Introduction: Of the more than 20 million patients undergoing groin hernia repair annually worldwide, 6% are scrotal hernias in high resource countries rising to 67% in low resource countries which represents a heavy disease burden on relatively young men during their most productive period of life. There are many open questions concerning management of scrotal hernia. These guidelines aim to improve the care for scrotal hernia patients by reducing recurrence rates, chronic pain and infection.Methods: After developing 19 key questions a systematic literature review was performed till 31 March 2021 for all relevant publications with search terms related to Scrotal Hernia. The articles were scored by all co-authors according to Oxford, SIGN and Grade methodologies. Statements and recommendations were formulated. Online Consensus meetings with 25 HerniaSurge members were organised with voting and grading Recommendations as “strong” (recommendations) or “weak” (suggestions) and by consensus, in some cases upgraded.Results: Only 23 articles (two level 2 registry and 21 level 3–5) were selected. It is proposed to define scrotal hernia as an inguinal hernia which has descended into and causes any scrotal distortion. A new classification for scrotal hernias was proposed based on hernia size, SI for upper third thigh, SII for middle thigh and SIII for lower third thigh or below. Irreducibility is denoted with IR. Despite weak evidence antibiotic prophylaxis is recommended. Urinary catheterization is recommended (upgraded) in complex cases (S2-3) due to prolonged operative time. Scrotal hernia repairs have higher associated morbidity and mortality compared to non-complex groin hernia repairs irrespective of surgical experience. Open anterior (mesh) approach is commonest technique and suture techniques in low resource countries. For minimally invasive approaches, TAPP resulted in less conversion to open approach compared to TEP.Conclusion: Although the evidence is scarce and often low quality scrotal hernia management guidelines aim to lead to better surgical outcomes irrespective of where patients live. This necessarily means a more tailored approach based on available resources and appropriate skills. The guidelines provide an impetus for future research where adoption of proposed classification will enable more meaningful comparison of different techniques for different hernia sizes.

Abstract Introduction 6% of all inguinal hernias are scrotal in high-resource countries rising to 67% in low-resource countries. This represents a heavy disease burden on relatively young men during their most productive period of life. Despite limited evidence these guidelines aim to improve treatment for scrotal hernia patients. Methods After developing 19 key questions a systematic literature review was performed Statements and recommendations were formulated. Online Consensus meetings with 25 HerniaSurge members were organised with voting and grading Recommendations as “strong” (recommendations) or “weak” (suggestions) and by consensus, in some cases upgraded. Results 23 studies were selected. Scrotal hernia is defined as an inguinal hernia which has descended into and causes any scrotal distortion. A new classification for scrotal hernias was proposed based on hernia size, SI=upper third thigh, SII=middle thigh and SIII=lower third thigh or below. IR denotes irreducibility. Despite weak evidence antibiotic prophylaxis and urinary catheterization is recommended (upgraded) in complex cases (S2–3) due to prolonged operative time. Scrotal hernia repairs have higher associated morbidity and mortality compared to non-complex groin hernia repairs. Open anterior (mesh) approach is commonest technique and suture techniques in low resource countries. TAPP resulted in less conversion to open approach compared to TEP. Conclusions Although evidence is scarce and often low-quality scrotal hernia management guidelines recommend more tailored approaches for better surgical outcomes based on available resources and appropriate skills and provide an impetus for future research where adoption of proposed classification will enable more meaningful comparison of different techniques for different hernia sizes.

BACKGROUND:Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. METHOD:A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. RESULTS:Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. CONCLUSION:The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

The native bursa is a structure lined by synovium located adjacent to a joint which may serve to decrease friction between the tendons and overlying bone or skin. This extra-articular structure can become inflamed resulting in bursitis. Steroid injections have proven to be an effective method of treating bursal pathology in various anatomic locations. Performing these procedures requires a thorough understanding of relevant anatomy, proper technique, and expected outcomes. Ultrasound is a useful tool for pre procedure diagnostic evaluation and optimizing needle position during these procedures while avoiding adjacent structures. The purpose of this article is to review core principles of ultrasound-guided musculoskeletal procedures involving bursae throughout the upper and lower extremities.

Coronavirus disease 2019 (COVID-19) has significantly disrupted medical education around the world and created the risk of students missing vital education and experience previously held within actively engaging in-person activities by switching to online leaning and teaching activities. To retain educational yield, active learning strategies, such as microlearning and visual learning tools are increasingly utilized in the new digital format. This article will introduce the challenges of a digital learning environment, review the efficacy of applying microlearning and visual learning strategies, and demonstrate tools that can reinforce radiology education in this constantly evolving digital era such as innovative tablet apps and tools. This will be key in preserving and augmenting essential medical teaching in the currently trying socially and physically distant times of COVID-19 as well as in similar future scenarios.

