Objective: Rare disease Background: An arteriovenous malformation (AVM) is an abnormal connection between an artery and a vein, bypassing the capillary network. An AVM of the superficial temporal artery (STA) can occur after trauma, iatrogenic injury, infection, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few reported cases. Symptoms include local pain, headache, tinnitus, or paresthesia, in addition to a palpable mass associated with thrill on palpation. Options for diagnosis include intra-arterial angiography, doppler ultrasound, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Current management options include surgical excision, ligation, and embolization; however, it is unknown which treatment is superior in terms of recurrence and which carries a lower risk of complications. Case Report: We present a case of a spontaneous STA AVM in a 76-year-old woman with past medical history significant for seasonal allergies and hyperlipidemia, who presented with pulsatile tinnitus and a palpable, tender mass located to the left temporal area. The mass had been present for several years, with gradual increase in size two to three years prior to presentation. She denied any history of trauma or procedure prior to presentation of the pulsatile mass. She underwent open excision with complete resolution of symptoms and no recurrence at 11-month follow-up. Conclusions: AVM of the STA is a condition that can occur secondary to trauma, infection, iatrogenic injury, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few cases documented in the literature. Surgical treatment remains the standard of management, with options including surgical excision, ligation, or embolization.

Inguinal hernia repair, although a common procedure, can present in complicated ways such as a sliding inguinal bladder hernia (IBH). This rare type of hernia can alter a patient's quality of life by obstructing urination, requiring manual scrotal compression to fully empty the bladder, and lead to devastating complications such as hydronephrosis and kidney failure. Treatment is typically by open inguinal hernia repair with manual bladder reduction, but this method poses risks of iatrogenic injury to the bladder. Within this case series, IBH repairs via open and robotic-assisted laparoscopic procedures are compared, and the morbidity and mortality of each method are analyzed. Although risk of recurrence is similar for both procedures, robotic surgeries are linked to decreased postoperative pain and length of hospital stay. The ease of dissection of pelvic anatomy and detailed view of the associated structures that robotic surgery can provide during a complex hernia repair encourages its use for IBH.

Introduction: Appendicitis is a very common diagnosis that surgeons manage daily. Some surgeons are still giving antibiotics to patients suffering from uncomplicated appendicitis in the postoperative setting, despite an abundance of evidence to support a single preoperative dose of antibiotics. In this paper, we will describe the management of post -operative antibiotics at our institutions following uncomplicated appendicitis with regard to the use of antibiotics in the post -operative setting. Methods: A retrospective chart review was performed analyzing post -operative antibiotic use and postoperative complications in 179 patients undergoing laparoscopic appendectomy for uncomplicated appendicitis. We retrospectively examined the patients to change our future practices as we perform appendectomies routinely, and there is practice variation at our centers. Current Procedural Terminology (CPT) codes for 'laparoscopic appendectomy' were used to identify the patients within our inclusion criteria. Twenty-four patients were excluded from the analysis as they had complicated appendicitis or met other exclusion criteria. We only studied the patient with uncomplicated appendicitis, as those with complicated appendicitis have a different clinical course that involves post -operative antibiotic administration or prolonged antibiotic administration with or without drain placement. Both arms of the study were homogeneous regarding patient characteristics. An independent test of the development of wound infection for those patients receiving post -operative antibiotics versus those not receiving post -operative antibiotics was conducted using the SPC XL 2010 Microsoft Excel (Redmond, USA) add -in. A p -value of <0.05 was considered statistically significant. This included the odds ratio for the development of complications. Results: There was no difference in the risk of infection rate in patients given post -operative antibiotics; however, given the odds ratio of 6.53, there is an association between an increased wound infection rate and patients who received post -operative antibiotics. Discussion: An appendectomy is a standard surgical procedure for acute appendicitis. The guidelines for using pre -operative antibiotics in uncomplicated appendicitis are well established; however, there is no specific recommendation on whether to continue antibiotics post -operatively. However, there is significant provider variability on this topic. Antibiotic use post -operatively in clean -contaminated cases, such as uncomplicated acute appendicitis, has been associated with higher risks of surgical site infections. Conclusion: The use of antibiotics post -operatively may not be indicated for uncomplicated laparoscopic appendectomy and may increase wound infections. A large-scale study including a larger population and extending it to other hospitals may increase statistical significance and help guide physician management.

