The transition from open to laparoscopic surgery for bilateral inguinal hernia repair: how we did it.

PURPOSE: To describe the transition process from open repair (OR) to laparoscopic repair (LR) of bilateral inguinal hernia in a small basic general hospital METHODS: We describe the technical details and training strategy used to facilitate the transition to systematic LR of bilateral inguinal hernia. We conducted a retrospective analysis of prospectively collected data from all patients undergoing bilateral inguinal hernia repair between January 2017 and December 2020. We analysed the evolution of LR and compared the surgical outcomes: complications, acute pain (24 h), chronic pain (> 3 months), and recurrence (1 year) of the patients operated on by OR and LR. RESULTS: We performed 132 bilateral inguinal hernia repairs, 55 (41.7%) ORs, and 77 (58.3%) LRs. A significant difference was observed in the choice of LR over time (2017: 9%, 2018: 32%, 2019: 75%, 2020: 91%, p < 0.001). The mean operative time was shorter in the OR group than in the LR group (56 min vs. 108 min, p < 0.001). However, the operative time of the LR decreased over the years. No significant differences were observed in complications or recurrence. LR was associated with lower acute postoperative pain at 24 h (2.2 vs. 3.1 points, p = 0.021) and lower chronic groin pain than OR (1.3% vs. 12.7%, p = 0.009). CONCLUSION: A structured and systematized training process made the transition from OR to LR of bilateral inguinal hernias feasible and safe in a small basic general hospital. This transition did not increase complications or recurrence. Additionally, LR was associated with a decrease in postoperative pain and chronic groin pain.

Results of a Prospective Cohort Study on Open Rives Technique of the Midline Incisional Hernia: Midline Closure and Mesh Overlap.

Background. Rives repair has been traditionally used for large abdominal wall defects with good results on terms of recurrence. However, it is limited by the lateral border of the posterior rectus sheath. The objective of our study was to evaluate recurrence rate, midline closure and mesh overlap in patients operated on elective midline incisional hernia by open Rives retromuscular repair. Methods. This is a prospective observational study of 83 patients who underwent elective open Rives technique between January 2014 and December 2018. Main inclusion criteria were adults with a midline incisional hernia. Recurrence, midline closure and mesh overlap were determined. Results. At a median postoperative follow-up of 32 (5-59) months, 8 cases of recurrence were reported. Patients with recurrence had wider hernia defects (101 ± 52 mm vs 66 ± 36 mm, P = .014) and were repaired with wider meshes (191 ± 93 mm vs 137 ± 68 mm, P = .042). However, although it was not statistically significant, midline closure was lower (38% vs 59%), as well as the overlapping relationship between mesh area and hernia defect area (2.937:1 vs 3.732:1) on patients that developed a recurrence. Conclusions. Rives technique provides good mid-term results in a midline incisional hernia (10% of recurrence at 36 months), including wider hernias in the recurrent cohort. The authors believe that other techniques which allow midline closure and placement of bigger meshes should be considered, especially in those hernias classified as W3 on EuraHS classification (more than 10 cm on width size).

Appropriate Use of Antibiotics in Acute Pancreatitis: A Scoping Review.

BACKGROUND: While selective use of antibiotics for infected pancreatic necrosis (IPN) in acute pancreatitis (AP) is recommended, studies indicate a high rate of inadequate treatment. METHODS: A search of PubMed, Scopus, and Cochrane databases was conducted, focusing on primary research and meta-analyses. Data were categorized based on core concepts, and a narrative synthesis was performed. RESULTS: The search identified a total of 1016 publications. After evaluating 203 full texts and additional sources from the grey literature, 80 studies were included in the review. The answers obtained were: (1) Preventive treatment does not decrease the incidence of IPN or mortality. Given the risks of bacterial resistance and fungal infections, antibiotics should be reserved for highly suspected or confirmed IPN; (2) The diagnosis of IPN does not always require microbiological samples, as clinical suspicion or computed tomography signs can suffice. Early diagnosis and treatment may be improved by using biomarkers such as procalcitonin and novel microbiological methods; (3) When indicated, early initiation of antibiotics is a key determinant in reducing mortality associated with IPN; (4) Antibiotics with good penetration into pancreatic tissue covering Gram-negative and Gram-positive bacteria should be used. Routine antifungal therapy is not recommended; (5) The step-up approach, including antibiotics, is the standard for IPN management; (6) Antibiotic duration should be kept to a minimum and should be based on the quality of source control and patient condition. CONCLUSIONS: Early antibiotic therapy is essential for the treatment of IPN, but prophylactic antibiotics are not recommended in AP. High-quality randomized controlled trials are required to better understand the role of antibiotics and antifungals in AP management.

