional stapler cartridge was applied starting at the colonic rim and including the small bowel part of the anastomosis. The isoperistaltic fashion of the ileo-colonic anastomosis was maintained. The remaining defect left to be closed was 2–3 cm. We compared the results of the novel technique with those of the ‘standard’ closure (full-length enterotomy). In the last 30 months, this technique was successfully used in 32 patients (Group A), compared with 33 patients (2012–2016) operated with ‘standard’ closure (Group B). Age, BMI and post-operative stage distribution were similar. The mean operative time was 175.2 min (± 36.7) in Group A and 165.9 min (± 42.5) in Group B (p = ns), with 53.1% and 27.3% of associated procedures (cholecystectomy, ovariectomy, etc.), respectively (p

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.

Background:Gallstone ileus, which is called Type Vb Mirizzi Syndrome, is a rare case of mechanical intestinal obstruction observed in older patients with history of cholelithiasis or cholecystitis. Diagnostic Imaging plays an important role in the management of patients with suspected gallstone ileus. X-Ray and Abdominal Computed Tomography (CT) are the preferred modality. Case presentation:The patient was diagnosed with gallstone ileus at the age of 45. The case had 10 years history of biliary colic disease. The patient who is suffered from intestinal obstruction. CT demonstrated pneumobilia involving the gallbladder, a 5, 5 cm calcified stone in the ileum and small bowel dilatation. He underwent enterolithotomy and a huge stone was removed. When gallbladder area was checked, the gallbladder was highly adherent (to colon and stomach) and was inflamed. We suspected malignancy so multipl biopsy was taken. Two-stage treatment model was planned. After the surgery, any emerging complications were closely monitored. Conclusions:Abdominal CT are the preferred modality for diagnosis. The main treatment for gallstone intestinal obstruction is surgery. First step enterotomy, later intented for the gallbladder. There are two type of surgical approach for gallbladder: one-stage treatment or two-stage treatment according the inflammation of gallbladder

Historically, omentalisation and serosal patching have been used to augment gastrointestinal wall defects or incisions where gastrointestinal viability is of concern. This report describes the novel use of a transversus abdominis muscle on-lay flap to augment and provide support to compromised intestine in three cases. The muscle flap was used to support: the ileum following reduction of an intussusception in a dog (case 1), the gastric wall following gastric strangulation, dilation and volvulus in a diaphragmatic rupture in a cat (case 2) and the jejunum following enterotomy and full-thickness ulcer resection with primary repair in a dog (case 3). All animals were discharged within 4 days postoperatively with no short- or long-term complications reported by either the referring veterinary surgeons on routine postoperative examination or on telephone follow-up with the owners (case 1: 10 months, case 2: 30 months, case 3: 6 weeks). The creation of a flap of the transversus abdominis muscle may provide a useful alternative or adjunct to previously described techniques for supporting the gastrointestinal tract when gastrointestinal tissue viability is questionable or resection is not feasible. Further prospective clinical evaluation studies would be indicated to determine whether the muscle flap remains viable or compare whether this technique should be recommended over conventional methods.

Square knots can be difficult to construct in deep body cavities. The reversing half-hitch alternating post (RHAP) surgical knot has noninferior tensile strength and performance characteristics in deep body cavities. We compared the enterotomy repairs of novice learners in simulated deep body cavities using RHAP versus square knots after proficiency-based training.Undergraduate students were randomized to RHAP (n = 10) or square knot (n = 10) groups and trained to defined proficiency. They then performed hand-sewn enterotomy repairs of cadaveric porcine small bowels on flat surfaces and in simulated deep body cavities. We recorded time to knot-tying proficiency and to enterotomy repair, and burst pressures for the repair.Mean time-to-proficiency in knot tying was equivalent between the RHAP and square knot groups (23 [standard deviation (SD) 3] v. 21 [SD 2] min, p = 0.33). Mean time for enterotomy repair in deep cavities was shorter for the RHAP group (16 [SD 2] min v. 21 [SD 1] min, p = 0.02). Mean burst pressures for enterotomy repair were equivalent on flat surfaces (128 [SD 41] v. 101 [SD 36] mm Hg, p = 0.31), and were significantly higher for the RHAP group in simulated deep body cavities (32 [SD 13] v. 105 [SD 37] mm Hg, p = 0.05).The RHAP knots appear to have superior performance versus square knots when tied in a deep body cavity by novice learners. Future work should focus on demonstrating the clinical relevance and broad utility of the RHAP knot in abdominal surgery. Both knot types should be taught to novice learners.L’exécution de noeuds plats peut être difficile dans les cavités corporelles profondes. Les noeuds de type demi-clé inversée alternée (RHAP, pour reversing halfhitch alternating post) ont une résistance à la traction et un rendement semblables à ceux des noeuds plats dans ces cavités. Nous avons comparé l’efficacité des noeuds plats et des noeuds de type RHAP réalisés par de nouveaux apprenants dans des cavités profondes simulées, après leur avoir enseigné les compétences nécessaires.Les étudiants de premier cycle ont été aléatoirement répartis en 2 groupes, soit le groupe RHAP (n = 10) et le groupe noeud plat (n = 10), et ont reçu une formation pour développer des compétences prédéfinies. Ils ont ensuite suturé à la main un intestin grêle provenant d’un cadavre de porc, sur une surface plane et à l’intérieur d’une cavité profonde simulée. Nous avons mesuré le temps nécessaire à l’exécution du noeud et à la suture complète de l’incision, de même que la pression que pouvait subir cette suture sans se rompre.Le temps moyen d’exécution du noeud était semblable entre les groupes RHAP et noeud plat (23 min [écart type (E.T.) 3 min] c. 21 min [E.T. 2 min]; p = 0,33). Le temps moyen nécessaire à la suture de l’incision dans la cavité profonde était plus court dans le groupe RHAP (16 min [E.T. 2 min] c. 21 min [E.T. 1 min]; p = 0,02). La pression moyenne que pouvait subir la suture sans se rompre était comparable pour les sutures effectuées sur une surface plane (128 mm Hg [E.T. 41 mm Hg] c. 101 mm Hg [E.T. 36 mm Hg]; p = 0,31), mais était significativement plus élevée dans le groupe RHAP pour les sutures faites dans la cavité profonde (32 mm Hg [E.T. 13 mm Hg] c. 105 mm Hg [E.T. 37 mm Hg], p = 0,05).Les noeuds de type RHAP semblent avoir un rendement supérieur à celui des noeuds plats lorsqu’ils sont réalisés dans une cavité profonde par de nouveaux apprenants. Des études ultérieures devraient se pencher sur la pertinence clinique et l’utilité générale de ces noeuds en chirurgie abdominale. Les 2 types de noeuds devraient être enseignés aux nouveaux apprenants.

