[Expert opinion on the basic surgical technique for laparoscopic ventral hernia repair]. / Técnica quirúrgica básica consensuada para el tratamiento por vía laparoscópica de las hernias ventrales.

Laparoscopic ventral hernia repair is currently the subject of intense debate, even though it provides a series of advantages over open surgery and is feasible and safe. Various studies have shown this technique to be as effective as open repair with a lower recurrence rate. Despite the excellent results of laparoscopic repair of ventral hernias, there are numerous controversies associated with this procedure. These controversies concern the indications and contraindications of the procedure, and technical aspects such as how to create the pneumoperitoneum, perform adhesiolysis, manage the hernia sac, and insert and fix the mesh to the anterior abdominal wall. Also controversial are outcome, complications related to postoperative seroma, and which type and size of mesh should be used. The present article aims primarily to address many of these issues, based on the experience of distinct surgeons with expertise in this approach, in order to provide data to establish a consensus on how laparoscopic ventral hernia repair should be performed.

The impact of the surgeon's experience on the results of laparoscopic hernia repair.

BACKGROUND: The aim of this study was to evaluate our experience with the totally extraperitoneal (TEP) laparoscopic approach to hernia repair. METHODS: We performed a prospective study of 1227 hernia repairs using the TEP technique over a 7-year period. The main outcome measurements were postoperative complications, conversion rate, learning curve effect, surgery time, hospital stay, return to work, and recurrence rate. RESULTS: The mean operating time was > 60 min during the first 50 cases, but it fall to 32 min for the last 200 cases (p < 0.05). The conversion rate was 5.7% (56 patients); declining from 17% in the first 100 cases to 2.2% for the final 500 cases (p < 0.01). There were 79 complications (6.4%) and 23 recurrences (2.3%); 42% of the complications and 61% of the recurrences appeared in the first 100 cases (p < 0.05). CONCLUSION: This study shows that postoperative complications, conversion rate, operating time, and recurrences are all substantially reduced as the surgeon's experience increases. Thus, once the learning curve is surpassed, TEP repair represents a good alternative to open techniques.

Evolution of laparoscopic cholecystectomy in the regional hospitals of Catalonia.

OBJECTIVE: to assess the safety and effectiveness of laparoscopic cholecystectomy in the hands of surgeons with different amounts of experience in laparoscopic surgery at 15 regional hospitals, and to analyze the evolution of the current performance in comparison with results published in 1993. METHODS: prospective study of 1168 laparoscopic cholecystectomies done in 1996 in 15 regional hospitals in Catalonia. RESULTS: in 887 cases (76%) the indication was uncomplicated cholelithiasis. Preoperative cholangiography was done selectively in 12 of the 15 hospitals. Preoperative endoscopic retrograde cholangiopancreatography was positive in only 50 cases (57.4%), with 9 complications (10.3%). In 87 patients (7.4%) conversions to open surgery occurred. Postoperative complications (6. 3%), bile duct injury (0.4%), reintervention (0.4%) and postoperative stay (2.8 days) decreased in comparison with the year 1993. CONCLUSIONS: the current results suggest an overall improvement in comparison with the 1993 findings, since the rate of complications and length of stay decreased. However, the increasing number of conversions was notable; this may be due to the increasing complexity of the indications and the rise in the number of surgeons still on the learning curve. Laparoscopic cholecystectomy is, in our setting and for many surgeons, a safe and effective procedure that yields results similar to those in other multicenter studies.

[Topical nitroglycerin: an alternative in the conservative treatment of biliary fistula]. / Nitroglicerina tópica: una alternativa en el tratamiento conservador de la fístula biliar.

A patient with post-laparoscopic cholecystectomy cystic duct leak successfully treated with conservative treatment is presented. The cystic duct leak was diagnosed through a CPRE where a Oddy sphyncter spasm was noted. The use of a topic Nytroglicerine resulted in a sphincter release and resolution of the fistula. A literature review of the importance of CPRE in the diagnosis and treatment of biliary injuries was carried out. In patients with nondilated bile ducts where the sphincterotomy or endoprothesis undergo with high morbidity, the use of topic nitroglycerine could be an effective alternative procedure.