Mid-Term Follow Up of TAPP Hernia Repair Without Staples and Glue: An Audit of the Data.

Groin hernia repair by using the laparoscopic transabdominal preperitoneal (TAPP) repair approach presents lower post-operative pain with a quicker return to normal patient activity compared to the open technique. Nevertheless, the long learning curve, general anaesthesia, and increased costs due to devices are the arguments against TAPP. Currently, the only mesh fixation techniques are those using glue or tacks. We report the audit of two years follow-up about our experience using a self-gripping lightweight mesh Parietex ProGrip™ (Covidien, Trevoux, France). The records of 39 patients for the first 50 procedures were reported. We registered wound infection, hematoma, seroma, neuralgia, numbness, and recurrence. In our opinion, TAPP procedure with ProGrip™ mesh is a feasible procedure without using fixation devices; costs, chronic pain and recovery are improved. Moreover, in the medium-term follow-up, we are able to reduce foreign body sensation and numbness.

Minimally invasive treatment of Mirizzi's syndrome: is there a safe way? Report of a case series.

Mirizzi's syndrome (MS) is a rare complication of the inveterate biliary lithiasis. Diagnostic and therapeutic standardization is still missing, especially since laparoscopic cholecystectomy has become the gold standard approach for symptomatic cholelithiasis. Our study is a retrospective analysis based on a case-series. It considered 370 cholecystectomies performed from 2006 to 2011. We selected 11 patients affected by MS (2.97%). We divided them according to Csendes' classification. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was used for biliary drainage when the patient suffered jaundice and/or cholangitis and, preoperatively, to confirm the suspicion of MS obtained through Magnetic Resonance Cholangio-Pancreatography (MRCP). We found it useful to exploit nasobiliary drainage (NBD) for intra-operative check of the biliary tree. In all 5 patients of the type 1 group MS was discovered intraoperatively and treated with Laparoscopic Sub-total Cholecystectomy (LSC). One patient suffered from biliary leakage, solved with NBD positioning. The type 2 group was made up of 2 women and 1 man. All of them were preoperatively submitted to ERCP and NBD positioning. Two underwent LSC and one was converted to laparotomy. The type 3 was represented by a 63-year-old woman suffering from recurrent cholangitis. She was submitted to MRCP, ERCP and then underwent LSC. The 2 patients affected by type 4 underwent open biliary reconstruction. In conclusion, every attempt should be made to identify MS prior to LCS since it will allow NBD insertion by ERCP. Once LCS is initiated, if MS is identified intra-operatively, we can provide the most practical surgical options.

Retrospective comparison of Traditional vs. LigaSure impact dissection during pancreatoduodenectomy: how to save money by using an expensive device.

Pancreatoduodenectomy is an exceptional procedure that requires an extensive dissection of the supramesocolic region extended to the first jejunal limb. Lymphadenectomy, required for cancer, increases the dissection surface. The extensive preparation of the area is traditionally conducted with bipolar ormonopolar instruments, while clips, ligatures, and sutures are used for haemostasis. LigaSure™ vessel sealing(LSVS; Valleylab, Boulder, CO) is a technology that obtains vessel closure by using the body's own collagen and elastin to create a permanent fusion zone. This is obtained by a combination of forceps pressure and radio frequency. This effect has been improved by the introduction of the Force Triad™ (Valleylab, Boulder,CO) energy platform, controlled by TissueFect™ (Valleylab, Boulder, CO) sensing technology. With this device, the surgeon is able to fuse vessels up to 7 mm, lymphatics, tissue bundles, and pulmonary vasculature in a fast-seal cycle of almost 4 seconds. In our daily practice of open surgery we observe a rapid improvement of abdominal drainage output with a drastic reduction of protein loss. Its practical significance is, in our opinion, that we obtain a rapid recovery of normal serum protein levels with a low number of blood/plasmasac transfusions and a real improvement of anastomosis healing. Moreover, the efficacy and the speed of work of the device allow us to reduce the operating time significantly but safely. We performed a retrospective analysis of the data of 20 pancreatic resections conducted both with traditional dissection and with the Liga-Sure Impact device with Force Triad platform in order to verify whether observed data were real. Our clinical results show that the use of the LigaSure Impact device with Force Triad energy platform is really useful in open surgery to save operating time, number of postoperative days, and hemoderivate administration.