Abdominal cocoon syndrome coexistent with military tuberculosis is a very rare entity, and its occurrence in a young adult male has not been previously reported. The disease in combination with military tuberculosis is associated with significant morbidity and mortality if underdiagnosed and untreated; hence, a high index of suspicion is required in a patient with tuberculosis presenting with intestinal pseudo-obstruction. The ideal treatment of the combination is surgical excision of cocoon along with oral anti-tubercular therapy (ATT), when the initial conservative management fails. However, surgery is frequently complicated by iatrogenic enterotomy due to the fibrinous cocoon. The best option in these cases may be a bail-out method of diverting jejunostomy. This helps relieve intestinal pseudo-obstruction and promotes early initiation of ATT as has been demonstrated in the present case.

Soil-transmitted helminths are so prevalent in the tropics and low developing countries. Pediatric clinical presentation of ascariasis, the most common helminth, as the intestinal obstruction is not only rare but also less described. We present a case of a 4-year-old girl with massive ascariasis. She presented with a 3-day history of acute abdominal pain associated with vomiting and an episode of passing long white roundworms, about 5 cm in length, through the nose. The child had mild constipation and passed pellets of hard stool once in the last 72 hours. She was in fair general condition at the examination but had significant findings on abdominal examination. On palpation, there was a soft mass localized in the left paraumbilical area and no tenderness, with normal bowel sounds on auscultation. Exploratory laparotomy was sanctioned where roundworms (Ascaris lumbricoides), saucepan full, were delivered through a 2.5 cm enterotomy incision. Postoperative management was carried out, and the child discharged on the 7th day of treatment including a 3-day course of albendazole 400 mg daily.

An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality. 170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m2). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic. Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.

To present a novel technique for the repair of parastomal hernias. A total of 15 patients underwent parastomal hernia repair. A robotic Sugarbaker technique was utilized for repair. The fascial defect was closed prior to robotic intraperitoneal placement of the mesh. Baseline demographics of the patients were obtained, and intra-operative and post-operative outcomes were tracked. The etiology of the ostomies was oncologic in all but three patients. Five of the stomas were urostomies (33.3%). Patient characteristics were as follows: age 64.9.1 ± 9.3 years, BMI 30.1 ± 4.7 kg/m2, smoking history 60.0%, and diabetes 6.7%. The mean size of the hernia defect was 46.0 ± 40.1 cm2 with a mesh size of 372.0 ± 101.2 cm2. The mean operative time was 182.0 ± 51.9 min. In seven patients, an inferolateral preperitoneal flap was created for mesh placement. Intraoperatively, only one enterotomy was made during dissection, which was repaired without complication. The mean length of stay was 4.2 ± 1.9 days. There was only one hernia recurrence (6.7%). There were no wound complications, surgical site infections, or mesh infections. A mean follow-up time of 14.2 ± 9.4 months was achieved. Robotic Sugarbaker parastomal hernia repair is a safe and effective technique. The results demonstrate the feasibility of fascial closure with this technique and a low recurrence rate. The authors propose this technique should be widely considered for parastomal hernia repair.

Veterinary use of the aminoglycoside antibiotics is under increasing scrutiny. This questionnaire‐based study aimed to document the use of aminoglycosides with a particular focus on gentamicin. An online questionnaire was delivered to generalist equine veterinary surgeons and specialists in internal medicine to determine the perceived importance, frequency of use and routes of administration of the aminoglycoside antibiotics. A series of hypothetical scenarios were also evaluated regarding gentamicin. Data were compared to evaluate the impact of the level of specialisation on prescribing practices for different antibiotics using Chi‐squared and Fischer's exact tests. Data were analysed from 111 responses. Gentamicin was commonly used empirically without culture and susceptibility testing. Generalists were more likely to use gentamicin only after susceptibility testing than specialists in a variety of clinical presentations including respiratory diseases, septic peritonitis, acute febrile diarrhoea, cellulitis and contaminated limb wounds (p, Gentamicin is the most important and commonly used aminoglycoside used in equine practice, although commonly used for conditions outside its marketing authorisation. Amikacin is the aminoglycoside most commonly used by the intra‐articular or regional route. Dosing of aminoglycosides used in clinical practice could be enhanced through wider use of therapeutic drug monitoring.