Comparison of two bundles for reducing surgical site infection in colorectal surgery: multicentre cohort study.

BACKGROUND: There is controversy regarding the maximum number of elements that can be included in a surgical site infection prevention bundle. In addition, it is unclear whether a bundle of this type can be implemented at a multicentre level. METHODS: A pragmatic, multicentre cohort study was designed to analyse surgical site infection rates in elective colorectal surgery after the sequential implementation of two preventive bundle protocols. Secondary outcomes were to determine compliance with individual measures and to establish their effectiveness, duration of stay, microbiology and 30-day mortality rate. RESULTS: A total of 32 205 patients were included. A 50% reduction in surgical site infection was achieved after the implementation of two sequential sets of bundles: from 18.16% in the Baseline group to 10.03% with Bundle-1 and 8.19% with Bundle-2. Bundle-2 reduced superficial-surgical site infection (OR 0.74 (95% c.i. 0.58 to 0.95); P = 0.018) and deep-surgical site infection (OR 0.66 (95% c.i. 0.46 to 0.93); P = 0.018) but not organ/space-surgical site infection (OR 0.88 (95% c.i. 0.74 to 1.06); P = 0.172). Compliance increased after the addition of four measures to Bundle-2. In the multivariable analysis, for organ/space-surgical site infection, laparoscopy, oral antibiotic prophylaxis and mechanical bowel preparation were protective factors in colonic procedures, while no protective factors were found in rectal surgery. Duration of stay fell significantly over time, from 7 in the Baseline group to 6 and 5 days for Bundle-1 and Bundle-2 respectively (P < 0.001). The mortality rate fell from 1.4% in the Baseline group to 0.59% and 0.6% for Bundle-1 and Bundle-2 respectively (P < 0.001). There was an increase in Gram-positive bacteria and yeast isolation, and reduction in Gram-negative bacteria and anaerobes in organ/space-surgical site infection. CONCLUSIONS: The addition of measures to create a final 10-measure protocol had a cumulative protective effect on reducing surgical site infection. However, organ/space-surgical site infection did not benefit from the addition. No protective measures were found for organ/space-surgical site infection in rectal surgery. Compliance with preventive measures increased from Bundle-1 to Bundle-2.

Outpatient inguinal hernia repair in Spain: a population-based study of 1,163,039 patients-clinical and socioeconomic factors associated with the choice of day surgery.

Reducing inpatient admissions and health care costs is a central aspiration of worldwide health systems. This study aimed to evaluate trends in outpatient surgery in inguinal hernia repair (IHR) and factors related to the outpatient setting in Spain. A retrospective cohort study (Record-Strobe compliant) of 1,163,039 patients who underwent IHR from January 2004 to December 2019 was conducted. Data were extracted from the public clinical administrative database CMBD ("Conjunto Mínimo Básico de Datos"). The primary outcome was the outpatient surgery rate. Univariate and multivariable analyses were performed to identify clinical and socioeconomic factors related to the outpatient setting. The overall proportion of outpatient repairs was 30.7% in 2004 and 54.2% in 2019 (p < 0.001). Treatment in a public hospital was the most remarkable factor associated with the likelihood of receiving an outpatient procedure (OR 3.408; p < 0.001). There were also significant differences favouring outpatient procedures for patients with public insurance (OR 2.351; p < 0.001), unilateral hernia (OR 2.903; p < 0.001), primary hernia (OR 1.937; p < 0.0005), age < 65 years (OR 1.747; p < 0.001) and open surgery (OR 1.610; p < 0.001). Only 9% of patients who pay for their intervention privately or 15% of those covered by private insurance were treated as outpatients. Spain has significantly increased the rate of outpatient IHR over the last 16 years. However, the figures obtained still leave a significant margin for improvement. Important questions about the acceptance of outpatient settings remain to be answered. Outpatient inguinal hernia repair in Spain. A population-based study of 1,163,039 patients: clinical and socioeconomic factors associated with the choice of day surgery.

Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines.

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

Cyanoacrylate for Safer Mesh Fixation During Laparoscopic Repair of Morgagni Hernia.

The surgical repair of all Morgagni hernias is recommended to avoid the risk of strangulation of hernia contents. Mesh augmentation repair can reduce the risk of recurrence, but severe injuries have been reported when tacks are used for mesh fixation to the diaphragm. Cyanoacrylate can provide reliable mesh fixation, and in addition, its application is easy and quick by either the transthoracic or laparoscopic approach. This report describes the main steps of laparoscopic mesh augmentation repair of a Morgagni hernia with a focus on atraumatic mesh fixation with cyanoacrylate, which should prevent the potential complications associated with the use of tacks or sutures.

Surgeon-led 7-VINCut Antibiotic Stewardship Intervention Decreases Duration of Treatment and Carbapenem Use in a General Surgery Service.

Antibiotic stewardship programs optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. In this prospective interventional study, a multidisciplinary team led by surgeons implemented a program aimed at shortening the duration of antibiotic treatment <7 days. The impact of the intervention on antibiotic consumption adjusted to bed-days and discharges, and the isolation of multiresistant bacteria (MRB) was also studied. Furthermore, the surgeons were surveyed regarding their beliefs and feelings about the program. Out of 1409 patients, 40.7% received antibiotic therapy. Treatment continued for over 7 days in 21.5% of cases, and, as can be expected, source control was achieved in only 48.8% of these cases. The recommendations were followed in 90.2% of cases, the most frequent being to withdraw the treatment (55.6%). During the first 16 months of the intervention, a sharp decrease in the percentage of extended treatments, with R2 = 0.111 was observed. The program was very well accepted by surgeons, and achieved a decrease in both the consumption of carbapenems and in the number of MRB isolations. Multidisciplinary stewardship teams led by surgeons seem to be well received and able to better manage antibiotic prescription in surgery.

Incisional hernia prevention using a cyanoacrilate-fixed retrofascial mesh. / Prevención de la hernia incisional mediante malla retrofascial fijada con cianoacrilato.

INTRODUCTION: The rate of incisional hernia in high-risk patients (obesity, cancer, etc.) is high, even in laparoscopic surgery. The aim of this study is to evaluate the safety of the use of cyanoacrylate fixed prophylactic meshes in the assistance incision in overweight or obese patients undergoing laparoscopic colorectal surgery. METHODS: A prospective, non-randomized cohort study of patients undergoing elective laparoscopic resection for colorectal cancer between January 2013 and March 2016 was performed. Those with a body mass index greater than 25kg / m2 were evaluated to implant a prophylactic meshes fixed with cyanoacrylate (Histoacryl®) as reinforcement of the assistance incision. RESULTS: 52 patients were analyzed (mean body mass index: 28.4±2kg / m 2). Prophylactic meshes was implanted in 15 patients. The time to put the mesh in place was always less than 5minutes. There was no significant difference in wound infection rate (12% vs. 10%). No mesh had to be explanted. Although the mean follow-up was shorter (14.1±4 vs. 22.3±9 months), there were no incisional hernia in the mesh group. On the other hand, in the non-mesh group, 1 acute evisceration (2.7%) and 4 incisional hernia of the assistance incision were observed (10.8%). There were no significant differences between groups regarding trocar incisional hernia (6.6 vs. 5.4%). CONCLUSIONS: The implantation of a reinforcement prophylactic mesh in overweight or obese patients undergoing laparoscopic colorectal surgery is safe and seems to reduce the short-term rate of incisional hernia. Fixation with cyanoacrylate is a rapid method that facilitates the procedure without additional complications.

Impact of Surgical Site Infections on Elective Incisional Hernia Surgery: A Prospective Study.

