Giant inguinoscrotal hernia is typically defined as hernia extending below the midpoint of the inner thigh, in the standing position. These hernias can be a demanding surgical problem as replacing bowel contents into the abdomen that can cause a life-threatening increase in intra-abdominal pressures. Various techniques such as preoperative progressive pneumoperitoneum (PPP), debulking of abdominal contents with visceral resections with or without omentectomy and phrenectomy have been suggested. We report the case of a 65-year-old patient with giant bilateral inguinal hernia. We applied a novel two-stage combined approach consisting of PPP with simultaneous single shot injection of botulinum toxin Type A into the anterior abdominal wall, and a second stage laparotomy with hernia repair (Stoppa technique). This technique makes possible the successful treatment of giant inguinal hernias without the need for visceral resection. To our knowledge, this is the first presented case of this combined treatment modality.

Postoperative nutrition via a jejunal tube after major abdominal surgery is usually well tolerated. However, some patients develop nonocclusive mesenteric ischemia (NOMI). This morbid complication has a grave prognosis with a mortality rate of 41% to 100%. Early symptoms are nonspecific, and no treatment guideline is available. We reviewed cases of NOMI at our institution and cases described in the literature to identify factors that impact the clinical course. Among five patients, three had no necrosis and one had segmental necrosis and perforation. These patients recovered with limited resection and decompression of the bowel and abdominal compartment. In one patient with extended bowel necrosis at the time of re-laparotomy, NOMI progressed and the patient died of multiple organ failure. The extent of small bowel necrosis at the time of re-laparotomy is a relevant prognostic factor. Therefore, early diagnosis and treatment of NOMI can improve the prognosis. Clinical symptoms of abdominal distension, cramps and high reflux plus paraclinical signs of leukocytosis, hypotension and computed tomography findings of a distended small bowel with pneumatosis intestinalis and portal venous gas can help to establish the diagnosis. We herein introduce an algorithm for the diagnosis and management of NOMI associated with jejunal tube feeding.

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Background The arc of Buhler (AOB), a rare anastomosis connecting the superior mesenteric artery (SMA) to the celiac trunk (CA), was found in a patient suffering from an adenocarcinoma of the pancreatic head. Case presentation Oncologic pancreaticoduodenectomy required resection of the AOB to achieve complete tumor removal. After an uneventful clinical course in the first days, the patient suffered a severe complication. Due to ischemia of the stomach and spleen, complete resection of the stomach, spleen, and remaining pancreas had to be performed. Conclusions The hemodynamic impact of this arterial variant has been discussed mainly for liver perfusion, which remained intact at all times in our case. Because of the serious obstacles mentioned above, we strongly recommend that the presence of AOB be considered in preoperative diagnosis and preservation when possible. If the AOB is likely to be ligated, stenosis of the SMA or CA should be excluded and resolved before surgery.