The Effect of Combined Spinal Epidural Anesthesia on Shoulder Pain in Laparoscopic Extraperitoneal Hernia Surgery.

BACKGROUND: Shoulder pain is a condition that seriously discomforts patients and develops caused by a peritoneal tear in laparoscopic extraperitoneal hernia repair (TEP) surgeries. Although surgeons generally prefer general anesthesia for the TEP technique, many studies have been carried out on the use of regional anesthesia in recent years. In our study, we aimed to investigate the efficacy and safety of the combined spinal/epidural anesthesia (CSEA) method to prevent shoulder pain in the TEP technique. METHODS: The patients who operated with the TEP procedure were divided into 2 groups; SA (group 1) and CSEA (group 2). The 2 patient groups were compared in terms of sex, age, body mass index, duration of surgery, total operation time, patient satisfaction, pain scores, length of hospital stay, adverse effects, intraoperative, and postoperative complications. RESULTS: The number of patients in group 1 was 42 and group 2 was 40. The mean operation time was recorded as 55.9 and 80.2 minutes in groups 1 and 2, respectively, which was statistically significantly shorter in group 1 ( P <0.001). Postoperative pain was significantly less in group 2 for the 4th hour ( P <0.0001) and the 12th hour ( P =0.047). There was no difference between the 2 groups in terms of peritoneal tear ( P =0.860). Intraoperative and postoperative shoulder pain was significantly less in group 2 ( P =0.038, P =0015, respectively). CONCLUSION: CSEA is an effective and safe anesthesia method for preventing shoulder pain that develops after TEP surgeries.

Does the subtotal cholecystectomy rate for acute cholecystitis change with previous endoscopic retrograde cholangiopancreatography?

BACKGROUND: Acute cholecystitis is one of the most common emergent surgeries. As a safe alternative in challenging operations, laparoscopic subtotal cholecystectomy (LSC) is widely used. We questioned whether the results in acute cholecystitis cases changed with a history of endoscopic retrograde cholangiopancreatography (ERCP). When we searched the literature, we could not find a study focusing on the subtotal cholestectomy results in acute cholecystitis. In our study, we aimed to investigate whether the history of ERCP affects the rates of subtotal cholecystectomy (SC) in acute cholecystitis. METHODS: The results of patients (n=470) who underwent surgery for acute cholecystitis at our clinic between 2016 and 2019 were retrospectively evaluated. The patients were divided into two groups according to their history of ERCP. The primary outcome was the SC rate. The secondary outcomes were conversion to open, postoperative complications, serious complications, operative duration, and length of hospital stay. RESULTS: The standard group included 437 patients, whereas the ERCP group included 33 patients. A total of 16 patients underwent SC, with 15 in the standard group and 1 in the ERCP group. There was no significant difference in terms of SC rates between groups (P=0.902). While four cases of operation were completed with conversion to open in the non-ERCP group, no conversion was seen in the ERCP group (P=0.581). No significant differences were detected between the groups in terms of complications, serious compli-cations, operation duration, length of hospital stay, and mortality. CONCLUSION: The results of this study showed that ERCP is not related to an increased rate of SC and conversion in patients with acute cholecystitis. Laparoscopic cholecystectomy for acute cholecystitis can be safely performed in patients with a history of ERCP. LSC is a safe procedure in challenging patients, and fenestrating SC can be preferred to avoid hazardous consequences in such cases.

Risk factors affecting benign anastomotic stricture in anterior and low anterior resections for colorectal cancer: a single-center retrospective cohort study.

PURPOSE: Although not as life-threatening as anastomotic leakage, anastomotic stricture reduces the quality of life. The risk factors for such an important life complication have not been revealed. This article examines the risk factors affecting anastomotic strictures due to colorectal cancers. METHODS: Patients who underwent anterior and low anterior resection for colorectal cancer under elective conditions between 2015 and 2021 were included in the study. The patients were divided into two groups, those who developed anastomotic stricture and those who did not. The parameters determined between the two groups were compared, and multivariate analysis of statistically significant parameters was performed. RESULTS: A total of 375 patients were included in the study. The anastomotic stricture was detected in 36 (9.6%) patients. In the multivariate analysis, non-mobilization of the splenic flexure and a proximal clean surgical margin of < 10 cm and a distal surgical margin of < 2 cm were identified as risk factors affecting anastomotic stricture. The risk factor with the highest odds ratio in the development of anastomotic stricture is the non-mobilization of the splenic flexure (p = 0.001, OR 11.375). CONCLUSION: It is recommended that the mobilization of the splenic flexure to reduce the development of strictures. In addition, a clean surgical margin of 10 cm proximally and 2 cm distally and high ligation of the inferior mesenteric artery may reduce the development of stricture.