Robotic surgery offers potential advantages of improved ability to complete procedures using a minimally invasive approach, recovery, and clinical outcomes. It has been previously established that safety net hospitals are outliers for surgical complications. As such, the adoption of new technology may not achieve the same outcomes as other institutions. We hypothesized that, compared to laparoscopic and open surgeries, robotic surgeries have fewer post-operative Clavien-Dindo complications at our safety net hospital. All robotic surgeries performed from 2017 to 2019 at a single, safety net hospital were reviewed. Cases were matched 1:3 to laparoscopic controls. Surgeries commonly performed open were additionally matched 1:3 to open counterparts. The primary outcome was Clavien-Dindo complications at 90 days post-operatively. Secondary outcomes included inadvertent enterotomy, conversion to open, operative duration, wound class, surgical site infection (SSI), surgical site occurrence (SSO), length of stay (LOS), reoperation, readmission, and recurrence. A total of 160 robotic surgeries were included and matched to 480 laparoscopic surgeries and 108 open surgeries. Open surgeries were associated with greater risk of Clavien-Dindo complication (OR = 2.7, p = 0.040, 95% confidence interval 1.0–6.9) than either robotic or laparoscopic surgeries. Robotic cases had increased operative duration when compared to laparoscopic (p

Objective To determine the prognostic value of (1) colonic venous lactate or peripheral lactate values obtained before and after manual correction of a large colon volvulus and (2) a combination of variables including pelvic flexure biopsy. Study design Prospective clinical study. Animals Forty adult horses in which large colon volvulus was diagnosed intraoperatively. Methods Colonic venous, peripheral venous, and arterial blood samples were collected to measure lactate values before and after manual correction. Mucosal biopsy samples were obtained in cases that underwent enterotomy or colonic resection and anastomosis. Interstitium to crypt (I:C) ratio and hemorrhage scores were measured. Optimal cutoff values were determined by receiver operator curve analysis, and associations between variables and short-term outcome were determined by univariable regression. Short-term survival was defined as horses being discharged from the hospital. P ≤ .05 was considered significant. Results No association was found between colonic venous lactate values before (P = .011) or after (P = .201) manual correction of large colon volvulus and determination of short-term outcome. Peripheral venous lactate at admission ≥3.2 mmol/L and after manual correction ≥5 mmol/L, arterial lactate postmanual correction ≥3.53 mmol/L, and histomorphometric measurements of mucosal hemorrhage ≥3 and I:C ratio > 1 were associated with poor short-term outcome. Conclusion Peripheral lactate values, histomorphometric measures of I:C ratio, and hemorrhage score provided prognostic information that could help guide recommendations made to owners. Clinical significance Peripheral lactate values after manual correction provide important intraoperative diagnostic information to assist in predicting case outcome in the operative and immediately postoperative period.

To evaluate two different barbed sutures for closure of pelvic flexure enterotomies and compare results achieved with two previously described closure techniques.Ex vivo.Twenty-four fresh cadaver adult equine large colons.Cadavers were randomly assigned to four closure groups (n = 6 each group): single-layer absorbable suture, double-layer absorbable suture, single-layer unidirectional barbed suture, or single-layer bidirectional barbed suture. Construction time, luminal reduction (percentage), bursting pressure, and method of failure were measured. Cost, leakage, exposed suture, and general appearance were recorded. Comparisons were performed with one-way analysis of variance and post hoc Bonferroni test (P .05).Double-layer absorbable closure had the highest bursting pressure (mean = 178.5 mm Hg, SD = 9.79, P .001) but took more time (P = .001) compared with all other groups. The construction time of both barbed suture closures did not differ from the single-layer closure (P .06). Bursting strengths of both unidirectional (mean = 91.6 mm Hg, SD = 5.57) and bidirectional (mean = 87.5 mm Hg, SD = 8.69) barbed sutures were lower (P .006 for both) than those of both single- (mean = 117.6 mm Hg, SD = 11.69) and double-layer (mean = 178.5 mm Hg, SD = 9.79) closures. Unidirectional barbed suture closure had a reduction in lumen diameter (P = .004) compared with bidirectional and single-layer closures.Enterotomy closures with the two different barbed suture patterns were comparable in bursting strength and construction time. However, the barbed suture patterns had lower bursting strength compared with traditional single- and double-layer closures. Unidirectional barbed suture closure also reduced lumen diameter.Closure of a large colon enterotomy with barbed suture patterns may be less secure than single- and double-layer suture closure.

BACKGROUND At present in Australia women are not routinely, systematically informed of the risks of childbirth. AIMS It is hoped this presentation of the perspective of some women who suffer unexpected obstetric complications will encourage change. MATERIALS AND METHODS The experience of women involved in obstetric medicolegal reports prepared by a colorectal surgeon over ten years is analysed. RESULTS Twenty women were identified. Sixteen had vaginal deliveries. All 16 suffered third or fourth-degree tears, six developed rectovaginal fistulae, six required stomas and 11 developed faecal incontinence. Of the four women who delivered by caesarean section, there were two post-operative caecal perforations, one unrecognised small bowel enterotomy, and one patient developed sepsis due to an infected haematoma. Seventeen of the 20 women were noted to suffer psychological sequalae. None of the women recollected being warned of the complication they suffered, and there was no record of such warnings in their medical records. CONCLUSION Informed written 'consent' for natural vaginal delivery is, understandably, a contentious topic. Although learning from medicolegal cases may go against the grain, as medical professionals it is very difficult to ethically justify the status quo, where women are not routinely simply informed of the risks of childbirth. This is not fair. Even if informing women does not decrease the incidence of complications, the women who subsequently suffer these complications may well handle them much better, recognising they could occur.

