PDI
NOVEMBER 2014 – VOL. 34, NO. 7
SHORT REPORTS
2. Twardowski ZJ, Nolph KD, Rubin J, Anderson PC. Peritoneal dialysis for psoriasis. An uncontrolled study. Ann Intern Med 1978 Mar; 88(3):349–51. 3. Whittier FC, Evans DH, Anderson PC, Nolph KD. Peritoneal dialysis for psoriasis: a controlled study. Ann Intern Med 1983 Aug; 99(2):165–8. 4. Gotloib L, Fudin R. Use of peritoneal dialysis and mesothelium in non primary renal conditions. Adv Perit Dial 2009; 25:2–5. 5. Hanicki Z, Cichocki T, Klein A, Smole´nski O, Sułowicz W, Czabanowska J. Dialysis for psoriasis — preliminary remarks concerning mode of action. Arch Dermatol Res 1981; 271(4):401–5. doi: 10.3747/pdi.2013.00249
An obturator hernia is a rare type of internal hernia that was first described in 1724 by Arnaud de Ronsil (1). This hernia is characterized by protrusion of the abdominal contents through the obturator foramen. The signs and symptoms of obturator hernia are nonspecific, and a missed diagnosis can result in significant morbidity and mortality. We present the case of a patient being treated by continuous ambulatory peritoneal dialysis (CAPD) who was diagnosed with an obturator hernia and describe the treatment and successful outcome. CASE REPORT
A 58-year-old woman, who had borne 2 children and was on CAPD due to liver cirrhosis and massive ascites that were secondary to chronic hepatitis B and C viral infections and end-stage renal disease, presented with a 1-year history of a right proximal, medial thigh mass. The soft, non-tender, reducible mass was approximately 10 cm in diameter. The patient denied abdominal pain, nausea, vomiting, or constipation. Ultrasound indicated a 7 × 4.2 cm cystic lesion in the right inguinal region that appeared to be related to fluid extravasation through the obturator foramen. Pelvic computed tomography (CT) indicated fluid extending from the right obturator foramen to the right thigh, about 13.1 cm in the largest dimension. There were no definitive bowel loops in the hernia sac (Figure 1). Hernia surgery involved a skin incision from the pubic tubercle to 10 cm above the mid-thigh. The surgical field was opened down to the adductor magnus muscle. The gracilis muscle and the adductor longus muscle were dissected. The anterior and posterior branches of the obturator nerve were recognized and protected. The
Figure 1 — Pelvic computed tomography (CT) scanning indicated fluid (about 13.1 cm in the largest dimension) extending from the right obturator foramen to the right thigh.
hernia sac was then identified and carefully dissected. The abdominal fluid was then released from the CAPD catheter using a suction machine. The hernia sac was reduced into the peritoneal cavity, and a cone plug (Optilene Mesh Elastic, B. Braun Melsungen AG, Germany) was inserted into the obturator canal. A 5 × 8 cm mesh (Optilene Mesh Elastic, B. Braun Melsungen AG, Germany) was then sutured to the superior ramus of the pubic bone superiorly, the adductor magus muscle inferiorly, the pectineal muscle anteriorly, and the obturator externus muscle posteriorly. A Jackson-Pratt drain was inserted into the obturator area, and the skin was closed with 4-0 nylon. A hernia belt was used to compress the hernia site for three months after surgery. Continuous ambulatory peritoneal dialysis was continued, but with half the amount of the dialysate and twice the frequency for 2 weeks after surgery. The Jackson-Pratt drain was removed after the drainage had decreased. The patient was discharged 4 days after surgery and was in stable condition. There was no evidence of a recurrent hernia during the 50 months of follow-up. DISCUSSION
Obturator hernias account for approximately 0.073% of all hernias (1). In Taiwan, 9 patients (8 females) presented with this condition from 1993 to 2003 at Kaohsiung Veterans General Hospital. Most patients are elderly multiparous women (2). Igari et al. reported 10 cases of obturator hernia affecting elderly, thin women (3), all of whom had symptoms of intestinal obstruction (i.e. vomiting with abdominal and/or thigh pain), but
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
803
