Laparoscopic incisional and ventral hernia repair (LIVHR) with PARIETEX™ Composite mesh.

OBJECTIVES: Laparoscopic incisional and ventral hernia repair (LIVHR) is widely used although its clinical indications are often debated. The aim of this study was to retrospectively describe the experience of our surgical centre in order to establish the safety, efficacy, and feasibility of LIVHR using PARIETEX(™) Composite mesh (Covidien, Mansfield, MA, USA). MATERIAL AND METHODS: Between January 2007 and November 2010, 87 patients were admitted to the Division of General Surgery of Aosta, with the diagnosis of abdominal wall hernia and underwent laparoscopic repair using PARIETEX(™) Composite mesh. The type and size of surgical defects, mean operative time, morbidity, mortality and rate of recurrence at one-year follow-up were retrospectively analysed. RESULTS: We performed 87 LIVHR: 51.7% for incisional hernia and 48.3% for epigastric or umbilical hernias. Mean operative time was 100 min., conversion rate was 3.4%. The mean size of abdominal defect was 6 cm (range: 2-15); in relation to umbilical hernias, mean size was 5.4 cm (range: 2-8). The mortality rate was 0%; overall morbidity was 16%. At one-year follow-up, we observed two cases of hernia recurrences. CONCLUSIONS: LIVHR using PARIETEX(™) Composite mesh is an effective and safe procedure with very low morbidity and low rates of postoperative pain and recurrence, especially in hernias with diameter of between 5 and 15 cm and in obese patients without previous laparotomies.

Robot-assisted gastrojejunal anastomosis does not improve the results of the laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Traditional laparoscopic surgery presents some difficulties for morbidly obese patients due to limited motion of instruments related to a thick abdominal wall, intraabdominal fat, and a large hepatic left lobe, with consequent loss of dexterity and greater musculoskeletal discomfort. Robotic technique could potentially overcome these limitations. This study aimed to evaluate robot-assisted laparoscopic Roux-en-Y gastric bypass in morbidly obese patients and to compare the results of robotic assistance with those of traditional laparoscopic technique. METHODS: Between September 2006 and June 2009, 110 morbidly obese patients underwent laparoscopic Roux-en-Y gastric bypass with robot-assisted hand-sewn gastrojejunal anastomosis using the da Vinci Surgical System. The data for these patients was compared with the data for 423 consecutive patients treated in a standard laparoscopic manner during the same period. RESULTS: The patients had a mean preoperative age of 42.6 years, a mean weight of 127.5 kg, and a mean body mass index (BMI) of 46.7 kg/m2. The total mean operative time was 247.5 min. The robotic setup time was 10.1 min, and the robotic operative time was 54.5 min. The conversion rate was nil. The intraoperative complication rate was 4.5%. The early and late major postoperative complication rates were 3.6 and 6.4% respectively. The cost per patient was 5777.76 €. For the standard laparoscopy, the operative time was significantly shorter (187 min; p<0.001), and the costs per patient were significantly lower (4658.28 €; p<0.001), whereas no differences were found in terms of the intra- or postoperative complication rates, revisional surgery, or hospital length of stay. CONCLUSIONS: Although safe and intuitive, the robotic approach was burdened by a longer operative time and higher equipment costs. Moreover, it did not seem to provide a real advantage over standard laparoscopy in terms of hospital length of stay and complications rates.

Comparison of short- and medium-term results between laparoscopically assisted and totally laparoscopic right hemicolectomy: a case-control study.

