Chronic neuropathic pain following inguinal hernia repair Toufik Berri Formosan Journal of Surgery 2019 52(4):111-121 Since recurrence rates have been considerably reduced with mesh repairs, chronic pain has recently become the main concern after inguinal hernia repair (IHR), with significant impact on patient satisfaction, societal cost, and quality of life. Some 31% of all patients with persistent postsurgical pain develop neuropathic pain (NP) after IHR seeing that the inguinal nerves that cross the surgical field can directly or indirectly be damaged. Because of the multiplicity of the risk factors and the complexity of the pathophysiological mechanisms, substantial attention has been devoted to the multidisciplinary approaches and to the preventive measures. More clinical trials are needed to improve the level of evidence of the use of pharmacological, surgical, and interventional procedures in both prevention and treatment of chronic NP following IHR. In this article, the current objectives are to review the incidence, risk factors, pathogenesis, diagnosis, prevention, and treatment of chronic NP after IHR.

Simultaneous or staged operation? Timing of cranioplasty and ventriculoperitoneal shunt after decompressive craniectomy Hsin-Yao Lin, Kai-Chun Lin, Cheng-Chia Tsai, Dehui Wan Formosan Journal of Surgery 2019 52(4):122-126 Aims: Cranioplasty and ventriculoperitoneal shunt (VPS) are common procedures for patients who undergo decompressive craniectomy. The ideal time for these two procedures remains controversial. Settings and Design: This is a retrospective, single institute, chart review comparing the complications associated with simultaneous and staged cranioplasty and VPS. Materials and Methods: From January 2012 to December 2017, 56 patients who underwent both cranioplasty and VPS surgery at our hospital were separated into simultaneous or staged operation groups. We compared the demographic data and complications, including infections, subdural or epidural hemorrhage, and revision surgery between the groups. Statistical Analysis Used: Independent Student's t-test was used for analysis of continuous variables, and Fisher's exact test was used for categorical data. MedCalc (version: 18.11) was used to perform all analysis. Results: Nineteen patients underwent simultaneous cranioplasty and VPS, whereas 37 underwent staged operation. Etiologies for craniectomy included traumatic brain injury, infarction, spontaneous subarachnoid hemorrhage, and spontaneous intracerebral hemorrhage. There were no significant differences in the baseline characteristics between the groups. The overall complication rate was 14.3%. Three (15.8%) patients experienced complications in the simultaneous group: One (5.3%) with skin infection and two (10.5%) with overdrainage. Five (13.5%) patients experienced complications in the staged group: three (10.8%) with skin infections, one with central nervous system (CNS) infections, and one with both skin and CNS infections. Overall complications, wound infections, CNS infections, overdrainage, and revision surgery showed no significant differences between the groups. Conclusions: Simultaneous cranioplasty and VPS showed complication rates similar to those of staged operation.

How to differentiate abdominal wall leiomyomas from desmoid tumors? Tommy Nai-Jen Chang, Ming-Mo Hou, Mohamed AbdelRahman, Chih-Wei Wang, Li-Jen Wang, Dennis S Kao, Shao-Chih Hsu, Soo-Ha Kwon, Shih-Yin Huang, John Wen-Cheng Chang, Chih-Hung Lin Formosan Journal of Surgery 2019 52(4):127-132 Background: Desmoid tumor and leiomyoma are abdominal wall tumors with similar clinical, radiographic, and histological features. However, differentiation between these two diseases is important because each may be linked to different systemic diseases, and their managements are entirely different. We proposed that misdiagnosis is possible in some cases. Patients and Methods: Between 1983 and 2010, patients with a history of uterine surgeries and diagnosed with either abdominal wall desmoid tumors or leiomyomas were studied. All the images reviewed by an independent radiologist and surgical specimen were reexamined by immunohistochemistry (IHC) techniques as a standard method to confirm the diagnoses. Results: Fifteen female patients (desmoid tumors, n = 10; leiomyomas, n = 5) were included. The diagnosis of IHC revealed that two cases initially thought to be leiomyomas were desmoid tumors, whereas the remaining 13 cases maintained their initial diagnoses. The accuracy of hematoxylin and eosin staining was 86.7%. All tumors excised without complications, except for one desmoid tumor that recurred and underwent another excision. Conclusion: Preoperative magnetic resonance imaging (MRI) can be considered to differentiate the two diseases, as well as the elimination of other associated systemic diseases should be performed routinely. If MRI is inaccessible or unavailable, preoperative fine-needle biopsy is recommended. Optional IHC staining is required if the primary histological assessment is equivocal or inconclusive.

