Erector Spinae Plane Block versus Transversus Abdominis Plane Block for Robotic Inguinal Hernia Repair: A Blinded, Active-Controlled, Randomized Trial.

BACKGROUND: Regional anesthetic nerve blocks are widely used in the treatment of pain after outpatient surgery to reduce opioid consumption. Erector spinae plane (ESP) block is a recently described technique with promising results in different scenarios. OBJECTIVES: To compare ESP block efficacy with the commonly used transversus abdominis plane (TAP) block in patients undergoing robot-assisted inguinal hernia repair. STUDY DESIGN: This was a randomized, blinded, active controlled, superiority trial with 2 parallel groups. The study was approved by the local ethics committee. Registration took place on; www. CLINICALTRIALS: gov with the identifier NCT04750512. SETTING: Adults undergoing robotic inguinal hernia repair were recruited between January 2021 and April 2022 in a single referral center of southern Switzerland. METHODS: To ensure blinding, the study employed a "double dummy" design, where all patients underwent both TAP and ESP blocks, but only one block was therapeutically active. The therapeutic block contained ropivacaine 0.2%, while the other infiltration contained placebo. The therapeutic intervention varied between groups, with one group receiving the TAP block as the active treatment and the other group receiving the ESP block as the active treatment. Computer generated 1:1 randomization determined allocation, which took place immediately prior to the intervention. As a result, blinding included patients, anesthesia, and surgery providers, outcome assessors and statistical analysts. The main outcome measure was the highest reported pain score on a Visual Analog Scale (VAS) during the 6 hours following the end of general anesthesia. Secondary outcomes included pain scores at set intervals, analgesic consumption, and complications. RESULTS: A total of 50 patients (25 per arm) were enrolled and included in the analysis. The study found no significant difference in the mean maximal VAS scores between the 2 groups (TAP block 22.2, ESP block 20, difference 2.2, 95% CI is -12.1 to 16.5). Secondary endpoints, including VAS pain scores at different time points, use of rescue analgesics, time to first walk, duration of stay, and frequency of adverse events, did not show any significant differences between the 2 groups. However, post-hoc analysis suggested a more stable effect over time for the ESP block compared to the TAP block. LIMITATIONS: The main limitation is a higher variance in VAS scores than expected in the power calculations. CONCLUSIONS: ESP block was not superior to TAP block in the treatment of post-operative pain among patients undergoing robotic inguinal hernia repair.

Three-point mesh fixation in robot-assisted transabdominal preperitoneal (R-TAPP) repair of 208 inguinal hernias: preliminary results of a single-center consecutive series.

PURPOSE: The aim of this study was to assess the efficacy of our mesh fixation technique in robot-assisted transabdominal preperitoneal inguinal hernia repair (R-TAPP). The primary outcome was the recurrence rate. Secondary outcomes were postoperative pain, chronic pain, and return to normal activities. METHODS: Between January 2018 and December 2019, we performed 208 consecutive R-TAPP in 161 patients and the mesh was fixed by three intracorporeal stiches using a Polyglactin 910 (Vicryl®) 3-0 suture. Patients were followed up at 10 and 30 days after surgery with a clinical evaluation for detection of early complications, postoperative pain, need for analgesics, return to normal activities, and satisfaction rate. Patients were further followed up at study conclusion in February 2021 for recurrence and chronic pain detection. RESULTS: Painkillers were stopped by 57% of the patients after the first postoperative day and by 96% after 1 week. Chronic pain (> 3 months after surgery) was observed in three patients (1.8%) and only one of them was treated with percutaneous ilioinguinal-iliohypogastric nerve infiltration. After a mean follow-up of 24.0 ± 6.7 months, only 1 recurrence (0.48%) was clinically detected and confirmed by a CT-scan. CONCLUSIONS: The 3-point mesh fixation technique is feasible during robot-assisted TAPP repair for inguinal hernia and seems to be a viable alternative to other fixation methods. Further long-term controlled investigations are needed to understand if this technique is effective in influencing recurrence and chronic pain rates.

Robot-assisted Treatment of Epigastric Hernias With a Suprapubic Approach.

