Search

Differentiation of direct inguinal hernias, indirect inguinal hernias, and femoral hernias is often difficult at clinical examination and presents challenges even at diagnostic imaging. With the advent of higher-resolution multidetector computed tomography (CT), the minute anatomic detail of the inguinal region can be better delineated. The authors examine the appearance of these hernias at axial CT, as the axial plane remains the diagnostic mainstay of evaluation of acute abdomen. They review and label key anatomic structures, present cases of direct and indirect inguinal hernias and femoral hernias, and demonstrate their anatomic differences on axial images. Direct inguinal hernias protrude anteromedial and inferior to the course of the inferior epigastric vessels, whereas indirect inguinal hernias protrude posterolateral and superior to the course of those vessels. The proposed lateral crescent sign may be useful in diagnosis of early direct inguinal hernias, as it represents lateral compression and stretching of the inguinal canal fat and contents by the hernia sac. Femoral hernias protrude inferior to the course of the inferior epigastric vessels and medial to the common femoral vein, often have a narrow funnel-shaped neck, and may compress the femoral vein, causing engorgement of distal collateral veins. Familiarity with these anatomic differences at axial CT, along with the lateral crescent sign of direct inguinal hernias, may help the radiologist better assist the clinician in accurate diagnosis of the major types of hernias of the inguinal region. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.312105129/-/DC1.

Cystic neoplasms of the pancreas have been recognized for almost 2 centuries, but the principles of management continue to evolve. Clinicians have a better understanding now of the diverse pathologies and behaviors of cystic neoplasms, and can characterize them more precisely into benign, malignant, and of uncertain potential in their manifestations. Treatment is dependent on accurate diagnosis and tailored to the potential aggressiveness of the lesion, the surgical fitness of the patient, and the probability of effecting long-term palliation or survival of the patient. In this article the authors review the classification based on the World Health Organization classification and the latest evidence-based literature of cystic neoplasms, and present their considerations for surgical management of the various lesions. A better understanding of the biologic potential of cystic neoplasms such as intraductal papillary mucinous neoplasms allows for a more patient-specific evidence-based management plan.

Gallstones cause various problems besides simple biliary colic and choplecystitis. With chronicity of inflammation caused by gallstone obstruction of the cystic duct, the gallbladder may fuse to the extrahepatic biliary tree, causing Mirizzi syndrome, or fistulize into the intestinal tract, causing so-called gallstone ileus. Stones may pass out of the gallbladder and travel downstream through the common bile duct to obstruct the ampulla of Vater resulting in gallstone pancreatitis, or pass out of the gallbladder inadvertently during surgery, resulting in the syndromes associated with lost gallstones. This article examines these varied and complex complications, with recommendations for management based on the literature, the data, and perhaps some common sense.

An intraductal papillary mucinous tumor (IPMT) is a rare cystic lesion of the pancreas, comprising only 1% of all pancreatic exocrine neoplasms. The prognosis for these lesions is typically favorable as compared with invasive ductal carcinomas. Nevertheless, the management of IPMTs involves surgical resection due to their malignant potential. When located in the pancreatic head, the conventional treatment for IPMT is pancreatoduodenectomy. Some authors have advocated limited pancreatectomy for low-grade IPMTs of the pancreas, thereby decreasing the morbidity of more extensive resection. In this report, we describe our technique of minimal pancreatectomy, whereby the uncinate process and associated branch duct were completely extirpated while preserving remainder of the pancreatic head, duodenum, and pancreatic ducts. The case presented underscores the feasibility and advantages of minimal pancreatic resection in the management of such tumors.

Carcinoma of the stomach remains one of the most common causes of cancer deaths in the world. The only treatment to offer hope for cure or long-term palliation is surgery. Optimal surgical resection requires an adequate margin of normal tissue around the tumor, dissection of perigastric lymph nodes, and en-bloc removal of organs involved by direct extension. Extended lymphadenectomy has not been shown to offer survival advantage in the West.

Ureterosciatic herniation is a rare benign event that can mimic diverticulosis or irritable bowel syndrome. This entity has been managed by a number of open surgical techniques. Laparoscopic repair of this entity enabled us to identify the defect, interpose mesh, and obliterate the hernia defect with minimal morbidity. This represents the first report of laparoscopic repair of a ureterosciatic hernia.

