Vadim Meytes

Intra-abdominal insufflation as a diagnostic modality for penetrating anterior abdominal wall trauma in a busy urban center: a retrospective case-series

Background: The optimal algorithm for evaluating patients with anterior abdominal stab wounds (AASW) is not clear and has been a long standing controversy. Currently, the workup and management of penetrating anterior abdominal wall trauma may involve the decision to proceed immediately to surgery based on the presentation of the patient, or the work up may involve local wound exploration (LWE), focused abdominal sonography for trauma (FAST) exam, CT scan, or serial abdominal exams. Here we discuss an observational sign utilizing the Veress needle intra-abdominal insufflation test that can be used in conjunction with the current AASW algorithm, to rule in peritoneal violation. Methods: Eight patients admitted to our level 1 trauma center with penetrating AASW were evaluated using LWE, FAST, or CT scan followed by Veress needle insufflation and DL for suspected intra-abdominal injuries. These cases were retrospectively evaluated for the efficacy of Veress needle insufflation as an observational test for peritoneal violation. Results: Eight hemodynamically stable patients from December 2013 to June 2014 presented to our level one trauma center after sustaining penetrating AASW. All eight patients went to the operating room for Veress needle insufflation and DL. Upon intra-abdominal insufflation using a Veress needle to a target pressure of 15 mmHg, all patients with peritoneal violations [5] were found to have CO2 escape from their wounds. The remaining three patients with no violation to the peritoneum did not have any appreciable CO 2 escape. Conclusions: Utilizing our technique of intra-abdominal insufflation combined with monitoring for CO 2 escape, we were able to successfully identify all patients with peritoneal violation and rule out violation in those without peritoneal injuries. With further research, our technique can be used to safely, accurately and in a timely manner stratify patients for the need of further diagnostic and interventional procedures.

A previously undescribed hernia containing an acutely inflamed appendix—case report and review of management on hernias containing the vermiform appendix

Hernias involving the appendix are unusual and are often found during surgical exploration. The rarity of these hernias makes it difficult to discuss standard of treatment. When an acutely inflamed appendix is encountered within a hernia, appendectomy should be performed with primary repair of the hernia. This case documents the unique finding of an appendix herniating through a previously undescribed region in the abdominal wall found in a patient presenting with acute appendicitis.

Major abdominal surgery in a patient with a metallic heart valve—balancing risks of thromboembolic events and perioperative bleeding

Surgical patients with mechanical valves are challenging, as their need for anticoagulation to reduce thromboembolic events is weighed against the risk for postoperative hemorrhage. Timing and bridging method for anticoagulation presents a great challenge for the surgeon. There is no protocol and consensus to our knowledge of managing acute major abdominal surgery in patients with metallic valves. We share our experience and review the current literature on this topic.

Single-institutions experience with acute kidney injury in the brain injury population

Background: Treatment of traumatic brain injury (TBI) in the hospital-setting focuses on prevention of the secondary insult sustained from elevated intracranial pressures. Hypertonic saline (HTS) as well as other agents are employed as part of the medical management armamentarium. A retrospective chart review was performed to analyze if more aggressive resuscitation with HTS can be tolerated by assessing the rate of acute kidney injury (AKI) using the Acute Kidney Injury Network (AKIN) criteria. Methods: Retrospective review of prospectively collected data from January 2012 through December 2014 was performed on 157 patients. AKIN criteria were used to assess for AKI. Results: In total, 93.6% of patients did not meet any AKIN criteria. Conclusions: AKI is an uncommon adverse effect of HTS use. Aggressive resuscitation with HTS may be tolerated and shorten the time to treatment by reaching therapeutic sodium levels more expeditiously.

