Surveillance of Surgical Meshes in Ventral Hernias and Unpredictability of Their History.

: The authors read the article "The importance of registries in the postmarketing surveillance of surgical meshes" by Kockerling et al, and they completely agree on the role of a clinical follow-up of surgical meshes even if they suggest that a surveillance longer than one year is advisable, particularly in IPOM repair, to collect not only late complications but also more serious adverse events. This seems be the only way to properly assess the safety of the mesh.

A Biologic Surgical Implant in Complex Abdominal Wall Repair: 3-Year Follow-Up Results of a Multicentric Prospective Study.

PURPOSE: Despite the advancements in the reinforcement and closure techniques available, complex abdominal wall reconstruction (CAWR) remains a challenging surgical undertaking with considerable risk of postoperative complications. Biological meshes were developed that may help to complement standard closure techniques and offer an alternative to synthetic meshes, which carry significant risks with their use in complex cases. PATIENTS AND METHODS: A total of 114 patients underwent surgical treatment for CAWR with a Permacol™ (a biologic surgical implant). The study objective was to evaluate the short-term (6 months), mid-term (12-24 months), and long-term (36 months) clinical outcomes (through 36 months) associated with the use of a biologic surgical implant in these cases. RESULTS: The cumulative hernia recurrence rate was 18.7% (17/91) at 24 months and 22.4% (19/85) at 36 months. Twelve (14.1%) subjects required reoperation for hernia repair within 36 months for repair of recurrent hernias. Between 6- and 36-months post-surgery, patients reported improvement in their Carolina comfort scale (CSS) measures of severity of pain, sensation of mesh, and movement limitations. CONCLUSION: A biologic surgical implant can provide long-term benefit to complex abdominal wall repairs in patients staged grade III according to the Ventral Hernia Working Group (VHWG).

A Western single-center experience with endoscopic submucosal dissection for early gastrointestinal cancers.

Endoscopic submucosal dissection (ESD) has gained worldwide acceptance as a treatment for early gastrointestinal cancers (EGICs). However, the management of these tumors in the Western world is still mainly surgical. Our aim was to evaluate the safety and feasibility of ESD at a European center. Based on the knowledge transferred by one of the most experienced Japanese institutions, we conducted a pilot study on 25 consecutive patients with EGICs located in the esophagus (n = 3), stomach (n = 7), duodenum (n = 1), and colon (n = 14) at our tertiary center over a 2-year-period. The main outcome measurements were complete (R0) resection, as well as en-bloc resection and the management of complications. The R0 and en-bloc resection rates were 100% and 84%, respectively. There were three cases of bleeding and five cases of perforation. With a median follow up of 18 months, two recurrences were observed. We conclude that ESD for early esophageal and gastric cancers is feasible and effective, while colonic ESD requires more expertise.

Outcomes of a new slowly resorbable biosynthetic mesh (Phasix™) in potentially contaminated incisional hernias: A prospective, multi-center, single-arm trial.

BACKGROUND: Resorbable biomaterials have been developed to reduce the amount of foreign material remaining in the body after hernia repair over the long-term. However, on the short-term, these resorbable materials should render acceptable results with regard to complications, infections, and reoperations to be considered for repair. Additionally, the rate of resorption should not be any faster than collagen deposition and maturation; leading to early hernia recurrence. Therefore, the objective of this study was to collect data on the short-term performance of a new resorbable biosynthetic mesh (Phasix™) in patients requiring Ventral Hernia Working Group (VHWG) Grade 3 midline incisional hernia repair. MATERIALS AND METHODS: A prospective, multi-center, single-arm trial was conducted at surgical departments in 15 hospitals across Europe. Patients aged ≥18, scheduled to undergo elective Ventral Hernia Working Group Grade 3 hernia repair of a hernia larger than 10 cm2 were included. Hernia repair was performed with Phasix™ Mesh in sublay position when achievable. The primary outcome was the rate of surgical site occurrence (SSO), including infections, that required intervention until 3 months after repair. RESULTS: In total, 84 patients were treated with Phasix™ Mesh. Twenty-two patients (26.2%) developed 32 surgical site occurrences. These included 11 surgical site infections, 9 wound dehiscences, 7 seromas, 2 hematomas, 2 skin necroses, and 1 fistula. No significant differences in surgical site occurrence development were found between groups repaired with or without component separation technique, and between clean-contaminated or contaminated wound sites. At three months, there were no hernia recurrences. CONCLUSION: Phasix™ Mesh demonstrated acceptable postoperative surgical site occurrence rates in patients with a Ventral Hernia Working Group Grade 3 hernia. Longer follow-up is needed to evaluate the recurrence rate and the effects on quality of life. This study is ongoing through 24 months of follow-up.

