Paraesophageal hernias have been historically associated with risk of substantial morbidity and mortality. We report a case of a 92 year old lady with acute gastric outlet obstruction due to a chronic paraesophageal hernia that was successfully treated by minimal invasive surgery. Anterior gastropexy was performed after the stomach was reduced. The hiatal opening was enlarged to reduce the risk of obstruction in the future. She was discharged well on the third day.
BACKGROUND: Identification and preservation of the recurrent laryngeal nerve (RLN) is of major concern in surgery of the thyroid gland. The purpose of this study was to review the surgical anatomy of the nerve and to describe its relationship to other important structures.
METHODS: A total of 325 patients were accrued in this prospective non-randomized study from January 1999 to December 2000. All patients who had total, subtotal and hemithyroidectomies were included in this study. Each side of the thyroid gland was considered as a separate unit in the analysis of the results.
RESULTS: Two hundred and seventy-six patients had thyroidectomies as their primary operation, while 49 patients had them as a reoperative procedure. There were 276 women and 46 men (6:1 female to male ratio) with a mean age of 43.1 years (range: 10-84 years). The total number of dissections was 502. The RLN was clearly identified in 491 (97.8%) dissections: single trunk in 323 dissections (65.8%), two extralaryngeal branches in 164 dissections (33.4%), and three extralaryngeal branches in three dissections (0.6%). One non-recurrent laryngeal nerve was encountered (0.2%) in the series. The proximity of the RLN to the inferior thyroid artery (ITA) was noted in 444 (90.4%) dissections: 372 (83.8%) nerves were described to be posterior and intertwined between the branches of the ITA, and in 72 (16.2%) RLNs, they were observed to be anterior to the ITA. The close association of RLN to an enlarged tubercle of Zuckerkandl was documented in 381 dissections (73.7%). A total of 231 RLNs (60.8%) was seen in the tracheoesophageal groove, 18 (4.9%) nerves were observed to be lateral to the trachea, and in 109 (28.3%), they were posterior in location. Of concern in 23 (6.0%) dissections the RLN was on the anterior surface of the thyroid gland, which is at highest risk of injury before curving down to pass behind the tubercle of Zuckerkandl. It appears that the anterior course of the RLN was seen more often in the reoperative procedures to the thyroid gland (20%).
CONCLUSIONS: Although various methods of localizing the RLN have been described, surgeons should be aware of the variations and have a thorough knowledge of normal anatomy in order to achieve a high standard of care. This will ensure the integrity and safety of the RLN in thyroid surgery. The anatomical variation may be minor in degree, but is of great importance as it may affect the outcome of the surgery and the patient's quality of life.
Intramural duodenal haematoma is a rare injury of the duodenum. Most reported cases are secondary to blunt trauma to the abdomen. Such injury following endoscopic intervention is even rarer, and there are no definite guidelines for its management. We report a case where endoscopic haemostasis of a bleeding duodenal ulcer resulted in a massive dissecting intramural duodenal haematoma with gastric outlet obstruction and obstructive jaundice.
Laparoscopic repair of ventral and incisional hernia has become increasingly popular as compared to open repair. The procedure has the advantages of minimal access surgery, reduction of post operative pain and the recurrence rate. A prospective study of laparoscopic incisional hernia repair was performed in our center from August 2002 to April 2004. Eighteen cases (n: 18) were performed during the study period. Fifteen cases (n: 15) had open hernia repair previously. Sixteen patients (n: 16) had successful repair of the hernia with the laparoscopic approach and two cases were converted to open repair. The mean hernia defect size was 156cm2. There was no intraoperative or immediate postoperative complication. The mean operating time was 100 +/- 34 minutes (75 - 180 minutes). The postoperative pain was graded as mild to moderate according to visual analogue score. The mean day of discharge after surgery was two days (1 - 3 days). During follow up, three patients (16.7%) developed seroma at the hernia sac which was resolved with conservative management after three weeks. One (5.6%) patient developed recurrence six months after surgery. In conclusion, laparoscopic repair of incisional hernia particularly recurrent hernia has been shown to be safe and effective in our centre. However, careful patient selection and acquiring the necessary advanced laparoscopic surgical skills coupled with the proper use of equipment are mandatory before embarking on this procedure.
Extragonadal teratomas and germ cell tumours are uncommon. Most teratomas of the head and neck present in the paediatric age group. Occurrence of such tumours in an adult is extremely rare and, to date, less than 40 cases have been reported in the literature. We report a case of a young man presenting with impending airway obstruction secondary to a malignant teratoma of the neck.