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Extended spinal anaesthesia using a spinal micro-catheter was used as a primary method of anaesthesia for elective colorectal cancer surgery in 68 high risk patients over a 14-year period in our institution. The technique was also useful in eight elective and 13 emergency abdominal surgeries. All patients suffered from severe chronic obstructive airway disease requiring multiple inhalers and drugs (ASA III). Thirty nine of these patients also suffered from angina, myocardial infarction, diabetes and other systemic diseases (ASA IV). Surgery included right hemicolectomy, left hemicolectomy, total colectomy, sigmoid colectomy, Hartman's resection, anterior resection of rectum, abdominoperineal resection, cholecystectomy (open and laparoscopic) and obstructed inguinal hernia requiring laparotomy. Spinal anaesthesia was performed under strict aseptic conditions with a 22 gauge spinal needle with a mixture consisting of 2.75ml of 0.5% heavy bupivacaine and 0.25ml of fentanyl (25microg). This was followed by placement of a spinal micro-catheter and the duration of anaesthesia was extended by intermittent injection of 0.5% isobaric bupivacaine. Brief hypotension occurred in 12.4% of patients during the establishment of anaesthetic block height to T6-7 and was duly treated with intravenous administration of fluid and ephedrine hydrochloride. Good anaesthesia resulted in all patients except for brief discomfort in some patients during hemicolectomy surgery possibly due to the dissection and traction on the peritoneum causing irritation to the diaphragm. The use of sedation was avoided. General anaesthesia was administered in one patient and this patient required postoperative ventilation and cardiovascular support in the Intensive Care Unit. The spinal micro-catheter was removed at the end of surgery. Postoperative pain relief was obtained by administering intravenous morphine through a patient controlled analgesia machine in the critical care ward area (High Dependency Unit). There was a low incidence of minor postoperative side effects such as nausea (14.6%), vomiting (7.9%), minor post dural puncture headache (5.6%) and pruritus (5.6%). We conclude that spinal anaesthesia with a micro-catheter may be used as a primary method of anaesthesia for colorectal cancer surgery and other major abdominal surgery in high-risk patients for whom general anaesthesia would be associated with higher morbidity and mortality.
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PMID:Spinal anaesthesia with a micro-catheter in high-risk patients undergoing colorectal cancer and other major abdominal surgery. 1803 40

We report an extremely rare case of an intramesosigmoid hernia with small bowel herniation in a defect on the right (medial) leaf of the mesosigmoid. A 46-year-old man was admitted to the hospital complaining of lower abdominal pain, nausea, and vomiting for 6 days. He had undergone an operation for a right inguinal hernia and an appendectomy during childhood. An abdominal X-ray film obtained at admission showed small bowel gas with niveau formation which was diagnosed as small-bowel obstruction. A decompression tube was immediately inserted, and the symptoms subsided. Enterography revealed two strictures separated by approximately 10 cm. However, the contrast medium flowed smoothly through the anal side of the strictures. After the decompression tube was removed, small-bowel obstruction recurred, and laparotomy was performed on the 18th day after admission. During the operation, small bowel herniation with a 4 x 3-cm defect was found on the right leaf of the mesosigmoid, and intramesosigmoid hernia was finally determined to be the cause of the small-bowel obstruction. The resection of the incarcerated part was necessary because a large amount of scar tissue was present on the surface. The postoperative course was uneventful, and no recurrence was observed after discharge. A review of this case indicated that the diagnosis might have been successfully obtained with enterography. Although we did not choose laparoscopic surgery, this surgical modality may also be an appropriate treatment for this disease.
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PMID:A case of an intramesosigmoid hernia. 1930 5

Inguinal hernia repair is one of the most common procedures in general surgery. All anesthetic methods can be used in inguinal hernia repairs. Local anesthesia for groin hernia repair had been introduced at the very beginning of the last century, and gained popularity following the success reports from the Shouldice Hospital, and the Lichtenstein Hernia Institute. Today, local anesthesia is routinely used in specialized hernia clinics, whereas its use is still not a common practice in general hospitals, in spite of its proven advantages and recommendations by current hernia repair guidelines. In this review, the technical options for local anaesthesia in groin hernia repairs, commonly used local anaesthetics and their doses, potential complications related to the technique are evaluated. A comparison of local, general and regional anesthesia methods is also presented. Local anaesthesia technique has a short learning curve requiring simple training. It is easy to learn and apply, and its use is in open anterior repairs a nice way for health care economics. Local anesthesia has been shown to have certain advantages over general and regional anesthesia in inguinal hernia repairs. It is more economic and requires a shorter time in the operating room and shorter stay in the institution. It causes less postoperative pain, requires less analgesic consumption; avoids nausea, vomiting, and urinary retention. Patients can mobilize and take oral liquids and solid foods much earlier. Most importantly, local anesthesia is the most suitable type of anesthesia in elder, fragile patients and patients with ASA II-IV scores.
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PMID:Current options in local anesthesia for groin hernia repairs. 2236 15

Amyand's hernia is a rare form of inguinal hernia, where the appendix is included in the hernia sac. We present the emergency case of an 81-year-old patient with right inguinal pseudo-tumor, accompanied by marked local pain, nausea, low grade fever and bowel disorders. Emergency surgery is indicated due to a suspected incarcerated inguinal hernia with imminent strangulation. The intraoperatory findings reveal the presence of a periappendicular abscess as the cause of gangrenous appendicitis, perforated in the right indirect inguinal hernia sac. The practice includes the evacuation of the abscess, appendectomy and surgical cure of the inguinal hernia--Bassini's procedure, Douglas drainage and subcutaneous drainage. The postoperative outcome was favorable, the patient being discharged on the fifth postoperative day. Postoperative checks performed at 3 and 9 months have not revealed the presence of a hernia recurrence.
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PMID:Perforated appendix with periappendicular abscess in a inguinal hernia sac--Amyand's hernia. 2302 21