Does mediastinal extension of the goiter increase morbidity of total thyroidectomy? A multicenter study of 19,662 patients.

PURPOSE: To compare the outcome in patients with cervical goiters and cervicomediastinal goiters (CMGs) undergoing total thyroidectomy using the cervical or extracervical approach. METHODS: This was a retrospective study conducted at six academic departments of general surgery and one endocrine-surgical unit in Italy. The study population consisted of 19,662 patients undergoing total thyroidectomy between 1999 and 2008, of whom 18,607 had cervical goiter (group A) and 1055 had CMG treated using a cervical approach (group B, n = 986) or manubriotomy (group C, n = 69). The main parameters of interest were symptoms, gender, age, operative time, duration of drain, length of hospital stay, malignancy and outcome. RESULTS: A split-sternal approach was required in 6.5% of cases of CMG. Malignancy was significantly more frequent in group B (22.4%) and group C (36.2%) versus group A (10.4%; both P < .001), and in group C versus group B (P = .009). Overall morbidity was significantly higher in groups B + C (35%), B (34.4%) and C (53.5%) versus group A (23.7%; P < .001). Statistically significant increases for group B + C versus group A were observed for transient hypocalcemia, permanent hypocalcemia, transient recurrent laryngeal nerve (RLN) palsies, permanent RLN palsies, phrenic nerve palsy, seroma/hematoma, and complications classified as other. With the exception of transient bilateral RLN palsy, all of these significant differences between group B + C versus group A were also observed for group B versus group A. CONCLUSIONS: Symptoms, malignancy, overall morbidity, hypoparathyroidism, RLN palsy and hematoma are increased in cases of substernal goiter.

Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study.

Patients undergoing colon resection are often concerned about their functional outcomes after surgery. The primary aim of this prospective, multicentric study was to assess the intestinal activity and health-related quality-of-life (HRQL) after ileocecal valve removal. The secondary aim was to evaluate any vitamin B12 deficiency. The study included patients undergoing right colectomy, extended right colectomy and ileocecal resection for either neoplastic or benign disease. Selected items of GIQLI and EORTC QLQ-CR29 questionnaires were used to investigate intestinal activity and HRQL before and after surgery. Blood samples for vitamin B12 level were collected before and during the follow-up period. The empirical rule effect size (ERES) method was used to explain the clinical effect of statistical results. Linear mixed effect (LME) model for longitudinal data was applied to detect the most important parameters affecting the total score. A total of 158 patients were considered. Applying the ERES method, the analysis of both questionnaires showed clinically and statistically significant improvement of HRQL at the end of the follow-up period. Applying the LME model, worsening of HRQL was correlated with female gender and ileum length when using GIQLI questionnaire, and with female gender, open approach, and advanced cancer stage when using the EORTC QLQ-CR29 questionnaire. No significant deficiency in vitamin B12 levels was observed regardless of the length of surgical specimen. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory.

Contemporary snapshot of tumor regression grade (TRG) distribution in locally advanced rectal cancer: a cross sectional multicentric experience.

