Synthetic Versus Biological Mesh in Laparoscopic and Open Ventral Hernia Repair (LAPSIS): Results of a Multinational, Randomized, Controlled, and Double-blind Trial.

OBJECTIVE: The aim of this study was to investigate the approach (open or laparoscopic) and mesh type (synthetic or biological) in ventral hernias in a clean setting.Summary of Background Data: The level of evidence on the optimal surgical approach and type of mesh in ventral hernia repair is still low. METHODS: Patients with a ventral abdominal hernia (diameter 4-10 cm) were included in this double-blind randomized controlled trial across 17 hospitals in 10 European countries. According to a 2 × 2-factorial design, patients were allocated to 4 arms (open retromuscular or laparoscopic intraperitoneal, with synthetic or Surgisis Gold biological mesh). Patients and outcome assessors were blinded to mesh type used. Major postoperative complication rate (hernia recurrence, mesh infection, or reoperation) within 3 years after surgery, was the primary endpoint in the intention-to-treat population. RESULTS: Between September 1st, 2005, and August 7th, 2009, 253 patients were randomized and 13 excluded. Six of 61 patients (9.8%) in the open synthetic mesh arm, 15 of 66 patients (22.7%) in the open biological mesh arm, 7 of 64 patients (10.9%) in the laparoscopic synthetic mesh arm and 17 of 62 patients (27.4%) in the laparoscopic biological mesh arm had a major complication. The use of biological mesh resulted in significantly more complications (P = 0.013), also after adjusting for hernia type, body mass index, and study site. The trial was prematurely stopped due to an unacceptable high recurrence rate in the biological mesh arms. CONCLUSIONS: The use of Surgisis Gold biological mesh is not recommended for noncomplex ventral hernia repair. TRIAL REGISTRATION: This trial was registered at controlled-trials.com (ISRCTN34532248).

[Effectiveness and safety of total thyroidectomy in the management of benign multinodular goiters]. / A total thyreoidectomia hatásossága és biztonságossága a jóindulatú multinodularis golyvák kezelésében.

BACKGROUND: The appropriate surgical procedure for benign multinodular goiters is debated. We report our clinical experience of performing total thyroidectomy for multinodular goiters, focusing on the outcome and complications to evaluate the efficacy and safety. MATERIAL AND METHODS: The medical records of 264 patients who underwent total thyroidectomy for multinodular goiter between 2000 and 2006 were reviewed retrospectively. We examined the indications for operation, average hospital stay, early and late postoperative complications, the results of the final pathology in particular the frequency of incidental thyroid cancers and the recurrence rates after an average 6.2 years follow-up. The results were compared to literature data. RESULTS: The indications for surgery were compression and/or dislocation of the trachea in 174 (65.9%) patients, hyperthyreodism in 74 (28%) and cosmetic problems in others. The mean hospital stay was 4 days. Thirty-one patients (11.7%) had transient hypocalcaemia, but only 1 (0.3%) was symptomatic, and only 4 (1.5%) had permanent hypocalcaemia. Other complications included hematoma 4 (1.5%), temporary unilateral recurrent laryngeal nerve palsy 7 (2.6%), permanent unilateral laryngeal nerve palsy 2 (0.75%), and seroma in 8 (3%) cases. Incidental thyroid carcinomas were found on hystology in 9 (3.5%) patients. No recurrence was observed during the follow-up. CONCLUSION: Total thyroidectomy may be the procedure of choice for the surgical management of benign multinodular goiter.

[Robotic surgery]. / Robotsebészet.

Due to the fast spread of laparoscopic cholecystectomy, surgical procedures have been changed essentially. The new techniques applied for both abdominal and thoracic procedures provided the possibility for minimally invasive access with all its advantages. Robots - originally developed for industrial applications - were retrofitted for laparoscopic procedures. The currently prevailing robot-assisted surgery is ergonomically more advantageous for the surgeon, as well as for the patient through the more precise preparative activity thanks to the regained 3D vision. The gradual decrease of costs of robotic surgical systems and development of new generations of minimally invasive devices may lead to substantial changes in routine surgical procedures.

[New possibilities in practical education of surgery]. / Új lehetoségek a sebészet gyakorlati oktatásában.

The fast spread of laparoscopic surgery in the surgical community also required introduction of new methods of surgical education of these techniques. Training boxes applied for this reason meant a considerable help. The technique of the virtual reality introduced simulation, which is a new possibility in education. For the first time in the history of surgery we can measure medical students' or residents' dexterity and one can get acquainted with a surgical procedure in the form of "serious games". By application of the up-to-date imaging methods we can plan the movements of the surgeon's hand even before the planned operation, practice and repeating can contribute to the safety of the real procedure. Open surgical procedures can be practiced on plastic phantoms mimicking human anatomy and the use of interactive touch devices and e-learning can also contribute to practical education of surgery.

