Management of groin hernias detected by ultrasound: a comprehensive study.

INTRODUCTION: It remains unclear whether ultrasound-detected hernias (UDH) are the sole cause of pain in patients with groin pain, and clinical examination plays a complementary role. The aim of our study is to describe the evolution of patients with ultrasound detected hernias in terms of development of groin hernia detected by physical examination, pain resolution, and alternative diagnosis. METHODS: An observational, descriptive, longitudinal study of a prospective case series including patients with UDH with groin pain. Follow-up evaluation included the following: follow-up time, side of pain, its evolution, time to resolution, clinical hernia (CH) development, need for surgical resolution, and the presence of postoperative pain and alternative diagnosis. RESULTS: A total of 98 patients with complete follow-up for groin pain and UDH were included. Seven patients (7.1%) developed CH, with a median time to conversion of 8 months. Four of them (4.1% of the total and 57.1% of the ones who developed CH) ended up having surgery. Fifty-three patients (54.1%) resolved their pain in a median time to resolution of 2 months, and 75.5% of them did so spontaneously. The majority of patients with persistent pain (73.3%) were able to lead a normal life and only reported pain with movement. More than half of the patients (53.3%) reached a specific diagnosis. Among those patients who did not develop CH, 39.6% reached an alternative diagnosis, the majority being musculoskeletal pathologies. CONCLUSION: Watchful waiting and a thorough search for other alternative causes of groin pain in UDH and clinically occult hernia would be a reasonable option.

Fascial dehiscence: predictable complication? Development and validation of a risk model: a retrospective cohort study.

PURPOSE: Fascial dehiscence is still an important cause of morbidity and mortality in the postoperative period of abdominal surgery. Different authors have sought to identify risk factors for this entity. Two risk scores have been developed, but they include postoperative variables, which hinder preventive decision-making during the early surgical period. Our aim is to identify preoperative and intraoperative risk factors for fascial dehiscence and to develop and validate a risk prediction score that allows taking preventive behaviors. METHODS: All adult patients, with no prior history of abdominal surgery, who underwent midline laparotomy by a general surgery division between January 2009 and December 2019 were included. Recognized preoperative risk factors for fascial dehiscence were evaluated in a univariate analysis and subsequently entered in a multivariate stepwise logistic regression model. A prognostic risk model was developed and posteriorly validated by bootstrapping. This study was conducted following the STROBE statement. RESULTS: A total of 594 patients were included. Fascial dehiscence was detected in 41 patients (6.9%). On multivariate analysis, eight factors were identified: chronic obstructive pulmonary disease (COPD), immunosuppression, smoking, prostatic hyperplasia, anticoagulation use, sepsis, and overweight. The resulting score ranges from 1 to 8. Scores above 3 are predictive of 18% risk of dehiscence with a sensitivity of 70% and specificity of 80% (ROC 0.88). CONCLUSIONS: We present a new preoperative prognostic score to identify patients with a high risk of fascial dehiscence. It can be a guide for decision-making that allows taking intraoperative preventive measures. External validation is still required.

Laparoscopic-guided distal loco-regional anesthetic infiltration technique in TAPP inguinal hernia repair: a double-blind randomized clinical trial.

BACKGROUND: Ultrasound-guided transversus abdominis plane block (US-TAP) is an important component of multimodal analgesia in laparoscopic inguinal hernia repair, although it has certain limitations. To overcome them, surgeons have developed several techniques to perform local anesthetic infiltration under laparoscopic guidance, but no trials evaluating these in transabdominal preperitoneal (TAPP) hernia repair were conducted till the date. The aim of this study was to compare the efficacy of a novel laparoscopic-guided local anesthetic infiltration technique (LDAI) with US-TAP in postoperative pain control and analgesic consumption for patients undergoing elective TAPP hernia repair. METHODS: This was a double-blind randomized controlled trial conducted at a single tertiary academic center between 2019 and 2020 on adult patients undergoing elective laparoscopic TAPP inguinal hernia repair. Postoperative pain and analgesic consumption were compared for LDAI vs. US-TAP up to 30 postoperative days. RESULTS: 62 patients were included (31 LDAI, 31 US-TAP). Female gender was significantly higher in the LDAI group (8, 25.81%; US-TAP 0; p = 0.005). Mean anesthetic time (US-TAP group: 142.2 min, SD = 17.7; LDAI group: 127.1 min, SD = 15.5; p < 0.001) and mean operative time (US-TAP group: 117.2 min, SD = 15.9; LDAI group: 103.8 min, SD = 15.2; p < 0.001) were significantly shorter in the LDAI group. Pain scores assessed at the first-hour postoperative, at the moment of discharge, and at 8, 24, and 48 postoperative hours showed no significant differences between both groups. No significant difference was found regarding postoperative analgesic rescue administration in the recovery room and analgesic consumption after discharge between groups. CONCLUSION: LDAI is a safe and effective local anesthetic technique in elective TAPP hernia repair. Pain control is similar to US-TAP block, with shorter anesthesthetic and surgical time and better health resources allocation.