Pre-operative chemoradiotherapy (CRT) followed by surgical resection is still the standard treatment for locally advanced low rectal cancer. Nowadays new strategies are emerging to treat patients with a complete response to pre-operative treatment, rendering the optimal management still controversial and under debate. The primary aim of this study was to obtain a snapshot of tumor regression grade (TRG) distribution after standard CRT. Second, we aimed to identify a correlation between clinical tumor stage (cT) and TRG, and to define the accuracy of magnetic resonance imaging (MRI) in the restaging setting. Between January 2017 and June 2019, a cross sectional multicentric study was performed in 22 referral centers of colon-rectal surgery including all patients with cT3-4Nx/cTxN1-2 rectal cancer who underwent pre-operative CRT. Shapiro-Wilk test was used for continuous data. Categorical variables were compared with Chi-squared test or Fisher's exact test, where appropriate. Accuracy of restaging MRI in the identification of pathologic complete response (pCR) was determined evaluating the correspondence with the histopathological examination of surgical specimens.In the present study, 689 patients were enrolled. Complete tumor regression rate was 16.9%. The "watch and wait" strategy was applied in 4.3% of TRG4 patients. A clinical correlation between more advanced tumors and moderate to absent tumor regression was found (p = 0.03). Post-neoadjuvant MRI had low sensibility (55%) and high specificity (83%) with accuracy of 82.8% in identifying TRG4 and pCR.Our data provided a contemporary description of the effects of pre-operative CRT on a large pool of locally advanced low rectal cancer patients treated in different colon-rectal surgical centers.

A single-surgeon randomized trial comparing sutures, N-butyl-2-cyanoacrylate and human fibrin glue for mesh fixation during primary inguinal hernia repair.

BACKGROUND: We sought to determine the efficacy of sutures, human fibrin glue and N-butyl-2-cyanoacrylate for mesh fixation in patients undergoing the plug and mesh procedure for groin hernia. METHODS: A total of 156 patients with 167 inguinal hernias (11 bilateral) underwent a plug and mesh procedure and were randomly assigned to received either sutures (n = 59 hernias), human fibrin glue (n = 52) or N-butyl-2-cyanoacrylate (n = 56) for mesh fixation. RESULTS: The overall morbidity rate was 38.98% in the suture group, 9.62% in the fibrin glue group and 10.71% in the N-butyl-2-cyanoacrylate group (suture v. fibrin glue, p < 0.001; suture v. N-butyl-2-cyanoacrylate, p < 0.001). There was no significant difference in morbidity between the fibrin glue and N-butyl-2-cyanoacrylate groups. Overall, short-term morbidity was significantly higher in the suture group (27.12%) than in the fibrin glue (9.62%, p = 0.01) or N-butyl-2-cyanoacrylate (8.93%, p = 0.004) groups, but there was no significant difference between the fibrin glue and N-butyl-2-cyanoacrylate groups. There was no significant difference between the groups in terms of mean postoperative stay (32.6 h in the suture group v. 30.8 h in the fibrin glue group v. 32.0 h in the N-butyl-2-cyanoacrylate group) or mean time to return to work (20.4 d in the suture group v. 20.3 d in the fibrin glue group v. 19.8 d in the N-butyl-2-cyanoacrylate group). Overall, long-term morbidity was significantly higher in the suture group (11.86%) than in the fibrin glue (0%, p = 0.001) or N-butyl-2-cyanoacrylate (1.78%, p = 0.03) groups. There was no recurrence in any of the groups. Two cases (3.39%) of chronic groin pain were reported in patients in the suture group. A sensation of extraneous body was reported in 5 (8.47%) patients who received sutures and in 1 (1.78%) patient in the N-butyl-2-cyanoacrylate group; there were no reported cases in the fibrin glue group (suture v. fibrin glue, p = 0.01; suture v. N-butyl-2-cyanoacrylate, p = 0.03; fibrin glue v. N-butyl-2-cyanoacrylate, p = 0.30). CONCLUSION: The use of human fibrin glue or N-butyl-2-cyanoacrylate is better tolerated than sutures in tension-free inguinal open repair using the plug and mesh technique in terms of overall immediate results, and there is a better trend in the long-term data.

Correction to: Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study.

One of the co-author Eliana Cagnazzo has been incorrectly published. The correct co-author name has been copied below.

