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This 81 year old man with severe CAD and CHF was referred for VCE following a negative endoscopic workup for chronic guaiac positive stools. Seen on only three frames, this sequence reveals a single mid small bowel telangectasia, a possible source for his chronic GI blood loss. He has been managed c...onservatively and continues to require intermittent transfusions despite oral iron therapy.
Loop duodenal switch is an end-to-side proximal duodeno-ileal bypass with a sleeve gastrectomy. The proximal duodenal stump is anastomosed to an ileal loop, 200 cm from the ileocecal valve. The procedure is a malabsorptive operation with some theoretical advantages: only one anastomosis is performed..., and so the operative time is shorter, and there is no mesenteric opening. It is not a mini-gastric bypass, as the gastric antrum, the pylorus and the first centimeters of the duodenum are preserved. The short term outcome shows a very good weight loss curve with no metabolic disturbances.
Surgical technique: A 3cm skin incision under spinal or general anesthesia, depending on the patients’ preference, starts half way the line between the superior anterior iliac spine towards the midline in a 30° angle to the pubic tubercle. Scarpa’s fascia is opened as well as the external obliq...ue aponeurosis. By using this skin line incision the internal ring will be immediately visualized. Although it is important to look for both direct and indirect hernias evaluating the groin, we do not taper the cord and directly evaluate the ring for indirect hernias. In case of an indirect hernia the sac is reduced or resected according to the preference of the surgeon and the preperitoneal space is entered bluntly through the dilated internal ring. In case of a direct hernia the approach slightly differs. One could prefer to open the transversalis fascia through the internal ring over a few centimeters or you can open the fascia more medially, at the site of the direct hernia. As primary point of concern the epigastric vessels should be identified and retracted softly upwards. Then a gauze can be introduced into the preperitoneal space and by doing so most of the space needed medially will be created. Then one can already palpate Cooper’s ligament and the pubic bone. Laterally to the internal ring more digital dissection is needed to create just the appropriate space for the mesh. By placing the mesh it is important not to introduce the mesh too medially. Laterally of the internal ring an adequate overlap of the mesh is necessary, especially in indirect hernias. No splitting of the mesh seems necessary. The patient will be asked to strain and push on the ring to control its place and to check adequate spreading of the mesh to cover the whole myopectineum of Fruchaud. One single stitch of vicryl 3/0 is placed taking both the fascia transversalis and the mesh.
Part three: The 3rd Annual W. B. Ingalls Memorial Prostate Health and Cancer Seminar features nationally renowned physicians and scientists presenting the most current study and practices for the diagnosis and treatment of prostate cancer. This day-long program offers in-depth exploration of prostate issues that range from monitoring PSA counts to cutting-edge research to current treatment trends.