Background. Ductal carcinoma in situ (DCIS) of the male breast is an uncommon disease, accounting for approximately 7% of all male breast carcinomas. Compared with invasive carcinomas of the breast, the prognosis associated with DCIS in men is excellent; however, clinical features, pathology, and treatment of this disease are not well defined in the literature. Methods. Records of 23 men with carcinoma of the breast treated at the Lahey Clinic from 1968 to 1991 were reviewed, revealing 4 patients with pure DCIS (17%). The reported management of DCIS in women is discussed in comparison with that of DCIS in men. Results. Of the four patients with DCIS, the presenting complaint was a retroareolar mass in three patients and a bloody nipple discharge in one patient. The pathologic subtype was papillary in one patient and intracystic papillary in three patients. Two patients were treated with partial mastectomy alone. Disease recurred locally as DCIS in both patients, requiring mastectomy at 30 and 108 months. No lymph node metastases were found in the three patients who underwent axillary dissection. All four patients were alive without disease at 133, 120, 36, and 32 months of follow-up, respectively. Conclusions. Although the sample size was small, our patients and a review of the literature suggest that most DCIS in men is of the papillary type and that mastectomy without axillary dissection is the preferred treatment.

The pace of change in hepatobiliary surgery requires a sound foundation in basic surgical principles. Further reductions in morbidity and mortality rates and appropriate use of alternative therapies require careful attention to preoperative risk assessment and patient selection. To operate safely and successfully on the liver and bile ducts, the surgeon must be well versed in normal and variant hepatobiliary anatomy, understand the underlying disease and therapeutic alternatives, and known techniques of reoperative biliary surgery. Surgeons who operate on the gallbladder must be prepared to confront a host of unexpected and difficult operative problems. Bile duct injuries must be repaired properly at the first attempt. Complex biliary operations require a great level of technical expertise and judgment to obtain successful results and should only be undertaken by experienced hepatobiliary surgeons. As proficiency with the more routine procedures improves, increasingly complex and extensive procedures become possible. We must constantly police ourselves to be certain that these more extensive procedures truly benefit our patients.

We report clinical features, surgical management, recurrences, and follow-up study of 12 patients with simple hepatic cyst, 11 patients with polycystic liver disease, and 19 patients with cystadenoma who were surgically treated over a 25-year period. The median age of patients was 48 years, and 37 women and 5 men were in the series. The most common presenting symptom and physical finding were chronic abdominal pain and tenderness in the right upper quadrant. The most commonly associated disease was polycystic kidney disease, which was an associated finding in 5 of the 11 patients with polycystic liver disease (45%). The most valuable diagnostic studies in all groups were computed tomography and ultrasonography. The location of the disease was bilobar in patients with polycystic liver disease, with a right lobe predominance in 18% of patients. The right lobe was also predominant in 83% of patients with simple hepatic cyst and 58% of patients with cystadenoma. Of all solitary cystic lesions in the left lobe, 75% of them were cystadenomas. Of the 66 surgical procedures performed, aspiration was associated with a failure rate of 100%; partial excision, a failure rate of 61%; and total excision and liver resection, a failure rate of 0%. Orthotopic liver transplantation was performed in three patients and was associated with two early deaths. Partial excision relieved symptoms in three patients (43%) with polycystic liver disease. Total excision, enucleation, or liver resection with cyst(s) is the treatment of choice for non-parasitic cystic lesions of the liver.

Neither computed tomography (CT) nor ultrasonography reliably distinguishes neoplastic from non-neoplastic pancreatic cysts. More invasive tests such as angiography or biopsy fail to differentiate these lesions in up to a third of patients. Because appropriate treatment differs greatly for these two classes of lesions, the clinician requires a more accurate means of confirming or excluding neoplasia. In an effort to refine the preoperative diagnosis of pancreatic cysts and evaluate the utility of endoscopic retrograde pancreatography (ERCP), we evaluated 11 patients with proven pancreatic neoplasia associated with cysts who underwent preoperative ERCP and CT scanning. Four patients had microcystic cystadenomas, two had a mucinous cystadenoma, one had a mucinous cystadenocarcinoma, and four had adenocarcinomas associated with cysts. CT identified a pancreatic cystic lesion in each patient. In all patients, ERCP showed either focal irregular narrowing, occlusion, or displacement of the main pancreatic duct at the corresponding location without the ductal changes of chronic pancreatitis. This helped to preoperatively differentiate these lesions from pseudocysts, hastening appropriate operation, obviating further testing and consultation, and aiding the intraoperative surgical strategy.

