Ann RC oll Surg Engl 2008; 90:6 94-695 694 A40-year-old man was admitted with a1-day history of sudden onset of left-sided chest pain radiating down to his left abdomen. The pain was constant in nature and he denied any previous episodes. He described one episode of vomiting but his bowelh abitw as normal and, in particular, he denied any episodes of rectal bleeding or diarrhoea. On functional enquiry,h ed escribed episodes of exertional dyspnoea whichwas new in onset. There was no pastmedical history of note, nor had he had recent trauma or surgery.On examination, he looked unwell and dyspnoeic. He was apyrexial and haemodynamically stable. Examination of the respiratory system revealed decreased air entry in the left lung base. He was noted to have as oft abdomen with some tenderness in the epigastrium. An ECG was normal. Initial laboratory investigations revealed aw hite cell count of 13.9. Arterial blood gases on air revealed ap O 2 of 9.01 and mildly raised lactate of 2.73. Initial chest radiography confirmed left lower lobe consolidation. Pleural tap and septic screen were sent.Eight hours after admission, the patient became progressively more tachycardic and complained of increasing abdominal pain. As urgical review was requested and this revealed tenderness in the LUQ. It was still felt that his abdominal signs were secondary to ap rimary chest infection. However,a sh is pain was disproportionate to his abdominal signs, aCTscan was arranged to exclude further pathology.T his revealed evidence of herniation of small bowel loops through al eft-sided anterior diaphragmatic hernia. Af luid collection was seen at the superior aspect of the hernia with collapse of the underlying lung and shift of the mediastinum to the right (Fig. 1).Tw elve hoursa fter admission, the patient was taken to theatre. Initial laparoscopy revealed as trangulated 3-cm left diaphragmatic hernia containings mall bowela nd transverse colon. The contents of the hernia were difficult to reduce laparoscopically; therefore, an emergency laparo- We report an unusual case of strangulated diaphragmatic (Morgagni) hernia resulting in ischaemia of the small and large bowel, which was initially diagnosed as ap neumonia. This case highlights the importance of being aware of this rare, but potentially fatal condition when assessing patients with respiratory symptoms and abdominal pain. CASE REPORT

No abstract

No abstract

PurposeEvidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.MethodsSurgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.ResultsThe study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.ConclusionIn the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

The LC of RKT is short, with improving skill up to 20-25 cases. The procedure is reproducible by surgeons experienced with open transplant and robotic surgery for other procedures, with comparable outcomes and low complication rates at a new center during adoption.