Standardization and learning curve in laparoscopic hernia repair: experience of a high-volume center.

PURPOSE: Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons. METHODS: The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors' experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed. RESULTS: The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia. CONCLUSIONS: The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency.

Predictive factors of recurrence for laparoscopic repair of primary and incisional ventral hernias with single mesh from a multicenter study.

Laparoscopic ventral hernia repair (LVHR) is a widely practiced treatment for primary (PH) and incisional (IH) hernias, with acceptable outcomes. Prevention of recurrence is crucial and still highly debated. Purpose of this study was to evaluate predictive factors of recurrence following LVHR with intraperitoneal onlay mesh with a single type of mesh for both PH and IH. A retrospective, multicentre study of data collected from patients who underwent LVHR for PH and IH with an intraperitoneal monofilament polypropylene mesh from January 2014 to December 2018 at 8 referral centers was conducted, and statistical analysis for risk factors of recurrence and post-operative outcomes was performed. A total of 1018 patients were collected, with 665 cases of IH (65.3%) and 353 of PH (34.7%). IH patients were older (p < 0.001), less frequently obese (p = 0.031), at higher ASA class (p < 0.001) and presented more frequently with large, swiss cheese type and border site defects (p < 0.001), compared to PH patients. Operative time and hospital stay were longer for IH (p < 0.001), but intraoperative and early post-operative complications and reinterventions were comparable. IH group presented at major risk of recurrence than PH (6.7% vs 0.9%, p < 0.001) and application of absorbable tacks resulted a significative predictive factor for recurrence increasing the risk by 2.94 (95% CI 1.18-7.31). LVHR with a light-weight polypropylene mesh has low intra- and post-operative complications and is appropriate for both IH and PH. Non absorbable tacks and mixed fixation system seem to be preferable to absorbable tacks alone.

Use of oxidized regenerated cellulose to achieve hemostasis during laparoscopic cholecystectomy: a retrospective cohort analysis.

OBJECTIVE: Laparoscopic cholecystectomy is the first-choice treatment for symptomatic cholelithiasis. Though generally safe, this procedure is not without complications, with bleeding the most frequent cause of conversion to open cholecystectomy. Oxidized regenerated cellulose (ORC) added to conventional hemostatic strategies, is widely used to control bleeding during surgery despite limited evidence supporting its use. This retrospective study analyzed patients undergoing laparoscopic cholecystectomy in an Italian center over a 16-month period, between October 2014 and February 2016, who experienced uncontrollable bleeding despite the use of conventional hemostatic strategies, requiring the addition of ORC gauze (Emosist®). RESULTS: Of the 530 patients who underwent laparoscopic cholecystectomy, 24 (4.5%) had uncontrollable bleeding from the liver bed. Of these, 62.5% had acute cholecystitis and 33.3% chronic cholecystitis; 1 patient was diagnosed with gallbladder carcinoma, postoperatively. Most patients had comorbidities, 16.7% had liver cirrhosis, and 37.5% used oral anticoagulants. The application of ORC rapidly controlled bleeding in all patients. Patients were discharged after a mean duration of 2.2 days. ORC was easy to use and well tolerated. Bleeding complications remain a relevant issue in laparoscopic cholecystectomy. ORC was able to promptly stop bleeding not adequately controlled by conventional methods and appears, therefore, to be a useful hemostat.