Although the risk of mesh infection following TEP hernia repair is small, it persists for more than 5 years and probably as long as the mesh remains in the body. Our report also raises the question as to whether there is a specific long-term risk of mesh infection following TEP hernia repair in patients with underlying inflammatory bowel disease and/or chronic heavy smoking. This needs to be studied prospectively.

Performing surgery at an incorrect site has devastating outcomes. The National Patient Safety agency and Royal College of Surgeons England have provided recommendations to promote correct site surgery with emphasis on surgical markings. There is little published data on surgical site marking practices amongst surgeons. A prospective audit on surgical site marking was performed on 500 surgical procedures: 204 inguinal hernias, 35 umbilical hernias, 48 varicose veins, 40 toenail removals, 123 excisions of skin lesions, 10 femoral artery procedures and 40 breast procedures. The results showed that 59% of markings were visible in theatre post sterile draping, 40.4% markings were not visible, and 0.6% (3/500) were not marked. Recommendations suggest the use of an arrow with an indelible marker pen. Our results show the use of an arrow in 64% of patients and this was the most common form of mark used. An appropriate marker pen was used on 88% of patients. There is no evident published data to compare our practice to that of other surgical units, however, to improve correct site surgery markings should be visible, recognisable and understood by all specialties and grades. A universal marking system to improve correct site surgery may be beneficial.

A 41-year-old man was transferred by ambulance to the emergency department following a road traffic accident. The patient left his home to walk his dog when his wife heard a crash from inside the house and arrived outside to find him 2 m from the roadside and semi-conscious.On arrival at hospital, the patient was talking, had a GCS of 14 (E3, M6, V5) and was haemodynamically stable. On examination, he had severe generalised abdominal tenderness. Other injuries of note included open left tibial and fibula fractures and a left hip abrasion.The patient was stabilised and sent for a computed tomography (CT) scan of his head, neck, chest, abdomen, and pelvis. The CT showed a right renal haematoma with some extravasation of contrast at the level of the pelviureteric junction (Fig. 1). Bone views also showed a fracture through L3 transverse process on the right side (Fig. 2). Other injuries of note on CT scan were right superior and inferior pubic rami fractures and pulmonary contusions.Initially, he maintained good urine output with no haematuria and his renal function was normal. In accordance with local protocol, his open lower limb fractures were fixed on the day of injury. An ultrasound scan the following day, demonstrated no evidence of a perirenal collection/urinoma; therefore, a conservative approach for his urological injury as initially adopted. A follow-up CT scan was performed 2 days' post-injury due to worsening right-sided abdominal pain, tachycardia and hypertension. This showed a larger right pelvicalyceal system leak and likely urinoma (Fig. 3).Retrograde ureteric studies were performed on day 3 post-injury; however, attempts to pass the guide wire into Complete transection of the pelvi-ureteric junction in an adult DT WALKER, F MASSOUH, NJ BARBER Departments of General Surgery and Urology, Frimley Park Hospital, Frimley, UK ABSTRACTWe present a unique case report of a 41-year-old man involved in a hit-and-run accident. The patient suffered a complete disruption of the pelvi-ureteric junction along with a fracture of the L3 transverse process. Occasionally seen in children, we believe this to be the first reported adult case. The report details the presentation and symptoms, with subsequent radiology. This case also demonstrates how using an effective multidisciplinary team approach and the ATLS principles, uncommon injuries can be identified and managed successfully. We revisit the classification of ureteric trauma and the accepted best surgical management.