Learning curve in open inguinal hernia repair: a quality improvement multicentre study about Lichtenstein technique.

PURPOSE: Inguinal hernia repair is one of the most performed procedure all over the world with more than 20 million procedures performed each year. Due to the lack of data in literature about the learning curve of the Lichtenstein procedure, we decided to reproduce a research on learning curves with the same methodology proposed in our previous study about laparoscopic hernia repair. The aim of this multicentre study was to analyse how many cases are required to achieve the learning curve for a Lichtenstein procedure. METHODS: We performed a retrospective analysis of the first 100 Lichtenstein procedures performed by 4 trainees from three different institutions and compared them with the same number of procedures performed by 3 senior surgeons from the same institutions. The data about the achieving of learning curve were evaluated with CUSUM and KPSS test. RESULTS: No differences about biometrical features were found between the seven groups of patients. CUSUM analysis showed that the trainees achieve the learning curve after 37-42 procedures, reaching an operative time similar to that one of the senior surgeons. CONCLUSIONS: In conclusion, we have shown that the number of procedures required to reach the learning curve from the beginning of surgical residency is around 40 hernia repairs. This number, produced in a controlled environment under strict supervision, could be the minimum requirement to start the procedure of accreditation and specialization in hernia surgery and is higher and steeper than previously reported.

Hemoperitoneum: a rare complication of hemorrhoid treatment.

Pile suturing has always been used by surgeons to treat hemorrhoidal disease. We report a case of hemoperitoneum complicating a pile suture. Ultrasonography and computed tomography scan indicated the need for an emergency laparoscopic procedure and conservative management. As other authors have pointed out, we do not know how to prevent this type of complication. This case suggests the possibility of life-threatening complications following treatment procedures for hemorrhoids and underlines the importance of conservative treatment when this is possible.

[Efficacy and safety of a salsobromoiodic gel solution in proctological surgery]. / Efficacia e sicurezza di una soluzione salsobromoiodica in chirurgia proctologica.

BACKGROUND: Surgical procedures for ano-rectal pathologies are always conditioned by an high percentage of side-effects. Indeed, the prevention of probable complications such as the non tissue-recovery or infection is a fundamental topic to guarantee an adequate follow-up. The aim of this comparative study is to assess the short-term outcomes of the use of a solution salsobromoiodic gel solution in postoperative period of patients undergoing proctological surgery. MATERIALS AND METHODS: The authors selected retrospectively a population of 80 patients, undergoing surgery for Milligan-Morgan hemorrhoidectomy. Based on the recommended medications postoperatively, patients were divided into two groups: the Group A applied the salsobromoiodic solution gel on the perianal surgical wound in the postoperative period, the Group B did not use any medical facility with the exception of a soap at neutral pH. The clinical features assessed at 5, 10, 15 and 30 days after surgery were: pain, burning and itching lenght, the healing time, the presence or absence of early or late superinfection, the time of re-epithelization, the need for surgical curettage. The subjective evaluation of quality of life was assessed using a Visual Analogue Scale (VAS). RESULTS: There was a statistically significant reduction in length of postoperative pain in patients of Group A compared to Group B (5.6 vs 10.4 days respectively; p<0.005). There was a more rapid wound healing and re-epithelialization in group A, 15 and 21,3 days, respectively, as compared to Group B, 22.9 and 31.7 days (p<0.005). There were no differences between the two groups in terms of burning, itching and early and late bacterial infection. Two patients in Group B required a surgical debridement of the wound. Patients who used postoperatively salsobromoiodic solution declared a better quality of life. CONCLUSIONS: The use of salsobromoiodic gel solution in the postoperative proctological surgery, resulted safe and was effective in reducing postoperative pain, in contributing wounds healing and improving the quality of life, as subjectively assessed by each patient.

Single access laparoscopic left hemicolectomy with or without inferior mesenteric artery preservation: our preliminary experience.

AIM: We report our preliminary experience in single access laparoscopic left hemicolectomy (SALLH) with or without inferior mesenteric artery preservation, showing the results of a selected group of patients. METHODS: This retrospective case series enclosed all patients operated between October 2009 and June 2012 of a left hemicolectomy with single laparoscopic access for benign and malignant diseases. The mean follow-up was 18 months. Intraoperative and postoperative results were recorded. RESULTS: This retrospective case series enclosed 24 patients. Mean operative time was 157.8 min. The mean final skin incision length was 3.65 cm. All operations were completed by a single access laparoscopic approach. There were no conversion or intraoperative mortality. There were no required any intraoperative blood transfusion. Only three cases of postoperative complication were registered. The mean flatus canalization was two days. The mean discharge time was seven days. At a mean 18-month follow-up there were no incisional hernia or deaths. CONCLUSION: As best of our knowledge, we report one of the largest experience gained in Italy about SALLH. We think that although SALC could be safe and feasible, it cannot be considered as a "new standard" procedure used by anyone. In contrast we retain that it is mandatory that SALC continued to be evaluated into larger multicentric RCT.