The effectiveness of FloSeal matrix hemostatic agent in thyroid surgery: a prospective, randomized, control study.

BACKGROUND: The objective of this study was to compare the effectiveness of FloSeal matrix hemostatic agent with hemostatic surgical procedures and Tabotamp in thyroid surgery. METHODS: One hundred fifty-five consecutive total thyroidectomy patients were recruited at our institution between January 2005 and December 2007. Exclusion criteria were applied. Patients were randomized to one of three hemostatic approaches: 49 received surgical procedures only, and 52 received oxidized regenerated cellulose patch (Tabotamp Fibrillar 2.5 x 5 cm) and 54 FloSeal (5,000 U/5 mL). The same surgeon performed all operations. RESULTS: Mean operating time was reduced in the FloSeal group (105 min) vs. surgical (133 min, p = 0.02) and vs. Tabotamp (122 min, p = 0.0003). Also, wound drain removal occurred earlier with FloSeal (p = 0.006 vs. surgical; p = 0.008 vs. Tabotamp) resulting in shorter postoperative hospital stay in the FloSeal group (p = 0.02 vs. surgical; p = 0.002 vs. Tabotamp). CONCLUSIONS: FloSeal matrix is an effective additional agent to conventional haemostatic procedures in thyroid surgery.

Surgically-induced bile duct injury is followed by early hepatic oxidative stress. A preliminary experimental study in rats.

BACKGROUND/AIMS: To study in the rat whether oxidative stress appears early in a model of short-term cholestasis induced by bile duct ligation. METHODOLOGY: Adult male rats underwent proximal bile duct ligation; controls underwent a sham operation. Animals were sacrificed at days 0, 1, 3, 7 and 10. Livers were removed for histological studies and biochemical analysis. RESULTS: GSH and PSH levels declined earlier in mitochondria than cytosol. Data were analyzed for statistical significance by ANOVA analysis. CONCLUSIONS: This study represents an experimental model which helps in the interpretation of the damage induced by bile duct injury in humans emphasizing an early detection of bile duct injury after surgery to ensure appropriate treatment and optimal patient outcome.

Botox for chronic anal fissure: is it useful? A clinical experience with mid-term follow-up.

BACKGROUND: Sphincterotomy has been the most commonly used treatment for chronic anal fissures. Although effective it is associated with incontinence (0-20%). Intrasphincteric Botulinum Toxin A injection seems to be a reliable option. The aim of this clinical report is to verify the effectiveness of this treatment in relieving symptoms and healing fissures without relapse. METHODS: The study design was an open label non-comparative prospective trial to evaluate the efficacy ofbotulinum toxin injection in anal sphincters. In the period 2003-2005 sixty patients were enrolled in our Unit of Coloproctology. After inoculation hygiene measures (sitz baths, Vaseline oil and water intake) were recommended. After the first 4 weeks without improvement we administered a second injection (30 U.I). After failure of the second administration the patient was addressed to surgery. Mean follow-up was 24 months; patients were re-evaluated at the 6th, 12th and 24th month. RESULTS: In 29 pts the fissure was healed (48.33%) after the first injection; 31 patients (51.6%) were re-treated; 20 pts presented a complete healing of the fissure in a period ranging between 4-5 weeks from the second injection and 11 patients were introduced to surgery. In 3 cases we observed haemorrhoidal thrombosis. Gas incontinence was reported in two patients and solved spontaneously. CONCLUSIONS: Our clinical experience suggests that botulinum toxin therapy can be considered effective and safe. It can be proposed to the patient as first line therapy before surgery.

Laparoscopic appendectomies: experience of a surgical unit.