BackgroundAscaris lumbricoidesandAscaris suumare the most common soil-transmitted helminths of humans and pigs, respectively. The zoonotic potential ofA. suumhas been a matter of debate for decades. This study was aimed to present a case of human ascariasis caused byA. suumin southern Italy.Case presentationA 75-year-old man presented to the department of surgery in Avellino (southern Italy) complaining of abdominal pain and vomiting. Physical examination revealed bloating and abdominal tenderness. A computed tomography scan showed air-fluid levels and small bowel distension. During exploratory laparotomy a small bowel volvulus with mesenteritis was evident and surprisingly an intraluminal worm was detected. The worm was removed with a small enterotomy and identified as an adult female ofA. suumbased on morphological and molecular analysis. Faecal examination revealed the presence of unfertilizedAscariseggs with an intensity of 16 eggs per gram (EPG) of faeces. The patient was treated with mebendanzole 100 mg twice a day for 3 days. The post-operative course was regular with re-alimentation after 3 days and discharge after 12 days.ConclusionsThis report shows asA. suumcan function as a relevant agent of human zoonosis. Therefore, in patients with bowel obstruction with no evident aetiology a helminthic infestation should be considered for an accurate diagnosis, especially in patients living in rural areas.

A 78-year-old male was turned up to the emergency room with a 5-day history of vomiting, diffuse abdominal pain, and altered bowel habits. After physical examination, routine blood tests, chest, and abdominal radiographs, as well as an abdominal ultrasound had been contacted to examine his ongoing symptoms, a serious intestinal obstruction was revealed. Bowel obstruction is interrelated with his medical history, as he suffered from inoperable prostate cancer. A CT scan was performed to exclude an associated complication. A plastic, 3cm diameter, water bottle cap was in the ileum revealed with no evidence of perforation or collection. A colonoscopy by an experienced endoscopist failed to reach and retrieve the plastic water bottle cap. Finally, the plastic water bottle cap was removed through an enterotomy. Even if a careful history taking can give a clue for diagnosis, the cause of bowel obstruction could be a surprise.

This is a case report of a 23-year-old male who presented to a hospital in Aleppo with a few months’ history of abdominal pain and diarrhea associated with progressive weight loss and ultimate cachexia. Patient’s history is significant for a trauma laparotomy due to a blast injury with management of a colonic and orthopedic injuries. Three months later he underwent a second laparotomy for reversal of the stoma after which his symptoms started and gradually became worse. The abdominal pain attacks were so severe unresponsive to analgesics and he had lost around 30 kg. He underwent CT scan on presentation which showed small bowel obstruction and was taken down to the operating room (OR) for exploration. In the operating room a hard mass was palpated in the small bowel and a small enterotomy was done overlying the mass with retrieval of a large surgical pad, gossypiboma, from the lumen. The enterotomy was closed primarily and the patient did well postoperatively and was discharged home.

A gossypiboma is a cotton sponge retained in the abdominal cavity after the operative procedure. It leads to tremendous morbidity, loss of money and even occasional death of the patient. Another problem on the part of treating the surgeon is defamation and medicolegal issue. We report a case of a 25- year young man presented with pain in abdomen and vomiting for six months, History of a lump in the right lumbar region for two months and with constipation for five days. He had operated for splenectomy after a blunt injury to the abdomen eight months back. On clinical examination, adhesive obstruction of bowel was suspected. On computed tomography, (CT), a foreign body was revealed. On laparotomy, there was evidence of sponge in a jejunum. By doing enterotomy, a large sponge was removed. Postoperative recovery was not associated with significant complications. An essential precaution is to look for retained foreign body and confirmation before the closure of any body cavity, as there may even after all precautionary exercises, occur retention of foreign bodies. Hence consider always the possibility of gossypiboma in the differential diagnosis of chronic abdominal pain or a mass in patients with a history surgery.

Diathermy-induced explosion in the operation theater, although rare, could be a devastating complication in any surgery, in terms of structural damage to equipment and theaters, or to human lives. Explosions in the gastrointestinal tract that have been documented, until now, have mainly been in the colon. Small bowel explosions are exceedingly rare, the only ones documented so far being in the proximal dilated loop of obstructed bowel. Explosion in the distal collapsed loop of obstructed small bowel has never been reported in literature. Here, we present a case of diathermy-induced explosion during enterotomy in the distal collapsed ileal loop of a patient with obstructed incisional hernia. In the obstructed bowel, a proliferation of hydrogen and methane producing bacteria can occur at all levels, leading to the accumulation of these combustible gases in explosive concentrations. Therefore, in cases of gastrointestinal tract obstruction, diathermy knife should be avoided to open the bowel at all levels, irrespective of the site of obstruction.