Risk Factors for Conversion in Laparoscopic Totally Extraperitoneal Inguinal Hernioplasty.

BACKGROUND: Conversion is a surgical concern because the surgical technique can change during surgery. Surprisingly, there is no study in the literature on the causes and risk factors leading to conversion in laparoscopic total extraperitoneal inguinal repair (TEP). There is also no consensus on the prevention and causes of this condition in TEP. The aim of this study was to evaluate the risk factors underlying the development of conversion during TEP. MATERIALS AND METHODS: We recruited 962 consecutive patients who underwent TEP between May 2016 and May 2021. All data were collected retrospectively. The outcomes of patients who converted to open surgery were compared with those without conversion. Multivariate analysis identified independent risk factors for conversion. RESULTS: The overall incidence of conversion was 4.05% (n=39). The median age was 42 years (18 to 83) and body mass index was 25.2 kg/m2 (15.67 to 32.9). Significant clinical factors associated with conversion included old age, American Society of Anesthesiologists (ASA) score, large peritoneal tear (PT), Charlson comorbidity index, previous surgery, large hernial defects, presence of scrotal hernia, and the defect size of inguinal hernia. Multivariate analysis identified independent risk factors for conversion: large hernial defect, large PT, previous lower abdominal surgery, previous hernia surgery, and scrotal hernia. CONCLUSION: Conversion is a minor complication seen during TEP and its incidence varies depending on many factors. Previous lower abdominal surgery and a large PT carries a 6-fold increased risk for conversion from laparoscopic to open surgery during TEP.

Partial cecum resection using endostapler in acute complicated appendicitis with appendiceal base necrosis.

INTRODUCTION: The method of stump closure is controversial in complicated patients, especially with appendix base necrosis or perforation. AIM: To evaluate the efficacy and safety of partial cecum resection technique with an endostapler in patients with appendix base necrosis or perforation. MATERIAL AND METHODS: Thirty-six patients who underwent laparoscopic partial cecum resection due to appendix base necrosis or perforation between 2015 and 2020 were retrospectively analyzed. In acute complicated appendicitis with appendiceal base necrosis or perforation, it was performed by laparoscopic partial cecum resection using an endostapler within a safe surgical margin. Demographic characteristics, duration of operation, days of hospital stay, and intra- and post-operative complications were evaluated. RESULTS: The mean age of the patients is 42.72 ±16.69, female/male ratio was 19/17 (52.8%/47.2%). No intraoperative complications developed. Mean operative time and hospital stay were 104.75 ±34.96, 4.58 ±2.82 days, respectively. Post-operative complications developed in 5 (13.7%) patients. One of them was wound infection (2.7%), 2 of them were ileus (5.5%) and 2 patients had an intraabdominal abscess (5.5%). Stapler line leak was not observed in any of the patients. CONCLUSIONS: The use of an endostapler in laparoscopic appendectomy is a safe and effective technique in cases where appendix base necrosis, appendix perforation or severe inflammation affects the base of the cecum.

Association between Acute Pancreatitis and COVID-19: Could Pancreatitis Be the Missing Piece of the Puzzle about Increased Mortality Rates?

