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Background: Hepatocellular carcinoma (HCC) is a significant cause of oncologic mortality worldwide. Liver transplantation represents a curative option for patients with significant liver dysfunction and absence of metastases. However, this therapeutic option is associated with significant blood loss and frequently requires various transfusions and intraoperative blood salvage for autotransfusion (IBS-AT) with or without a leukocyte reduction filter. This study aimed to analyze available evidence on long-term oncologic outcomes of patients undergoing liver transplantation for HCC with and without IBS-AT., Methods: Per PRISMA guidelines, a systematic review of keywords "Blood Salvage," "Auto-transfusion," "Hepatocellular carcinoma," and "Liver-transplant" was conducted in PubMed, EMBASE, and SCOPUS. Studies comparing operative and postoperative outcomes were screened and analyzed for review., Results: Twelve studies totaling 1704 participants were included for analysis. Length of stay, recurrence rates, and overall survival were not different between IBS-AT group and non IBS-AT group., Conclusion: IBS-AT use is not associated with increased risk of recurrence in liver transplant for HCC even without leukocyte filtration. Both operative and postoperative outcomes are similar between groups. Comparison of analyzed studies suggest that IBS-AT is safe for use during liver transplant for HCC., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: There are still controversies regarding the time of surgical management for acute appendicitis (AA). The main objective of this study was to recognize the surgical deferral time in patients with acute appendicitis and its relationship with the severity of presentation., Materials and Methods: We performed a retrospective review of prospectively collected data of all patients with acute appendicitis undergoing appendectomy from August 2018 to August 2020 in an academic, public hospital. Elapsed time from arrival to the emergency room to skin incision was determined. Patients were divided into three groups based on the elapsed time: less than 6 h, between 6 and 12 h, and more than 12 h., Results: A total of 782 patients were included. Of them, 443 (56.6%) patients had a surgical deferral time of less than 6 h, 238 (30.4%) patients between 6 and 12 h, and 101 (13%) patients of more than 12 h. Patients with more than 12 h of surgical deferral time had a more complicated clinical presentation (P = 0.013), a higher frequency of abscess formation (P = 0.022), higher requirement for the use of surgical drainage (P = 0.018), and longer length of hospital stay (P = <0.001)., Conclusion: Surgical deferral >12 h was associated with a higher incidence of complicated appendicitis, intra-abdominal abscesses, and overall hospital stay. However, in the multivariate analysis, only total evolution time, from the first symptom to surgery, was a significant independent predictor of complicated appendicitis., Competing Interests: Declaration of competing interest The Author(s) declare(s) that there is no conflict of interest., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Background: Even though the goal of safely performing cholecystectomy is already a priority in general surgical training programs, we aimed to study how many residents and attendings reached the critical view of safety (CVS) in laparoscopic cholecystectomy., Materials and Methods: Retrospective review of prospectively collected data of all patients with biliary surgical conditions, which underwent laparoscopic cholecystectomy and their corresponding postoperative notes with self-reported CVS from May 2019 to May 2020 in an academic hospital. Comparisons of operative variables between postgraduate year and attendings were made., Results: Laparoscopic cholecystectomy was performed in 126 elective cases (62.6%) and 75 (37.3%) emergency cases. On 105 (83.3%) of the elective cases and on 54 (66.7%) emergency cases, a CVS was successfully performed. PGY3 and PGY5 had higher odds of achieving CVS compared to attendings OR 6.09 (95% CI 2.05 to 8.07) and 4.51 (95% CI 1.0 to 10.20), respectively. Overall, attendings had decreased odds ratio of achieving CVS of 0.488 when compared to all residents. Elective procedures had increased odds ratios of achieving CVS of 3.44 (95% CI 1.52 to 7.74). On elective cases, attendings performed significantly faster procedures when compared to PGY2-4, but not PGY5. No differences were seen between operative speeds between PGY. Third-year residents were identified as having the highest frequency of CVS; however, these differences were not statistically significant. In emergency cases, blood loss, operative time, CVS, and bile duct injuries revealed non-significant differences between operators., Conclusion: CVS was reached