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Treatment of Obturator Hernia in a Patient Undergoing Peritoneal Dialysis
SHORT REPORTS
NOVEMBER 2014 – VOL. 34, NO. 7 PDI
804
a tension-free mesh to stimulate a local inflammation reaction, with the edematous tissue improving access to the obturator hernia. We also used a hernia belt to maintain compression for three months after surgery. After 50 months of follow-up, there was no recurrent hernia or other significant problems. The technique described here is especially useful for patients undergoing CAPD. We recommend that this simple method be considered as standard for treatment of an obturator hernia in a patient undergoing CAPD. DISCLOSURES
This work was funded by grants from Taipei Veterans General Hospital (V102 C-183) and the Program for Progress Towards Top-Level University in National Yang Ming University to TH Chen; Taipei Veterans General Hospital Grant (V102 A-014) to P-J Tsai. Shih-Yi Kao1 Ta-Chung Lee2 Zen-Chung Weng3 Tien-Hua Chen4 Pei-Jiun Tsai5,6* Ten-Chan General Hospital Zhongli1 Taoyuan, Taiwan, R.O.C. Department of Rehabilitation & Health Center2 Su-Ao & Yuan Shan Branch of Taipei Veterans General Hospital, Taiwan, R.O.C. Division of Cardiovascular Surgery3 Department of Surgery, Taipei Medical University Hospital Taipei, Taiwan, R.O.C. Department of Surgery3 School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, R.O.C. Department of Surgery4 Veterans General Hospital, National Yang Ming University School of Medicine, Taipei, Taiwan, R.O.C. Institute of Clinical Medicine5 National Yang-Ming University, Taipei, Taiwan, R.O.C. Department of Critical Care Medicine6 Veterans General Hospital, Taipei, Taiwan, R.O.C. *email: [email protected] REFERENCES 1. Petrie A, Tubbs RS, Matusz P, Shaffer K, Loukas M. Obturator hernia: anatomy, embryology, diagnosis, and treatment. Clin Anat 2011; 24:562–9.
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none of whom had previous abdominal surgery. The differential diagnosis in such cases should include obturator hernia, because early diagnosis and prompt initiation of treatment reduces the risk of surgical complications and is associated with improved outcomes (4). Our patient had none of the symptoms suggestive of an intestinal obstruction; however, the presence of increased intraabdominal pressure as a result of massive ascites from liver cirrhosis and end-stage renal disease likely contributed to the formation of the obturator hernia. Meziane et al. first reported the use of CT scanning for the diagnosis of obturator hernia in 1983 (5). Since the widespread adoption of CT scanning, the pre-operative diagnosis has improved from 43% to 90% in some reports (6). In our case, a pelvic CT scan indicated a mass with septations and fluid extending from the right obturator foramen into the right thigh. There were no bowel loops in the hernia sac. There are various methods for repair of an obturator hernia (7), and most of these are similar to the methods used for a femoral hernia (8). A midline incision provides the best exposure, allows reduction of the hernia contents, and facilitates bowel resection if necessary. However, exploratory laparotomy and the inguinal approach were contraindicated for our patient. The patient could not tolerate hemodialysis due to the risk of a precipitous drop in blood pressure. It was necessary to maintain an integral abdominal cavity so that CAPD could be continued, because this was the only renal replacement therapy available for this patient. Thus, we considered a thigh approach to be better for our patient. Lobo et al. presented a simple technique for obturator hernia repair in which a polypropylene mesh (Ethicon Endo-Surgery, Inc, Ohio, USA) is sutured to Cooper’s ligament (7), and then allowed to cover the obturator canal. This method is similar to the tensionfree mesh femoral hernioplasty proposed by Irving Lichtenstein in 1974 (9). The tension-free mesh covers the hernia defect and micrifies it by the resulting inflammation reaction. Another repair method, proposed by Nelson et al. in 2003 (10) and modified by Tanaka et al. in 2010 (11), utilizes an