Purpose The growth or rupture of cerebral aneurysms is thought to be a complex arterial wall response caused by an interaction of biological and hemodynamic factors. Current approaches that analyze the effects of flow stress on vascular cells are limited by their simplistic design, lacking patient-specific vascular anatomic features that contribute to disease. In this study, we compare wall shear stress (WSS) acquired using 4D Flow MRA from a 3D printed model with patient-specific aneurysm to gene expression of endothelial cells attached inside the same vascular model. Materials and methods Patient-specific vascular models were created from follow-up images in patients whose saccular aneurysms were confirmed to grow afterwards by CT angiography. The vascular models were connected to a flow-pump and a 4D Flow MRA was performed. WSS data was calculated from the acquisition and post-processed using a custom MATLAB environment. The same vascular models were coated with fibronectin and rotated in 3D with endothelium in culture incubator for cell lining. Viscosity-adjusted culture media was perfused using the same perfusion conditions with 4D Flow MRA. After perfusion, RNA was extracted from endothelial cells in the parent artery and the aneurysm and gene expression was examined using quantitative PCR (qPCR). In addition, the morphology of endothelial cells in specific regions of the model were observed with confocal microscopy. Results Endothelial cells in growing regions with low wall shear within the aneurysm were irregular in shape and size and associated with up-regulation of inflammatory genes compared with cells in the parent artery that exhibited typical spindle shape and aligned with the directionality of flow. Conclusions This research model enables a new approach to bridge the gap of biophysical flow phenomonology and the biological impact of complex flow patterns on endothelial cells using patient-derived imaging data. This approach is likely to be useful to determine flow-driven biological changes in vascular endothelium that contribute to aneurysm growth and rupture. Disclosures N. Kaneko: None. S. Tateshima: None. M. Loecher: None. J. Villablanca: None. D. Chen: None. Y. Komuro: None. W. Chang: None. D. Ennis: None. F. Vinuela: None. G. Duckwiler: None. J. Hinman: None.

OBJECTIVE::to evaluate the method of training and continuing education of 18 surgeons in 2014, and 28 surgeons in 2015, in the Holy Homes of Ribeirao Preto, Araraquara, Franca and San Carlos of São Paulo, in the performance of Lichtenstein inguinal herniorrhaphy, tutored by the Faculty of Medical Sciences of the São Paulo Holy Home and the organization HERNIA HELP - "Hernia Repair for the Underserved".METHODS::the training was tutored and systematized through an active methodology of teaching and learning, aiming to offer competence, skills and attitudes, measured by a previously validated Qualification Form, qualifying leaders in trainees' improvement.RESULTS::in 2014 the outcomes were: the difficulty of the case, direction, incision, dissection, mesh preparation, mesh cutting, mesh setting, closing, instruments, respect to tissues, flow, time and motion, and performance, all presented change in the general rating (p=0.000002); there was greater confidence in the execution of the procedure in 80% of trainees, considered "very valuable" in 93.3% of the interventions. In 2015, 28 surgeons were trained by ten surgeons previously qualified in 2014. The nerve identification rate, a relevant time the Lichtenstein technique, was 95.5% for the Iliohypogastric, 98.5% for the ilioinguinal and 89.4% for the genital branch of the genitofemoral nerve.CONCLUSION::the applied teaching method is possible, reproducible, reliable and valid. The joint efforts offer enormous opportunity of directed education, reaching underserved populations, revealing the great teacher-student social responsibility.OBJETIVO::avaliar resultados do método de treinamento e educação continuada de 18 cirurgiões, em 2014, e 28 cirurgiões, em 2015, nas Santas Casas de Ribeirão Preto, Araraquara, Franca e São Carlos do Estado de São Paulo, na realização da Herniorrafia Inguinal à Lichtenstein, tutorados pela Faculdade de Ciências Médicas da Santa Casa de São Paulo e pela organização HERNIA HELP - "Hernia Repair for the Underserved".MÉTODOS::treinamento tutorado e sistematizado, através de metodologia ativa de ensino e aprendizagem, visando a oferecer competência, habilidade e atitudes, auferidas por um Formulário de Qualificação previamente validado, qualificando líderes no aperfeiçoamento de treinandos.RESULTADOS::em 2014, os desfechos foram: dificuldade do caso, direção, incisão, dissecção, preparo da tela, corte da tela, fixação da tela, fechamento, instrumentos, respeito aos tecidos, fluxo, tempo e movimento e desempenho, apresentaram mudança na Classificação Geral (p=0,000002); houve maior confiança na execução do procedimento em 80% dos treinandos, sendo considerado "Muito Valioso" em 93,3% das participações. Em 2015, os 28 cirurgiões foram treinados por dez cirurgiões previamente qualificados em 2014. A taxa de identificação dos nervos, tempo relevante da técnica de Lichtenstein, foi 95,5 % para o ílio-hipogástrico, 98,5% para o ilioinguinal e 89,4% para o ramo genital do nervo genitofemoral.CONCLUSÃO::o método de ensino aplicado é possível, reprodutível, confiável e válido. Os mutirões oferecem a enorme oportunidade do ensino, dirigido, atingindo populações carentes, revelando a grande responsabilidade social docente-discente.