significantly more often in elective than in emergency surgeries. There is still a lack of residents and attending surgeons who still failed to complete CVS during LC, highlighting the need for further education. Future studies should be attempted to repeat this study with a larger sample size and multiple coaching sessions to determine long-term efficacy., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Esophageal duplication cysts are a rare congenital cystic malformation from faulty intrauterine recanalization of the esophagus during the 4-8 th weeks of development. They account for 20% of all gastrointestinal duplication cysts and commonly involve the distal esophagus. Presenting symptoms may be related to size and location., Materials and Methods: Following the PRISMA guidelines, a systematic review was performed by searching published literature in various databases. Data from 97 reported case reports were pooled to present a descriptive and statistical analysis., Results: Patient population was composed of 51(52.5%) males and 46 (47.5%) females, and mean ages was 42.3 years (18-77). Distal cysts were the most prevalent. Seventy-nine (81.4%) patients were symptomatic; common symptoms included dysphagia, chest pain, cough and weight loss. Fifteen (15.5%) patients were treated conservatively and 75 (84.5%) by surgical treatment, among them thoracotomy in 30 (30.9%) patients and VATS in 17 (17.5%) patients. Mean length of hospital stay was 8.6 days (range: 1-26 days). One fatality was registered. Location, unlike size, was not found to influence presenting symptoms or treatment employed. Frequency of conservative treatment was not significantly different between symptomatic and asymptomatic patients. Open approaches were associated with longer stays than their minimally invasive counterparts., Conclusion: Esophageal duplication cysts remain rare in adults and are frequently located in the distal esophagus. Larger cysts are more likely to cause symptoms. Various surgical techniques may successfully be employed in the treatment of this pathology. Minimally invasive procedures have a shorter hospital stay., (© 2021. Société Internationale de Chirurgie.)

Background: Bariatric surgery has been a popular way for many women to reach a healthy body mass index, and as a consequence, a decreased body mass, which causes a greater chance of fertility, with improved pregnancy and better maternal outcomes., Objective: Describe a single-center experience of pregnancies complicated by internal hernias after gastric bypass., Setting: Academic Medical Center., Methods: During 2011 and 2019 a series of patients were treated for internal hernia after gastric bypass at our teaching hospital. The hospital records were retrospectively reviewed., Results: Seven women were treated. Median age was 33 years (range: 24-39 yr). Median gestational age was 25.6 weeks (range: 5-33 wk). Median time from Roux-en-Y gastric bypass to pregnancy was 4 years (range: 1-7 yr). Median body mass index was 24 kg/m 2 (range: 24-31 kg/m 2 ). Five (71.4%) patients underwent an exploratory laparotomy, and 2 (28.5%) patients a diagnostic laparoscopy. In all patients, an internal hernia of the small bowel in the Petersen space was encountered. Median length of pregnancy was 38 weeks (range: 33.6-39.6 wk). Six (85.7%) patients underwent C-section, and 1 (14.2%) patient gave birth by vaginal delivery. There was only 1 maternal postoperative complication and no fetal postoperative complications. Median follow-up was 9 months (range: 2-20 mo)., Conclusion: The rapid growth in bariatric surgery on obese women of fertile age could result in more cases of internal herniation during pregnancy in the future. An internal hernia should be suspected when encountering a postgastric bypass pregnant patient with abdominal pain, nausea, and vomiting., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Lipomas are the most common soft tissue tumor. Giant lipomas are defined by measuring at least 10 cm in diameter in one dimension or by a minimum of 1000 g. They often are asymptomatic; however, they can cause compression syndromes due to nerve damage and difficulties in walking., Presentation of Case: We described the case of a 25-year-old female with no significant medical history who began her condition two years before her consultation. The patient referred to the appearance of a non-painful mass on her right thigh with progressive growth that hinders daily activities. A simple CT scan reported a 10.3 × 8.1 × 19.6 cm adipose mass with infiltration towards the semitendinosus muscle and the biceps femoris muscle. A free margin resection of the tumor was performed, and the involved muscles were preserved. The patient had a satisfactory postoperative outcome., Discussion: Lipomas are common benign soft tissue tumors that arise from fatty