BACKGROUND: Robot-assisted ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are placed laterally to meet the distance from the fascial defect. The aim of our study is to report our experience of epigastric hernia treatment with trocar insertion in the suprapubic region. MATERIALS AND METHODS: On a prospectively collected dataset on robot-assisted surgery, patients treated for epigastric hernias with suprapubic approach were identified. Demographic and clinical data were collected and analyzed. RESULTS: Twelve patients were selected. Median age was 58.5 years [interquartile range (IQR): 47.8 to 67.3 y]; 4 patients were male (33.3%) and the median body mass index was 23.9 kg/m2 (IQR: 22.3 to 26.2 kg/m2). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR: 13.75 to 31.0 mm); median larger mesh diameter was 13.5 cm (IQR: 9.5 to 15.0 cm); and median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication or conversion to open surgery occurred. Postoperatively, 2 patients presented a seroma and median length of hospital stay was 2.0 days (IQR: 1.75 to 3 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 4 to 29 mo). CONCLUSIONS: In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.

Surgical site infections after lung resection: a prospective study of risk factors in 1,091 consecutive patients.

BACKGROUND: To assess incidence and risk factors of surgical site infections (SSI) (wound infection, pneumonia, empyema) in a monocentric series of patients undergoing lung resection over a decade. METHODS: All patients undergoing lung resection at our institution in 2006-2015 [wedge resection, n=579; lobectomy, n=472 (12% after chemo/radiotherapy); pneumonectomy, n=40 (47% after chemo/radiotherapy)], were prospectively enrolled. Perioperative SSI risk factors were recorded: age, gender, blood haemoglobin, lymphocyte count, serum albumin, forced expiratory volume in 1 second percentage (FEV1%) of predicted, antibiotic prophylaxis, length of stay, diabetes, malignancy, steroid therapy, induction chemo/radiotherapy, resection in 2006-2010/2011-2015, urgent/elective procedure, videothoracoscopic/open approach, resection type, operative time. SSIs diagnosed within 30 days from surgery were prospectively recorded and association with risk factors was evaluated. RESULTS: Of the 1,091 resected patients [median age, 65 (range, 13-91) years; male, 74%; malignancy, 65%], 124 (11.4%) developed one or more SSI. Wound infection, pneumonia and empyema rates were respectively 3.2%, 8.3% and 1.9%, stable through the decade. Overall infection rates after wedge resection, lobectomy and pneumonectomy were 4.8%, 17.4% and 35.0%, respectively. Thirty-day postoperative mortality was 0.6%; of the 7 deaths, 4 were causally related with SSI. Multivariable analysis showed that male gender, diabetes, preoperative steroids, induction chemo/radiotherapy, missed antibiotic prophylaxis and resection type were independent risk factors for overall SSI. CONCLUSIONS: SSI rates after lung resection were stable over the decade. The observed 11.4% frequency of SSI indicates that postoperative infections remain a relevant issue and a predominant cause of mortality after lung surgery. Focusing on SSI risk factors that are perioperatively modifiable may improve surgical results.

Chest pain control with kinesiology taping after lobectomy for lung cancer: initial results of a randomized placebo-controlled study.

OBJECTIVES: Kinesiology taping (KT) is a rehabilitative technique performed by the cutaneous application of a special elastic tape. We tested the safety and efficacy of KT in reducing postoperative chest pain after lung lobectomy. METHODS: One-hundred and seventeen consecutive patients, both genders, age 18-85, undergoing lobectomy for lung cancer between January 2013 and July 2015 were initially considered. Lobectomies were performed by the same surgical team, with thoracotomy or video-assisted thoracoscopic surgery (VATS) access. Exclusion criteria (n = 25 patients) were: previous KT exposure, recent trauma, pre-existing chest pain, lack of informed consent, >24-h postoperative intensive care unit treatment. After surgery, the 92 eligible patients were randomized to KT experimental group (n = 46) or placebo control group (n = 46). Standard postoperative analgesia was administered in both groups (paracetamol/non-steroidal anti-inflammatory drugs, epidural analgesia including opioids), with supplemental analgesia boluses at patient request. On postoperative day 1 in addition, in experimental group patients a specialized physiotherapist applied KT, with standardized tape length, tension and shape, over three defined skin areas: at the chest access site pain trigger point; over the ipsilateral deltoid/trapezius; lower anterior chest. In control group, usual dressing tape mimicking KT was applied over the same areas, as placebo. Thoracic pain severity score [visual analogue scale (VAS) ranging 0-10] was self-assessed by all patients on postoperative days 1, 2, 5, 8, 9 and 30. RESULTS: The KT group and the control group had similar demographics, lung cancer clinico-pathological features and thoracotomy/VATS ratio. Postoperatively, the two groups also resulted similar in supplemental analgesia, complication rate, mean duration of chest drainage and length of stay. There were no adverse events with KT application. After tape application, KT patients reported overall less thoracic pain than the control group, the difference being significant on postoperative day 5 [median VAS, 2 (interquartile range, 1-3) vs 3 (2-5), P < 0.01] and day 8 [median VAS, 1 (0-2) vs 2 (1-3), P < 0.05]. Moreover, on postoperative day 30 persistence of chest pain (VAS ≥3) was reported less frequently by the KT group than by the control group (7 vs 24%; P = 0.03). CONCLUSIONS: KT after lung lobectomy is a safe and effective auxiliary technique for chest pain control. ISRCTN REGISTRY: ISRCTN37253470.

Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery.

BACKGROUND: Recently major developments in video imaging have been achieved: among these, the use of high definition and 3D imaging systems, and more recently indocyanine green (ICG) fluorescence imaging are emerging as major contributions to intraoperative decision making during surgical procedures. The aim of this study was to present our experience with different laparoscopic procedures using ICG fluorescence imaging. PATIENTS AND METHODS: 108 ICG-enhanced fluorescence-guided laparoscopic procedures were performed: 52 laparoscopic cholecystectomies, 38 colorectal resections, 8 living-donor nephrectomies, 1 laparoscopic kidney autotransplantation, 3 inguino-iliac/obturator lymph node dissections for melanoma, and 6 miscellanea procedures. Visualization of structures was provided by a high definition stereoscopic camera connected to a 30° 10 mm scope equipped with a specific lens and light source emitting both visible and near infra-red (NIR) light (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany). After injection of ICG, the system projected high-resolution NIR real-time images of blood flow in vessels and organs as well as highlighted biliary excretion . RESULTS: No intraoperataive or injection-related adverse effects were reported, and the biliary/vascular anatomy was always clearly identified. The imaging system provided invaluable information to conduct a safe cholecystectomy and ensure adequate vascular supply for colectomy, nephrectomy, or find lymph nodes. There were no bile duct injuries or anastomotic leaks. CONCLUSIONS: In our experience, the ICG fluorescence imaging system seems to be simple, safe, and useful. The technique may well become a standard in the near future in view of its different diagnostic and oncological capabilities. Larger studies and more specific evaluations are needed to confirm its role and to address its disadvantages.

Laparoscopic treatment of deep infiltrating endometriosis: results of the combined laparoscopic gynecologic and colorectal surgery.

BACKGROUND: The short-term results of a retrospective consecutive series of multidisciplinary laparoscopic approach to deep infiltrating endometriosis with intestinal involvement requiring segmental bowel resection procedures are presented. METHODS: Patients with radiologically or intraoperative-confirmed endometriosis, who underwent a combined laparoscopic segmental bowel resection by a team of gynecologists and colorectal surgeons, were retrospectively reviewed. The postoperative data were collected in a specific database and analyzed for short-term (30 days) postoperative outcomes with the comparison between two specimen's extraction methods. RESULTS: Forty-one patients (median age of 36 years, range 25-44) have been operated by a combined team of gynecologist and colorectal surgeons. The median operative time was 247.5 min (range 155-375), and median estimated blood loss was 300 ml (range 100-1300). In 20 patients, the surgical specimens were extracted transvaginally, while in 21 cases, a sovrapubic transverse Pfannenstiel minilaparotomy was used. No intraoperative complications or conversion to laparotomy were reported. An acceptable cumulative rate of postoperative morbidity was observed (6/41, 15 %), without any postoperative deaths. Comparing the two subgroups of patients with different modalities of specimen retrieval, postoperative pain (assessed by visual analog scale) was significantly reduced in the transvaginal extraction group (median: 1 and range: 0-2 vs median: 3, 5 and range: 1-6; p = 0.002), without any statistically significant differences in terms of complications. CONCLUSION: Laparoscopic bowel segmental resection combined with gynecologic surgery for deep infiltrating endometriosis with intestinal involvement is a valid treatment option with a low rate of postoperative complications. Transvaginal specimen extraction allows the same results of minilaparotomic incision, minimizing surgical trauma and warranting a clear benefit in terms of reduction of postoperative pain.

Vagus nerve stimulation for standardized monitoring: technical notes for conventional and endoscopic thyroidectomy.

Standardization of the intraoperative neuromonitoring (IONM) technique is an essential aspect of modern monitored thyroid surgery. The standardized technique involves vagal nerve stimulation. VN stimulation is useful for technical problem solving, detecting non-recurrent laryngeal nerve (non-RLN), recognizing any recurrent laryngeal nerve (RLN) lesions, and precisely predicting RLN postoperative function. Herein, we present technical notes for the VN identification to achieve the critical view of safety of the VN stimulation with or without dissection.

Efficacy, safety and effectiveness of image-guided percutaneous microwave ablation in cystic renal lesions Bosniak III or IV after 24 months follow up.