BACKGROUND: The COVID-19 pandemic caused by SARS-CoV-2 commenced in Wuhan China in 2019 and soon spread worldwide. SARS-CoV-2 enters the cell by binding to the ACE II receptor and begins viral replication. The effects and clinical findings of SARS-CoV-2 on the liver, kidney, heart, gastrointestinal (GI) system and especially lungs have been widely discussed. However, the effects on the pancreas-another organ that also expresses ACE II-have not been studied. METHODS: This work prospectively evaluated data from 316 patients who were admitted with a diagnosis of COVID-19 pneumonia. The patients were categorized into three according to the severity of pneumonia (mild, severe, critical). Demographic data, rate of pancreatitis, biochemical parameters, and radiological images from each group were analyzed. The patients were divided into two groups and outcomes were compared: COVID-19 patients with acute pancreatitis (Group P) and without acute pancreatitis (Group C). RESULTS: The median age was 54 (18-87), and the median age for patients with acute pancreatitis was 55 (26-84). As an expected finding, we found a positive correlation between advanced age and mortality (p = 0.0003). 12.6% of the patients had acute pancreatitis. While pancreatitis was not seen in patients on mild status, the rate of pancreatitis was 32.5% in critical patients. Hospitalization and mortality rates were higher in patients with COVID-19 accompanied by acute pancreatitis (p = 0.0038 and p < 0.0001, respectively). C-Reactive Protein (CRP) and ferritin were significantly higher in those who had pancreatitis (p < 0.0001). D-Dimer and procalcitonin levels had only a small difference (p = 0.1127 and p = 0.3403, respectively). CONCLUSION: Acute pancreatitis alone is a clinical condition that can lead to mortality and may be one of the reasons for the exaggerated immune response developing in the progression of COVID-19. Our results point out that the presence of pancreatic damage triggered by SARS-CoV-2 can deteriorate the clinical condition of patients and the mortality rate may increase in these patients.

Management of appendiceal neuroendocrine tumors in the light of new guidelines.

PURPOSE: Appendiceal neuroendocrine tumors (ANETs) are the most common in the appendix, detected in histopathological appendectomy specimens, which are resected for acute appendicitis. If tumor detection does not show signs of metastatic disease or obvious features of carcinoid syndrome, preoperative diagnosis remains a challenge. However, the treatment and follow-up algorithm change over time. In our study, we aimed to present 10 years of diagnostic and management experience. MATERIAL AND METHODS: A retrospective study of all patients who underwent emergency appendectomy, with the intention to treat clinically acute appendicitis at Bakirkoy Dr. Sadi Konuk Hospital (Istanbul, Turkey), was undertaken. Patients with diagnoses other than ANETs were excluded. Age, gender, preoperative clinical findings, operative procedure, and histopathological results identified as ANETs were evaluated. RESULTS: ANETs were detected in 24 patients (0.42%) in the histopathological examination of 5720 appendectomy specimens between December 2011 and October 2020. Mean age of patients was 30 years, with 58.3% female. The majority were located at the tip of appendix (62.5%). Eleven patients (45.83%) were graded as T1, one patient (4.16%) as T2, 11 (41.83%) as T3, and one patient (4.16%) as T4. Secondary hemicolectomy was performed in four patients. Median postoperative follow-up was 43 (17-108) months. CONCLUSION: In addition, ANETs are rare and largely detected by chance; therefore, precise examination of routine appendectomy specimens is essential for diagnosis. Accurate tumor staging, in light of new algorithms, has an important place in follow-up and treatment management.

Gastrointestinal Stromal Tumours.

OBJECTIVE: To analyse the gastrointestinal stromal tumours (GIST) patients' inter-demographics, histological type and association with secondary tumours. STUDY DESIGN: A case series. Place and Duration of the Study: Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey, between January 2010 and December 2018. METHODOLOGY: Fifty-eight patients diagnosed with GIST and operated at the study place were analysed retrospectively. The demographics, symptoms, diagnosis, treatment, tumour location, histopathology, risk classification, and prognosis were recorded. RESULTS: The mean age was 60.62 ± 10.63 (37-83) years and the male to female ratio was 1:1. The most common symptom was abdominal pain (51.7%). Tumour site was the stomach in the majority (86.2%), followed by the small intestine and colon. One patient also had a secondary malignancy. The most common histologic type was spindle cell, followed by mixed cell type. C-kit (CD117) and CD34 mutations were positive in 87.9% and 75.9% of the cases. One patient had liver metastasis on diagnosis and another had peritoneal implants per-operatively, who died after 36 months due to midgut volvulus. The mean follow-up period was 32.03 ± 13.67 months. Two patients developed liver metastasis in the early postoperative period. CONCLUSION: Surgical resection and imatinib treatment have been provided with good prognosis. The most common histology is spindle cell type. GISTs might be associated with other cancers which should be searched and analysed. Key Words: Gastrointestinal stromal tumour, Secondary malignancy, Treatment, Prognosis.