tissue and may challenge surgical management due to their extension and dimensions; they often require delicate surgical intervention due to their potential risk of malignant transformation. We believe surgical pathologists and radiologists must draw attention to muscle involvement and the infiltrative pattern., Conclusion: Giant lipomas should always raise awareness of malignant transformation. Radiological guidance should provide enough evidence to decide whether to do a biopsy or not; hence, saving the patient an extra invasive procedure. We recommend taking at least 1 cm of border margin while removing these tumors to avoid local recurrence., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The implications of bowel obstruction occurring secondary to femoral hernia have not been discussed in the literature recently. Thus, we report our experience of treating patients with femoral hernias complicated by bowel obstruction versus patients with femoral hernias not complicated by bowel obstruction., Methods: The subjects of this retrospective study were patients admitted to our hospital for the treatment of femoral hernias between 2016 and 2019. We used the Fisher and Student's T test to compare the preoperative characteristics, treatment, and outcomes of patients with bowel obstruction versus those without bowel obstruction., Results: A total of 53 patients (mean age, 66.9 ± 15.1 years) were treated, 18 (33.9%) of whom underwent elective surgery and 35 (66%) of whom required emergency surgery (p = 0.001). The mean time between the development of symptoms and hospitalization was 4.5 ± 3.1 days for the patients with bowel obstruction and 1.6 ± 3.2 days for those without bowel obstruction (p = 0.001). The length of hospital stay was 11.1 ± 21.1 days for the patients with bowel obstruction and 1 ± 1.8 days for those without bowel obstruction (p = 0.028). Overall morbidity and mortality rates were 13.2% and 5.6%, respectively., Conclusion: Femoral hernias causing bowel obstruction are associated with greater time between the development of symptoms, hospitalization, and with a longer hospital stay.

Background: The present study aims to present a case series of patients who underwent splenectomy for splenic primary solid tumors without preoperative histopathologic diagnosis., Methods: From 2013 to 2019, 12 patients underwent splenectomy for solid primary splenic tumors at 3 different academic medical centers. All electronic medical records were retrospectively reviewed., Results: Seven (58.3%) patients were women, and 5 (41.6%) were male. The median age was 48 years (range: 25-72 years). In 8 (66.6%) patients, a conventional approach was performed. In 2 (16.6%), a hand-assisted laparoscopic surgery procedure was completed, and in other 2 (16.6%) patients, a laparoscopic approach was auspiciously achieved. Median operative time was 135 minutes (range: 60-210 minutes), and median blood loss was 500 mL (range: 200-1500 mL). Procedure-related morbidity was found in 2 (16.6%) patients, and the mortality rate was 0%. The final histopathologic diagnosis was lymphoma in 5 (41.6%) patients, lymphangioma in 3 (25%) patients, hamartoma in 2 (16.6%) patients, angiosarcoma, and sclerosing angiomatoid nodular transformation (SANT) in 1 (8.3%) case each., Conclusion: Splenectomy should be the treatment of choice when encountering a primary splenic tumor without the need for preoperative fine-needle aspiration biopsy, avoiding the complications this technique entails.

Introduction: Mirizzi syndrome is an infrequent complication of long-standing cholelithiasis. Extrinsic compression of the common hepatic duct is usually caused by an impacted stone in Hartmann's pouch or cystic duct resulting in the development of cholecystobiliary fistula. This syndrome is classified based on the presence and severity of cholecystobiliary fistula. Mirizzi syndrome is challenging to diagnose preoperatively and may require complex biliary surgical procedures for resolution., Results: We present three patients with Mirizzi syndrome with different clinical presentations. All were successfully treated by cholangioscopy with electrohydraulic lithotripsy. Endoscopic treatment is a safe alternative with a high success rate. Single-operator cholangioscopy combined with lithotripsy has been shown to have a 90-100% success rate in the treatment of biliary stones., Conclusion: Herein, we present our experience treating Mirizzi syndrome with single-operator cholangioscopy guided electrohydraulic lithotripsy. Difficult management of Mirizzi syndrome has led to research of new treatment options to minimize the risk of high-rate complications. Single-operator cholangioscopy in combination with laser lithotripsy is an adequate and safe alternative for the treatment of this condition., Competing Interests: None., (© 2021 The Author(s).)