[Examination of cytoprotective and anti-inflammatory effect of PACAP-38 on small bowel autotransplantation]. / A PACAP-38 citoprotektív és antiinflammatórikus hatásának vizsgálata vékonybél-autotranszplantációs modellben.

INTRODUCTION: The small intestine is one of the most sensitive organs to ischemia-reperfusion injury during transplantation. Cytoprotective effect of pituitary adenylate cyclase-activating polypeptide (PACAP) is well known. The aim of our study was to measure changes of PACAP-38-like immunoreactivities and cytokine levels in intestinal grafts stored PACAP-38 containing preservation solution. MATERIAL AND METHODS: Small-bowel autotransplantation was performed on male Wistar rats (n = 56). Grafts were stored in University of Wisconsin (UW) solution at 4 °C for 1 (GI), 3 (GII), and 6 hours (GIII); and in PACAP-38 containing UW solution for 1 (GIV), 3 (GV), and 6 hours (GVI). Reperfusion lasted 3 hours in each group. Intestinal PACAP-38 immunoreactivities were measured by radioimmunoassay. To measure cytokine from tissue homogenates we used rat cytokine array and Luminex Multiplex Immunoassay. RESULTS: Levels of PACAP-38-like and PACAP-27-like immunoreactivities decreased by preservation time compared to control. This decrease was significant following 6 hours cold storage (p < 0.05). Values remained significantly higher in grafts stored in PACAP-38 containing UW. Expressions of sICAM-1, L-selectin, tissue inhibitor of metalloproteinase-1 were increased in GIII and were decreased in GVI. CONCLUSION: PACAP-38 increased tissue levels of PACAP-38 and PACAP-27, and decreased cytokine expression. This indicates that PACAP-38 has anti-inflammatory and cytoprotective effects in intestinal autotransplantation model.

[The mechanism of adhesion formation and the possibilities of modeling -- a preliminary study]. / Az adhaesioképzodés mechanizmusa és modellezésének lehetoségei -- Elokísérleti modellek.

A huge number of factors play a significant role in the process of adhesion formation, like bleeding, the presence of foreign bodies, tissue injury, tissue destruction, ischemia and hypoxia. Adhesions are present in 95% of the cases following abdominal surgery. As a result of adhesions a large number of postoperative complications can occur, such as abdominal pain, bowel motility disturbances and infertility. Hence, it is important to know the precise mechanism of adhesion formation process and establish a suitable animal model to investigate the underlying mechanisms. Molecules which play a part in the process of adhesion formation were collected from the international literature. Male Wistar rats were used to create the adhesion model. Bleeding, implantation of foreign bodies, creation of ischemic areas and tissue destructions were carried out. Within this experiment the tiny bleeding and ischemic areas did not result in adhesion formation. The adhesion formation due to foreign body implantation depends on the type of the materials. Due to the inhibitory mechanism of adhesion formation there was no adhesion detectable due to tiny peritoneal destruction. The most reliable model was the one when gross tissue destruction of the abdominal wall was applied and the resulting bleeding initiated the adhesion formation process. It is also extremely important to know the key participants in the complex process of adhesion formation. This reliable model can help to work out the proper method of prevention.

[Trocar site herniation (TSH) following laparoscopic cholecystectomy: incidence, pathogenesis, and prevention -- animal study]. / A trokárok helyén kialakult hasfali sérvekrol (Trocar Site Hernia) laparoscopos cholecystectomia után: incidencia és megelozés -- állatkísérletes tanulmány.

INTRODUCTION: In 1968 R. E. Fear first reported a trocar site hernia (TSH) in his large series on laparoscopy. Currently, the incidence of TSH is estimated to be 0.65-2.80%. Ports ≥10-mm are usually closed, but ports of the 5-mm trocars are always left open, which may lead to herniation. MATERIAL AND METHODS: Authors guided teaching courses for hands-on animal laparoscopic cholecystectomy (LC) operations, where trainees performed LC-s on 60 animals. Two and four weeks following the operations the animals underwent second look laparoscopy to detect adhesion formation. RESULTS: Trocar site herniation was observed, and in 20% of the animals herniation was found. 70% of the hernias were situated in the 5-mm ports and 30% in the 10-mm ports. CONCLUSION: Port sites should be closed to prevent the formation of TSH. Attention should be payed on the closure of 5-mm trocar sites as well.