Mini-single-incision laparoscopic cholecystectomy: Pursuing the least invasive procedure Shu-Hung Chuang Formosan Journal of Surgery 2019 52(4):133-138 Background: Both mini-laparoscopic surgery and single-incision laparoscopic surgery are feasible and safe alternatives to conventional multi-incision laparoscopic surgery. Materials and Methods: Fifty-one conventional single-incision laparoscopic cholecystectomies (CSILCs) and 34 mini-single-incision laparoscopic cholecystectomies (MSILCs) were performed by a single surgeon for uncomplicated diseases. Compared with a 2-cm paraumbilical incision in CSILC, the incision in MSILC was 1.2 cm in length. Results: In the CSILC period, all the procedures were performed successfully except one (2.2%). In the MSILC period, 6 (15%) CSILCs and 34 (85%) MSILCs were scheduled. All the former procedures were successful, whereas three MSILCs were converted to CSILCs. Fewer patients needed more than two pethidine doses, and the accumulated dosage was lower in the MSILC period compared with the CSILC period (2 [5.0%] vs. 11 [24.4%] and 0.595 ± 0.505 mg/kg vs. 0.936 ± 0.912 mg/kg, P < 0.05). The complication rates were 2.2% and 2.5% in the CSILC and MSILC periods, respectively (Clavien–Dindo Grade I). Conclusion: MSILC can be performed safely for uncomplicated diseases. Compared with CSILC, MSILC has advantages of reduced postoperative pain and faster recovery but potentially increases operative time. Careful patient selection with a low threshold of conversion is obligatory.

Late-onset radial nerve palsy associated with conservatively managed humeral shaft fracture Wahyu Widodo, Elfikri Asril, Rizky Priambodo Wisnubaroto Formosan Journal of Surgery 2019 52(4):139-142 Radial nerve palsy commonly associated with humeral shaft fracture, at the time of injury (primary), after manipulation (secondary), or late onset (not related to injury or manipulation). For the latter, there are still few documented cases regarding late-onset radial nerve palsy. In this case report, we present a case of late-onset radial nerve palsy associated with humeral shaft fracture treated with coaptation splint, which became evident 5 weeks after treatment. Surgical exploration revealed that the radial nerve had become stretched and encapsulated in callus and fibrous tissue. Neurolysis was performed with subsequent recovery of the radial nerve 12 weeks after the surgery.

Multiple paragangliomas involving carotid body and vagal region Jaimanti Bakshi, Atul Kumar Goyal, Dharam Vir, Naresh Kumar Panda Formosan Journal of Surgery 2019 52(4):143-146 Paragangliomas are rare neuroendocrine tumors also known to occur in the head-and-neck regions and generally involve the carotid body or vagal region. Till date, only a single study has reported the occurrence of paragangliomas involving both the carotid body and vagal region. The present study, to the best of our knowledge, is the second study in the world which reported the multiple paragangliomas involving the carotid body and vagal region. The patient in the present case study was a 45-year-old male with a single swelling in the left upper part of the neck. In the preoperative clinical examination, the swelling was identified as carotid body tumor, and the patient was then planned for surgery. The intra-operative findings revealed that it involved both the vagal and carotid body and was subsequently operated successfully. Postoperatively, the swelling was described as bilateral carotid paragangliomas with left vagal paraganglioma.

Retiform and epithelioid hemangioendothelioma arising from the spleen Chuang-Wei Chen, Koung-Hung Hsiao, Tzung-Ju Lu, Chieh-Wen Lai Formosan Journal of Surgery 2019 52(4):147-150 Splenic hemangioendothelioma (HE) is an extremely rare vascular tumor with an uncertain malignant potential. Experience of treatment with this tumor is limited due to their rare occurrence. We herein describe a case of a 53-year-old woman who was found a splenic tumor incidentally. Radiological findings revealed marked splenomegaly with multiple ill-defined hypodense masses as well as a low-density nodule at the left lobe of the liver. The patient underwent splenectomy and wedge resection of the liver. Final pathology confirmed the diagnosis of an admixture of retiform and epithelioid HE of the spleen with metastasis of the liver. However, distant metastases of bilateral lungs developed 6 months after the operation. She received oral thalidomide therapy without significant progression of the disease over a period of 26 months' follow-up. To the best of our knowledge, only 11 cases had been described in the literature. We report the first case of splenic HE metastatic to both liver and lungs. Our patient received thalidomide, a drug with antiangiogenic action, was shown to let the disease progression slow down. It may be recommended for those patients with relapsed disease or metastases.

Clipping of spinal arteriovenous fistula of the filum terminale under intraoperative angiography guidance Yun-Ju Lee, Kai-Chun Lin, Cheng-Chia Tsai, Hsin-Yao Lin Formosan Journal of Surgery 2019 52(4):151-153 Arteriovenous fistula of the filum terminale (AVFFT) is an uncommon disease. We reported a case of this rare condition and we used intraoperative angiography to identify the completeness of fistula obliteration. A 53-year-old man presented with a history of low back pain and radiating pain of bilateral legs for 2 months. Lumbar spine magnetic resonance imaging revealed edema of conus medullaris at the T10–L1 level; engorged vein was also identified from L1 to L4. Digital subtraction angiography confirmed the diagnosis of AVFFT. Clipping of fistula was successfully performed, and complete obliteration was confirmed by intraoperative angiography. Magnetic resonance imaging follow-up showed no edema postoperatively. The patient's symptoms/signs improved tremendously. Both radiological and clinical outcomes were good after complete occlusion of the fistula was done. Hence, we suggested intraoperative angiography in hybrid OR as a useful tool to identify the fistulous point and confirm complete occlusion the fistula.