Background: The purpose of this survey-based study was to evaluate the implementation of virtual learning in a single academic general surgery program, compared with the well-established face-to-face academic curriculum used before., Methods: From April 2020 to the present, virtual sessions were created via Zoom Videos Communications, Inc. (San Jose, CA, USA). A survey composed of 15 questions about the perceived quality and utility of the virtual sessions was developed. The survey was sent out to all general surgery residents of a general surgery program in November of 2020., Results: All residents enrolled in the program answered the survey, i.e., 22 (73.3%) men and 8 (26.7%) women with 6 (20.2%) residents per year (PGY 1-PGY 5). Over half of residents ( n  = 17, 56.7%) felt similar academic performance during online sessions when compared to the older model. Perceptions of the level of organization of academic sessions increased during the online model ( n  = 20, 66.7%). Twenty (66.7%) residents agreed it was easier to attend sessions during the online model. Fourteen (46.7%) residents reported their attendance to the sessions increased, and 14 (46.7%) residents would prefer this modality after the pandemic is over, with 8 (26.7%) being neutral about it., Conclusion: This study, to our knowledge, is the first to survey general surgery residents about the transition from a face-to-face curriculum to an e‑learning curriculum. The demonstrated effectiveness of the transition from face-to-face academic activities to virtual activities makes it a feasible tool for graduate medical education programs to adjust to a virtual model., Competing Interests: Conflict of interestM. Gonzalez-Urquijo, D. E. Gonzalez-Hinojosa, J. Rojas-Mendez and M. Rodarte-Shade declare that they have no competing interests., (© Springer-Verlag GmbH, AT part of Springer Nature 2021.)

Objectives: The present study describes a cohort of patients diagnosed with Mirizzi syndrome from type I to Vb, over a period of four years. It aimed to identify diagnostic and management pitfalls of Mirizzi syndrome, as well as their concomitant cholecystobiliary or cholecystoenteric fistulas., Material and Methods: We retrospectively reviewed all electronic medical records of patients who underwent surgery for Mirizzi syndrome at a single institution., Results: Twenty-two patients (0.6%) were diagnosed with Mirizzi syndrome. Most of the patients were females (n=19, 86.3%). Mean age was 43.8 years (range: 21-71 years). Ultrasound was performed in all (100%) patients. Six (27.2%) patients had a CT scan and six (27.2%) patients had endoscopic retrograde cholangiopancreatography. Overall preoperative diagnosis was achieved on 36.6% (n=8) of the patients. There were the same total and partial cholecystectomies, accounting for ten (45.5%) cases each, one hepaticojejunostomy with cholecystectomy (4.5%), and one enterolithotomy (4.5%). Laparoscopic cholecystectomy was attempted in 15 (68.1%) patients, with conversion to open surgery in 93.3% (n=14) of the patients. An open approach was made in five (22.7%) cases. Four (18.1%) patients were reported as MS type I, both types II and III each account for 22.7% (n=5) of the cases, there was only one (4.5%) patient with type IV, and seven (31.8%) patients with type V., Conclusion: There are limited studies of patients with Mirizzi syndrome, including type V classification, and when this syndrome is suspected, a preoperative diagnosis should be made to avoid bile duct injuries or lesions to adjacent organs., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (Copyright © 2020, Turkish Surgical Society.)