Biological Scaffolds for Abdominal Wall Repair: Future in Clinical Application?

Millions of abdominal wall repair procedures are performed each year for primary and incisional hernias both in the European Union and in the United States with extremely high costs. Synthetic meshes approved for augmenting abdominal wall repair provide adequate mechanical support but have significant drawbacks (seroma formation, adhesion to viscera, stiffness of abdominal wall, and infection). Biologic scaffolds (i.e., derived from naturally occurring materials) represent an alternative to synthetic surgical meshes and are less sensitive to infection. Among biologic scaffolds, extracellular matrix scaffolds promote stem/progenitor cell recruitment in models of tissue remodeling and, in the specific application of abdominal wall repair, have enough mechanical strength to support the repair. However, many concerns remain about the use of these scaffolds in the clinic due to their higher cost of production compared with synthetic meshes, despite having the same recurrence rate. The present review aims to highlight the pros and cons of using biologic scaffolds as surgical devices for abdominal wall repair and present possible improvements to widen their use in clinical practice.

[Familial polyposis coli associated with carcinoma of the uterine cervix]. / Poliposi familiare del colon in associazione a carcinoma della cervice uterina.

Familial polyposis coli is a heterogeneous disease with a broad spectrum of clinical manifestations including not only multiple polyposis of the small bowel, but also multiple primary tumours, such as carcinoma of the ampulla of Vater, subcutaneous tumours, bone tumours, central nervous system tumous and gynaecological malignancies. This report is of two brothers with familial polyposis, each showing peculiar distinctive features. In one case, polyposis was diagnosed during emergency surgery for ileo-colic intussusception. The patient later developed a tumour of the uterine cervix. Polyposis coli was identified late in the second patient who showed an evolution towards colonic adenocarcinoma with multiple hepatic metastases. The possible association of familial polyposis and extracolonic malignancies has already been emphasized in the literature. In this report we wish to stress the advisability of periodic gynaecological check-ups in affected patients.

A new mesh design for plug and patch groin hernia repair: Parietene PP.

Plug and patch hernioplasty is a technique showing very good results. Actually some criticisms mainly concern the amount of prosthetic material and the shrinkage of the plug resulting in recurrence of hernia, groin pain, and/or migration. The new tridimensional mesh Parietene PP allows to achieve a plug and patch hernioplasty, without any risk of plug migration. The Parietene PP hernia repair in simple and easy to learn. Preliminary results are very satisfactory and comparable with the best outcome from mesh plug repair, without any risk of plug migration.

Abdominal aortic aneurysm following acute pancreatitis.

Vascular lesions may complicate the course of acute pancreatitis. The activated pancreatic enzymes, particularly elastase, might cause lysis of the elastic component of the arterial wall thus leading to aneurysmal changes. This report is on a case of aneurysm of the infrarenal aorta following complicated acute pancreatitis and treated by endovascular technique.

Central mesh failure (CMF) after abdominal wall repair. A rare cause of recurrence.

Central Mesh Failure (CMF) after abdominal wall repair (AWR) is uncommon but should be considered in case of recurrence. The mechanism is unclear and different theories are actually proposed, as the action of opposite forces acting in the abdominal wall on the prosthesis, and the characteristics of the device to be implanted. The use of lightweight meshes in some cases could be inadequate to withstand the bursting strenght of the abdominal wall. Three cases of incisional hernia recurrence due to central mesh failure are here reported. KEY WORDS: Abdominal wall repair (AWR), Central mesh failure (CMF), Hernia recurrence, Lightweight mesh.

Chronic anemia due to transmural e-PTFE anti-adhesive barrier mesh migration in the small bowel after open incisional hernia repair: A case report.