Appendicitis is one of the most common causes of acute abdomen in adults and appendectomy is the most common emergency abdominal procedure. Laparoscopic appendectomy has gained popularity only in recent years and the optimal approach for the treatment of acute appendicitis is still under debate. This retrospective study aimed at examining the current indications for laparoscopic appendectomy. 1024 patients undergoing laparoscopic appendectomy between February 1992 and December 2007 were retrospectively reviewed. 39.9% of patients (n=408) underwent emergency surgery. In 616 cases (60.1%) conservative management was performed in vain and these patients underwent an elective operation. In the 36 patients with an intraoperative normal appendix, other pathological findings were laparoscopically detected and treated. Conversion to an open procedure was required for 13 (1.3%) cases. The mean operative time was 38 min and the average length of postoperative hospitalization was 2.5 days. The overall morbidity rate was 2.6%. Laparoscopic appendectomy should be considered a procedure of choice for the treatment of non-complicated appendicitis. We stress the possibility to laparoscopically treat even complicated appendicitis in the surgical setting with substantial experience in minimally invasive surgery.

Management of descending duodenal injuries secondary to laparoscopic cholecystectomy.

AIM: To report our experience of managing patients affected by descending duodenal injuries secondary to laparoscopic cholecystectomy and to review the literature. METHODS: Analysis of 5 cases of descending duodenal injury as a consequence of laparoscopic cholecystectomy managed between June 1992 and September 2006. RESULTS: The median age was 59 (range 49-67) years. In all cases an emergency laparotomy showed an injury to the descending duodenum. Two patients underwent direct suture of the duodenum and external biliary drainage through a T-tube, 1 case underwent a duodenojejunostomy and in another a duodenopancreatectomy. The latter patient underwent drainage of the duodenum with a Petzer tube, followed 5 days later by gastric resection, closure of the duodenal stump and repair of the duodenal wound by suture. The median postoperative stay was 45 days and 1 patient died. CONCLUSION: Descending duodenal injuries are extremely rare complications of laparoscopic cholecystectomy with potentially fatal consequences if not promptly recognized and treated. The site of the descending duodenal injury is important for determining the surgical approach.

Multiple pancreaticoduodenal penetrating gunshot trauma evolving into acute necrotizing pancreatitis. A combined surgical and minimally invasive approach.

CONTEXT: Shotgun injuries are the cause of increasing surgical problems related to the proliferation of firearms. Gunshot pancreaticoduodenal traumas are unusual in urban trauma units. Their management remains complex because of the absence of standardized, universal guidelines for treatment and the high incidence of associated lesions of major vessels as well as of other gastrointestinal structures. Surgical treatment is still controversial, and the possibilities offered by the safe and effective mini-invasive techniques seem to open new, articulated perspectives for the treatment of pancreaticoduodenal injury complications. CASE REPORT: We present the case of a 27-year-old man with multiple penetrating gunshot trauma evolving into acute necrotizing pancreatitis, treated by combining a surgical with a mini-invasive approach. At admission, he presented a Glasgow Coma Score of 4 due to severe hemorrhagic shock. First, surgical hemostasis, duodenogastric resection, multiple intestinal resections, peripancreatic and thoracic drainage were carried out as emergency procedures. On the 12th postoperative day, the patient underwent re-surgery with toilette, external duodenal drainage with Foley tube and peripancreatic drainage repositioning as a result of a duodenal perforation due to acute necrotizing pancreatitis. Eight days later, following the accidental removal of the peripancreatic drains, a CT scan was done showing a considerable collection of fluid in the epiploon retrocavity. Percutaneous CT-guided drainage was performed by inserting an 8.5 Fr pigtail catheter, thus avoiding further re-operation. The patient was successfully discharged on the 80th postoperative day. CONCLUSIONS: The treatment of multiple pancreaticoduodenal penetrating gunshot traumas should focus on multidisciplinary surgical and minimally invasive treatment to optimize organ recovery.

The semiopen first umbilical trocar access technique in laparoscopic surgery: easy and safe.