BACKGROUND: Although incisional hernia repair is classified as a clean surgery, it still has a high incidence of surgical site infection (SSI) (0.7%-26.6%). The presence of an SSI could increase early recurrence rates after incisional hernia repair. PATIENTS AND METHODS: Patients undergoing elective incisional hernia repair with no bowel contamination between January and December 2015 were assessed prospectively. Demographic and surgical data, local post-operative complications, and one-year recurrence rates in patients with and without SSI were compared. The management of SSI was determined. RESULTS: Patients with SSI (16/101) showed more prolonged surgical procedures (91 ± 39 vs. 63 ± 30 min, p = 0.012), more post-operative sero-hematomas (38% vs. 8%, p = 0.001), and a higher one-year recurrence rate (19% vs. 4%, p = 0.047). Multivariable analysis revealed the only identified risk factor for SSI to be post-operative sero-hematomas (p = 0.042; odds ratio [OR] = 4.17 [1.05-16.54]). Patients who developed an SSI required antibiotic agents and daily treatment from one to five months. One of these required the removal of the mesh. CONCLUSIONS: Surgical site infection rates are high for incisional hernia surgery (16%), and associated with local complications. Surgical site infection requires long-term treatments and leads to a higher one-year recurrence rate.

Single-incision laparoscopy versus standard laparoscopy for colorectal surgery: A systematic review and meta-analysis.

The aim of this meta-analysis was to evaluate if the advantages of single-incision laparoscopic surgery (SILS) to perform a colorectal resection justify a broad application of this approach. A total of 32 studies including 3863 patients, comparing colorectal procedures performed with SILS or multi-port laparoscopy (LCS) were analyzed after a systematic review. Colorectal SILS had comparable outcomes to multi-port LCS in terms of operating time (P = 0.44), conversion rate (2.0% vs 3.0%; P = 0.52), reoperations (1.1% vs 1.7%; P = 0.26), postoperative complications (14.4% vs 13.6%; P = 0.10) and mortality (0.24% vs 0.68%; P = 0.46). Mean hospital stay was significantly shorter in CSILS group, (MD = -0.88 [-1.33, -0,42], 95% CI, P = 0.0001), but heterogeneity was found (I2 = 65%; P < 0.0001). The oncological results of SILS for colorectal cancer were satisfactory, as demonstrated by similar average lymph node retrieval (P = 0.72) and adequate resection margins (negative in all cases) compared to those obtained with LCS. Nevertheless, there are currently no available long-term follow-up data comparing the survival rates and local recurrence between both approaches. Insufficient data were available for evaluating long-term incisional hernia rates, and other potential benefits associated with colorectal SILS (cosmesis, postoperative pain) remain to be objectively proved. To date there is insufficient evidence to recommend widespread use of SILS instead of LCS for colorectal surgery.

Role of Combined Post-Operative Venous Lactate and 48 Hours C-Reactive Protein Values on the Etiology and Predictive Capacity of Organ-Space Surgical Site Infection after Elective Colorectal Operation.

BACKGROUND: C-reactive protein (CRP) has been assessed to detect organ-space surgical site infection (OSI). Nevertheless, data about peri-operative oxygen debt and surgical stress-elicited biologic markers to explain and allow for the early detection of OSI are lacking. We analyzed immediate post-operative venous lactate, early CRP levels, and intra-operative hemodynamic values on the capacity to predict OSI after elective colorectal operation. PATIENTS AND METHODS: Patients undergoing an elective colorectal surgical procedure with anastomosis between March 2013 and August 2014 were included and assessed prospectively. Post-operative lactate values at L-0, L-6, and L-24 hours, CRP (basal and 48 h), and the percentage of operative time (POT) with systolic blood pressure below 100 mm Hg and heart rate above 90 beats per minute in patients with and without OSI were compared. Binary logistic regression was constructed for L-0 and CRP-48, and receiver-operating characteristic (ROC) was analyzed for sensitivity (S), specificity (Sp), positive (PPV) and negative (NPV) predictive values. RESULTS: Patients with OSI (11 of 100) showed higher L-0 and L-24 (3.2 ± 2.5 vs. 1.6 ± 0.8; p = 0.025 and 1.9 ± 1.2 vs. 1.2 ± 0.4 mmol/L; p = 0.025) and CRP-48 (188 ± 80 vs. 74 ± 52 mg/L; p = 0.001). The ROC from logistic regression showed area under the curve of 0.899 (95% confidence interval [CI] 0.805-0.992), S of 72% (95% CI 43.2%-90.5%), Sp of 95% (95% CI 88.6%-98.4%), PPV of 66% (95% CI 38.9%-86.4%) and NPV of 0.96 (95% CI 90%-99%). L-0 was higher in those patients with hypotension during more than 60% of the POT (2.4 ± 2.1 vs. 1.6 ± 0.8; p = 0.038). Patients with OSI had a higher POT with hypotension (50 ± 28% vs. 30 ± 28%; p = 0.032) and tachycardia (18 ± 27% vs. 5 ± 16%; p = 0,024). CONCLUSIONS: The combination of immediate post-operative lactate and CRP at 48 hours proved to be useful in predicting OSI after elective colorectal operation. Assessment of peri-operative lactate is a potential target for intra-operative goal-oriented management aimed at improving post-operative outcomes.