We presented a case of a 64-year-old female patient with a history of gastric bypass that presented with bowel obstruction due to a bezoar. She arrived at the emergency department, referring to severe abdominal pain, nausea, and vomiting. Abdominal X-ray reported gastric distention and hydro-air levels. CT scan reported swirling of the mesentery vessels and a collapsed intestinal loop, mimicking an internal hernia. Laparotomy was accomplished, which shows obstruction at 60 cm from the ileocecal valve. An enterolithotomy was performed, and a 6 × 6 cm phytobezoar was extracted. The patient had a satisfactory postoperative outcome, discharging her home on the fourth postoperative day. On a 12 month-follow up, the patient is doing well with no further complications. Gastric bypass continues to be one of the most performed bariatric procedures with low complication rates. It is important to note that not all intestinal obstructions in postoperative bariatric surgeries are due to internal hernias or adhesions. The differential diagnosis of intestinal obstruction due to bezoar must be present in patients who underwent bariatric surgery. Nutritional counseling is essential for the follow-up of patients, emphasizing fluid intake and slow chewing, as well as the use of absorbable materials for suture during the surgery.

Meckel's diverticulum is a congenital anomaly, resulting from incomplete obliteration of the most proximal portion of the omphalomesenteric duct. It generally remains silent, but life-threatening complications may arise in 4-6% of the patients. We present a case of a 16-year-old male, who arrived at the emergency room with crampy abdominal pain, nausea, and vomiting, suggestive of acute appendicitis. Surgical exploration revealed 150 cm of infarcted small bowel, secondary to a mesodiverticular band of a Meckel's diverticulum at the site of obstruction. The ischemic small bowel with Meckel's diverticulum was resected, and an ileo-ileal anastomosis was carried out. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. He was seen 12 months after his initial surgery, with a favorable outcome.

Purpose: Colonic volvulus constitutes a significant cause of large bowel obstruction in adults. Most studies of colonic volvulus come from high endemic zones and are limited by the small number of patients. In our region, there is a shortage of studies concerning this disorder, and treatment of colonic volvulus remains controversial., Methods: This is a retrospective study of 34 patients who presented with colonic volvulus at a single academic institution in a 4-year period and their respective treatment and outcomes., Results: A total of 34 patients, 17 males (50%) and 17 females (50%), with a mean age of 55 ± 23.9 years underwent treatment for colonic volvulus. Twelve patients (35.3%) underwent initial decompression, followed by a Hartman procedure in 4 patients (11.7%) and sigmoid resection with primary anastomosis in 3 patients (8.8%), with 3 fatalities (8.8%) following initial decompression. Two patients (5.8%) were lost to follow-up. Twenty-two patients (64.7%) underwent emergency surgery, of whom 16 (47%) underwent a Hartman procedure, with colorectal anastomosis in 9 patients (26.4%), with 3 fatalities (8.8%) immediately after the first procedure. Four patients (11.7%) were lost to follow up after the Hartman procedure. Of the 6 remaining patients (17.6%), of the emergency surgical group, 3 patients (8.8%) had an initial sigmoidectomy and primary anastomosis, and the remaining 3 patients (8.8%) had a cecal volvulus with a right hemicolectomy performed with primary anastomosis in 2 patients (5.8%) and with a fatality in the remaining patient, on whom a terminal ileostomy was performed for damage control. The mean hospital stay was 5.7 days, with an overall mortality rate of 23.5%., Conclusion: Acute colonic volvulus in our region is not as uncommon as in other parts of the world. This disorder must be suspected when a patient presents with abdominal pain, abdominal distension, and bean sign on plain X-rays and/or a whirl sign on computed tomography scan.

