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In the October 2015 issue of BJS, two randomized clinical trials, a systematic review and a review on the subject of bleeding in surgery are published. Click on the podcast logo to the right.
The picture shows an interstitial hernia, causing small bowel obstruction. A 76-year-old woman with a history of previous total abdominal hysterectomy was admitted with symptoms and signs of small bowel obstruction. An emergency laparotomy was carried out and a large left-sided interstitial hernia containing distal jejunum was found. The small bowel was bruised but viable with an obvious transition point. A primary suture repair of the interstitial hernia was performed with complete obliteration of the interstitial space.
An interstitial hernia is a rare type of hernia that passes between the layers of the abdominal wall. Classically, as shown here, an interstitial hernia passes through a defect in the transversus abdominus and internal oblique muscles, but not through the intact aponeurosis of the external oblique. These hernias may not present with an obvious lump and may go unrecognized. There should be a high index of suspicion in a patient with previous abdominal surgery presenting with symptoms and signs of small bowel obstruction. Meticulous closure of the abdominal wall at the time ofinitial surgery remains the best way of avoiding interstitial hernia formation.
This woman presented with a 1-month history of abdominal swelling and discomfort. She was otherwise healthy with regular menstruation. CT revealed a large (32 × 24 × 13 cm) unilocular cystic intra-abdominal mass. Differentials included either a mesenteric, ovarian or peritoneal inclusion cyst. At laparoscopy, the cyst was arising from the right ovary. The cyst was decompressed laparoscopically and resected along with the right ovary. The specimen was retrieved via a Pfannenstiel incision.
This 50-year-old woman presented wtih a flare-up of her ulcerative colitis and a painful pretibial skin lesion. Pyoderma gangrenosum (PG) was diagnosed. PG is an uncommon inflammatory and ulcerative skin condition that typically affects young and middle-aged adults, with a female preponderance. It presents with an inflammatory pustule which rapidly progresses to a painful skin ulcer that has a characteristic violacious border. More than half of patients who develop PG have associated systemic disease, notably inflammatory bowel disease. However, unlike erythema nodosum, which is more commonly seen in inflammatory bowel disease than PG, ulcer severity is less likely to be linked directly to disease activity.
Diagnosis is based on history and clinical examination. Biopsy typically shows dermal neutrophilia, accompanied by a mixed inflammatory cell infiltrate with or without lymphocytic vasculitis. Treatment is of the underlying systemic disease. PG lesions usually regress rapidly following treatment with systemic corticosteroids.
A 72-year-old woman presented with progressive shortness of breath and coughing while exercising. CT showed a right-sided extrapulmonary multinodal cystic tumour. Considering her progressive complaints and possible malignancy, a right-sided thoracotomy was performed. An 11-cmmass proved to be a low-grade B-cell thymoma. Over 50 per cent of all anterior mediastinal tumours are thymomas. Myasthenia gravis was absent in this patient. Surgical removal is first-choice therapy.
Discussion of the July 2015 issue (102:8), which carries a selection of articles on aortic aneurysms. Click on the podcast logo.
A 74-year-old woman presented to the emergency department with a painful ulcerated necrotic lesion on the right side of her tongue. She had a 2-week history of new-onset headache, blurred vision and jaw claudication. A temporal artery biopsy confirmed the initial diagnosis of giant cell arteritis. On physical examination both superficial temporal arteries had palpable pulses with no tenderness or enlargement. Her neurological, opthalmic and vascular examinations were normal, as was CT of the neck and head. Tongue necrosis is an atypical presentation of temporal arteritis. This rare complication is commonly reversible with prompt steroid therapy.
Listen to Lord Darzi share his opinion of this BJS Special Issue and where he believes surgical innovation is crucial in the global arena. Click here to watch the video.
An otherwise fit 34-year-old man presented with acute appendicitis. He was taken to theatre for laparoscopic appendicectomy. A 23-cm mildly inflamed and faecolith-laden appendix was found in the retrocaecal position with some periappendiceal inflammation. The procedure had to be converted to open operation owing to technical difficulty resulting from the length of appendix. The patient made an uneventful postoperative recovery. The Guinness Book of Records informs that the longest appendix recorded was removed at autopsy from a 72-yearold Croatian man: 26 cm. http://www.guinnessworldrecords.com/world-records/1000/largest-appendix-removed
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