[The treatment of Aspergillus empyema using open thoraco-myoplasty with the preservation of lung function -- case report]. / Aspergillus empyema kezelése nyitott thoracostomiával és izomplasztikával, a tüdo funkciójának megorzésével -- esetismertetés.

CASE REPORT: Invasive aspergillosis is a life threatening complication in immune-compromised patients causing lung tissue destruction. Aspergillus empyema requires aggressive multimodality treatment. MATERIAL AND METHOD: We present a case of Aspergillus empyema treated by thoracic and plastic surgery preserving the lung function in an 18 year-old male patient suffering dermatomyositis and treated with steroids for a long time. After open window thoracostomy (OWT) we used pedicled musculus latissimus dorsi (MLD) flap and mobilised the anterior serratus muscle to close the pleural cavity. CONCLUSION: The intrathoracic use of muscle flaps after OWT in case of chronic Aspergillus empyema can preserve the underlying lung tissue. Cooperation of thoracic and plastic surgeons - as in the cases presented - provides an excellent opportunity to treat successfully of otherwise hopeless patients.

[In vitro development of laparoscopic skills]. / A laparoscopos készségek in vitro fejlesztése.

Minimally invasive surgery is a popular alternative to open surgical procedures. Laparoscopic surgeries require highly skilled surgeons with solid theoretical background and significant amount of practice. Pelvitrainers or simulators provide a good opportunity for practicing and developing laparoscopic skills. Laparoscopic training of medical students of the Semmelweis University is performed at the Institute of Experimental Surgery and Surgical Techniques on Apollo pelvitrainers. The trainer, the performed exercises and the time limits have to be validated by several measurements. Statistical evaluation of the results provides a possibility for the numerical evaluation of surgical skills as well as validating the usability of the pelvitrainer. In our study we tested the peg transfer exercise in pelvitrainers on four groups with different surgical background and level of expertise, complete novices (50 persons), medical students (326 persons), surgical residents (15), and experienced surgeons (4), respectively. A time limit of 240 s was defined for novices and 100 s for professionals. During the evaluation of the results the average time and the number of errors were calculated. The mean completion time of amateurs was 365.7 ± 130 s (mean ± standard deviation), with 2.57 errors. The performance of medical students was characterized by 159.3 ± 61.1 s average time with 1.21 errors, the completion time of residents was 257.9 ± 75.7 s with 1.13 error points, and 117.2 ± 29.1 s for the surgeons. These data show significant differences between the group, except between the results of medical students and surgeons. We plan to extend this study with the inclusion of more, experienced surgeons.

Paradoxical alteration of indocyanine green concentration in bile and the visibility of the intra-operative fluorescence cholangiography in pigs.

Background: A significant difference exists between the reported optimal timing of indocyanine green (ICG) injection during fluorescence cholangiography and ICG dissipation time from the serum. There are no reports on alterations in ICG concentration in biliary fluid over time. Herein, we measured the concentration of ICG and the fluorescence intensity ratio between the common bile duct (CBD) and liver, which was recognized as a parameter of the visibility of the CBD. Materials and methods: ICG (0.05 mg/kg) was injected intravenously into female pigs (n = 7). Afterwards, the fluorescence of the CBD and liver was detected at 30 min, 2 h, and 4 h. Biliary fluid was collected from cannulated CBD tubes. The fluorescence intensity was measured using captured images and calculated using the ImageJ image-processing program. ICG concentration was measured using spectrophotometry and compared using an analysis of variance test. Results: Biliary ICG concentrations at 30 min, 2 h, and 4 h were 92.07 ± 27.72 µg/mL, 37.14 ± 9.76 µg/mL (p < 0.05 vs. 30 min), and 13.91 ± 5.71 µg/mL (p < 0.05 vs. 30 min), respectively; p < 0.01. The CBD/liver fluorescence intensity ratios at 30 min, 2 h, and 4 h were 1.25 ± 0.72, 2.39 ± 1.28 (p < 0.05 vs. 30 min and 4 h), and 3.38 ± 1.73 (p < 0.05 vs. 30 min and 2 h), respectively. Conclusions: The ICG biliary concentration was highest at 30 min, whereas the CBD/liver fluorescence intensity ratio was highest at 4 h. Decreasing the fluorescence intensity of the liver may be an important approach for improving the visualization of the CBD during fluorescence cholangiography. Institutional protocol number: PE/EA/491-5/2020.

Comparison of oxidative stress & leukocyte activation in patients with severe sepsis & burn injury.