Pyogenic liver abscess: current status and predictive factors for recurrence and mortality of first episodes.

BACKGROUND: In times of modern surgery, transplantation and percutaneous techniques, pyogenic liver abscess (PLA) has essentially become a problem of biliary or iatrogenic origin. In the current scenario, diagnostic approach, clinical behavior and therapeutic outcomes have not been profoundly studied. This study analyzes the clinical and microbiological features, diagnostic methods, therapeutic management and predictive factors for recurrence and mortality of first episodes of PLA. METHODS: A retrospective single-center study was conducted including 142 patients admitted to the Hospital Italiano de Buenos Aires, between 2005 and 2015 with first episodes of PLA. RESULTS: Prevailing identifiable causes were biliary diseases (47.9%) followed by non-biliary percutaneous procedures (NBIPLA, 15.5%). Seventeen patients (12%) were liver recipients. Eleven patients (7.8%) died and 18 patients (13.7%) had recurrence in the first year of follow up. The isolation of multiresistant organisms (p = 0.041) and a history of cholangitis (p < 0.001) were independent risk factors for recurrence. Mortality was associated with serum bilirubin >5 mg/dL (p = 0.022) and bilateral involvement (p = 0.014) in the multivariate analysis. CONCLUSION: NBPLA and PLA after transplantation may be increasing among the population of PLA in referral centers. History of cholangitis is a strong predictor for recurrence. Mortality is associated to hiperbilirrubinemia and anatomical distribution of the lesions.

Laparoscopic peritoneal lavage for Hinchey III diverticulitis: is it as effective as it is applicable?

BACKGROUND: Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable. OBJECTIVE: The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis. DESIGN: This study was conducted as a retrospective analysis of prospectively collected data. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria. MAIN OUTCOME MEASURES: Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed. RESULTS: Seventy-five patients required emergency surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized (Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2-82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3-90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0-10). The feasibility of the method was 96.0% (95% CI 90.4-100), and its applicability was 59.0% (95% CI 44.8-73.2). Median operative time was 89 minutes (range, 40-200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7-36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76-93). LIMITATIONS: This was a single-institution retrospective study. CONCLUSIONS: The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis.

Incarcerated left-sided Amyand's hernia and synchronous ipsilateral femoral hernia: first case report.

BACKGROUND: The finding of a vermiform appendix within the peritoneal sac of an inguinal hernia is called Amyand's hernia. The reported incidence of Amyand's hernia and femoral hernia is 1% and 3.8%, respectively. To our knowledge, no cases have been reported in the literature that associate these two entities. We present the first case of incarcerated left-sided Amyand's hernia and synchronous ipsilateral femoral hernia found during emergency surgery. CASE PRESENTATION: A 72-year-old woman was admitted to the Emergency Department for a complicated left inguinal hernia. An inguinotomy was performed that detected a large direct hernial sac and a synchronous femoral hernia. The opening of the inguinal hernia showed the presence of the cecum and the appendix, both without signs of inflammation. The femoral space was evaluated transinguinally, identifying the larger omentum that had slipped into the femoral canal. The primary closure of the posterior wall defect was performed with the McVay technique due to its large size, and then the hernioplasty was completed with a polypropylene mesh. No postoperative complications were reported. CONCLUSIONS: In the context of an incarcerated Amyand's hernia, the decision to perform an appendectomy in addition to hernia repair with or without mesh will depend on intraoperative findings.

Strategies for follow up after hernia surgery during COVID 19 Pandemia.

The end of 2019 was marked by the emergence of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Our problem is centered in the post operative follow up of those patients who underwent an elective procedure immediately before the isolation and those who require an emergency surgery. We outline the measures we have taken to reduce the possibility of spread of the virus.