While hepatocellular carcinoma (HCC) is one of the world’s most common malignant neoplasms, with its highest prevalence in southeast Asia and portions of Africa, it remains a relatively rare malignancy in the western world. The incidence of concomitant cirrhosis is significantly higher in Asia, being over 70% [1–5] compared to less than 40% in western countries [6,7]. The overall 5-year survival after resection with curative intent in the West approaches 35–45% [8–10], whereas it ranges from 15% to 30% in the East [1, 2, 11, 12]. Recent implementation of mass screening programs using alphafeto protein and ultrasound in high-risk populations in Japan and China have identified increasing numbers of patients with small (

• Records of 11 patients undergoing biliary reconstruction after laparoscopic cholecystectomy are reviewed. Ductal injuries resulted from failure to define the anatomy of Calot's triangle. Risk factors include scarring, acute cholecystitis, and obesity. Presenting findings included anorexia, ileus, failure to thrive, pain, ascites, and jaundice. All patients required hepaticojejunostomies, which were multiple and above the hepatic bifurcation in four patients. Given the extensive nature of these injuries and the frequent need for intrahepatic anastomosis and early stenosis of repairs by referring physicians, we recommend reconstruction be undertaken by an experienced hepatobiliary surgeon. To avoid injuries, a greater appreciation of risk factors and anatomic distortion and variance and strict adherence to principles of dissection and identification of anatomic structures are suggested. The use of cholangiography and a low threshold for conversion to the open procedure are advised. (Arch Surg. 1992;127:596-602)

• Duodenal adenocarcinoma, a rare malignant lesion, is associated with a poor 5-year survival. Few series have addressed differences between resectable tumors of the proximal and distal duodenum. We reviewed records of 17 consecutive patients with adenocarcinoma of the duodenum who underwent resection: 10 had adenocarcinoma of the proximal duodenum, and seven had tumors of the distal duodenum. Most patients underwent pancreatoduodenectomy. Five patients with adenocarcinoma of the distal duodenum underwent segmental resection. No perioperative deaths occurred. Six of 10 patients with proximal tumors died of metastatic disease. Of the seven patients with tumors of the distal duodenum, five are alive without evidence of disease, and two died of unrelated causes. The survival of patients with adenocarcinoma of the distal duodenum is surprisingly good, and segmental resection is the procedure of choice. (Arch Surg. 1992;127:557-560)

The management of intra-abdominal sepsis includes drainage of septic foci, debridement of devitalized tissue, and prevention of continuing peritoneal contamination. An algorithm is presented as an aid to the thought process.

• Conservative management of pancreatic fistulas resulting from trauma, operation for tumor, or operation for pancreatitis has met with variable success. To assess optimal management strategies and outcome, we reviewed the records of 35 patients with external pancreatic fistulas (26 patients), pancreatic ascites (6 patients), or pancreatic pleural effusion (3 patients). Treatment included no operation in 5 patients, oversewing of the fistula in 7 patients, internal drainage in 11 patients, and resection in 12 patients. One (3%) postoperative death occurred. The overall rate of operative success was 83% (25 patients). The incidence of recurrent fistulas was about the same regardless of the procedure. Patients treated successfully without operation did not have pancreatitis as an underlying disease. Patient selection is of great importance in the decision to resect or to drain and is based in part on imaging the pancreatic duct and fistula. ( Arch Surg . 1989;124:571-573)

• From 1963 to 1983, 26 patients with cystic neoplasms of the pancreas were treated at the Lahey Clinic, Burlington, Mass. Cystadenoma (15 patients) was more common than cystadenocarcinoma (11 patients). Preoperative symptoms, such as abdominal pain, were present for as long as 18 years before diagnosis. The mean size of cysts was 7 cm. Distal pancreatectomy, the most common operation, was performed in ten patients. Eight of the 11 patients with cystadenocarcinoma had metastatic disease at the time of surgical exploration. There was one postoperative death (3.8%). Patients with cystadenocarcinoma had an adjusted median survival time after operation of 6.0 months. The long prodrome in many of the cancer patients suggests that benign cystadenomas, particularly of the mucinous type, may undergo malignant degeneration. Benign cystadenoma seems unlikely to recur after adequate resection. Whenever possible, complete excision of cystadenoma and cystadenocarcinoma is the procedure of choice. ( Arch Surg 1987;122:443-446)

Fragmentation of bile duct stones by mechanical, electrohydraulic, and laser intraluminal lithotripsy has greatly facilitated the ability to remove stones that are otherwise difficult to remove by standard manipulative techniques. Even these approaches fail when stones lack access or are impacted within the biliary tree. Extracorporeal shock-wave lithotripsy (ESWL) was evaluated in the United States in a multicenter trial with 56 patients. Stone fragmentation occurred in 91 percent of patients and duct clearance in 79 percent. Adjunctive procedures were used in 54 percent. Two ESWL treatments were required for fragmentation in 28 percent. Complications were mild and relatively infrequent. Hemobilia (8 percent), gross hematuria (6 percent), and biliary sepsis (4 percent) occurred less frequently than expected. There were no deaths during the 1 to 31 days of hospitalization (mean 9 days). We conclude that ESWL is a safe and effective adjunct to the treatment of difficult-to-remove bile duct stones under the conditions observed in this trial.