BACKGROUND: This study aimed to compare the short- and medium-term results obtained by totally laparoscopic right colectomy (TL) with those obtained by laparoscopically assisted right colectomy (LAC) for the treatment of right colon cancer. METHODS: A retrospective study compared two nonstatistically different groups (50 TL and 50 LAC cases) managed for nonmetastatic malignant tumors. The study outcomes included operative time, length of minilaparotomy, intraoperative complications, postoperative pain, time to resumption of the gastrointestinal functions, permanence of abdominal drain, analgesic therapy duration, postoperative complications, hospitalization time, number of harvested lymph nodes, and distant metastases onset. RESULTS: The mean operative times were 78 ± 25 min (TL group) and 92 ± 22 min (LAC group) (p < 0.05). The findings showed a lower postoperative pain level associated with a reduction in analgesic consumption (p > 0.05) and earlier restoration of digestive function in the TL group than in the LAC group. The mean hospital stays were approximately 5 days (TL) and 7 days (LAC) (p < 0.05). No complications occurred either intra- or postoperatively, and similarly, the TL group experienced no mortality. In comparison, the LAC group had a 30% complication rate (p < 0.05). The complications included one case of intraoperative small bowel lesion, three cases of postoperative respiratory infections, three cases of anastomotic leakage, two cases of intestinal occlusion, three cases of minilaparotomy infection, one case of postoperative femoral neurosis, one case of postoperative heart attack, and one case of postoperative pancreatitis. The mortality rate was 0%. Neither group had a recurrence of the neoplastic disease during a 4-year follow-up period. CONCLUSIONS: The findings seem to demonstrate that TL right colectomy is feasible and safe, yielding results comparable with those of the open approach but offering improved postoperative patient comfort. The limits of this retrospective comparative study do not allow definitive conclusions to be drawn despite the encouraging data for the next prospective randomized studies.

Laparoscopic management of non-midline incisional hernia: A multicentric study.

BACKGROUND: The laparoscopic repair of non-midline ventral hernia (LNM) has been debated. The aim of this study is to analyze our experience performing the laparoscopic approach to non-midline ventral hernias (NMVHs) in Northwest Italy for 6 years. METHODS: A total of 78 patients who underwent LNM between March 2008 and March 2014 in the selected institutions were analyzed. We retrospectively analyzed the peri- and postoperative data and the recurrence rate of four subgroups of NMVHs: subcostal, suprapubic, lumbar, and epigastric. We also conducted a literature review. RESULTS: No difference was found between the four subgroups in terms of demographic data, defect characteristics, admission data, and complications. Subcostal defects required a shorter operating time. Obesity was found to be a risk factor for recurrence. CONCLUSIONS: In our experience, subcostal defects were easier to perform, with a lower recurrence rate, lesser chronic pain, and faster surgical performance. A more specific prospective randomized trial with a larger sample is awaited. Based on our experience, however, the laparoscopic approach is a safe treatment for NMVHs in specialized centers.

Preoperative Predictive Factors of Successful Weight Loss and Glycaemic Control 1 Year After Gastric Bypass for Morbid Obesity.

BACKGROUND: Gastric bypass (GBP) is one of the most effective surgical procedures to treat morbid obesity and the related comorbidities. This study aimed at identifying preoperative predictors of successful weight loss and type 2 diabetes mellitus (T2DM) remission 1 year after GBP. METHODS: Prospective longitudinal study of 771 patients who underwent GBP was performed at four Italian centres between November 2011 and May 2013 with 1-year follow-up. Preoperative anthropometric, metabolic and social parameters, the surgical technique and the previous failed bariatric procedures were analyzed. Weight, the body mass index (BMI), the percentage of excess weight lost (% EWL), the percentage of excess BMI lost (% BMIL) and glycated haemoglobin (HbA1c) were recorded at follow-up. RESULTS: Univariate and multivariate analysis showed that BMI <50 kg/m(2) (p = 0.006) and dyslipidaemia (p = 0.05) were predictive factors of successful weight loss. Multivariate analysis of surgical technique showed significant weight loss in patients with a small gastric pouch (p < 0.001); the lengths of alimentary and biliary loops showed no statistical significance. All diabetic patients had a significant reduction of HbA1c (p < 0.001) after surgery. BMI ≥ 50 kg/m(2) (p = 0.02) and low level of preoperative HbA1c (p < 0.01) were independent risk factors of T2DM remission after surgery. CONCLUSIONS: This study provides a useful tool for making more accurate predictions of best results in terms of weight loss and metabolic improvement.