Anorectal avulsion: Management of a rare rectal trauma.

INTRODUCTION: Traumatic injuries of the rectum are unusual even though their treatment is challenging and often lead to high morbidity and mortality rate. PRESENTATION OF CASE: This paper reports a rare case of complete rectal avulsion with multiple fracture and hemoperitoneum treated with a multistep approach in our department. DISCUSSION: The anorectal avulsion is a rare rectal trauma; only few reports are available. Treatment key points of rectal trauma are: direct repair, diverting stoma and sacral drainage. CONCLUSION: We reported a case of anorectal avulsion with complete detachment of external sphincter muscle. A multidisciplinary approach was mandatory in this kind of lesions.

[Mucoprolassectomy with circular stapler: early results with a new device]. / Mucoprolassectomia con suturatrice circolare: utilizzo di un nuovo device.

AIMS: Stapled transanal mucosectomy is widely used by a lot of surgeon and in RCT, when compared to other haemorrhoidectomy techniques, it didn't show a real primacy. We describe results obtained with a new device, the EEA™ 33-mm Hemorrhoid and Prolapse Stapler Set con DST Series™ (Covidien™), used on 65 patients. PATIENTS AND METHODS: Sixty-five patients underwent a stapled transanal mucosectomy for grade III (n° 20), IV (n° 15) haemorrhois and rectal prolapse (n° 30). The operation were performed by two surgeons. Results. Resected tissue had a mean width of 4.2 cm (3.3-6.1 cm) and a mean weight of 11 g (8-21 g). Surgical time were 22 min (15-35 min). Bleeding of the suture line were observed in 5 cases (7.7%) and they required a mean of 2 haemostatic stitch (1-5) in adsorbable suture 2/0. Mucoprolapsectomy was considered excellent in 55 patients (84.7%), good in 8 patients (12.3%), bad in 2 patients (3%) by surgeons. There were no early and late complications like bleeding, abscesses, anastomotic dehiscence. We report two case of perianal haematoma that don't need any treatment and one case of anal stenosis treated with dilatation therapy. Post-operative pain, estimated with VAS, emphasized an excellent response to NSAIDs in first postoperative day, in 10 cases (15.4%) we prolonged analgesic therapy for 3 days, in one case (1.5%) for one week. After 6 month all patients were revaluated with physical examination and anoscopy. Only one patient (1.5%) had an asymptomatic recurrence of rectal prolapse. CONCLUSION: We conclude that the new device makes easy and standardized surgery. The new device reduce a lot of difficult in patients with tight pelvis and a small distance between ischiatic tubers.

[Identification of internal fistolous orifice: evolution of methylene blue technique with a mini-probe]. / Identificazione dell'orifizio fistoloso interno: evoluzione della tecnica di iniezione con blu di metilene tramite mini-catetere.

INTRODUCTION: Often perianal fistulas can be difficult typing and traditional anatomical classifications do not help the surgeon in accurate diagnosis of the fistula as an outpatient procedure and therefore does not allow a timely surgical currettage. The aim of our study was to introduce in the management of anal fistulas performed on an outpatient injection with methylene blue of the fistula through a small polyethylene catheter in order to detect in real time the internal opening of the fistula and drive so the next currettage surgery. MATERIALS AND METHODS: A total of 50 consecutive patients 21 female and 29 male, relating to our clinic with symptoms suggestive of colon proctology perianal fistula, aged between 36 and 69 years were selected for our study. After running the news-gathering medical history, physical examination, digital examination through examination anoscope, using a polyethylene catheter in a small scale, of methylene blue was injected through the external fistula orifice looking inside the spreading of liquid. Subsequently, the patient was started on specillazione currettage and possible surgery. RESULTS: 62 outpatients were treated intramural fistulas, diagnosed with the injection technique with methylene blue running always probing and practiced a wide dish made of the mucosa, submucosa and circular muscle layer of the internal drainage with sphincterotomy. In particular, the technique injection of methylene blue was sufficient to diagnose 42 out of 62 cases examined (67.7%). In the remaining 20 cases it was necessary to integrate diagnosis with MRI-defecates on the complexity of fistulas (10 horseshoe, 6 trans sphincteric and 4 intersphincteric. CONCLUSIONS: Methylene blue injection is a low-cost screening technique, simple to perform on an outpatient basis and in the case of suprasphincteric fistulas also a simple diagnostic technique is sufficient to allow the closure of the fistula.

