Ann R Coll Surg Engl 2009; 91: 280-286 280Obesity is a world-wide epidemic 1 and is associated with multiple serious co-morbidities, both physical and psychological. Over the last decade, there has been an exponential rise in the number of bariatric procedures being offered, 2 as these have consistently been shown to be the only way to achieve sustainable weight loss and improvement in comorbidities, particularly type II diabetes and hypertension. There are many different surgical operations available to achieve weight loss; the choice of surgery depends on a number of factors, not least the experience of the surgeon and the patient's individual requirements. The predominant operation performed in the UK is the laparoscopic adjustable gastric band (LAGB), which is a purely restrictive procedure. Other procedures incorporate a malabsorptive element and include the Roux-en-Y gastric bypass (RYGB) and the biliopancreatic diversion (with or without duodenal switch; BPD, BPD/DS; Fig. 1A). Other operations include sleeve gastrectomy (Fig. 1B) which can be used as a definitive procedure or as a bridge to further by-pass surgery, and the largely historic vertical banded gastroplasty. All surgery carries some degree of risk and the decision to operate is made after a careful balance of the risks versus the benefits. This particular group of patients often have limited physiological reserves and this, together with their physical size, may make the surgery high-risk. Early detection and appropriate management of complications is crucial to prevent long-term morbidity and mortality.This review highlights the main complications that the general surgeon on-call may encounter as an emergency and illustrates the appropriate management strategies.A full literature search was carried out using PubMED and the Cochrane Library. Relevant international articles published in the last 10 years were assessed. Keywords for search purposes included bariatric, surgery, complications, emergency and management. Band-related complications Dysphagia/band slippageImmediate postoperative dysphagia is seen in some patients following LAGB. This is usually due to excessive perigastric fat resulting in a tightly fitting band or to postoperative oedema. Complete dysphagia, even for saliva, may take up to 10 days to resolve. Postoperative intravenous steroids and a strict nil-by-mouth regimen appear to increase the resolution rate for the oedema and thus hasten recovery. These patients are often in-patients until postoperative dysphagia resolves and so it is late dysphagia that more commonly The prevalence of obesity surgery is increasing rapidly in the UK as demand rises. Consequently, general surgeons on-call may be faced with the complications of such surgery and need to have an understanding about how to manage them, at least initially. Obesity surgery is mainly offered in tertiary centres but patients may present with problems to their local district hospital. This review summarises the main complications that may be encountered. MATERIALS AND M...

Obesity is a modern-day epidemic with serious physical, psychological and economic implications for the patients. Tackling obesity is now a priority for most healthcare providers. Managing such patients can be complex, emotional, time consuming and often frustrating. Obesity surgery, in its various forms, has revolutionised this struggle. With appropriate selection of patients, adequate resources and a multidisciplinary team involvement, obesity can now effectively be "cured". It is vital that those who deal with obese patients know how to access these services and understand the processes involved in the journey from initial assessment to postoperative follow-up. Obesity surgery has a major impact in reducing obesity-related comorbidities such as diabetes and hypertension and contributes to society by returning patients to work. Prevention must be at the heart of any strategy to manage obesity, but, for established cases, surgery is taking centre stage and will continue to flourish as new techniques and procedures are developed.