Comparison of General, Epidural, and Spinal Anesthesia in Laparoscopic TEP (Total Extraperitoneal Repair) for Inguinal Hernia.

PURPOSE: Laparoscopic total extraperitoneal repair (TEP) is one of the most preferred minimally invasive methods for inguinal hernia repair. In our study, we aimed to compare the advantages and disadvantages of general anesthesia (GA), spinal anesthesia (SA), and epidural anesthesia (EA) for TEP operations. MATERIALS AND METHODS: This is a retrospective study involving 221 patients who underwent TEP surgery for inguinal hernia between January 2018 and July 2020. Patients were divided into 3 groups as GA (n=77), SA (n=70), and EA (n=74). Demographic data of the patients, duration of anesthesia and surgery, perioperative and postoperative complications, postoperative pain, anatomical delineation, hospital stay and quality of life were evaluated. RESULTS: Anesthesia time was the longest in the EA group (23.1±2.32 min) and significantly prolonged the operation time (P<0.001). When the visual analog scale scores were compared, it was observed that the patients in the GA group felt significantly more pain (P<0.001). While the rates of hypotension and headache were higher in regional anesthesia (P<0.001 and P<0.002), there was no significant difference in urinary retention, postoperative nausea/vomiting, and shoulder pain (P=0.274, 0.262, and 0.314, respectively). SA and EA groups were found to be superior compared with the GA group in terms of patient satisfaction (P<0.001). CONCLUSION: Regional anesthesia (SA and EA) can be safely performed in TEP surgeries, gives results similar to the anatomical delineation satisfactory and complication rates of GA, and results in less postoperative pain.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience.

PURPOSE: Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD. METHODS: The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed. RESULTS: There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively). CONCLUSIONS: CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

Effects of COVID-19 pandemic on general surgical emergencies: are some emergencies really urgent? Level 1 trauma center experience.

PURPOSE: The aim of this paper is to investigate the effect of COVID-19 pandemic on general surgical emergencies as well as analyzing the effectiveness of measures taken in reducing the incidence of COVID-19 in patients and healthcare professionals. METHODS: Patients who underwent emergency surgery between the pandemic period of March 14th to May 15th 2020 and within the same period from the previous year were reviewed retrospectively. COVID-19 incidence in patients and health professionals working in the general surgery department during these periods was questioned. RESULTS: Demographic data were similar between the two time periods. The number of patients who underwent surgery in the pandemic group (n = 103) was lower than the control group (n = 252). There was a 59.1% reduction in emergency surgeries. The biggest decreases were the admissions of incarcerated hernia, uncomplicated appendicitis and acute cholecystitis (92%, 81.3%, 47.3%, respectively). During the pandemic, an increase was of patient rates who underwent surgery for complicated appendicitis and AMIO (p = 0.001, p = 0.019, respectively). The rate of mortality was higher in patients who underwent emergency surgery during pandemic (p = 0.049). The results of COVID-19 screening were positive in 6 (6/103, 5.82%) patients undergoing emergency surgery. None of the doctors working in the ward were infected with COVID-19 infection (0/20). The screening tests were positive in only two nurses working on the ward (2/24, 8.33%). CONCLUSION: In this and similar pandemics, we suggest that a new algorithm is necessary to approach emergencies and the results of this study can contribute to that end.

Laparoscopic Total Extraperitoneal Inguinal Hernia Repair Under Epidural Anesthesia Versus General Anesthesia.

INTRODUCTION: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is a well-known approach to inguinal hernia repair. The present study aims to compare the advantages and disadvantages of the TEP technique under general anesthesia (GA) and epidural anesthesia (EA). MATERIALS AND METHODS: The patients were divided into 2 groups as those undergoing TEP under EA (Group 1) and those undergoing TEP under GA (Group 2). The 2 patient groups were compared in terms of sex, age, body mass index data, duration of surgery, total operation time, patient satisfaction, VAS scores (1, 4, 12, and 24 h), length of hospital stay, and postoperative complications. RESULTS: The number of patients operated under EA (Group 1) was 30, and the number of patients operated under GA (Group 2) was 32. Only in the postoperative first hour VAS scores was statistically significantly less and the need for analgesia evaluated in both groups was found to be statistically significantly lower in Group 1 (P<0.001). The mean operation time was recorded as 62 and 46.50 minutes in Groups 1 and 2, respectively, which was statistically significantly shorter in Group 2 (P<0.001). There was no difference between the 2 groups regarding complications, hospital stay, recovery, or surgery time. Conversion rate is 0 in both groups. CONCLUSIONS: Lower postoperative VAS scores and lower postoperative VAS scores and lower analgesic used requirements of EA, it is thought that EA can be safely applied in the TEP procedure as an alternative in patients who cannot be administered GA.