[Results about the use of a silicone catheter in the stadiation of rectal mucosal prolapse and hemorrhoidal prolapse]. / Risultati sull'uso di un catetere siliconato nella stadiazione del prolasso mucoso del retto o del prolasso emorroidario.

INTRODUCTION: Rectal mucosal prolapse was characterized by the protrusion of the mucosa alone in the rectal lumen. Hemorrhoidal prolapse is an extreme pathological condition oh haemorrhoidal disease. The Authors after an experience conducted in ambulatory patients have performed a technique for the staging of rectal mucosal prolapse and hemorrhoidal prolapse based on the use of an endorectal silicone catheter with a balloon in the extremity. PATIENTS AND METHODS: A total of 40 patients with proctological symptoms during ambulatory visit has been submitted to a less invasive test in comparison to those traditional, using an endorectal silicone catheter with a balloon in the extremity, to insert in rectal lumen and to remove outside through the anus. RESULTS: Only in 18 patients, the method gave the exact size of the prolapse and only 16 patients was able to accurately predict the reducibility or not. Of the 18 patients in 12 patients showed a mucosal prolapse was 50% of the circumference of the anal canal, in 6 patients showed a prolapse was between 50% and 75%. In 22 patients had been diagnosed with the absence of prolapse, then denied by the plug test that showed prolapse below the 50%. CONCLUSIONS: The assessment of mucosal prolapse and hemorrhoidal prolapse through silicone catheter test has not proven better than the traditional plug test.

[Utility of plug test during anoscopy for the ambulatory evaluation of rectal mucosal prolapse]. / Utilità del test della garza durante anoscopia per la stadiazione ambulatoriale del prolasso mucoso del retto.

INTRODUCTION: Rectal mucosal prolapse was characterized by the protrusion of the mucosa alone in the anal lumen. The Authors, to correctly establish the intraoperatory stage of rectal mucosal prolapse have performed a test based on the intrarectal introduction of a plug of great dimension, to successively pull-through the anal canal during anoscopy. PATIENTS AND METHODS: A total of 30 patients with proctological symptoms and with diagnosis of rectal mucosal prolapse has been submitted, in ambulatory setting, to a less invasive test with a small plug and in second time, using a plug entirely inserted in rectal lumen and to remove outside through the anus during anoscopy. RESULTS: In all cases the plug test used during anoscopy permitted the perfect evaluation of the prolapse extension. In 12 patients the plug test evidenced a mucosal prolapse occupying the 25% of anal canal, in 10 patients the 50% of anal canal and in 8 patients a mucosal prolapse occupying up to the 50% of the anal circumference. The first 22 patients were treated transfixed stitch technique (TST) while for the other patients Longo surgical technique was preferred. CONCLUSIONS: The plug test during anoscopy is efficacious to achieve differential diagnosis between rectal mucosal prolapse and haemorrhoidal prolapse. Indeed. it is useful to choice more precisely the type of surgical intervention.

[Chronic pelvic pain treatment with posterior tibial nerve stimulation]. / Trattamento del dolore pelvico cronico mediante stimolazione del nervo tibiale.

INTRODUCTION: Chronic pelvic pain is a common problem that has a high impact on quality of life of patients who are affected. The technique of percutaneous neuromodulation by electrical stimulation of the tibial nerve (Percutaneous Tibial Nerve Stimulation PTNS) is described by Stoller for the treatment of overactive bladder syndrome in the 90s is currently being tested in the treatment of chronic pelvic pain. MATERIALS AND METHODS: The study included 35 patients with chronic pelvic pain: 17 were treated with a protocol based on 12 PTNS stimulation sessions performed weekly (Group A), 18 were treated with a protocol based on 12 sessions PTNS stimulation performed 3 times a week (group B). All patients were evaluated before and after treatment, by means of diary quality of life score (I-QoL, SF36) and proctologic examination. RESULTS: At the end of treatment 11/17 patients (63%) in group A and 12/18 patients (67%) in group B were considered a successes. Overall 4/11 (36%) patients in group A and 5/11 (45%) patients in group B recovered completely after treatment. In both groups, patients reported a subjective improvement after 6-8 stimulation sessions. At follow-up 36/8 months there were more complications. CONCLUSIONS: In conclusion, the use of PTNS in the treatment of chronic pelvic pain shows encouraging results in patients not responding to standard analgesic therapy.