Although inguinal herniorrhaphy is low risk, patients still return to the urgent care or ED. We performed a retrospective study on 19,296 inguinal hernia operations across 14 Southern California Kaiser Permanente medical centers over five years. Unplanned returns within the first postoperative week were evaluated focusing on four potentially avoidable diagnoses (AD): pain, constipation, urinary retention, and nausea/vomiting. Overall, 1370 (7%) patients returned to the urgent care/emergency department, of which 537 (39%) had an AD. There was no difference in total returns (7.1 vs 7.4%, P = 0.33) or AD returns [2.8 vs 2.6%, (P = 0.44)] for males vs females. Of the 537 total AD returns, there were 205 (38%) patients with pain, 191 (36%) with urinary retention, 112 (21%) with constipation, and 29 (5%) with nausea/vomiting. Most AD returns (78%) occurred within the first three postoperative days. Pain was greater in open operations [44 vs 26%, (P < 0.05)], and urinary retention was greater in the laparoscopic group [27 vs 55%, (P < 0.05)]. The overall rate of return was higher for laparoscopic compared with open unilateral operations [8 vs 6%, (P < 0.05)], but similar between approaches for bilateral operations [11 vs 10%, (P = 0.32)].
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PMID:An Analysis of Early Postoperative Returns after Inguinal Hernia Surgery. 3074 80

We describe a case of attachment of an appendix vermiformis following an inguinal hernia plug repair according to Rutkow and Robbins. A 62-year-old man presented at our outpatient clinic with a progressive sensation of tightness in the right groin area, painful urge of miction and long-lasting nausea with abdominal discomfort. During an open groin exploration, the appendix was found attached to an intraperitoneally located plug. The appendix and plug were removed with an uneventful recovery. During follow-up, the patient was free of groin pain and miction had normalised. Surprisingly, his long-lasting nausea and abdominal discomfort had disappeared as well.
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PMID:Symptomatic attachment of appendix vermiformis following a plug inguinal hernia repair. 3153 47

Appendix epiploica (AE) in an incarcerated inguinal hernia sac is very rare. We herein report the case of a 57-year-old man admitted to the emergency department with complaints of nausea, swelling, and pain in the left inguinal area. He was diagnosed with left incarcerated inguinal hernia and treated laparoscopically with transabdominal preperitoneal (TAPP) mesh hernioplasty. During the operation, AE, lodged in the direct hernia sac, was seen to originate from the sigmoid colon. The narrow internal inguinal ring was incised at the 2 o'clock position using a monopolar hook, and the hypertrophic AE was reduced to the abdomen and resected. The patient was discharged uneventfully on the second postoperative day.
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PMID:Incarcerated Appendix Epiploica in Inguinal Hernia Sac: Treatment with Laparoscopic TAPP Approach-Report of a Rare Case. 3214 98

Amyand's hernia (AH) is a rare condition in which the vermiform appendix is herniated into the inguinal sac regardless of whether the appendix appears normal or is inflamed. Most cases of AH are diagnosed intraoperatively at the time of inguinal hernia repair as its clinical diagnosis is difficult, and the role of computed tomography (CT) and other diagnostic imaging has not been described well in the literature. We report the case of a 79-year-old female who presented to the emergency department with nonspecific symptoms of nausea, vomiting, and constipation. Her symptoms were nonspecific, and physical examination suggested that she did not have a strangulated hernia or appendicitis, but the emergency CT scan of the abdomen showed a perforated appendix trapped in the sac of a right-sided inguinal hernia. Complicated appendicitis in an AH is a surgical emergency, and an accurate diagnosis is necessary for proper triage of patients and appropriate management. CT plays a significant role in revealing an unsuspected diagnosis of AH. Radiologists must be aware of this rare presentation of the appendix in an inguinal hernia sac and be familiar with AH subtypes.
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PMID:Identification of perforated appendicitis within a right inguinal hernia sac (Amyand's hernia) by emergency abdominal CT scan: A case report. 3288 5

Background. Microsurgery has quickly become the "gold standard" approach for vascular surgical steps during neurosurgery. However, despite its advantages, the microscope has not been widely adopted in general surgery. A new 3D-surgical exoscope, the ORBEYETM, has been developed and introduced to some surgical specialties. Herein, we present our preliminary experience with the ORBEYETM exoscope as applied to a number of general surgical procedures. Method. Throughout February 2020, 7 patients had undergone varying surgical procedures at our institute utilizing the ORBEYETM in some of specific procedural steps where the surgeons felt that the surgery would benefit from more enhanced magnification. Upon completion, all the surgeons who had taken part in the procedure were asked if they had experienced any nausea, dizziness, or eyestrain during its use. Results. The ORBEYETM was employed in a number of surgical steps for the following procedures: throughout an inguinal hernia repair, during a duodeno-cephalo-pancreatectomy, for a subtotal gastrectomy, during para-aortic mass dissection, and during Ivor Lewis procedure. None of the surgeons involved in the procedures reported experiencing any nausea, dizziness nor eyestrain, nor any other physical discomforts. Conclusion. To the best of our knowledge, ours is the very first report on the employment of the ORBEYE exoscope during general surgery. Our experience assures us that this highly ergonomic technology with its high-resolution 4K 3D optical system allows the surgeon to perform safe and precise surgery in several dedicated steps in which adequate magnification is required with no adverse effects to the surgeon or the surgical procedure itself.
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PMID:Use of the ORBEYETM Exoscope in General Surgery: The Advent of Video-Assisted Open Surgery. 3305 34


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