Objective: Rare disease Background: Ureteroinguinal hernias are exceptionally rare and are seldom diagnosed in the preoperative setting. There are 2 classifications of this type of hernia: paraperitoneal and extraperitoneal. Case Report: We report a case of a 67-year-old man who presented with urinary symptoms and a reducible right inguinal hernia. A computed tomography (CT) scan of the abdomen and pelvis suggested an ureteroinguinal hernia. Further diagnostics and treatment via cystoscopy, retrograde pyelogram, and right ureteral stent placement were performed, confirming the diagnosis and providing relief of the obstructive uropathy. The patient underwent an attempted elective transabdominal preperitoneal repair that was converted to an open Lichtenstein repair. Intraoperatively, an extraperitoneal ureteroinguinal hernia was identified. The patient did well postoperatively, and the stent was removed 1 month later. Conclusions: Only 20% of the ureteroinguinal hernias described in the literature are extraperitoneal. In our case presentation, we demonstrated successful identification and treatment of an extraperitoneal ureteroinguinal hernia. The diagnosis was made using a combination of the clinical presentation, CT of the abdomen and pelvis, and cystoscopy with retrograde pyelogram. The extraperitoneal classification was an intraoperative diagnosis. The treatment consisted of a temporizing ureter stent and definitive management with an open Lichtenstein repair. We recommend obtaining a CT scan when a patient presents with a combination of urinary symptoms and an inguinal hernia because this process was invaluable in our preoperative diagnosis. Stent placement at the time of diagnosis permitted an elective repair and aided in the identification of the ureter during the hernia repair.

Internal hernias are an uncommon cause of small bowel obstruction and present a challenging clinical diagnostic scenario. They result from the abnormal protrusion of an abdominal organ through a peritoneal defect and can cause intermittent obstructive symptoms, diffuse abdominal discomfort, and postprandial pain. Paraduodenal hernias comprise 53% of all internal hernias 1 and occur due to failure of the fixation of either the left or transverse mesocolon to the posterior abdominal wall. Its relative rarity results in mortality between 20 and 50% 2 because of delayed diagnosis and consequent obstruction, strangulation, and bowel ischemia. Our case series describes three patients before and after operative fixation of paraduodenal hernia. Only one of the three was identified by preoperative radiologist interpretation. Subsequent diagnosis and definitive treatment were completed by surgical staff to resolve undiagnosed undulating abdominal pain and obstructive-type symptoms. We further analyze left-sided paraduodenal hernias after laparoscopic and robotic repair to define common symptomatology, typical CT findings, and preferred laparoscopic repair techniques.

When managing an infected groin, though rarely performed, a transobturator bypass remains an important alternative in the armament of a vascular surgeon. Autologous vein and synthetic PTFE are known conduit options for obturator bypasses, although the advantage of utilizing an autologous biological conduit when dealing with infection may not be an option for every patient. On literature review, bovine carotid grafts have been used in infrainguinal revascularizations with comparable results to autologous vein; however, no cases can be found for its use in obturator bypass thus far.

Foramen of Winslow hernias are one of the most uncommon types of internal hernias that a surgeon will encounter. They are often initially indolent with vague symptoms that present over an extended period of time. Unfortunately, these hernias are not often diagnosed prior to requiring emergent operative intervention. This case report describes a patient who had a long history of vague abdominal pain and radiographic evidence of a foramen of Winslow hernia 4 years prior to presenting with acute obstructive symptoms. This raises the question: Should foramen of Winslow hernias, if diagnosed early, be repaired on an elective basis?

Pneumatosis intestinalis can be identified radiographically incidentally in an asymptomatic patient, or it may be present in its fulminant form with peritonitis. Although multiple mechanisms have been postulated, most believe it arises from mechanical or infectious factors. Respiratory factors have also been described as possible causes for this condition. Clinically, it is important to differentiate among patients whom require surgical intervention from those who would benefit from conservative management, such as hyperbaric oxygen, changes in diet, and/or antibiotic administration. Although supplemental oxygen has become the standard of care for the treatment of benign pneumatosis intestinalis, we question whether all patients require oxygen therapy as a treatment. Although oxygen may be beneficial, the literature suggests there may be detrimental effects from oxygen toxicity and the free radicals formed during hyper-oxygenation. Furthermore, given the rising epidemic of antibiotic resistance and the various toxicities associated with usage of antibiotics, do all patients really require antibiotics? We present a case of a patient with complaints of hematuria, but no other gross abdominal complaints and was incidentally found to have pneumatosis intestinalis and pneumoperitoneum without any evidence of vascular compromise or ischemia. This patient was managed successfully with conservative treatment without oxygen therapy or antibiotics.

Pyometra, by definition, is a collection of purulent fluid within the uterine cavity. Incidence has been estimated to range from 0.1% to 0.5%. Typically, this is linked to postmenopausal women; however, it has been linked to premenopausal women with concordant use of intrauterine devices. Based on our knowledge, there have been less than 50 recorded cases reported in the English literature regarding perforation of pyometra resulting in acute abdomen and fewer than 25 resulting in pneumoperitoneum. We report a patient who was evaluated for diffuse peritonitis caused by perforated pyometra who was successfully treated with surgical intervention.

Subcapsular bilomas are a rare complication of laparoscopic cholecystectomy and an even more rare occurrence to occur spontaneously. We present a case of left sided subcapsular biloma following a laparoscopic cholecystectomy. The location of the biloma was unrelated to our area of dissection. The operation was without difficult dissection or pressurization of the biliary tree. In addition, we present percutaneous drainage alone, without ERCP as adequate management in subcapsular bilomas.