incision from the pubic tubercle to 10 cm above the mid-thigh. The hernia sac is identified and reduced into the peritoneal cavity, followed by insertion of a cone plug. The technique employs a mesh plug, which is now well established in groin hernioplasty. This plug sits astride the defect of the obturator canal in the preperitoneal plane, with the position effectively maintained by the essential intra-abdominal pressure. In our case, we modified Lockwood’s infra-inguinal approach and combined the concepts of tension-free mesh and a plug. Thus, we used a plug to resolve the increased intra-abdominal pressure caused by CAPD and
PDI
NOVEMBER 2014 – VOL. 34, NO. 7
doi: 10.3747/pdi.2013.00116
Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis Refractory peritonitis is a major cause of peritoneal dialysis (PD) technique failure that requires catheter removal (1). To date, there is no well-proven adjuvant treatment for PD peritonitis when response to antibiotics is suboptimal. In our center, intravenous (IV) antibiotics with adjunctive lavage was offered when pending catheter removal in refractory cases, after we first experienced an unexpected cure in 2010 when such strategy was applied for symptom relief. In the present case series, we present the outcomes of IV antibiotics with adjunctive lavage in severe PD peritonitis. CASE SERIES
In our center, cefazolin/ceftazidime are empirical antibiotics of choice upon presentation of PD peritonitis and are adjusted subsequently according to microbiology reports. In non-responsive cases, antibiotics escalation is often considered and catheter removal arranged when
deemed refractory, where wait times for the procedure varies depending on operating room availability. From November 2010 to December 2012, there were 13 peritonitis episodes in 12 patients who had received IV antibiotics with adjunctive lavage when pending catheter removal (except 1 who declined the procedure). Lavage was performed by the Baxter HomeChoice automated peritoneal dialysis system (Baxter Healthcare Corporation, Deerfield, IL, USA) with fill volume at 2 L and 2-hour dwell time usually over 48 to 72 hours. Antibiotics were switched from intra-peritoneal (IP) to IV route during lavage and back to the IP route when the usual PD schedule resumed. Among the 13 peritonitis episodes, there were 2 fungal and 2 tuberculosis cases that had catheters removed as planned. Both tuberculosis episodes were considered culture-negative initially as their culture results were available only after catheter removal. The other 9 bacterial peritonitis cases were our subjects of interest, with patients’ details and peritonitis progress shown in Table 1 and Figure 1, respectively. Successful cure was achieved in 6 episodes where catheter removal could be withheld. We need to highlight Patient H, a frail elderly person who declined catheter removal and hemodialysis. Respecting her desire for comfort care, repeated lavage was offered that often resulted in pain improvement and worsened again once cycler was off. Her trend of C-reactive protein (CRP) changes is included in Figure 1, which seemingly paralleled usage of lavage. We decided against further lavage eventually when her general condition was poor and she succumbed. DISCUSSION
Management options are limited for refractory peritonitis patients who refuse catheter removal or have poor tolerance to hemodialysis. Our strategy of IV antibiotics with adjunctive lavage is controversial since antibiotics are preferably given IP and peritoneal defense might be impaired during lavage (2). With respect to the antibiotics route, studies comparing IP to IV/oral route with the same antibiotics were relatively scarce in the literature and there was a lack of concrete evidence supporting the superiority of the IP route. While IP vancomycin/ tobramycin was superior to IV-arm only in gram-positive peritonitis (3), similar effectiveness was found between IP and IV vancomycin in a trial (4), and another fluoroquinolone study favoring the IP route was limited by very high bacterial resistance (5). Lavage may enhance removal of inflammatory cells and bacteria (6) and might account for the better pain control that was consistently seen in our series. Although we did not perform o bjective