The purpose of this study was to evaluate a novel hernia repair glue fixation device (LiquibandFix8™) in laparoscopic IPOM repair for incisional hernias. All ventral incisional hernia patients requiring laparoscopic IPOM repair were included in the study. A retrospective review of the data was performed. 137 patients underwent 138 laparoscopic IPOM repairs for incisional hernias using n-butyl-2-cyanoacrylate (LiquibandFix8™) for mesh fixation over a 40-month period by a single experienced laparoscopic surgeon. There were 70 males and 67 females, median age 54 years (range 23–80 years). Defects were predominantly midline n = 123/138 (89%) and were closed by transfascial sutures in 126/138 (91%) prior to IPOM repair (IPOM plus). Mesh fixation was successful in all 138 repairs. Synthetic meshes (Symbotex™ [polyester/collagen composite, Medtronic] n = 80, and Dynamesh® [polypropylene/PVDF composite, FEG Textiltechnik mbH] n = 5) and biologic meshes (Surgimend® [bovine collagen dermal matrix, Integra] n = 53) were used. Median follow-up was 32 months (range 12–48 months). There were 16 adverse events in 12 patients (9%): conversion to open surgery (inadvertent enterotomy) 2 (1.5%), bladder perforation 1, intraperitoneal bleeding 2, port-site haematoma 2, port site wound infection 1, post-op ileus 2, chest infection 1, seroma 1 (1%), hernia recurrence 3 (2%) and chronic pain 2 (1.5%). This retrospective study shows that mesh fixation in laparoscopic IPOM using cyanoacrylate glue with the Liquiband Fix8™ device is feasible, safe, easy to learn, and is associated with a low risk of seroma, hernia recurrence and chronic pain with short-medium term follow-up.

Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30–39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively. TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.

Se reporta el caso de un equino hembra de raza Pura Sangre de Carrera de tres años con síndrome abdominal agudo relacionado a una hernia umbilical irreductible, inflamada y tumefacta, que fue derivada a cirugía. Durante el procedimiento quirúrgico se detectó una adherencia necrótica en la parte antimesentérica de un segmento del íleon. Con el fin de extraer la porción afectada se practicó una enterotomía, la cual fue reforzada mediante la transposición del ligamento ileocecal para evitar una estenosis o el posible colapso de la línea anastomótica. Los resultados de la cirugía fueron satisfactorios y el paciente evolucionó favorablemente.

The most common technique described for robotic ventral hernia repair (RVHR) is intraperitoneal onlay mesh (IPOM). With the evolution of robotics, advanced techniques including retro rectus mesh reinforcement, and component separation are being popularized. However, these procedures require more dissection, and longer operative times. In this study we reviewed our experience with robotic ventral/incisional hernia repair (RVHR) with hernia defect closure (HDC) and IPOM. Retrospective chart review and follow-up of 31 consecutive cases of ventral/incisional hernia treated between August 2011 and December 2018. Demographics, operative times, blood loss, length of stay (LOS), hernia size, location, and type, mesh size and type, recurrence, conversion to open ventral hernia repair (OVHR) and complications including bleeding, seroma formation and infection were analyzed. Mean age was 63.9 years old, with median BMI of 31.24 kg/m2. Median hernia area was 17 cm2. Mean operating time was 142.61 min (SD 59.79). Mean LOS was 1.46 days (range 1–5), with 48% being outpatient, and overnight stay in 32% for pain control. Conversion was necessary in 12.9% cases. Complication rate was 3% for enterotomy. Recurrence was 14.81% after a mean follow-up of 26.96 months. There was significant association of recurrence with COPD history (P = 0.0215) and multiple hernia defects (P = 0.0376). Our recurrence rate (14.81%) compares favorably to those reported in literature (16.7%) for LVHR with HDC and IPOM. Our experience also indicates that IPOM is associated with satisfactory outcomes, low conversion and complications rates, and short LOS.

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.

The puma (Puma concolor) is a large felid native to the Americas and one of the endangered species of the Brazilian fauna. Digestive disorders such as fecalomas are common in veterinary practice. Fecalomas are masses of retained feces that accumulate in the large colon and progress to hard fecal concretions that are difficult and painful to expel. Inadequate diets and mechanical intraluminal or extraluminal intestinal obstructions are the major causes of fecaloma. Tenesmus, anorexia, vomiting and dehydration are common clinical signs. The diagnosis is based on medical history and physical examination, and can be confirmed by imaging assessment. Fecalomas are amenable to conservative and surgical treatment, depending on disease severity. This paper describes a case of fecaloma in a puma. The diagnosis was made during exploratory laparotomy and improper diet incriminated as the cause. Surgical intervention consisted of enterotomy followed by removal hardened retained feces. Postoperative dietary management consisted of a liquid follow by a soft diet, with reintroduction of the regular diet after full recovery. Dietary supplementation with vegetable fibers was prescribed for life to prevent recurrence.

Superior mesenteric artery syndrome can lead to duodenal obstruction due to vascular compression. We treated a patient with superior mesenteric artery syndrome by performing a complete laparoscopic duodenojejunostomy with a linear stapled closure of the common enterotomy. A 72-year-old woman presented with nausea, vomiting, and weight loss. CT revealed superior mesenteric artery syndrome. Conservative management was not effective. Because the patient required a surgical bypass for long-term relief, a laparoscopic duodenojejunostomy was performed. In past cases, hand-sewn sutures were made through a small incision to avoid stenosis when the common enterotomy was closed. For our patient, we closed the common enterotomy with a linear stapler in a complete laparoscopic maneuver. We performed the closure after placing several temporary sutures to minimize the amount of intestinal wall to be removed. Laparoscopic duodenojejunostomy is a minimally invasive procedure, and a linear stapled closure of a common enterotomy is a safe surgical technique that reduces invasiveness.

