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Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is recognised to occur after cardiac and traditional open abdominal surgery. However, SIADH after laparoscopic surgery is not well documented in the literature. We report a case of SIADH after laparoscopic (totally extraperitoneal) inguinal hernia repair in an elderly man. KEywORdS SIADH -Laparoscopy -Inguinal hernia repairAccepted 1 January 2012; published online 30 April 2012CORRESPONdENCE TO Muneer Ahmed, Department of General Surgery, Princess Royal Hospital, Apley Castle, Telford, Shropshire TF1 6TF, UK E: muneer_ahmed@hotmail.co.uk Case historyA 74-year-old man was seen routinely in the outpatient clinic with a long standing reducible swelling in his right groin with no obstructive symptoms. He had a past medical history of hypertension, transient ischaemic attacks, benign prostatic hypertrophy and dyspepsia. His medication included bendroflumethiazide 2.5mg once daily (od), simvastatin 40mg od, aspirin 75mg od, tamsulosin 400mcg od and omeprazole 40mg od. He was an ex-smoker with moderate alcohol consumption who was independent and lived with his wife. Clinical examination demonstrated a reducible right indirect inguinal hernia and he was booked for an elective laparoscopic totally extraperitoneal (TEP) right inguinal hernia repair as a day case patient.The procedure was straightforward with an extraperitoneal pneumoperitoneum established, a right direct inguinal hernia identified and reduced, a 12cm x 15cm Ultrapro ® mesh (Ethicon, Somerville, NJ, US) deployed and meticulous haemostasis applied. The patient was transferred to the recovery room for a brief period before being transferred back to the day surgery ward prior to discharge.Four hours after returning from recovery, the on-call team was called urgently by nursing staff as the patient had started to become extremely agitated, confused, had vomited twice and then began to experience tonic-clonic seizures. On arrival, he had a score of 3/15 on the Glasgow coma scale (GCS), a blood pressure (BP) of 201/99mmHg, a heart rate (HR) of 92bpm and oxygen saturation of 99% on a facemask. Arterial blood gas analysis conducted at the time showed: pH 7.32, pO 2 31.1kPa, pCO 2 3.4kPa, HCO 3 13.4mmol/l, base excess -12mmol/l, serum sodium 118mmol/l and potassium 3.2mmol/l. This demonstrated a profound metabolic acidosis with hyponatraemia. Intracranial pathology was excluded by computed tomography (CT) of the head, which was normal. Repeat blood sampling demonstrated serum sodium of 116mmol/l. Urea and creatinine measurements were within normal limits.The patient was transferred to the intensive care unit for invasive monitoring and slow correction of his sodium level. Measured serum osmolality was 241mOsm/kg and urinary sodium concentration was 89mmol/l with a urine osmolality of 576mOsm/kg. Pre-operatively, his serum sodium had been 137mmol/l. His GCS score rapidly returned to normal.A chest x-ray demonstrated some haziness in the right hilar region and subsequent CT of the thorax was ...

Background The age group of patients presenting acutely with biliary pathology is rising and gallstone disease can no longer be said to be a disease of the young. The World Health Organisation classifies those aged 65 and over as elderly. Early cholecystectomy is accepted as a safe and effective method of managing acute biliary pathology, reducing further admissions, and reducing in-hospital stays. Our unit does not use age as barrier but uses performance status and co-morbidity to identify potential candidates for cholecystectomy. Method Patients over the age of 65 who underwent acute cholecystectomy (AC) via the emergency cholecystectomy lists, were audited from 31st December 2019 to 31st June 2021. Patient demographics, co-morbidities and surgical factors were recorded. The primary outcome measures were in-hospital stay and re-admission, secondary outcomes were complications and perioperative mortality. Results 41 elderly patients underwent AC during the audit period, (Female 56%, Male 44%). 30 patients had acute cholecystitis (73%). The median inpatient stay following surgery was 2 days (range 2–5 days) and the median admission to surgery time was 6 days (range 5–12 days). Three patients had a subtotal cholecystectomy. There were 3 complications from surgery which were all between a Clavien-Dindo score of 2 and 3. There were 3 immediate post-operative readmissions, with one 30-day mortality from ERCP pancreatitis and not from the operation. Conclusion Early cholecystectomy appears to be a safe and effective treatment for this group of patients and based on this evidence we should continue to offer this treatment to patients irrespective of age.

Background Acute or hot cholecystectomy (AC) has been established as a safe and efficacious modality of managing acute biliary pathology. However, it has been performed with caution in the elderly (defined by the world health organisation as patients over the age of 65). The NICE guidance in this area does not preclude this practise on elderly patients. Our acute cholecystectomy service treats patients of all ages according to performance status and fitness for surgery rather than age we audited our results in this age group. Methods All patients over the age of 65 who underwent acute cholecystectomy in the dedicated emergency cholecystectomy lists were audited from the period starting 31st December 2019 to 31st June 2021. Patient demographics, co-morbidies and surgical factors were recorded. The primary outcomes measure was in hospital stay and re-admission, secondary outcome were complications and perioperative mortality. Results 41 elderly patients underwent AC during the audit period, (male 18: female 23). Majority of patients had acute cholecystitis 30(73%). The median inpatient stay following surgery was 2 days(range 2-5 days) and the median admission to surgery time was 6 days (range 5-12 days). Only 3(7%) patients had a subtotal cholecystectomy. There was only 3 complications from surgery which were all between a clavien-dindo score of 2 and 3. There were 3 readmission in the immediate post-operative period. There was one 30-day mortality which was from necrotising pancreatitis as a result of ERCP and not from the operation. Conclusions Acute cholecystectomy in this age group appears to be safe and effective way to treat acute biliary pathology and compares similarly to the outcomes in the younger groups.