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
805
Downloaded from http://www.pdiconnect.com/ at WASHINGTON UNIVERSITY on November 14, 2015
2. Hsu CH, Wang CC, Jeng LB, Chen MF. Obturator hernia: a report of eight cases. Am Surg 1993; 59:709–11. 3. Igari K, Ochiai T, Aihara A, Kumagai Y, Iida M, Yamazaki S. Clinical presentation of obturator hernia and review of the literature. Hernia 2010; 14:409–13. 4. Nasir BS, Zendejas B, Ali SM, Groenewald CB, Heller SF, Farley DR. Obturator hernia: the Mayo Clinic experience. Hernia 2012; 16:315–9. 5. Meziane MA, Fishman EK, Siegelman SS. Computed tomographic diagnosis of obturator foramen hernia. Gastrointest Radiol 1983; 8:375–7. 6. Schmidt PH, Bull WJ, Jeffery KM, Martindale RG. Typical versus atypical presentation of obturator hernia. Am Surg 2001; 67:191-5. 7. Lobo DN, Clarke DJ, Barlow AP. Obturator hernia: a new technique for repair. J R Coll Surg Edinb 1998; 43:33–4. 8. Sorelli PG, El-Masry NS, Garrett WV. Open femoral hernia repair: one skin incision for all. World J Emerg Surg 2009; 4:44. 9. Hachisuka T. Femoral hernia repair. Surg Clin N Am 2003; 83:1189–205. 10. Nelson M, Aravind B, Davies C, Sullivan B, Tayton K, Stephenson BM. Obturator hernioplasty: a new operative approach and technique of repair. Ann R Coll Surg Engl 2003; 85:61–2. 11. Tanaka N, Kikuchi J, Ando T. Elective plug repair of an incarcerated obturator hernia by the thigh approach after noninvasive manual reduction: report of two cases. Surg Today 2010; 40:181–4.
SHORT REPORTS
NOVEMBER 2014 – VOL. 34, NO. 7
SHORT REPORTS
2. Twardowski ZJ, Nolph KD, Rubin J, Anderson PC. Peritoneal dialysis for psoriasis. An uncontrolled study. Ann Intern Med 1978 Mar; 88(3):349–51. 3. Whittier FC, Evans DH, Anderson PC, Nolph KD. Peritoneal dialysis for psoriasis: a controlled study. Ann Intern Med 1983 Aug; 99(2):165–8. 4. Gotloib L, Fudin R. Use of peritoneal dialysis and mesothelium in non primary renal conditions. Adv Perit Dial 2009; 25:2–5. 5. Hanicki Z, Cichocki T, Klein A, Smole´nski O, Sułowicz W, Czabanowska J. Dialysis for psoriasis — preliminary remarks concerning mode of action. Arch Dermatol Res 1981; 271(4):401–5. doi: 10.3747/pdi.2013.00249
An obturator hernia is a rare type of internal hernia that was first described in 1724 by Arnaud de Ronsil (1). This hernia is characterized by protrusion of the abdominal contents through the obturator foramen. The signs and symptoms of obturator hernia are nonspecific, and a missed diagnosis can result in significant morbidity and mortality. We present the case of a patient being treated by continuous ambulatory peritoneal dialysis (CAPD) who was diagnosed with an obturator hernia and describe the treatment and successful outcome. CASE REPORT
A 58-year-old woman, who had borne 2 children and was on CAPD due to liver cirrhosis and massive ascites that were secondary to chronic hepatitis B and C viral infections and end-stage renal disease, presented with a 1-year history of a right proximal, medial thigh mass. The soft, non-tender, reducible mass was approximately 10 cm in diameter. The patient denied abdominal pain, nausea, vomiting, or constipation. Ultrasound indicated a 7 × 4.2 cm cystic lesion in the right inguinal region that appeared to be related to fluid extravasation through the obturator foramen. Pelvic computed tomography (CT) indicated fluid extending from the right obturator foramen to the right thigh, about 13.1 cm in the largest dimension. There were no definitive bowel loops in the hernia sac (Figure 1). Hernia surgery involved a skin incision from the pubic tubercle to 10 cm above the mid-thigh. The surgical field was opened down to the adductor magnus muscle. The gracilis muscle and the adductor longus muscle were dissected. The anterior and posterior branches of the obturator nerve were recognized and protected. The
Figure 1 — Pelvic computed tomography (CT) scanning indicated fluid (about 13.1 cm in the largest dimension) extending from the right obturator foramen to the right thigh.