INTRODUCTION: Meshes are commonly employed in abdominal hernia repair to reduce recurrence rates. Prosthetic repair, however, increases the risk of mesh related complications, including migration into adjacent viscera and erosion which can occur as uncommon and can be difficult to be diagnose. PRESENTATION OF CASE: This is a case of transmural migration of composite mesh into the bowel, presenting as chronic abdominal pain and anemia 14 years after incisional hernia repair. DISCUSSION: Mesh implantation in hernia repair has increased the incidence of complications, such as seroma, hematoma and infection. Migration into adjacent viscera and erosion may present as complications related to the use of meshes. Their precise frequency after abdominal wall hernia repair is not well known and their late occurrence can make the diagnosis difficult. CONCLUSION: Transmural migration of composite mesh is an uncommon complication of incisional hernia repair. Its pathogenesis is still not completely clear but it has been reported many years after implant surgery. It should be considered in a typical presentation of patients with history of previous prosthetic ventral hernia repair.

Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences.

BACKGROUND: The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. METHODS: The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. RESULTS: The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. CONCLUSION: The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.

Laparoscopically assisted treatment of entero-atmospheric fistula following abdominal wall repair of complex incisional hernia: Case report.

INTRODUCTION: Entero-atmospheric fistula (EAF) is an uncommon complication. Its timing and surgical management could be extremely challenging because extensive adhesions may heavily affect the approach to the abdominal cavity. PRESENTATION OF CASE: We hereby report a case of EAF in a 70 year-old man. In order to control the fistula output and the surrounding tissue damage from enteric content, the patient was managed conservatively using different technical solutions. Finally, the patient underwent surgery that started with a laparoscopic approach in order to avoid the hostile abdomen. DISCUSSION: Due to the lack of guidelines, treatment of EAF requires a multidisciplinary approach and different technical options based on the experience and inventiveness of the surgeon. Among others, the vacuum assisted wound management proved to be a useful support andlaparoscopy demonstrated to be valuable in approaching the abdominal cavity. CONCLUSION: According to our experience the success of the treatment of EAF may be improved adopting a multidisciplinary approach and well-planned surgery in referral centers.

Surgical approach to piles at risk of severe postoperative pain: tricks and tips.

AIM: Aim of the present study is to propose a clinic-therapeutic course for the treatment of hemorrhoidal disease able to combine radical anatomic surgery with a painless postoperative path. MATERIAL OF STUDY: The present study is based on the evaluation of 20 selected patients who underwent radical hemorrhoidectomy for very high grade hemorrhoidal disease. The clinical course was characterized by careful bowel cleansing, hemorrhoidectomy according to Milligan-Morgan using LigaSure, intraoperative perianal infiltration of Ropivacaine and postoperative use of analgesic drugs. DISCUSSION: A low postoperative pain may descend from a scheduled timing of clinical procedures. Preoperative bowel cleansing delays the first postoperative evacuation, thus avoiding the perianal nerve stimulation. The use of LigaSure allows to perform surgical excision in a perfect way: lack of hemostatic stitches, less tissue trauma, very low early morbidity. A rational and scheduled intra and postoperative drug administration offers a highly significant contribution to the pain control. The intra and postoperative use of drugs makes it possible to perform the so-called "preventive anesthesia with activation of the pain memory" and postoperative evacuations with low pain perception. All patients, in fact, reported low and well tolerated pain, satisfaction and return to normal activities in a short period. CONCLUSIONS: Radical hemorrhoidectomy with LigaSure and attention to pre, intra and postoperative protocol makes the procedure painless, safe and with low morbidity. KEY WORDS: Hemorrhoidectomy, LigaSure, Painless procedure.

Made in Italy for hernia: the Italian history of groin hernia repair.

UNLABELLED: The history of groin hernia surgery is as long as the history of surgery. For many centuries doctors, anatomists and surgeons have been devoted to this pathology, afflicting the mankind throughout its evolution. Since ancient times the Italian contribution has been very important with many representative personalities. Authors, investigators and pioneers are really well represented. Every period (the classic period, the Middle Age, the Renaissance and the post-Renaissance) opened new perspectives for a better understanding. During the 18th century, more information about groin anatomy, mainly due to Antonio Scarpa, prepared the Bassini revolution. Edoardo Bassini developed the first modern anatomically based hernia repair. This procedure spread worldwide becoming the most performed surgical technique. After World War II synthetic meshes were introduced and a new era has begun for hernia repair, once again with the support of Italian surgeons, first of all Ermanno Trabucco. But Italian contribution extends also to educational, with the first national school for abdominal wall surgery starting in Rome, and to Italian participation and support in international scientific societies. Authors hereby wish to resume this long history highlighting the "made in Italy" for groin hernia surgery. KEY WORDS: Bassini, Groin hernia, History, Prosthetic repair.

