I. Robertson

Incisional hernia appendicitis: A report of two unique cases and literature review

INTRODUCTION Acute appendicitis is a common surgical emergency. The presence of an inflamed appendix in an incisional hernia is rare. Incisional hernias complicate both open and laparoscopic surgery. PRESENTATION OF CASE We describe two unique cases of acute appendicitis within incisional hernias following an open cholecystectomy and a diagnostic laparoscopy. Acute appendicitis was diagnosed intraoperatively and a formal appendicectomy was performed with subsequent primary repair of the hernial defect in each case. DISCUSSION The method chosen for primary repair of an incisional hernia containing an acutely inflamed appendix depends on a number of factors including size of hernial defect and degree of contamination. Closure of 5mm port sites is not routine in current surgical practice. Herniation of intra-abdominal contents through such defects can occur rarely. The repair of an incisional hernia using mesh in a contaminated surgical field is controversial. There may be advantages in the use of biological meshes. CONCLUSION Surgical awareness of potential complications relating to the management of incisional hernia appendicitis is of primary importance in determining intraoperative strategy.

Non-operative management of diverticular perforation in a patient with suspected Ehlers–Danlos syndrome

INTRODUCTION No consensus exists regarding definitive management of colonic perforation in Ehlers-Danlos syndrome (EDS), with various authors advocating different operative techniques. Spontaneous colonic perforation is a recognised complication of vascular-type EDS (type IV), with many reported cases in the literature. No such cases have been reported concerning classical-type EDS (type I/II). PRESENTATION OF CASE A 55-year-old male with a family history of EDS presented with acute lower abdominal pain and signs of localised peritonitis. Following resuscitation, computerised tomography identified perforation of a sigmoid diverticulum with localised intraperitoneal air. Considering the potential complications associated with laparotomy in a patient with EDS, a trial of conservative management was undertaken including image-guided drainage of a mesenteric abscess. Intensive care monitoring, nutritional support and intravenous antibiotics also facilitated successful non-operative management. Following discharge, molecular studies confirmed COL5A1 mutation, and a diagnosis of classical Ehlers-Danlos syndrome was established. DISCUSSION This is the first reported case of successful conservative management of colonic diverticular perforation in a patient with classical Ehlers-Danlos syndrome. CONCLUSION EDS is highly significant in the surgical context, with the causative genetic factors serving to further complicate the course of surgical intervention. In the absence of consensus regarding best surgical management, due consideration should be given to non-operative management of benign colonic perforation.

Higher surgical training opportunities in the general hospital setting; getting the balance right.

BackgroundThe general hospital can play an important role in training of higher surgical trainees (HSTs) in Ireland and abroad. Training opportunities in such a setting have not been closely analysed to date.AimsThe aim of this study was to quantify operative exposure for HSTs over a 5-year period in a single institution.MethodsAnalysis of electronic training logbooks (over a 5-year period, 2007–2012) was performed for general surgery trainees on the higher surgical training programme in Ireland. The most commonly performed adult and paediatric procedures per trainee, per year were analysed.ResultsStandard general surgery operations such as herniae (average 58, range 32–86) and cholecystectomy (average 60, range 49–72) ranked highly in each logbook. The most frequently performed emergency operations were appendicectomy (average 45, range 33–53) and laparotomy for acute abdomen (average 48, range 10–79). Paediatric surgical experience included appendicectomy, circumcision, orchidopexy and hernia/hydrocoele repair. Overall, the procedure most commonly performed in the adult setting was endoscopy, with each trainee recording an average of 116 (range 98–132) oesophagogastroduodenoscopies and 284 (range 227–354) colonoscopies.ConclusionsGeneral hospitals continue to play a major role in the training of higher surgical trainees. Analysis of the electronic logbooks over a 5-year period reveals the high volume of procedures available to trainees in a non-specialist centre. Such training opportunities are invaluable in the context of changing work practices and limited resources.

Synchronous breast and colon cancer: factors determining treatment strategy.

A 67-year-old woman presented with synchronous breast and colonic tumours, in the absence of family history. Following multidisciplinary discussion, the patient was started on endocrine therapy for breast cancer. Initial surgical management consisted of right hemicolectomy together with segmental resection of a serosal deposit adherent to the distal ileum, for a moderately differentiated pT4NO caecal carcinoma. Three months later, right mastectomy and axillary clearance confirmed node positive invasive ductal carcinoma. The original treatment plan was to prioritise adjuvant chemotherapy for breast cancer postmastectomy. However, the subsequent CT finding of an enlarged, suspicious mesenteric lymph node mass on repeat staging raised concern regarding its origin. Image-guided biopsy revealed metastatic colonic adenocarcinoma and the patient was switched to a colon cancer chemotherapy regime. Following adjuvant chemotherapy for colonic carcinoma, an en-bloc surgical resection of the enlarging metastatic nodal mass was performed with clear resection margins. The patient is currently asymptomatic.

Retraction Note: Paediatric Ewing-like sarcoma arising from the cranium – a unique diagnostic challenge

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Robertson et al. Diagnostic Pathology (2016) 11:54 DOI 10.1186/s13000-016-0502-6