hernia sac was then identified and carefully dissected. The abdominal fluid was then released from the CAPD catheter using a suction machine. The hernia sac was reduced into the peritoneal cavity, and a cone plug (Optilene Mesh Elastic, B. Braun Melsungen AG, Germany) was inserted into the obturator canal. A 5 × 8 cm mesh (Optilene Mesh Elastic, B. Braun Melsungen AG, Germany) was then sutured to the superior ramus of the pubic bone superiorly, the adductor magus muscle inferiorly, the pectineal muscle anteriorly, and the obturator externus muscle posteriorly. A Jackson-Pratt drain was inserted into the obturator area, and the skin was closed with 4-0 nylon. A hernia belt was used to compress the hernia site for three months after surgery. Continuous ambulatory peritoneal dialysis was continued, but with half the amount of the dialysate and twice the frequency for 2 weeks after surgery. The Jackson-Pratt drain was removed after the drainage had decreased. The patient was discharged 4 days after surgery and was in stable condition. There was no evidence of a recurrent hernia during the 50 months of follow-up. DISCUSSION
Obturator hernias account for approximately 0.073% of all hernias (1). In Taiwan, 9 patients (8 females) presented with this condition from 1993 to 2003 at Kaohsiung Veterans General Hospital. Most patients are elderly multiparous women (2). Igari et al. reported 10 cases of obturator hernia affecting elderly, thin women (3), all of whom had symptoms of intestinal obstruction (i.e. vomiting with abdominal and/or thigh pain), but
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
803
Downloaded from http://www.pdiconnect.com/ at WASHINGTON UNIVERSITY on November 14, 2015
Treatment of Obturator Hernia in a Patient Undergoing Peritoneal Dialysis
SHORT REPORTS
NOVEMBER 2014 – VOL. 34, NO. 7 PDI
804
a tension-free mesh to stimulate a local inflammation reaction, with the edematous tissue improving access to the obturator hernia. We also used a hernia belt to maintain compression for three months after surgery. After 50 months of follow-up, there was no recurrent hernia or other significant problems. The technique described here is especially useful for patients undergoing CAPD. We recommend that this simple method be considered as standard for treatment of an obturator hernia in a patient undergoing CAPD. DISCLOSURES
This work was funded by grants from Taipei Veterans General Hospital (V102 C-183) and the Program for Progress Towards Top-Level University in National Yang Ming University to TH Chen; Taipei Veterans General Hospital Grant (V102 A-014) to P-J Tsai. Shih-Yi Kao1 Ta-Chung Lee2 Zen-Chung Weng3 Tien-Hua Chen4 Pei-Jiun Tsai5,6* Ten-Chan General Hospital Zhongli1 Taoyuan, Taiwan, R.O.C. Department of Rehabilitation & Health Center2 Su-Ao & Yuan Shan Branch of Taipei Veterans General Hospital, Taiwan, R.O.C. Division of Cardiovascular Surgery3 Department of Surgery, Taipei Medical University Hospital Taipei, Taiwan, R.O.C. Department of Surgery3 School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, R.O.C. Department of Surgery4 Veterans General Hospital, National Yang Ming University School of Medicine, Taipei, Taiwan, R.O.C. Institute of Clinical Medicine5 National Yang-Ming University, Taipei, Taiwan, R.O.C. Department of Critical Care Medicine6 Veterans General Hospital, Taipei, Taiwan, R.O.C. *email: [email protected] REFERENCES 1. Petrie A, Tubbs RS, Matusz P, Shaffer K, Loukas M. Obturator hernia: anatomy, embryology, diagnosis, and treatment. Clin Anat 2011; 24:562–9.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
Downloaded from http://www.pdiconnect.com/ at WASHINGTON UNIVERSITY on November 14, 2015