Objectives To determine the safety of surgically-placed gastrostomy feeding tubes in dogs with septic peritonitis. Materials and methods Retrospective analysis of 43 dogs with septic peritonitis that had undergone surgical exploration and gastrostomy tube (de Pezzer or Foley) placement as part of the surgical procedure. Postoperative recovery times, hospitalisation times, complication rates and overall survival times were documented. Results The most common cause of septic peritonitis was dehiscence of an enterotomy or enterectomy site. Fifteen dogs had a Foley gastrostomy tube placed and 28 had a de Pezzer gastrostomy tube placed. The median time from surgery to the start of enteral nutrition was 16 hours (range 3 to 28 hours). There were no major complications relating to the gastrostomy tube; minor complications occurred in 11 (26%) patients. The overall median time spent in hospital was 5 days (range 3 to 29 days) for patients surviving to discharge and 22 (51%) dogs survived overall. Clinical significance Gastrostomy feeding tubes provide a safe way to provide enteral nutrition to dogs with septic peritonitis; they are associated with a low complication rate in these patients.

OBJECTIVE To report the intestinal incisional dehiscence rate following enterotomy for foreign body removal in dogs. ANIMALS 247 client-owned dogs with intestinal foreign bodies treated with enterotomy between November 2001 and September 2017. PROCEDURES Medical records were reviewed, and data were collected regarding signalment, history, surgery, clinicopathologic findings, hospitalization, intestinal incisional dehiscence, and survival to hospital discharge. Dogs were grouped according to whether intestinal incisional dehiscence occurred (dehiscence group) or did not occur (nondehiscence group) following enterotomy, and the rate of dehiscence for the total number of enterotomies during the study period was calculated. Univariable analysis was performed to identify variables associated with intestinal incisional dehiscence. RESULTS 8 of the 247 (3.2%) dogs had preoperative septic peritonitis, and all 8 dogs survived to hospital discharge. Incisional dehiscence occurred following 5 of the 247 (2.0%) enterotomies, and only 2 dogs in the dehiscence group did not survive to hospital discharge. Duration of hospitalization was longer for dogs in the dehiscence group than for dogs in the nondehiscence group. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that enterotomy for intestinal foreign body removal had a lower rate of dehiscence in dogs during the study period, compared with rates previously reported; however, the low rate should not be used as a reason to perform an enterotomy rather than an enterectomy when needed. Surgeons should thoroughly evaluate the bowel and perform an enterotomy only when indicated.

Intestinal wounds require precise closure after intestinal biopsy, enterotomy, or enterectomy in small animals. Preexisting factors such as intra-abdominal sepsis and hypoalbuminemia as well as poor surgical technique increase the risk of intestinal dehiscence, with considerable negative impact on patient morbidity and mortality. Live dog studies have demonstrated the dangers of mucosal eversion especially in the septic abdomen. Approximating patterns preserve luminal diameter, heal optimally, and have equal bursting strength compared with inverting patterns after 24 hours. Simple interrupted and simple continuous suture patterns and disposable skin staples are established alternatives for manual wound closure. Knotless quilled suture currently used in laparoscopic gastropexy techniques shows bursting strength equal to monofilament sutures in dog cadaveric intestine. Dehiscence rates with hand sewn vs titanium automated stapling anastomosis are similar in uncomplicated cases; however, auto stapling devices may be the preferred method of anastomosis when preexisting abdominal sepsis is present and when patient size allows it. Regardless of the technique, current standard of care involves leak testing and omental wrapping, followed by early postoperative feeding. The past decade has ushered in an exciting new era of laparoscopic assisted techniques that have the potential to reduce postoperative pain and patient morbidity. An understanding of these applications will establish the future of minimally invasive small animal intestinal surgery for veterinary specialists. In summary, surgeons have a variety of methods at their disposal for optimal clinical outcome in small animal intestinal surgery.

BACKGROUND: Ligation clips are used ubiquitously throughout minimally invasive surgery for apposition of tissues. Their size limits their application beyond ligation of small tubular structures. A novel clip and clip applicator that allows for broad-area clamping and rotation has been developed by our team. The primary aim of this study is to provide preliminary data assessing tensile strength of the clip across apposed segments of bowel. METHODS: A comparative study evaluating the maximum load (N) held across two apposed tissues by (a) our novel broad-area clip and (b) a conventional commercial clip was performed. Two sections of porcine bowel were clamped together and the maximum load (N) was measured using a tensile strength material testing machine. A preliminary experiment comparing staple line leak pressures in a porcine model ± clip enforcement of staple line was also conducted. p

Objective To compare surgical models for teaching enterotomies to students. Study design Prospective, randomized study. Sample population Second-year veterinary students (n = 59) and faculty surgeons/surgery residents (n = 19). Methods Participants performed an enterotomy on each of 3 models (equine cadaver intestine, SurgiReal small intestine simulator, and SynDaver canine bowel) and completed a survey comparing them to either an enterotomy on an anesthetized pig (students) or intestinal surgery experience (faculty/residents). Surveys results were compiled and analyzed. Results Both student and faculty/resident groups rated cadaver intestine as more similar to live intestine compared with the synthetic models for incision, tissue handling, mucosal eversion, needle passage, knot tying, and best preparing for live intestine. Students rated SynDaver as more similar to live intestine than SurgiReal for incision and ranked SurgiReal as more similar to live intestine than SynDaver for mucosal eversion. There was no difference between the ranks assigned to SurgiReal and SynDaver for faculty/residents. Faculty/residents responded most often that cadaver intestine would be the model they recommend for training students. Conclusion Cadaver intestine was the model most similar to live intestine for all variables tested. SurgiReal and SynDaver models were comparable to each other but did not simulate live intestine as well as cadaver intestine. Clinical significance Cadaver intestine more closely approximated live intestine compared with either synthetic model. SurgiReal and SynDaver may be adequate alternatives if cadaver intestine is unavailable.