Splenic abscess following laparoscopic cholecystectomy: a case report of a rare disease and a review of its management

Splenic abscess is a rare disease that has several predisposing factors. Case reports have documented post-surgical development of splenic abscesses, most commonly after laparoscopic sleeve gastrectomy. We present the case of a 69-year-old female with gallstone pancreatitis who underwent an uncomplicated laparoscopic cholecystectomy. The hospital course was complicated by persistent postoperative leukocytosis with a CT scan demonstrating a moderate sized splenic abscess. Interventional radiology was consulted for percutaneous drainage, and the patient was subsequently discharged home in stable condition. Splenic abscess is an important entity to remember as it is associated with significant mortality. Prompt treatment is vital for improving patient survival. Image guided percutaneous interventions have been increasing used and carry numerous benefits compared to surgical approaches. However, there is a paucity of data comparing the efficacy of percutaneous and surgical therapies. Percutaneous interventions can be successfully performed when the abscess is unilocular/bilocular, has a discrete wall, has no internal septations, or has thin liquid content. Further investigation through multicenter, prospective, randomized clinical trials are needed to analyze treatment options.

A unique surgical emergency: ileosigmoid knotting

Ileosigmoid knot (ISK) is a rare cause of bowel obstruction that leads to gangrenous bowel necrosis. In this condition, the ileum and sigmoid colon wrap around each other, causing a knot and strangulation of both structures. ISK is extremely rare in North America; most cases are reported in Asia and Africa. Furthermore, ISK typically presents in adults in their fourth decade or older. Here we present the rare case of an ISK in a 14-year-old male.

Myxedema pseudovolvulus: case series and review of the literature

Severe hypothyroid presenting with colonic dilation is a phenomenon known as myxedema pseudo-volvulus. We present two cases of middle-aged males who presented to our institution with sigmoid volvulus and hypothyroidism. We treated one with laparotomy and sigmoid resection and the other was treated conservatively with thyroid hormone replacement and resolution of his symptoms. Here we review the literature and explore treatment options for this rare presentation.

Gastric bypass is safe and effective for the super-super-obese patient

Background: Obesity in the United States is on the rise with a growing percentage of patients being diagnosed as super-super-obese (SSO) defined as patients with a body mass index (BMI) ≥60 kg/m ² . This patient population is at high risk of mortality due to associated comor-bidities. In patients with BMI ≤49 kg/m ² , the Roux en-Y gastric bypass (RYGB) is considered the ‘gold standard’ surgical treatment for BMI reduction. However, there are limited studies to extrapolate that into SSO patients and some surgeons advocate for a staged approach. The goal of this study is to analyze the safety and efficacy of RYGB surgery in the SSO population. Methods: Between September 2004 to April 2015, 78 SSO patients underwent RYGB surgery at NYU Lutheran Medical Center. A retrospective study was performed to analyze re-duction of preoperative comorbidities, postoperative outcomes and complications, total percentage of excess weight loss (%EWL) and patient follow up. Results: Thirty six patients were males and 42 were females with a mean age of 37±10. The mean BMI was 65±4.8 kg/m ² and 12 (15.3%) had a BMI ≥70 kg/m ² . The average OR time was 123±50 minutes, estimated blood loss (EBL) was 10±7.9 mL, and the average length of stay was 75±38 hours. None of the patients were converted to open surgery and 66 (83.5%) had no postoperative complications. For patients with complications, all were Clavien-Dindo grade 1–2 and did not require any invasive interventions. Of the 46 patients who followed up within 6 months, 45 (98.7%) had a decrease in %EWL with an average of 26%±14%. Thirty six (78.3%) of these follow up patients had preoperative comorbidities and 15 (41.7%) had significant improvement or even complete resolution post-surgery. Conclusions: In our experience, the RYGB is a safe and effective single stage surgical treatment for SSO patients. These patients start to achieve a significant BMI reduction as well as improvement or resolution of their comorbidities without significantly high complication rate however, longer follow up is needed. Follow up in general within this patient population is a nationwide problem and is something that needs to be more consistent in order to better track the postoperative course of the SSO patient.