Various spine exposure techniques have been described to help minimize the risk of vascular and visceral injuries, particularly using an anterior approach. Although lateral approaches to the spine have been described, these techniques have been shown to increase the risk of lumbar plexopathy and genitofemoral nerve palsy. We describe a novel endoscopic, balloon-assisted approach to the retroperitoneum, which offers full exposure and visualization of the lateral lumbar spine. The peri-operative data and images of six patients who underwent balloon-assisted endoscopic retroperitoneal (BAER) exposure were collected and reviewed. Postoperative follow-up notes were also reviewed to assess for signs or symptoms that would suggest visceral or vascular injury. Primary outcomes include intraoperative vascular or visceral injury, blood loss, and mortality. Six patients underwent direct lateral interbody fusion (DLIF) operations via the BAER exposure technique. The cohort was followed up for an average of 8.5 months postoperatively. None of the patients experienced vascular or visceral injuries. One patient (1 of 6) experienced ipsilateral thigh weakness, which resolved. There were no mortalities. BAER exposure of the lumbar spine is a safe technique in minimally invasive DLIF operations. It offers optimal visualization of the iliac vessels, ureter, and lumbar plexus.

A number of clinical conditions are caused by disorders affecting the mucosal lining of the gastrointestinal tract. Some patients suffer from a loss of mucosal surface area due to congenital defects or due to surgical resections ("short bowel syndrome"). Other patients have inborn or acquired defects of certain mucosal functions (e.g., glucose-galactose malabsorption, bile acid malabsorption). Many patients with these mucosal disorders could be more effectively treated if healthy mucosa were available in larger quantities as a replacement or functional supplement. We therefore developed methods to transplant mucosal stem cells from one part of the intestine to another and to make bioengineered intestinal mucosa. We generated an animal model of bile acid malabsorption using rats that underwent resection of the distal 25% of their small intestine (ileum). This resulted in significant losses of bile acids with the fecal excretions in these animals. We subsequently harvested ileal stem cell clusters from neonatal donors, removed the mucosa from a segment of proximal intestine (jejunum), and implanted the stem cell clusters into the debrided segment of jejunum. After four weeks, the animals had developed a functional "neomucosa." We inserted the "neo-ileal" segment into continuity as a substitute ileum. Postoperative measurements of fecal bile acid excretion showed that we were able to reverse the malabsorption syndrome in this model. This was the first reported neo-mucosa-based treatment of a malabsorption syndrome in vivo. We subsequently studied different biodegradable PGA and PLLA scaffoldings to generate bioengineered intestinal mucosa. We implanted these materials into omentum of rats and were able to identify a PGA/PLLA hybrid material on which engraftment rates of 36% of the available surface area could be achieved. Most recently, we developed a novel technique that permits direct observation of cell-biomaterial interactions after implantation into omentum or intestine in vivo. This method will help to optimize engraftment conditions for stem cell clusters on biomaterials.

Inferior alveolar nerve blockade is one of the most common, yet technically difficult local procedures performed. Inadvertent injury to the inferior alveolar or lingual nerve, resulting in persistent anesthesia, paresthesias, loss of taste, or pain in the distribution of these nerves, is more common than once thought. We report on two cases of lingual nerve injury during routine inferior alveolar nerve blockade. These cases are consistent with the hypotheses that direct nerve trauma, whether by nerve-needle contact or compression by anesthetic bolus, and the neurotoxic effects of specific anesthetic preparations may produce long term nerve damage. When this damage occurs to the pain-sensing A-delta and C-fibers, symptoms may resemble those seen in complex regional pain syndrome.