Though perineal hernias remain rare, the incidence is reportedly rising. Secondary to the historical rarity, optimal method of repair and outcomes after repair remain poorly understood. Therefore, we reviewed the past 25 years of our institutional experience with perineal hernia repair. A retrospective review of an institution-maintained database was conducted from January 1, 1994 to January 31, 2018 for patients undergoing perineal hernia repair. Data were collected on patient characteristics, operative technique, and post-operative outcomes. Twenty-one patients (n = 12 male) underwent perineal hernia repair in the study period with two-thirds of the operations occurring in the most recent 7 years (since January 1, 2011). The median time to repair was 13 months (range 2–127) after index operation. The approach was transabdominal in nine, perineal in nine, and combined in three. Mesh, a tissue flap, or a combination of these was used in 19 of the cases and 6 additional abdominal wall hernias were repaired concurrently. Post-operative complications consisted of superficial surgical-site infection (n = 2), infected seroma (n = 1), and a missed enterotomy (n = 1). Follow-up ranged from 0 to 112 months (median 2 months) and only one recurrence was noted. Presentation for repair of perineal hernia has increased at our instituion over the past 2 decades. Outcomes did not differ between the three repair approaches and the choice of mesh or tissue-based repair. Surgeons should base these decisions on hernia complexity and local tissue conditions.

Stomach bezoar is a foreign body in the digestive organ, formed as a result of ingestion and digestion of certain substances that have vegetable, animal or chemical origin. This pathology, rarely found in patients, has another name, that is, gastric concretions. The article presents a clinical case of complex diagnosis and treatment of intestinal obstruction caused by plant bezoar (persimmon). The results of traditional x-ray, ultrasound, MSCT and endoscopic methods are presented. Surgical treatment was carried out: laparotomy, enterotomy, removal of bezoar.

OBJECTIVE To evaluate the influence of preconstructed effector loop location using a barbed unidirectional suture on leakage pressures following canine enterotomy closure. STUDY DESIGN Randomized, experimental, cadaveric. ANIMALS OR SAMPLE POPULATION Grossly normal jejunal segments from three canine cadavers. METHODS Jejunal segments were harvested and randomly assigned based upon effector loop location from the beginning of the incisional line. Groups (n = 12/group) included 0 mm, 5 mm, 10 mm, 15 mm, and intact controls (n = 6/group), repaired using a 3-0 unidirectional barbed suture in a simple continuous pattern. Initial leakage pressure (ILP), maximum intraluminal pressure (MIP), repair time, and leakage location were recorded. RESULTS Mean ILP for 0 mm group (24.42 ± 8.43 mmHg) was lower (p ≤ .001) compared to all experimental groups with ILP ~40% lower. There was no difference in MIP among experimental groups (p = .239). Repair time increased (p

Background Anastomotic stenosis following esophagojejunostomy reconstruction by the overlap method with absorbable barbed sutures occurs only rarely in patients who have undergone laparoscopic surgery. We report anastomotic stenosis by the overlap method that we attributed to the lack of tactile sensation during robot-assisted surgery. Case presentation An 83-year-old man underwent robot-assisted laparoscopic proximal gastrectomy and lymph node dissection at our hospital for treatment of gastric cancer. Double tract reconstruction followed with side-to-side esophagojejunostomy (overlap method) performed with an endoscopic linear stapler. On completion of the anastomosis, the enterotomy was closed under robotic assistance with absorbable barbed suture. Once solid foods were introduced, the patient had difficulty swallowing and felt as though his digestive tract was stopped up. When upper gastrointestinal endoscopy was performed, we found the anastomotic lumen to be coated with food residue. After rinsing off the residue with water, we could see barbed suture protruding into the anastomotic lumen that had become entangled upon itself, which explained how the food residue had accumulated. We cut the entangled suture under endoscopic visualization using a loop cutter. Conclusion This case highlights a stricture caused by insufficiently tensioning barbed suture, which subsequently protruded into the anastomotic lumen and became entangled upon itself. We believe this occurrence was associated with the lack of tactile sensation in robot-assisted surgery.

A fístula colecistocólica é uma complicação rara da litíase biliar. A apresentação clínica é variável e inespecífica.Os autores descrevem um caso clínico de uma paciente com obstrução mecânica baixa provocada pela impactação no cólon sigmoide de um cálculo biliar procedente de uma fístula colecistocólica.Perante a tentativa infrutífera de remoção do cálculo através da colonoscopia, procedeu-se a laparotomia, com enterotomia após mobilização do cálculo e remoção do mesmo e colostomia lateral, sem intercorrências intraoperatórias.A eleição da técnica cirúrgica e o prognóstico são inevitavelmente condicionados pelo estado geral e comorbilidades associadas.

We present a rare case of adult intussusception (AI) due to a small bowel fibroma, which presented as recurrent subacute symptoms. To our knowledge, this is the first reported case managed by intraluminal excision of the causative lesion by enterotomy as opposed to bowel resection. A 34-year-old woman presented with recurrent colicky abdominal pain. Computed tomography demonstrated ileoileal intussusception, with magnetic resonance imaging revealing a 2.3-cm intraluminal lesion acting as a lead point. The patient underwent laparotomy and the intussusception was reduced. Palpation of the lesion demonstrated a pedunculated polyp without suspicious features; so the lesion was resected via enterotomy as opposed to small bowel resection. Histopathological analysis diagnosed a benign fibroma. AI is a rare but important entity, with potentially devastating consequences for delayed diagnosis. The majority of lesions causing AI are benign and may be amenable to intraluminal resection via enterotomy, thus avoiding unnecessary bowel resection.