High-Volume, Low-Concentration Intraperitoneal Bupivacaine Study in Emergency Laparoscopic Cholecystectomy: A Double-Blinded, Prospective Randomized Clinical Trial.

Background. Laparoscopic cholecystectomy (LC) often results in postoperative pain, especially in the abdomen. Intraperitoneal local anesthesia (IPLA) reduces pain after LC. Acute cholecystitis-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent LC with IPLA application. The aim was to determine the postoperative analgesic efficacy of high-volume, low-dose intraperitoneal bupivacaine in urgent LC. Materials and Methods. Fifty-seven patients who were American Society of Anesthesiologists physical status I or II were randomly assigned to receive either normal saline (control group) or intraperitoneal bupivacaine (test group) at the beginning or end of urgent LC. The primary outcome was the postoperative pain score of the Visual Analogue Scale (VAS). The secondary outcomes included Visual Rating Prince Henry Scale (VRS), patient satisfaction, and analgesic consumption. Results. Postoperative VAS scores at the first and fourth hours were significantly lower in the test group than in the control group (P < .001). Postoperative VRS scores at the first, fourth, and eighth hours were significantly lower in the test group than in the control group (P < .001, P = .002, P = .004, respectively). Analgesic use was significantly higher in the control group at the first postoperative hour (P < .001). Shoulder pain was significantly lower, and patient satisfaction was significantly higher in the test group relative to the control group (both P < .001). Conclusion. High-volume, low-concentration intraperitoneal bupivacaine resulted in better postoperative pain control and reduced incidence of shoulder pain and analgesic consumption in urgent LC.

Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial.

PURPOSE: The use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery. METHODS: The use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission. RESULTS: In our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups. CONCLUSION: Our clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.

Could Early Postoperative Complications be Considered as Risk Factor for Recurrence after Pilonidal Sinus Surgery?

Background: There is no widespread consensus in treatment techniques of sacrococcygeal pilonidal disease (PD). Among surgical techniques, especially Karydakis procedure (KP) or modified Limberg flap (MLF), are frequently preferred. Causing prolonged follow-up and return to daily activity, postoperative complications are very annoying. We aimed to determine risk factors for possible complications and especially recurrence in the patients undergoing surgical treatment for PD. Methods: This is a seven-year retrospective study, which was conducted between January 2011 and January 2018. Eight hundred forty-one patients were evaluated in this work. We performed the same technique-the same surgeon approach in our surgical treatment. All cases were divided into two groups as KP (n=417) and MLF (n=424). Results: It was found no significant difference between the KP and MLF groups in terms of age, gender, BMI, smoking, history of acute abscess drainage (HAAD), the timing of suture removal, the follow-up period, seroma, hematoma, dehiscence, wound infection (WI), pain and recurrence. In this study, the follow-up period of patients was 48.6 21.4 months in KP group and 48.2 +- 21.7 months in MLF group (Mean - SD). American Society of Anesthesiologists (ASA) score were found to be higher in the KP group. While mean duration of operation (DO) was shorter in the KP group, the timing of drain removal, hospitalisation period and return to daily activity (RDA) were longer. There was an established enhancing effect of BMI, HAAD, DO, and RDA on the early complications (EC) development in both of the groups, and of ASA scores on the EC development in the KP group. The rate of recurrence ratio was determined to be 6% in the KP and 4.72% in the MLF groups. In both of the groups, dehiscence or WI was found to be risk factors for recurrence. Conclusion: Although its DO is short, KP technique bear some of the disadvantages such as prolonged HP and delayed RDA. A significant positive correlation was found between various factors such as higher BMI, presence of HAAD, prolonged DO, prolonged RDA and the development of EC in both groups. We concluded that dehiscence and WI from EC may be evaluated as independent risk factors for recurrence. We also concluded that recurrence may be prevented if wound care is carried out carefully in the patients who developed dehiscence or wound infection.