PURPOSE OF THE STUDY: The aim of the study was to assess the efficacy, safety and effectiveness of percutaneous image-guided microwave ablation (MWA) in Bosniak category III or IV cystic renal lesions after 24 months follow-up duration. METHODS: Between May 2008 and December 2012, computed tomography (CT)- or ultrasound (US)-guided MWA was performed in 6 patients with 7 cystic renal lesions (range 13.8-27 mm, mean 17.02 mm, SD 8.5 mm) Bosniak category III or IV. The number of treatment sessions, treatment results, lesion size changes and complications were evaluated. Technical success (TS), technical effectiveness (TE), local tumor progression rate (LTPR), cancer-specific survival rate (CSSR) and overall survival rate (OSR) were computed. MAIN FINDINGS: TS was 100% (7/7) and TE was 100%; LTPR was 0%; CSSR and OSR were 100%. No major complications were observed. CONCLUSION: Our preliminary experience with MWA shows a potential role for US/CT-guided percutaneous MWA in treating Bosniak category III or IV cystic renal lesions, as a safe approach to treat selected patients not suitable for surgery.

Web-based information on intraoperative neuromonitoring in thyroid surgery.

BACKGROUND: This is a preliminary analysis of intraoperative neuromonitoring (IONM)-related websites available to the general public with respect to thyroid surgery. METHODS: Four key terms and/or phrases (neuromonitoring AND thyroid AND neck surgery, intraoperative neuromonitoring, intraoperative electrophysiological monitoring, IONM) were entered separately into the search engines Google.com, Yahoo.com and Bing.com. The first 50 results obtained for each search procedure were evaluated. Websites were evaluated for content quality using the validated DISCERN rating instrument. Readability was graded by the Flesch Reading Ease Score and the Flesch-Kincaid Grade Level. RESULTS: The results were related to scientific publications in most cases (64%). A large percentage (59%) of the servers are located in the USA. The main language used is English (91%); only 19% of the websites are multilingual or in other languages. 58% of the sites were rated as excellent to good and 42% as fair to poor. The median Flesch Reading Ease Score was 49.6; the median Flesch-Kincaid Grade Level was 13.85. CONCLUSIONS: World Wide Web information about IONM in thyroid surgery is too specific and difficult and poorly accessible to the general public.

Laparoscopic caecal wedge resection with intraoperative endoscopic assistance.

BACKGROUND AND PURPOSE: Cancer is a potential evolution of adenomatous polyps, that is why nowadays screening programs for colorectal cancer are widely diffused. Colonoscopy is the gold standard procedure for identifying and resecting polyps; however, for some polyps resection during colonoscopy is not possible. The aim of the present study is to identify a fast and safe procedure for endoscopically resecting unresectable polyps. METHODS: Patients with endoscopically unresectable polyps were scheduled for laparoscopic wedge resection under colonoscopic assistance. RESULTS: From November 2010 to November 2012 we treated 15 patients with endoscopically unresectable adenomatous polyps. All patients underwent a laparoscopic caecal wedge resection with intraoperative endoscopic assistance. All procedures were completed without complications and in all cases complete resection of the polyps was achieved. CONCLUSIONS: Laparoscopic wedge caecal resection with intraoperative colonoscopy is a fast and safe procedure that can be performed for large polyps that could not be treated endoscopically.

Use of 3 mm percutaneous instruments with 5 mm end effectors during different laparoscopic procedures.

BACKGROUND AND PURPOSE: With a recent focus on minimizing the visibility of scars, new techniques have been developed. Minilaparoscopy reemerged as an attractive option for surgery as it limits tissue trauma, reduces post-operative pain and improves cosmesis. This study was designed to describe our experience with percutaneous trocarless 3 mm instruments used in combination with standard 5 mm and 10 mm laparoscopic instruments in different general surgery procedures. METHODS: We used the PSS (Percutaneous Surgical Set, Ethicon Endo surgery, Cincinnati, OH, USA) in different surgical procedures as accessory instruments in combination with standard 5 mm and 10 mm standard laparoscopic instruments. MAIN FINDINGS: The use of percutaneous instruments was safe and feasible in all performed procedures. The surgical technique was not modified. The percutaneous instruments can assure a good grip and can be used for traction and counter-traction. No complications have been described. No pain at the site of insertion has been reported. The skin, muscle and peritoneal defects were smaller than with the 3 mm laparoscopic traditional instruments. CONCLUSIONS: Percutaneous approach seems to be a good option in general surgery in terms of efficiency, offering better cosmetic results and good pain control.