HAL-RAR (Doppler guided haemorrhoid artery ligation with recto-anal repair) is a safe and effective procedure for haemorrhoids. Results of a prospective study after two-years follow-up.

PURPOSE: To analyse prospectively results of HAL-RAR technique by evaluating pain, perioperative complications and clinical outcome after two years followup. METHODS: A prospective study design including 30 consecutive patients with haemorrhoids grade III-IV treated from June 2012. After discharge, patients received a specific questionnaire to record postoperative pain, delayed complications, evolution/disappearance of the symptoms that led to the surgical intervention (bleeding, prolapse, itching, pain and soiling). A visual analog scale (VAS) was used to measure pain. Outpatient follow-up was carried out at 7 days, and 1, 6 and 12 months and annually thereafter. Pre, intra and postoperative data (including physical examination) had been recorded prospectively. RESULTS: The median operating time (range) was 40 (26-60) minutes. Average hospital stay (range) was 11 (3-25) hours. No postoperative complications were observed in 29 cases (96.6%). Median follow-up was 26 (12-36) months. All the patients attended the follow-up. Mean postoperative pain was VAS = 1.7 on the seventh day and it was practically non-existent (VAS = 0.7) 1 month after the procedure. 87.5% of patients confirmed complete relief of symptoms after 30 days and 93% of patients feel free of symptoms 6 months after the procedure. No patient has experienced late complications as dyschezia, urgency, soiling or faecal incontinence. After 24 months follow-up, recurrence of bleeding and prolapse was observed in only 1 patient; 93% of patients have considered results of HAL-RAR as very good or excellent. CONCLUSION: HAL-RAR is safe and almost painless technique and it has very good results in the control of haemorrhoidal symptoms. This procedure should be considered as an effective first treatment option for haemorrhoids.

Value of C-reactive protein in the assessment of organ-space surgical site infections after elective open and laparoscopic colorectal surgery.

BACKGROUND: Although C-reactive protein (CRP) has proved useful in the assessment of post-operative infections, its value at those time points useful to assess organ-space surgical site infection (OSI) after open and laparoscopic colorectal surgery has not been clarified. METHODS: We compared values of CRP on post-operative days two and five and percentage of change between those days (Δ%D2-5) in patients with and without OSI, after open (OPEN) and laparoscopic (LAP) colo-rectal surgery. Receiver-operating characteristic analysis was performed and indices of test performance of sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, and likelihood ratios (LR+ and LR-) were assessed. RESULTS: The best CRP predictive values for OSI were D5 >120 mg/L (area under the curve [AUC] 0.959; 95% confidence interval [CI] 0.890-0.990) and Δ%D2-5 <40% (AUC 0.968; 95% CI 0.901-0.994; p=0.0001) in OPEN and D5 >66 mg/L (AUC 0.921; 95% CI 0.841-0.969) and Δ%D2-5 <48% (AUC 0.894-95% CI 0.806-0.952; p=0.0001) in LAP. The best measure was NPV (100%; CI 93.6%-100% for D5 and Δ%D2-5 in OPEN and 98.4%, CI 91.3%-99.7% for D5 and 100%, CI 93.4%-100% for Δ%D2-5 in LAP). CONCLUSIONS: In patients with CRP <120.66 mg/L on post-operative day 5 or a decay from post-operative day two to five of >40%-48% in OPEN and LAP, respectively, OSI may be ruled out and the patient discharged safely. Careful workup is needed in those patients with higher postoperative CRP concentrations or lower apparent decay values.