Intestinal infarction by internal hernia in Petersen's space after laparoscopic gastric bypass.

UNLABELLED: Intestinal occlusion by internal hernia is not a rare complication (0.2%-5%) after Laparoscopic Roux-en-Y-GBP (LGBP) with higher morbidity and mortality related to mesenteric vessels involvement. In our Center, from October 2009 to April 2013 we have had 17 pts treated for internal hernia on 412 LGBP (4.12%). CLINICAL CASE: 28-year-old woman, operated of LGBP (BMI = 49; co-morbidity: diabetes mellitus and arthropathy) about 10 mo before, was affected by recurrent abdominal pain with alvus alteration lasting for a week. After vomiting, she went to first aid Unit of a peripheric hospital where she made blood tests, RX and US of abdomen that resulted normal so she was discharged with flu like syndrome diagnosis. After 3 d the patient contacted our Center since her symptoms got worse and was hospitalized. Blood tests showed an alteration of hepatic enzymes and amylases. The abdominal computed tomography (CT) showed the presence of fluid in peri-splenic, peri-hepatic areas and in pelvis and a "target like imagine" of "clustered ileal loops" with a superior mesenteric vein (SMV) thrombosis involving the Portal Vein. During the operation, we found a necrosis of 80 cm of ileus (about 50 cm downstream the jejuno-jejunal anastomosis) due to an internal hernia through Petersen's space causing a SMV thrombosis. The necrotic bowel was removed, the internal hernia was reduced and Petersen' space was sutured by not-absorbable running suture. An anticoagulant therapy was begun in the post-operative time and the patient was discharged after 28 d. CONCLUSIONS: The internal hernia diagnosis is rarely confirmed by preoperative exams and it is obtained in most cases by laparoscopy but the improvement of technologies and the discover of "new" CT signs interpretation can address to an early laparoscopic treatment for high suspicion cases.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results of a 18-year single-centre experience.

BACKGROUND AND OBJECTIVES: The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle-low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period. METHODS: Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan-Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors. RESULTS: A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2%, with a rate of anastomotic leakage of 13.8%. Average follow-up was 85.9 months (range 13-210). Actuarial local recurrence rate was 4.13% at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8% at 5 years, 71 and 73% at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery. CONCLUSIONS: Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.

The SIC-GIRCG 2013 Consensus Conference on Gastric Cancer.

The topic chosen by the Board of the Italian Society of Surgery for the 2013 annual Consensus Conference was gastric cancer. With this purpose, under the direction of 2 chairmen, 36 experts nominated by the Regional Societies of Surgery and by the Italian Research Group for Gastric Cancer (GIRCG) participated in an experts consensus exercise, preceded by a questionnaire and mainly held by telematic vote, in accordance with the rules of the Delphi method. The results of this Consensus Conference, presented to the 115th National Congress of the Italian Society of Surgery, and approved in plenary session, are reported in the present paper.

Laparoscopic surgery for colon cancer.

Colon cancer is a major problem in Western countries and complete surgical resection is the main treatment. Since its introduction the laparoscopic approach has been used to achieve bowel resection with a better postoperative course and better aesthetic outcomes. Initial concerns about the radicality of the resection and the oncologic outcomes have been overcome in the last decade. All over the world large trials have been conducted to compare the laparoscopic approach and the traditional laparotomic one. A review of literature has been conducted to find evidence about this issue, revealing 24 relevant trials. The laparoscopic approach showed short-term benefits without compromising oncological safety. However intraoperative complication rates during laparoscopic colon resections seem to be increased, mainly due to the increased rate of intraoperative bowel injury. This finding confirms a great need for training and a wide learning curve for the surgeon. Our review supports the continued use of laparoscopic surgery in patients with colon cancer.