BACKGROUND & OBJECTIVES: We evaluated pro- and anti-oxidant disturbances in sepsis and non-sepsis burn patients with systemic inflammatory response syndrome (SIRS). Adhesion molecules and inflammation markers on leukocytes were also analyzed. We hypothesized that oxidative stress and leukocyte activation markers can lead to the severity of sepsis. METHODS: In 28 severe sepsis and 27 acute burn injury patients blood samples were collected at admission and 4 days consecutively. Oxidative stress markers: production of reactive oxygen species (ROS), myeloperoxidase, malondialdehyde and endogenous antioxidants: plasma protein sulphydryl groups, reduced glutathione, superoxide dismutase and catalase were measured. Flow cytometry was used to determine CD11a, CD14, CD18, CD49d and CD97 adhesion molecules on leukocytes. Procalcitonin, C-reactive protein, fibrinogen, platelet count and lactate were also analyzed. RESULTS: Pro-oxidant parameters were significantly elevated in sepsis patients at admission, ROS intensity increased in burn patients until the 5th day. Endogenous antioxidant levels except catalase showed increased levels after burn trauma compared to sepsis. Elevated granulocyte activation and suppressed lymphocyte function were found at admission and early activation of granulocytes caused by increasing activation/migration markers in sepsis. Leukocyte adhesion molecule expression confirmed the suppressed lymphocyte and monocyte function in sepsis. INTERPRETATION & CONCLUSIONS: Severe sepsis is accompanied by oxidative stress and pathological leukocyte endothelial cell interactions. The laboratory parameters used for the evaluation of sepsis and several markers of pro- and antioxidant status were different between sepsis and non-sepsis burn patients. The tendency of changes in these parameters may refer to major oxidative stress in sepsis and developing SIRS in burns.

Evaluation of efficacy and biocompatibility of a novel semisynthetic collagen matrix as a dural onlay graft in a large animal model.

BACKGROUND: Semisynthetic collagen matrices are promising duraplasty grafts with low risk of cerebrospinal fluid (CSF) fistulas, good tissue integration and minor foreign body reaction. The present study investigates the efficacy and biocompatibility of a novel semisynthetic bilayered collagen matrix (BCM, B. Braun Aesculap) as dural onlay graft for duraplasty. METHODS: Thirty-four pigs underwent osteoclastic trepanation, excision of the dura, and placement of a cortical defect, followed by duraplasty using BCM, Suturable DuraGen™ (Integra Neuroscience), or periosteum. CSF tightness and intraoperative handling of the grafts were evaluated. Pigs were sacrificed after 1 and 6 months for histological analysis. FINDINGS: BCM and DuraGen™ showed superior handling than periosteum with a trend for better adhesion to dura and CSF tightness for BCM. Periosteum, which was sutured unlike the synthetic grafts, had the highest intraoperative CSF tightness. Duraplasty time with periosteum was significantly higher (14.4 ± 2.7 min) compared with BCM (2.8 ± 0.8 min) or DuraGen™ (3.0 ± 0.5 min). Tissue integration by fibroblast infiltration was observed after 1 month for all devices. More adhesions between graft and cortex were observed with DuraGen™ compared with BCM and periosteum. No relevant adhesions between leptomeninges and BCM were observed and all devices showed comparable lymphocytic reaction of the brain. All devices were completely integrated after 6 months. BCM and DuraGen™ showed a trend for an enhanced lymphocytic reaction of the brain parenchyma compared with periosteum. Implant rejection was not observed. CONCLUSION: Semisythetic collagen matrices are an attractive alternative in duraplasty due to their easy handling, lower surgical time, and high biocompatibility.

[Effect of ischemic postconditioning on oxidative stress and structural tissue changes in intestinal warm ischemic and autotransplantation models]. / Az ischaemiás posztkondicionálás hatása az oxidatív stresszre és a szöveti struktúrára vékonybél meleg ischaemiás és autotranszplantációs modellekben.

INTRODUCTION/AIM: Our study investigated the effect of ischemic postconditioning (IPO) in intestinal warm ischemia/reperfusion (I/R) and autotransplantation models. MATERIALS AND METHODS: Warm ischemia was performed by occlusion of superior mesenteric artery for 1, 3 and 6 hours in white domestic pigs (n = 15). Prior to 3 hours reperfusion the intestine was postconditioned by 3 cycles of 30-seconds ischemia and 30-seconds reperfusion (IPO protocol). In the cold ischemia group (n = 15) the bowel was preserved in University of Wisconsin solution for 1, 3, and 6 hours. Prior to 3 hours reperfusion IPO protocol was applied, too. Tissue samples were collected after laparotomy (control) and at the end of the reperfusion periods. As far as oxidative stress markers, malondialdehyde and reduced glutathione (GSH) levels and superoxide dismutase (SOD) activity were determined. Tissue damage was evaluated by qualitative (Park-classification) and quantitative (Scion Image) methods. RESULTS: As regards oxidative stress parameters, lipidperoxidation decreased and the protective effect of endogenous antioxidants (GSH, SOD) retained significantly by IPO procedure at the end of reperfusion. Tissue injury correlated significantly by the duration of warm ischemia and cold preservation. Quantitative analysis demonstrated that IPO ameliorated tissue injury in each group (p < 0.05). CONCLUSION: IPO significantly attenuated intestinal oxidative stress and morphological damages in warm and cold I/R models.

