eTEP inferior access with tailored retromuscular dissection for small to mid-sized umbilical hernia repair with or without inguinal hernia: early experience.

INTRODUCTION: The minimally invasive surgical repair of combined inguinal and ventral hernias often requires shifting from one approach or plane to another. The traditional enhanced-view totally extraperitoneal Rives-Stoppa repair consists of a large retro muscular dissection that is unjustified for small ventral hernias. Here we describe a modification to the minimally invasive Rives-Stoppa repair using a limited retro muscular dissection based on the ventral defect size for small/medium-sized hernias, with or without combined inguinal hernias. METHODS: From a single surgical team, a retrospective study was performed over a 1-year period. Demographics, hernia characteristics, surgical techniques, intraoperative/postoperative complications, and outcomes were all analyzed and reported. We also included detailed surgical steps, landmarks, pitfalls, and personal tips for this technique. RESULTS: Twenty-four patients underwent a laparoscopic limited retromuscular dissection ventral hernia repair utilizing the eTEP access technique. Eighteen were primary umbilical hernias and six postoperative incisional hernias, and nine were combined ventral and inguinal hernia repairs. Eight of the primary umbilical hernias were EHS classified as medium size, 11 small, and for the incisional hernias, three were classified as M3W1 and two as M3W2. One procedure was converted to TAPP. There were no intraoperative complications. The mean length of stay was 1.25 days (range 1-3). There was one postoperative retromuscular hematoma and no recurrence during the follow-up period. CONCLUSION: eTEP with limited dissection offers a good and safe solution for small to medium size hernias; it provides an efficient solution when an inguinal hernia is to be addressed as well.

Proctored preceptorship model for learning eTEP repair for inguinal hernia for general surgery residents.

BACKGROUND: Enhanced-view total extra-peritoneal (eTEP) inguinal hernia repair is a technically demanding procedure with a steep learning curve. AIM: Examine the feasibility and effectiveness of an instructor approach to teaching residents how to perform laparoscopic eTEP independently following a dedicated course of individual teaching. METHODS: Prospective analysis of eTEP procedures performed by residents between March 2018 and September 2020. Six residents dispersed into three groups-Group A: two junior residents, Group B: two mid-level residents and Group C: two senior residents. All residents performed a unilateral IHR comprised of five core steps. Data reviewed for each procedure included the time of each step, total time and autonomy degree as assessment for every step: 1st degree-dependent (physical assistance), 2nd degree-partially dependent (vocal assistance) and 3rd degree-independent. Early and late procedures were divided at 50% of cases. RESULTS: Participants performed 44 procedures (220 steps). Late procedures presented with a significant improvement in all degrees of autonomy (1st degree p = 0.002, 2nd degree p = 0.007 and 3rd degree p < 0.0001) and in every step (Step 1 p = 0.015, Step 2 p = 0.006, Step 3 p < 0.0001, Step 4 p < 0.0001, Step 5 p = 0.002). There was no significant difference in surgery duration between early and late procedures (p = 0.32). At early procedures, junior residents needed significantly higher rates of physical intervention (1st degree) compared to the senior residents (p = 0.004). Conversely, there was no significant difference in 2nd degree of autonomy (p = 0.46), 3rd degree (p = 0.06) and surgery duration (p = 0.16). The last three procedures performed by all participants had no significant difference between the seniority groups in autonomy (1st degree p = 0.1, 2nd degree p = 0.18 and 3rd degree p = 0.1). CONCLUSION: Dedicated course with an individual instructor's approach is effective in achieving competence, autonomy and confidence in performing eTEP in a short time.

Core Body Temperature but Not Intraabdominal Pressure Predicts Postoperative Complications Following Closed-System Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Administration.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) following cytoreductive surgery (CRS), performed using closed-abdomen technique (CAT), may affect intraabdominal pressure (IAP). High IAP may increase postoperative complications due to decreased venous return and hypoperfusion to vital organs. Elevated core body temperature (CBT) may cause multiorgan dysfunction. Low IAP or CBT could result in suboptimal HIPEC and potentially translate into early disease recurrence. The aim of the present study is to identify possible correlations between IAP or CBT and postoperative complications. PATIENTS AND METHODS: Continuous intraabdominal pressure measurement was performed by intraabdominal catheter. Inflow temperature was set at 44 °C, and mean perfusate temperature was 42 °C. CBT was measured continuously in the distal esophagus. We compared the rate of postoperative complications between the low IAP group (2-10 mmHg, n = 28), target IAP group (10-20 mmHg, n = 71), and high IAP group (20-34 mmHg, n = 16) as well as with CBT as a continuous variable. RESULTS: 115 patients were included in the study. There was no difference between IAP groups in terms of age, gender, primary diagnosis, operative peritoneal cancer index, CBT, or operative time. There was no correlation between IAP and postoperative complications or with prolonged hospital stay. On multivariate analysis, elevated mean CBT was a positive predictor of postoperative complications (p = 0.035). CONCLUSIONS: IAP level during closed-abdomen technique HIPEC is not associated with postoperative complications. However, elevated CBT may increase postoperative complications.