none of whom had previous abdominal surgery. The differential diagnosis in such cases should include obturator hernia, because early diagnosis and prompt initiation of treatment reduces the risk of surgical complications and is associated with improved outcomes (4). Our patient had none of the symptoms suggestive of an intestinal obstruction; however, the presence of increased intraabdominal pressure as a result of massive ascites from liver cirrhosis and end-stage renal disease likely contributed to the formation of the obturator hernia. Meziane et al. first reported the use of CT scanning for the diagnosis of obturator hernia in 1983 (5). Since the widespread adoption of CT scanning, the pre-operative diagnosis has improved from 43% to 90% in some reports (6). In our case, a pelvic CT scan indicated a mass with septations and fluid extending from the right obturator foramen into the right thigh. There were no bowel loops in the hernia sac. There are various methods for repair of an obturator hernia (7), and most of these are similar to the methods used for a femoral hernia (8). A midline incision provides the best exposure, allows reduction of the hernia contents, and facilitates bowel resection if necessary. However, exploratory laparotomy and the inguinal approach were contraindicated for our patient. The patient could not tolerate hemodialysis due to the risk of a precipitous drop in blood pressure. It was necessary to maintain an integral abdominal cavity so that CAPD could be continued, because this was the only renal replacement therapy available for this patient. Thus, we considered a thigh approach to be better for our patient. Lobo et al. presented a simple technique for obturator hernia repair in which a polypropylene mesh (Ethicon Endo-Surgery, Inc, Ohio, USA) is sutured to Cooper’s ligament (7), and then allowed to cover the obturator canal. This method is similar to the tensionfree mesh femoral hernioplasty proposed by Irving Lichtenstein in 1974 (9). The tension-free mesh covers the hernia defect and micrifies it by the resulting inflammation reaction. Another repair method, proposed by Nelson et al. in 2003 (10) and modified by Tanaka et al. in 2010 (11), utilizes an incision from the pubic tubercle to 10 cm above the mid-thigh. The hernia sac is identified and reduced into the peritoneal cavity, followed by insertion of a cone plug. The technique employs a mesh plug, which is now well established in groin hernioplasty. This plug sits astride the defect of the obturator canal in the preperitoneal plane, with the position effectively maintained by the essential intra-abdominal pressure. In our case, we modified Lockwood’s infra-inguinal approach and combined the concepts of tension-free mesh and a plug. Thus, we used a plug to resolve the increased intra-abdominal pressure caused by CAPD and
PDI
NOVEMBER 2014 – VOL. 34, NO. 7
doi: 10.3747/pdi.2013.00116
Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis Refractory peritonitis is a major cause of peritoneal dialysis (PD) technique failure that requires catheter removal (1). To date, there is no well-proven adjuvant treatment for PD peritonitis when response to antibiotics is suboptimal. In our center, intravenous (IV) antibiotics with adjunctive lavage was offered when pending catheter removal in refractory cases, after we first experienced an unexpected cure in 2010 when such strategy was applied for symptom relief. In the present case series, we present the outcomes of IV antibiotics with adjunctive lavage in severe PD peritonitis. CASE SERIES
In our center, cefazolin/ceftazidime are empirical antibiotics of choice upon presentation of PD peritonitis and are adjusted subsequently according to microbiology reports. In non-responsive cases, antibiotics escalation is often considered and catheter removal arranged when