BACKGROUND: First access in laparoscopy still causes trouble and a small percentage of visceral and vascular injuries. Residents and surgeons-in-training often have doubts about which technique is safer and "friendlier." Semiopen technique (SO) for the first umbilical trocar access was originally described in 2002. We report our retrospective analysis using SO that shows its safety and easiness. METHODS: In the period from January 2003 to November 2007, 300 unselected patients, including obese patients (body mass index > 30) were treated with laparoscopy beginning with a periumbilical approach using SO. We usually prefer to enter the cavity with a STEP cannula stiffened by an unarmed Veress needle of 1.9 mm. There were 112 men and 188 women with ages ranging from 16 to 82 years. The procedure was performed by an expert laparoscopic surgeon in 260 cases and by residents or surgeons without expertise in laparoscopy in 40 cases. RESULTS: We experienced no injuries of the viscera or vessels (0%). The mean time to enter the abdomen was 180 seconds, including obese patients. CONCLUSIONS: After our limited experience with the SO, we believe that every surgeon who tries it will experience safety of the Hasson and the comfort of the Veress.

Emergency surgery for acute respiratory failure secondary to spontaneous thyroid hemorrhage.

A 42-year-old woman was evaluated for an emergency at our surgical department for acute dyspnea associated with a spontaneous and rapidly enlarging mass of the neck. Clinical examination revealed a large, firm, nonfluctuant thyroid swelling on the right side of the neck. An urgent computerized tomography scan showed a hematoma within the right lobe of the thyroid and tracheal deviation with marked luminal narrowing. Because of the rapid progression of respiratory distress, endotracheal intubation by flexible laryngoscopy revealing normal vocal cords function and emergency total thyroidectomy were performed. During the operation, the thyroid gland showed a huge, edematous, nonfluctuant, rubbery, firm swelling with easy bleeding on touch, but the capsule appeared to be intact without rupture. Microscopic examination revealed a colloid multinodular goiter with massive parenchymal hemorrhage. Recovery was uneventful, and the patient was discharged 2 days after the operation.

Endoscopic resection of benign very low-risk gastric gastrointestinal stromal tumors. Is it enough?

Great ongoing debate still exists over the definition, diagnosis and treatment of gastrointestinal stromal tumour especially for small gastric submucosal tumours. Simple endoscopic biopsy is not sufficient to determine their biological behaviour and their complete excision is necessary. We report the case of a 65-year-old woman, who was kept under observation after previously operated breast cancer, with a casual computed tomography-diagnosed submucosal gastric lesion. Endoscopy and endoscopic ultrasound confirmed a submucosal mass of 2-3 cm in diameter. An endoscopic resection was performed and the mass was integral at pathologic examination. It confirmed the stromal origin with a mitotic index of 1 (5/50 high power field). No more treatment was carried out because it was classified as a very low risk gastrointestinal stromal tumour according to Fletcher's classification. After 34 months follow-up, the patient is disease free and we believe that endoscopic treatment is sufficient and recommended for mainly intragastric growing gastrointestinal stromal tumour with a diameter of less than 3 cm.

Massive mesenteric ischemia resulting from a giant strangulated umbilical hernia.

Hernia repair is the most commonly practiced operation in the departments of surgery in developed countries. Huge abdominal hernias are uncommon in western civilization. We present a rare case of a 73-year-old woman with a diagnosis at admission of intestinal obstruction caused by a giant strangulated umbilical hernia. At the clinical and radiological examination, the patient showed an enormous strangulated umbilical hernia with acute abdomen, atrial fibrillation, and pulmonary subedema. Emergency laparotomy showed a huge peritoneal umbilical sac containing massive mesenteric ischemia starting from 40 cm after the Treitz ligament and extended to the right colonic flexure. A near-total resection of the small bowel, a right colectomy with double terminal stomas, and a direct hernia repair without prosthetic mesh were performed. Twenty days after the operation, the patient was discharged and begun domiciliary total parenteral nutrition, and 24 months after surgical treatment she is still alive.