Hybrid fascial closure with laparoscopic mesh placement for ventral hernias: a single surgeon experience

Background: Incisional hernia and primary ventral hernia are among the most common surgical problems that general surgeons face annually in the United States (U.S.). Over 2 million laparotomies are performed in the US and the subsequent incisional hernia rate is 3–20%. At our institution, over the last several years, one surgeon has been performing a unique repair of intermediate-sized hernias by combining open and laparoscopic approaches. We hypothesized that, through a minimal incision, lysis of adhesions and primary repair can be performed, which can then be buttressed with a laparoscopically placed mesh that provides a generous underlay reinforcement that cannot be achieved in open repair. Furthermore, this technique provides the additional benefit of apposition of the rectus muscles and decreased seroma formation compared to laparoscopic hernia repair. Methods: Patients that underwent ventral hernia repair with laparoscopic assistance at NYU Lutheran Medical Center between October of 2012 and January 2015 form this study population. Each patient’s demographic, intra-operative, and postoperative data were collected and analyzed. Patient demographics included gender, age, BMI, prior abdominal surgery, co morbidities, and anticoagulation use. Intra-operative data included defect size, mesh size, and operative time. Postoperative data included complications, length of hospitalization, re-currences, seroma formation, surgical site infections (SSI), and mesh explantation. The surgical technique was as follows: a minimal incision was used over the defect which was only big enough to allow dissection down to the hernia borders. The hernia was reduced and lysis of adhesions of surrounding tissue performed. The hernia was sized and a mesh chosen to provide at least 3 to 5 cm of underlay around the defect. A series of one to four stay sutures were placed in the midline of the mesh and the mesh was placed intra-corporeally. The defect was closed primarily using the Smead-Jones technique (in 17 of 19 patients) to provide a tension-free double layer closure. The abdomen was in-sufflated, the mesh visualized, fixed to the midline via the stay sutures, and tacked circumferentially. The subcutaneous tissue and the skin were closed with absorbable suture. Results: A total of 19 patients (12 females, 7 males) underwent the hybrid hernia repair from October 2012 through January 2015. Only 1 (5%) was admitted postoperatively due to severe underlying co morbidities. The average size of the hernia defect was 5.94 cm 2 (2.5–15 cm 2 ) with an average mesh size of 16×16 cm 2 (9×9–25×20 cm 2 ) being used. Average operative time was 153 minutes with a range of 69–281 minutes. One (5%) had an early (within the first three months post-surgery) recurrence of the hernia. One patient (5%) had an early superficial SSI noticed during the 1 week follow-up appointment and was treated with oral antibiotics. None of the patients required re-hospitalization. None of the patients developed any seroma or any deep tissue infections requiring mesh explantation. Fourteen (74%) of the 19 patients were reached via telephone for further follow-up. All 14 patients were satisfied with the results of their surgery with only 1 complaint of pre-existing gastritis unrelated to the surgery. All of the patients that were employed prior to the surgery were able to return to work post-operatively. None of the patients reported any residual incisional or back pain. Conclusions: Hybrid ventral hernia repair has the physiological benefit of fascial continuity by re-approximating the hernia edges. This technique also maximizes the benefit of laparoscopic repair while mini-mizing associated complications. Patients had no severe wound complications. This surgical technique resulted in a low recurrence rate, and minimal pain after the procedure, making the hybrid technique a safe alternative method when repairing intermediate sized ventral hernias.

Co-existent appendicitis and cholecystitis

Acute appendicitis and acute cholecystitis are common entities, but rarely do they present concurrently. We present the case of a 40-year-old male who arrived at the emergency department with an 18-hour history of non-bilious, non-bloody vomiting, and abdominal pain located to the right upper and right lower quadrants. The patient was taken for a synchronous laparoscopic appendectomy and cholecystectomy. We used a total of five laparoscopic ports to successfully complete both procedures. When faced with a rare presentation of seemingly two separate acute processes, a combined laparoscopic approach is both safe and effective. The use of five laparoscopic ports provides optimal exposure for both procedures.