The Spigelian hernia is a rare variety of ventral hernia and has an incidence ranging from 0.1–2% of all abdominal wall hernias. It occurs through a well-defined defect in the Spiegel’s fascia adjacent to the semilunar line. It can be congenital or acquired. The acquired variety is predisposed by stretching and weakening of the abdominal wall by factors that increase the intraabdominal pressure. These hernias are most commonly located in the interparietal plane with no visible or palpable mass, and only 50% of cases could be diagnosed clinically before any surgical intervention. Radiological investigations like USG and CT scans confirm the clinical diagnosis or pick up the subclinical varieties that present with non-specific pain in the anterior abdominal wall. Surgery is the mainstay of management. These hernias are prone to early incarceration and strangulation and therefore should be operated at the earliest. It is stressed that a prosthetic mesh should be used for a better outcome as it decreases recurrence. Conventional open hernioplasty has been largely replaced by a laparoscopic approach such as TAPP, TEP, IPOM and robotic-assisted surgery. Early diagnosis and surgery prevent morbidity and dreaded complications.
Part of the book: Hernia Surgery
Gallbladder cancer (GBC) is associated with a sinister prognosis, a short survival time, and early metastasis to distant sites. Chronic inflammation of the gallbladder due to gallstone disease and biliary bacteria remain key factors in the pathogenesis of GBC. The association of chronic bacterial infections with the development of GBC has provided a new perspective on the causation of GBC. A strong link between chronic Salmonella infection and enterohepatic strains of Helicobacter species with GBC has been suggested. It is believed that many other enteric bacterial strains, predominantly the Enterobacteriaceae species, are associated with the development of GBC. However, the available literature mainly comprises observational studies and small meta-analyses necessitating the requirement of a higher level of evidence. This chapter discusses the role of the gut microbiome, dysbiosis and its association with carcinogenesis, and the organisms associated with the causation of GBC.
Part of the book: Immunology of the GI Tract
The concept of telehealth has revolutionized the healthcare delivery system. Based on this concept, telesurgery has emerged as a promising and feasible option, providing surgical care to remotely located patients. This has become possible by advancements in the robotic system combined with the cutting-edge technology of telecommunication. Since the ability to perform telepresence surgery was hypothesized, consistent development and research in this novel area have led to the beginning of telesurgical care, which can fulfill the demand for surgical care in remote locations. In addition to the benefits of robotic-assisted minimally invasive surgery, telesurgery eliminates geographical barriers, which helps patients have better access to quality surgical care. It may reduce the overall financial burden by eliminating the travel expense of the patients, providing expertise through the telepresence of experienced surgeons, and reducing the operating room personnel. The telesurgical approach is also being utilized for telementoring, i.e., real-time guidance and technical assistance in surgical procedures by highly skilled surgeons. Despite the numerous technological improvements in telesurgery, its widespread implementation in clinical setting still lags, mandating the identification of the offending factors that limit its clinical translation.
Part of the book: Telehealth and Telemedicine
Enhanced recovery after surgery (ERAS) protocols are specialized perioperative care guidelines. The protocol was first published in 2005. Since then, it has been associated with improved perioperative outcomes. This multimodal peri-operative protocols standardize the perioperative care to minimize the surgical stress response and post-operative pain, reduce complications, improve post-operative outcomes, expedite recovery and decrease the length of hospital stay. It initially started with colorectal surgery, but now it is used in hepatobiliary, upper gastrointestinal system, urology, gynecology, vascular surgery, bariatric, and non-gastro intestinal specialties. Its role is well established in elective surgery. Now there are enough evidence suggesting its role in emergency surgeries as well. There are 24 elements of the ERAS bundle. However, only some critical elements of the ERAS bundle are feasible to be used in emergency surgery. Postoperative pain management is one of the significant elements in the ERAS bundle. Multimodal analgesia is the optimal modality for pain control. It facilitates early ambulation and rehabilitation. Current evidence recommends the ERAS protocol. However, each item within the protocol constantly changes over time, depending upon the evidence.
Part of the book: Topics in Postoperative Pain
Crohn’s disease (CD) is a chronic, recurrent, immune-mediated inflammatory bowel disease that demonstrates a spectrum of intestinal and extra-intestinal manifestations. The pathogenesis of CD is multifactorial and involves a complex interplay between environmental and microbiological factors in a genetically susceptible host. There is robust evidence suggesting the role of gut microbial dysbiosis in the development as well as exacerbation of CD by immune dysregulation and alteration in the immune microbiota crosstalk. Patients with CD show reduced commensal microbial diversity, along with increased numbers of pathogenic Enterobacteriaceae and Proteobacteriaceae. Faecalibacterium prausnitzii, an anti-inflammatory molecule-producing bacteria, is also seen in reduced numbers in patients with CD and is associated with an increased risk of recurrence. There has been a paradigm shift in the management of patients of CD, from controlling symptoms to controlling inflammation and promoting mucosal healing. Current treatment strategies aim to replace, remove, reset, or redesign the gut microbiota for the therapeutic benefits of patients with CD. These include microbial restoration therapies such as dietary modification, the use of pre-, pro-, and postbiotics, and fecal microbiota transfer (FMT). This chapter focuses on the role of gut microbiota in the pathophysiology of CD and the emerging concepts in microbial therapeutics.
Part of the book: Crohn’s Disease
Gallstone disease (GSD) refers to all the patients with symptoms due to gallstones (cholelithiasis). The presence of gallstones is a common problem seen in 10–15% of western population; with 1–4% of the population developing symptoms. The most common presentation of patients of GSD is biliary colic. There are several mechanism for cholelithiasis and all these processes are slow. Cholesterol stones are the most common variety of gallstones. Cholesterol stones cannot form if the gallbladder is completely emptied several times a day. Therefore, the total or partial extension of bile storage due to impaired gallbladder movement seems to be an important factor for cholelithiasis. Gallbladder dysmotility is an important risk factor for the development of GSD. Insufficient gallbladder motility may be associated with many risk factors for cholesterol gallstone formation, such as pregnant women, obese patients, and their rapid weight loss, diabetes mellitus, and patients receiving total parenteral nutrition. Transabdominal ultrasound is the mainstay in the evaluation of patients with GSD. The presence of gallbladder dysfunction can be studied using cholecystokinin (CCK)-stimulated cholescintigraphy to evaluate for gallbladder ejection fraction (GBEF); with values <40% after 30 mins of CCK infusion considered diagnostic. The definitive treatment of GSD is cholecystectomy.
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