Spigelian hernias were first described by Joseph Klinkosch in the 18th century, and have since posed a diagnostic and surgical problem owing to their non-specific presentation and rarity. While the management of unilateral hernias is fairly well described in today's literature, bilateral Spigelian hernias are very rare. We describe the emergency management of a patient with bilateral Spigelian hernias, diagnosed on computed tomography. case historyA 52-year-old woman was admitted to the surgical assessment unit after having developed right iliac fossa pain over the previous 12 hours. The onset was gradual and the pain had worsened with time. She had noticed a swelling over the right side. She had opened her bowels normally that day and, despite being nauseated, she had not vomited. She had no urinary or gynaecological symptoms. The patient was otherwise fit and well, and had not undergone any previous surgery. She was on no regular medication. She smoked 15 cigarettes a day and drank alcohol rarely. On arrival, the patient's vital observations were entirely normal. Examination revealed a very tender right iliac fossa with voluntary guarding. There was a distinct 10cm x 10cm smooth mass palpable, which appeared to be intra-abdominal rather than in the abdominal wall. This was particularly tender and did not have a cough impulse. The remainder of the abdomen was soft. Rectal examination revealed an empty rectum. Her routine blood results on admission were within the normal limits and an arterial blood gas showed a normal lactate level of 0.9mmol/l.In view of the rapid onset of symptoms and despite the lack of inflammatory features, the main differential diagnosis at this stage was an appendicular mass and computed tomography (CT) was organised. This revealed bilateral Spigelian hernias (Figs 1 and 2). The left contained small bowel loops and the descending colon. The right contained the caecum and ileum with surrounding fat stranding, suggesting the presence of reactive inflammatory changes.A laparoscopy was performed and reduction of the rightsided hernia (Fig 3) was attempted. The left side had reduced prior to surgery. The plan was to repair both hernias simultaneously at laparoscopy. Unfortunately, this was not possible as it was impossible to reduce the incarcerated caecum safely. A midline laparotomy incision was made and the hernia reduced manually via an intra-abdominal approach. The caecum, appendix and terminal ileum were extracted and deemed viable. The right-sided peritoneal defect was plicated using 3/0 Vicryl ® (Ethicon, Somerville, NJ, US) interrupted sutures. The midline incision was then closed in a standard fashion. A transverse incision was made over the right hernial orifice and the defect repaired with size 0 Prolene ® (Ethicon) continuous sutures. The left hernia was not fixed on this occasion. discussion Spigelian hernias were first described by Joseph Klinkosch in the 18th century.

Spigelian hernias were first described by Joseph Klinkosch in the 18th century, and have since posed a diagnostic and surgical problem owing to their non-specific presentation and rarity. While the management of unilateral hernias is fairly well described in today's literature, bilateral Spigelian hernias are very rare. We describe the emergency management of a patient with bilateral Spigelian hernias, diagnosed on computed tomography. case historyA 52-year-old woman was admitted to the surgical assessment unit after having developed right iliac fossa pain over the previous 12 hours. The onset was gradual and the pain had worsened with time. She had noticed a swelling over the right side. She had opened her bowels normally that day and, despite being nauseated, she had not vomited. She had no urinary or gynaecological symptoms. The patient was otherwise fit and well, and had not undergone any previous surgery. She was on no regular medication. She smoked 15 cigarettes a day and drank alcohol rarely. On arrival, the patient's vital observations were entirely normal. Examination revealed a very tender right iliac fossa with voluntary guarding. There was a distinct 10cm x 10cm smooth mass palpable, which appeared to be intra-abdominal rather than in the abdominal wall. This was particularly tender and did not have a cough impulse. The remainder of the abdomen was soft. Rectal examination revealed an empty rectum. Her routine blood results on admission were within the normal limits and an arterial blood gas showed a normal lactate level of 0.9mmol/l.In view of the rapid onset of symptoms and despite the lack of inflammatory features, the main differential diagnosis at this stage was an appendicular mass and computed tomography (CT) was organised. This revealed bilateral Spigelian hernias (Figs 1 and 2). The left contained small bowel loops and the descending colon. The right contained the caecum and ileum with surrounding fat stranding, suggesting the presence of reactive inflammatory changes.A laparoscopy was performed and reduction of the rightsided hernia (Fig 3) was attempted. The left side had reduced prior to surgery. The plan was to repair both hernias simultaneously at laparoscopy. Unfortunately, this was not possible as it was impossible to reduce the incarcerated caecum safely. A midline laparotomy incision was made and the hernia reduced manually via an intra-abdominal approach. The caecum, appendix and terminal ileum were extracted and deemed viable. The right-sided peritoneal defect was plicated using 3/0 Vicryl ® (Ethicon, Somerville, NJ, US) interrupted sutures. The midline incision was then closed in a standard fashion. A transverse incision was made over the right hernial orifice and the defect repaired with size 0 Prolene ® (Ethicon) continuous sutures. The left hernia was not fixed on this occasion. discussion Spigelian hernias were first described by Joseph Klinkosch in the 18th century.