OBJECTIVE To quantify the relative risk of intestinal dehiscence in dogs undergoing intestinal resection and anastomosis (IRA), compared with enterotomy, for surgical management of small intestinal foreign bodies, and to evaluate the association between nasogastric tube placement for early enteral nutrition (EEN) and hospitalization time. ANIMALS 211 dogs undergoing 227 surgeries for intestinal foreign body removal. PROCEDURES Medical records were reviewed for dogs undergoing a single-site sutured enterotomy or IRA for foreign body intestinal obstruction between May 2008 and April 2018. Multivariable logistic regression was used to quantify the association between surgical procedure and dehiscence. Multiple linear regression was used to quantify the association of nasogastric tube placement with total hospitalization time. RESULTS Dehiscence rates were 3.8% (7/183) and 18.2% (8/44) for enterotomy and IRA, respectively. Overall dehiscence rate for all surgeries was 6.6% (15/227). The odds of intestinal dehiscence for IRA were 6.09 times (95% CI, 1.89 to 19.58) the odds for enterotomy. An American Society of Anesthesiologists score > 3 (OR, 4.49; 95% CI, 1.43 to 14.11) and an older age (OR, 1.02 [95% CI, 1.01 to 1.02] for each 1-month increase in age) were significantly associated with greater odds of intestinal dehiscence, regardless of surgical procedure. Placement of a nasogastric tube was not associated with intestinal dehiscence or decreased total hospitalization time when controlling for the year of surgery. CONCLUSIONS AND CLINICAL RELEVANCE Patients undergoing IRA were at a significantly higher risk of intestinal dehiscence, compared with patients undergoing enterotomy. Although this finding should not be used to recommend enterotomy over IRA, this information may be useful in guiding owner expectations and postoperative monitoring.

Posponer cirugias electivas durante el proceso pandemico de Covid-19 aumento el riesgo de complicaciones graves de enfermedades benignas. El ileo biliar es una de las raras complicaciones de la colelitiasis (0,3-0,5%). Los episodios recurrentes de colecistitis aguda estan involucrados en la fisiopatologia. La demostracion de la triada de Rigler en tomografia computarizada es diagnostica. Para reducir la morbilidad se recomienda la cirugia dos etapas: extirpar el calculo por enterotomia en la primera operacion, cirugia biliar en la segunda operacion. El ileo biliar debe estar en el diagnostico diferencial de las obstrucciones intestinales mecanicas, especialmente en pacientes con antecedentes de ataques de colecistitis durante el proceso pandemico de Covid-19 porque las cirugias electivas se detuvieron.Postponing elective surgeries during the coronavirus disease-19 (COVID-19) pandemic process increased the risk of severe complications of benign diseases. Gallstone ileus is one of the rare complications of cholelithiasis (0.3-0.5%). Recurrent episodes of acute cholecystitis are involved in pathophysiology. Demonstration of Rigler's triad on computed tomography is diagnostic. To reduce morbidity stepped surgery is recommended: remove the stone by enterotomy at the first operation and biliary surgery at the second operation. Gallstone ileus should be in the differential diagnosis of mechanical intestinal obstructions, especially in patients with a history of cholecystitis attacks during the COVID-19 pandemic process because elective surgeries stopped.

Funder: CMR Surgical, Objective: To evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a preclinical setting. Summary background data: Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots. Methods: Cadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device’s safety in performing cholecystectomy or small bowel enterotomy. Results: Nine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons’ preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (n = 6) and small bowel enterotomy (n = 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications. Conclusions: This preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility.

Background Peutz-Jeghers Syndrome (PJS) is an uncommon intestinal polyposis disorder. Bowel obstructions are a recurring problem in PJS and as many as 50% of these patients require surgery. The current standard of care for these patients is to perform a flexible enteroscopic polypectomy. The traditional push-pull enteroscopy however, might be unavailable or unsuitable in an emergency setting. Alternatively, repeated laparotomies with multiple small bowel resections can lead to short bowel syndrome. Methods In our series, we describe an innovative technique where a short midline laparotomy permitted sufficient access to reduce the intussusception(s) and perform a bowel walk. Rigid laparoscopic instruments were introduced within the small bowel lumen via enterotomies, to perform polypectomies along the entire small bowel length. This precludes the need for small bowel resections which can thwart the development of short bowel syndrome. Results Two patients with PJS presenting with acute small bowel obstruction underwent surgery using the described approach. Another two patients with PJS having multiple intussusceptions on CT underwent an elective prophylactic polypectomy using the same approach. We were able to run the bowel in its entirety and a maximum of 41 polyps were retrieved from the port site enterotomy. The operating times were modest and no unique complications pertaining to this technique were encountered. Conclusion Small bowel polypectomy using rigid instrumentation employing a limited midline laparotomy is an attractive option for both emergency and elective settings in patients with PJS., Highlights • Bowel obstructions are a recurring problem in PJS. • Polypectomy using rigid instrumentation serves as an attractive option for patients with PJS, undergoing a laparotomy for acute bowel obstruction. • This technique can be empolyed in both, elective as well as emergency settings.