In the Experimental Model of Acute Mesenteric Ischemia, The Correlation of Blood Diagnostic Parameters with the Duration of Ischemia and their Effects on Choice of Treatment.

Purpose/Aim: Acute mesenteric ischemia is a syndrome characterized by sudden onset abdominal pain followed by intestinal necrosis. Morbidity and mortality increase with delayed diagnosis. Even with the latest radiological diagnostic methods, early diagnosis and initiation of treatment can be delayed. Using an experimental model, here we aim to determine the relationship between the laboratory parameters used to detect acute mesenteric ischemia and the duration of irreversible ischemia. Materials and Methods: A total of 30 male Wistar albino rats were divided into five groups, all of which underwent general anesthesia: (i) Superior mesenteric artery (SMA) dissection with laparotomy was performed, and blood samples and intestinal segment samples were taken after 2 hr (Sham group); (ii) volvulus of one-third of the small intestines was performed manually by laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (Volvulus group); (iii) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (SMA+ligated 2-hr group); (iv) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 4 hr (SMA+ligated 4-hr group); and (v) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 6 hr (SMA+ligated 6-hr group). Results: The mean lactate dehydrogenase (LDH) activities of the SMA+ligated 2-hr and SMA+ligated 6-hr groups were statistically higher than the control group (p = .004). Compared to the Sham and Volvulus groups, the mean lactate level of the SMA+ligated 6-hr group was significantly higher (p = .004). Compared to the Sham and Volvulus groups, the mean D-dimer levels of the SMA+ligated 4-hr and SMA+ligated 6-hr groups were significantly higher (p = .004 and .003, respectively). By histopathological evaluation, we found that pathological damage increased as the ischemia lengthened. Conclusions: Mesenteric ischemia leads to an irreversible loss of intestinal perfusion and an increase in parameters of ischemia. Irreversible tissue damage occurs after 4 hr of ischemia and peaks after 6 hr, whereas parameters of ischemia (D-dimer, LDH, and L-Lactate levels) are highest at 2 hr after the onset of ischemia.

Comparison of slit mesh versus nonslit mesh in laparoscopic extraperitoneal hernia repair.

INTRODUCTION: Endoscopic hernia repair integrates the advantages of tension-free preperitoneal mesh support of the groin with the advantages of minimally invasive surgery procedures. AIM: To compare outcomes between slit mesh (SM) and nonslit mesh (NSM) placement in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. MATERIAL AND METHODS: This is a retrospective study of 353 patients who underwent TEP inguinal hernia repair between January 2010 and December 2011. One hundred forty-nine and 154 hernias were operated on in the SM and NSM groups, respectively. Postoperative complications, recurrence, early postoperative pain, and chronic pain levels were evaluated. RESULTS: In a total of 303 patients, hernia repair was performed as 395 direct and indirect hernias. Nonslit mesh was converted from TEP to transabdominal preperitoneal patch plasty (TAPP) in 4 patients in the group and 6 patients in the slit mesh group. The average operation time of the SM group was significantly higher than that of the NSM group (p < 0.001). In the evaluation of early postoperative pain, VAS levels of the NSM group were statistically significantly lower than those of the SR group in all evaluations (p = 0.001). The pain rate of the SM group after 3 months of chronic pain was significantly higher than that of the NSM group (p = 0.004). There was no difference in recurrence rate, 6th month chronic pain, wound infection or wound hematoma. CONCLUSIONS: The use of SM and NSM in TEP operations is not different in terms of recurrence and complications. However, the use of NSM gives better results in terms of early postoperative pain and chronic pain.

Efficacy and reliability of the use of a needle grasper to prevent trocar site hernia.