Early and late effects of absorbable poly(vinyl alcohol) hernia mesh to tissue reconstruction.

Hernia is a defect of the abdominal wall. Treatment is principally surgical mesh implantation. Non-degradable surgical meshes produce numerous complications and side-effects such as inflammatory response, mesh migration and chronic pain. In contrast, the biodegradable, poly (vinyl alcohol) (PVA) based polymers have excellent chemical, mechanical and biological properties and after their degradation no chronic pain can be expected. The toxicology of PVA solution and fibers was investigated with Human dermal fibroblast- Adult cell line. Implantation tests were observed on long-term contact (rat) and large animal (swine) models. To measure the adhesion formation, Diamond and Vandendael score were used. Macroscopical and histological responses were graded from the samples. In vitro examination showed that PVA solution and fibers are biocompatible for the cells. According to the implantation tests, all samples were integrated into the surrounding tissue, and there was no foreign body reaction. The average number of adhesions was found on the non-absorbable suture line. The biocompatibility of the PVA nanofiber mesh was demonstrated. It has a non-adhesive, non-toxic and good quality structure which has the potential to be an alternative solution for the part of the hernia mesh.

Poly(amino acid) based fibrous membranes with tuneable in vivo biodegradation.

In this work two types of biodegradable polysuccinimide-based, electrospun fibrous membranes are presented. One contains disulfide bonds exhibiting a shorter (3 days) in vivo biodegradation time, while the other one has alkyl crosslinks and a longer biodegradation time (more than 7 days). According to the mechanical measurements, the tensile strength of the membranes is comparable to those of soft the connective tissues and visceral tissues. Furthermore, the suture retention test suggests, that the membranes would withstand surgical handling and in vivo fixation. The in vivo biocompatibility study demonstrates how membranes undergo in vivo hydrolysis and by the 3rd day they become poly(aspartic acid) fibrous membranes, which can be then enzymatically degraded. After one week, the disulfide crosslinked membranes almost completely degrade, while the alkyl-chain crosslinked ones mildly lose their integrity as the surrounding tissue invades them. Histopathology revealed mild acute inflammation, which diminished to a minimal level after seven days.

Efficacy of different hemostatic devices for severe liver bleeding: a randomized controlled animal study.

BACKGROUND: Correct hemostasis in liver surgery is hard to achieve because of the oozing bleeding. The aim of this study was to compare the potential benefits of a new compress to the 2 commercial hemostatic compresses. METHODS: Collagen- and cellulose-based hemostatics were investigated. A standardized resection was treated by applying different hemostatics in a randomized order, and bleeding times were measured. Macroscopic evaluation of the liver and tissue sampling for histological investigations were carried out after 21 days. RESULTS: The bleeding times of bovine collagen (BoCo), protein-coated equine collagen (PECo), and oxidized cellulose (OxCe) were 140 ± 88, 243 ± 140 (P = .005 vs BoCo), and 352 ± 70 s (P < .001 vs BoCo), respectively. Microscopic evaluation of the PECo presented fibrosis and significant inflammation in the implantation zone, whereas BoCo and OxCe caused only fibrosis in the wound area. CONCLUSION: BoCo showed significantly better hemostatic effect than PECo and OxCe.

[Principles of the management of adult inguinal hernia--recommendations by the European Hernia Society]. / Felnottkori lágyéksérvek kezelésének alapelvei--az Európai Sérvsebészeti Társaság ajánlása.

The European Hernia Society (EHS) presented the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the management of inguinal hernia from diagnosis to aftercare. These have been developed by a Working Group consisting of expert surgeons with representatives of 14 member countries of the EHS. The Guidelines are evidence-based and, when necessary, a consensus of all members was reached. The Guidelines have been reviewed by a Steering Committee as well. Before finalisation, feedback from the relevant national hernia societies was obtained. The Guidelines can be used to adjust local protocols, training purposes as well as quality control. In order to keep them updated the next revision will be published in 2012. A short update of new high-level evidence will be provided by the Working Group during the EHS annual congress until the next revision.