Acute Appendicitis During Pregnancy: Different from the Nonpregnant State?

BACKGROUND: Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. However, the current literature is scarce and composed of relatively small case series. We aimed to compare the presentation, management, and surgical outcomes of presumed acute appendicitis between a contemporary cohort of pregnant women and nonpregnant women of reproductive age. METHODS: The study group included 92 pregnant patients who underwent appendectomy for presumed acute appendicitis at a single tertiary medical center in 2000-2014. Preoperative, operative, and postoperative clinical data were derived from medical records and compared to data for 494 nonpregnant patients of reproductive age who underwent appendectomy in 2004-2007 at the same institution. RESULTS: Median age was 28 years (range 25-33) in the study group and 26 years (range 20-34) in the control group (P = 0.1). There were no between-group differences in mean white blood cell count, patient interval, hospital interval, or operative time. Preoperative abdominal ultrasound was used in a significantly higher proportion of patients in the pregnant group than in the nonpregnant group (73 and 27 %, respectively, P < 0.001) and computed tomography, in a significantly lower proportion of patients (1 vs. 16 %, respectively, P < 0.001) . The two groups had similar rates of negative appendectomy (23 and 22 %, P = 0.9), complicated appendicitis (12 and 11 %, P = 0.9), and overall postoperative complications (15 and 12 %, P = 0.3). CONCLUSIONS: The clinical presentation and outcome of presumed acute appendicitis are similar in pregnant women and nonpregnant women of reproductive age. Therefore, similar perioperative management algorithms may be applied in both patient populations.

Bisphosphonate-related jaw necrosis: a team approach management and prevention.

Osteonecrosis means the process of bone death. Bisphosphonates (BPs) are becoming recognized increasingly as having a significant impact on dental treatments. BPs are the most widely used class of anti-resorptive drugs. They prevent bone resorption through osteoclast inhibition and are considered the standard of care for the management of metastatic bone disease. BPs are used for the treatment of skeletal disorders such as osteoporosis, hypercalcaemia of malignancy, osteolytic lesions arising from solid tumours and Paget's disease, breast cancer or prostate cancer. Jaw necrosis appears to be associated with the intravenous (i.v.) use of BPs. The aim of this review paper is to update the understanding of healthcare professionals to the osteonecrosis of jaws, mechanism of action and classification of BPs, management of the patients with BP-related osteonecrosis (BRON) of the jaws. An interdisciplinary approach has been emphasized to prevent and manage the condition. Finally, the role of dental practitioners including dental hygienists has been discussed to early diagnose the BRON and improve the quality of life of patients with the condition.

Halitosis among racially diverse populations: an update.

The aim of this paper is to highlight the cultural perceptions of halitosis to dental professionals. Halitosis (oral malodour or bad breath) is caused mainly by tongue coating and periodontal disease. Bacterial metabolism of amino acids leads to metabolites including many compounds, such as indole, skatole and volatile sulphur compounds (VSC), hydrogen sulphide, methyl mercaptan and dimethyl sulphide. They are claimed to be the main aetiological agents for halitosis. Gastrointestinal diseases are also generally believed to cause halitosis. In general, physicians and dentists are poorly informed about the causes and treatments for halitosis. The paper reviews the prevalence and distribution of halitosis, oral malodour, its aetiology, concepts of general and oral health and diseases and their perception among racially diverse population. Eating, smoking and drinking habits and understanding of halitosis as a social norm among different people has been highlighted. The treatment options have also been presented very briefly. A brief discussion about general importance within existing healthcare services has been highlighted. Oral malodour may rank only behind dental caries and periodontal disease as the cause of patient's visits to the dentist. It is a public social health problem. The perception of halitosis is different in culturally diverse populations. So the dental professionals should be aware of the cultural perceptions of halitosis among racially and culturally diverse populations. There is a need to integrate the cultural awareness and knowledge about halitosis among the dental professional for better understanding of halitosis to treat patients with the social dilemma of halitosis to improve the quality of life and well-being of individuals with the problem. It is concluded that dental professionals (especially dental hygienists) should be prepared to practice in a culturally diverse environment in a sensitive and appropriate manner, to deliver optimal oral health and hygiene care.