INTRODUCTION: Port site herniation is one of the serious complications of laparoscopic surgery, which decreases its benefits. Closure of a fascia defect at the port site is an important problem of laparoscopic surgery, especially in obese patients. AIM: To evaluate needle grasper fascia closure. MATERIAL AND METHODS: We closed the port site fascia using a percutaneous organ-holding device (needle grasper) in laparoscopic cholecystectomy patients. This study included 334 patients who underwent laparoscopic cholecystectomy between January 2015 and January 2017 in our hospital. Patients were divided into 2 fascia closure groups: group 1 with a standard simple suturing technique and group 2 with a needle grasper to close the port site. Patient demographics, operative details, and postoperative outcomes were collected and evaluated. RESULTS: There were 243 female and 91 male (total 334) patients with the mean age of 49.18 ±13.15 years. Only 1 patient in the BMI > 30 kg/m2 group of patients had port site hernia development with the needle grasper technique at the end of the 8-month follow-up period. The port site hernia incidence was higher in group 1 than group 2 (p < 0.001), but there was no significant difference in terms of operation duration between the two groups (p < 0.001, p = 0.709, respectively). In patients with a BMI > 30 kg/m2, both operation duration and port site hernia incidence were higher in simple suture closure than in the needle grasper technique (p < 0.001, p = 0.016, p = 0.005). CONCLUSIONS: The needle grasper technique is easy, simple, safe, fast, and effective for fascia closure of port sites. This method can also be applied in obese patients easily, safely and in a short time.

A promising technique for easier single incision laparoscopic cholecystectomy: needle grasper traction of gallbladder.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the primary treatment method for benign gallbladder diseases. Single incision laparoscopic cholecystectomy (SILC) was reported to be superior in terms of work return, cosmetic results, and post-operative pain, but limited maneuver capacity and overlapping of hand tools are technical difficulties associated with SILC that endanger patient safety. AIM: To perform SILC using a needle grasper for gallbladder traction, thus simplifying the dissection of Calot's triangle. MATERIAL AND METHODS: The files of patients who underwent elective LC for gallbladder stone and polyps in general surgery clinics between December 2013 and December 2014 were analyzed retrospectively. The patients were divided into two groups: needle-grasper-assisted SILC (nSILC) and conventional laparoscopic cholecystectomy (CLC). Age, gender, height, weight, body mass index, visual analog scale (VAS) scores, ASA score, duration of operation, duration of post-operative hospital stay, complications, drain use, conversion to open and conventional technique, and oral feeding beginning time were analyzed. RESULTS: There were no per-operative or post-operative complications in either of the groups, and no significant differences were found between the groups in terms of complications. The mean duration of the operation was significantly longer in the nSILC group. There was no difference between the groups in terms of hospital stay. The mean visual analogue scale (VAS) scores in conventional nSILC were significantly lower for all hours. The patient satisfaction in terms of cosmetic results was better in the nSILC group. CONCLUSIONS: Needle-grasper-assisted SILC reduces the number of tools that need to be held by surgeons; it also provides safe dissection, better cosmetic results, and less post-operative pain in elective cases.

Open mesh and laparoscopic total extraperitoneal inguinal hernia repair under spinal and general anesthesia.

INTRODUCTION: Mesh placement is the main standard in repair of inguinal hernia, and laparoscopic repair is the standard of care via spinal, epidural, or combined anesthesia. Here, we compared open and laparoscopic total extraperitoneal (TEP) repairs under general (GA) and spinal anesthesia (SA). METHODS: Inguinal hernia patients (n=440) were analyzed retrospectively. There were four groups: Group 1 was TEP under GA (TEP-GA) (n=111); Group 2 was open mesh repair (OM) under SA (n=116) (OM-SA); Group 3 was open mesh repair under GA (n=117) (OM-GA); Group four was TEP under SA (n=96) (TEP-SA). The age, body mass index, duration of operation, hospital stay, postoperative Visual Analog Scale scores, recurrence, postoperative pain, urinary retention, headache, and patient satisfaction were all recorded. RESULTS: There was no significant difference in terms of hypotension, vomiting, seroma and scrotal edema, recurrence, and wound infection incidence between the groups. However, the operation duration, hospital stay period, headache, urinary retention, postoperative Visual Analog Scale scores, chronic pain, and patient satisfaction showed significant differences between groups. CONCLUSION: Laparoscopic TEP hernia repair is a safe and effective method along with its advantages of shorter hospital stay, less recurrence, less postoperative pain, higher patient satisfaction, and similar postoperative complication rates. SA has the disadvantage of higher incidence of headache and urinary retention compared to GA.