deemed refractory, where wait times for the procedure varies depending on operating room availability. From November 2010 to December 2012, there were 13 peritonitis episodes in 12 patients who had received IV antibiotics with adjunctive lavage when pending catheter removal (except 1 who declined the procedure). Lavage was performed by the Baxter HomeChoice automated peritoneal dialysis system (Baxter Healthcare Corporation, Deerfield, IL, USA) with fill volume at 2 L and 2-hour dwell time usually over 48 to 72 hours. Antibiotics were switched from intra-peritoneal (IP) to IV route during lavage and back to the IP route when the usual PD schedule resumed. Among the 13 peritonitis episodes, there were 2 fungal and 2 tuberculosis cases that had catheters removed as planned. Both tuberculosis episodes were considered culture-negative initially as their culture results were available only after catheter removal. The other 9 bacterial peritonitis cases were our subjects of interest, with patients’ details and peritonitis progress shown in Table 1 and Figure 1, respectively. Successful cure was achieved in 6 episodes where catheter removal could be withheld. We need to highlight Patient H, a frail elderly person who declined catheter removal and hemodialysis. Respecting her desire for comfort care, repeated lavage was offered that often resulted in pain improvement and worsened again once cycler was off. Her trend of C-reactive protein (CRP) changes is included in Figure 1, which seemingly paralleled usage of lavage. We decided against further lavage eventually when her general condition was poor and she succumbed. DISCUSSION
Management options are limited for refractory peritonitis patients who refuse catheter removal or have poor tolerance to hemodialysis. Our strategy of IV antibiotics with adjunctive lavage is controversial since antibiotics are preferably given IP and peritoneal defense might be impaired during lavage (2). With respect to the antibiotics route, studies comparing IP to IV/oral route with the same antibiotics were relatively scarce in the literature and there was a lack of concrete evidence supporting the superiority of the IP route. While IP vancomycin/ tobramycin was superior to IV-arm only in gram-positive peritonitis (3), similar effectiveness was found between IP and IV vancomycin in a trial (4), and another fluoroquinolone study favoring the IP route was limited by very high bacterial resistance (5). Lavage may enhance removal of inflammatory cells and bacteria (6) and might account for the better pain control that was consistently seen in our series. Although we did not perform o bjective
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
805
Downloaded from http://www.pdiconnect.com/ at WASHINGTON UNIVERSITY on November 14, 2015
2. Hsu CH, Wang CC, Jeng LB, Chen MF. Obturator hernia: a report of eight cases. Am Surg 1993; 59:709–11. 3. Igari K, Ochiai T, Aihara A, Kumagai Y, Iida M, Yamazaki S. Clinical presentation of obturator hernia and review of the literature. Hernia 2010; 14:409–13. 4. Nasir BS, Zendejas B, Ali SM, Groenewald CB, Heller SF, Farley DR. Obturator hernia: the Mayo Clinic experience. Hernia 2012; 16:315–9. 5. Meziane MA, Fishman EK, Siegelman SS. Computed tomographic diagnosis of obturator foramen hernia. Gastrointest Radiol 1983; 8:375–7. 6. Schmidt PH, Bull WJ, Jeffery KM, Martindale RG. Typical versus atypical presentation of obturator hernia. Am Surg 2001; 67:191-5. 7. Lobo DN, Clarke DJ, Barlow AP. Obturator hernia: a new technique for repair. J R Coll Surg Edinb 1998; 43:33–4. 8. Sorelli PG, El-Masry NS, Garrett WV. Open femoral hernia repair: one skin incision for all. World J Emerg Surg 2009; 4:44. 9. Hachisuka T. Femoral hernia repair. Surg Clin N Am 2003; 83:1189–205. 10. Nelson M, Aravind B, Davies C, Sullivan B, Tayton K, Stephenson BM. Obturator hernioplasty: a new operative approach and technique of repair. Ann R Coll Surg Engl 2003; 85:61–2. 11. Tanaka N, Kikuchi J, Ando T. Elective plug repair of an incarcerated obturator hernia by the thigh approach after noninvasive manual reduction: report of two cases. Surg Today 2010; 40:181–4.
SHORT REPORTS