International consensus conference on open abdomen in trauma.

BACKGROUND: A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS: The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS: OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION: OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Intraoperative gamma probe detection of head and neck paragangliomas with 111In-pentetreotide: a pilot study.

AIMS AND BACKGROUND: The aim of this study was to assess whether intraoperative radiolocalization of head and neck paragangliomas with 111In-pentetreotide may increase surgical effectiveness, reducing the risk of recurrence. METHODS: Our study included eight patients with untreated, recently diagnosed paragangliomas (four unilateral and four bilateral tumors of the carotid body). After i.v. injection of approximation 150 MBq 111In-pentetreotide, preoperative somatostatin receptor scintigraphy (SRS) was performed. SPECT of the neck was performed at four hours and planar images of the head and neck were also obtained at four and 24 hours post injection. Scintigraphy was always compared with the results of conventional imaging methods (MRI, angiography and sonography). Intraoperative detection was performed on 11 lesions 24 hours after radiopharmaceutical administration using a handheld gamma probe. RESULTS: Preoperative SRS showed high radiotracer uptake in all patients. All the intraoperatively detected lesions were radically resected and histologically confirmed to be involved by tumor. No false positive results were recorded. Gamma probe detection revealed a small intracranial extension not detected by other imaging methods in a patient with a paraganglioma of the right carotid, and partial involvement of the carotid artery in another patient. During follow-up (median 3.5 years; range, 4 months-7 years) all patients remained disease free according to all parameters. CONCLUSIONS: To our knowledge, this is the first experience of radioguided surgery in paraganglioma. Although our study included a relatively small number of patients, we suggest that intraoperative gamma probe detection may be a powerful tool to improve surgical effectiveness.

New "all-in-one" device for mesh plug hernioplasty: the Trabucco repair.

UNLABELLED: Although Mesh Plug Repair (MPR) represents an effective method for the treatment of groin hernia, some criticisms still concern adverse effects related to the plug (shrinkage, chronic pain, migration and erosion). Different mesh and plug devices have been proposed in the past mostly to prevent migration but none of these achieved the same popularity as the cone or flower-shaped plug. Authors hereby present a pilot study with a new tridimensional device, denominated NeT Plug and Patch, that avoids any risk of migration. Results after 12 months follow-up have demonstrated low incidence of postoperative and chronic pain, with both patients and surgeons greatly satisfied. NeT Plug and Patch has proven to achieve a simple and effective repair for primary inguinal hernias. KEY WORDS: Mesh-plug, Plug migration, Trabucco repair.

[Extrauterine endometriosis: what interest for the general surgeon? Presentation of 3 clinical cases and review of the literature]. / Endometriosi extrauterina: quale interesse per il chirurgo generale? Presentazione di 3 casi clinici e revisione della letteratura.

Extragonadal endometriosis is rarely diagnosed preoperatively for the variety of its localizations. Presentations to general surgeons may be atypical and pose diagnostic difficulty, mimicking other acute diseases. We report three cases treated with surgical operation. Case 1: a 28-year-old woman admitted for bowel obstruction due to coecal endometriosis, with appendix mucocele, peritoneal pseudomyxoma and ovarian endometrioma. The patient underwent right colectomy and right adnexectomy in the emergency setting. Case 2: a 31-year-old woman with endometriosis of the distal extraperitoneal portion of the round ligament presenting as an irreducible inguinal hernia. An operation was performed: the round ligament and a polycystic structure encompassing it were completely excised. Case 3: a 41-year-old woman, with umbilical endometriosis diagnosed by her gynaecologist, was admitted to our department for excision. Surgical treatment of extragonadal endometriosis is adequate. However, postoperative follow-up is mandatory and hormonal suppressive therapy may be indicated by the gynaecologist.

A retrospective study evaluating the use of Permacol™ surgical implant in incisional and ventral hernia repair.

BACKGROUND: The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. METHODS: Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. RESULTS: Median follow-up time was 649 days (max: 2857), median age 57 years (range 23-91), and BMI 32 kg/m(2) (range 17.6-77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives-Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan-Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. CONCLUSIONS: Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. CLINICAL TRIAL REGISTRATION NUMBER: NCT01214252 (http://www.clinicaltrials.gov).