Background: A cholecystoenteric fistula (CEF) is an uncommon complication of gallstone disease. The aim of this study was to present our experience of a series of patients with CEF, presenting with or without gallstone ileus, along with their surgical outcomes., Methods: From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution, of which 15 were diagnosed with a CEF. All electronic medical records were retrospectively reviewed., Results: Fifteen patients presented with CEF. Ten patients presented cholecystoduodenal fistula, four patients cholecystocolonic, and one patient cholecystogastric counterparts. Twelve patients were female. The median patient age was 61 years (range 33-86 years). Five patients presented with gallstone ileus treated by laparotomy and enterolithotomy. In ten patients, a laparoscopic approach was attempted, but conversion to open surgery was necessary for eight of them. The median operative time was 140 min (range 60-240 min), and the median operative blood loss was 50 mL (range 10-600 mL). The procedure-related morbidity and mortality rates were 13.3% and 6.7%, respectively., Conclusions: There is no consensus on the best treatment modality for a CEF, as the treatment outcome is mostly dependent on the surgeon's expertise and the patient's condition. Not all CEFs are accompanied by gallstone ileus. For such case, the main purpose is to resolve the intestinal obstruction and, unless necessary, avoidance of the gallbladder area., Competing Interests: Competing interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article., (Copyright © 2019 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Introduction: Minimally invasive techniques have been used to treat vesicoureteral reflux (VUR) on pediatric patients. The aim of this study is to review the experience of the laparoscopic approach for VUR by the laparoscopic extravesical ureteral reimplantation (LEVUR) Lich-Gregoir technique., Materials and Methods: We performed a multicentric retrospective study. From 2001 to 2009, 81 pediatric patients with VUR constituting 95 ureteral units underwent LEVUR. Reflux was grade II in 32%, grade III in 55%, and grade IV in 8%., Results: LEVUR was performed successfully on the 81 patients with 95 ureteral units. Mean operative time was 105 minutes for left-sided reimplants, 70 minutes for right sided, and 180 minutes for bilateral reimplants. Mean hospital stay was 1.6 days. Urinary catheter was kept in place for a mean time of 0.5 days. Follow-up was achieved for at least 1 year with regular clinic visits, urinalysis, ultrasound, and voiding cystourethrogram. Four patients (4.2%) had evidence of recurrent VUR in a follow-up of 6 to 36 months after antireflux surgery., Conclusions: Although new endoscopic techniques have been widely available for VUR, they have a lower success rate and might require multiple attempts before success. We report that LEVUR has an acceptable success rate (95.8%) and durability compared with open and endoscopic procedures., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Intragastric migration is a late and rare postsurgical complication in patients with gastric band placement. Gastric band erosion rate has previously been described to be 1.46%. In this report, we present the case of a 43-y-old male with gastric band erosion undergoing a laparoendoscopic retrieval of the gastric band, due to intragastric migration., Method: A hybrid procedure was performed to retrieve the gastric band. A laparoscopic approach was initially used to extract the connecting tube. Endoscopy was then performed to cut the gastric band with a specific cutter system and was subsequently extracted transorally., Results: The postoperative course was uneventful. Clear liquids were started on day 1, and the patient was discharged on day 2., Discussion: The purpose of this study was to describe a hybrid technique for the removal of an eroded gastric band, as a safe and feasible option in patients with band erosions., Conclusion: The laparoscopic approach enables safe extraction of the connecting tube, while endoscopy allows extraction of the band without creating a large incision in the stomach.

Introduction: About 0.2-10% of patients with prior orchiopexy will require reoperation for recurrent cryptorchidism. The most common approach for these patients has been an open inguinal repeat orchiopexy. The aim of this report is to show results and feasibility with the totally laparoscopic approach for failed prior open orchiopexy., Subjects and Methods: Nine patients with 11 recurrent undescended testes were treated by the totally laparoscopic orchiopexy approach. We used a four-port technique, starting with laparoscopic dissection of the vas deferens and spermatic vessels as high as possible in order to get adequate length of these structures. The inguinal internal ring was opened, and the testis was dissected to finally bring it into the abdominal cavity. A transcrotal trocar was introduced all the way to the abdominal cavity to finally pull through the testis into the scrotum., Results: Laparoscopic orchiopexy was performed satisfactorily in all but 1 case in a mean time of 90 minutes. We did not experience any perioperative complications. In a mean follow-up of 25 months there has not been any recurrent cryptorchidism or atrophic testis., Discussion: Laparoscopy offers the advantage of achieving an extensive mobilization of spermatic vessels and a careful dissection of the vas deferens. The totally laparoscopic approach for a failed orchiopexy represents a feasible, safe, and successful procedure.