Does Abdominoplasty Add Morbidity to Incisional Hernia Repair? A Randomized Controlled Trial.

Background Abdominoplasty is considered an operation linked to a considerable rate of morbidity. The convenience of simultaneously performing an incisional hernia repair and an abdominoplasty remains controversial. Methods A total of 111 patients were randomized prospectively to compare isolated incisional hernia repair and hernia repair when combined with abdominoplasty. Primary end points were in-hospital stay and early morbidity. Secondary end points were late morbidity, recurrences, and quality of life. Patients were followed-up for 24 months. Results Duration of the surgical procedure differed significantly between both groups (39 vs 85 minutes, P < .001) and postoperative hospital stay (2.5 vs 3.5 days; P < .001). No statistically significant differences in early or late morbidity between both groups were detected. The perceived quality of life for patients was higher in the combined surgery group (P < .001) that in the isolated hernia repair group. Conclusions Postoperative in-hospital stay and early and late morbidity do not differ significantly between isolated incisional hernia repair and simultaneous hernia repair with abdominoplasty, but associated abdominoplasty provides a higher quality of life when indicated.

Which should be the gold standard laparoscopic technique for handling Spigelian hernias?

BACKGROUND: The advantages and disadvantages of both extraperitoneal and intra-abdominal laparoscopic Spigelian hernia repair are still being discussed. To our knowledge, no study has compared both techniques in terms of safety, feasibility, and cost-effectiveness. METHOD: Prospective data were collected to compare the results of the extraperitoneal approach with the intra-abdominal approach in laparoscopic Spigelian hernia repair, between 2000 and 2012 (n = 16). Diagnosis was confirmed preoperatively by ultrasonography and/or tomography. RESULTS: Spigelian hernias occur mostly in women (69 %), on the left side (56 %) and at a median age of 62 (range: 38-83). In our study, the extraperitoneal technique was performed in seven patients, while the intra-abdominal approach was indicated in nine. No complications, re-admissions, or recurrences were detected in either during a mean follow-up of 48 months (range: 18 months-9 years). The statistical study showed that there was no difference in either morbidity or the recurrence rate between a totally extraperitoneal (TEP) and an intraperitoneal onlay mesh (IPOM) repair. The mean duration of an IPOM repair was, though, shorter than that of a TEP repair (30 vs. 48 min, P = 0.06). The combined fixation technique (tacks + glue) did not modify the results but did reduce the costs, as shown in the cost-effectiveness study where the intra-abdominal approach was cheaper (1260 vs. 2200 euros, P < 0.001). CONCLUSION: Laparoscopy seems to be a safe and feasible technique whichever the approach chosen, be it intra or extraperitoneal. Our experience shows that intra-abdominal laparoscopic Spigelian hernia repair should be recommended as the gold standard because of its technical and economic advantages. The IPOM procedure with a lightweight titanium-coated mesh fixed using a combined technique is a highly effective option for Spigelian hernia repair.

[Diabetic foot infections. Prevalence and antibiotic sensitivity of the causative microorganisms]. / Infecciones del pie diabético. Prevalencia de los distintos microorganismos y sensibilidad a los antimicrobianos.

BACKGROUND: Foot infections are a common reason for hospitalization and a cause of complications in patients with diabetes. The aim of this study was to determine the prevalence of microorganisms found on culture in complicated diabetic foot infections in hospitalized patients, and the sensitivity of the causative microorganisms to antimicrobial agents. METHODS: Between December 2001 and December 2005 in our department, 84 samples in 62 diabetic patients with moderate/severe infection were collected for microbiological study. RESULTS: At least one microorganism was isolated in 88% of samples. The most frequently isolated germ group was gram-positive bacteria (55% of the samples), with Staphylococcus aureus (33%) in the first position, followed by Pseudomonas aeruginosa (12%), Enterococcus spp. (9%), and Escherichia coli (8%). Culture for anaerobic microorganisms was only performed in half the samples; 25% were positive, and Peptostreptococcus spp. predominated. Among the multiresistant microorganisms, methicillin-resistant staphylococci aureus (MRSA) were the most common, accounting for 38% of the isolated strains of S. aureus, ie, 12% of all samples. As to the gram-negative microorganisms, nearly 30% of E. coli strains were resistant to amoxicillin/clavulanic acid and ciprofloxacin. CONCLUSION: Most of the cultures in our study were monomicrobial, with S. aureus being the most prevalent microorganism, followed by enterobacteria and P. aeruginosa. The main resistant microorganism in diabetic foot infections requiring hospitalization was methicillin-resistant golden staphylococcus, which was found in 12% of the series.

[CT colonography vs. barium enema for the preoperative study of colorectal cancer in patients with incomplete colonoscopy]. / Colonografía tomográfica computarizada frente a enema opaco en el estudio preoperatorio del cáncer colorrectal en pacientes con colonoscopia incompleta.

BACKGROUND AND OBJECTIVE: The complete preoperative evaluation of the colon is necessary in colorectal cancer owing to the frequency of synchronous tumors. The objective of this paper was to evaluate the utility of the computed tomography colonography (CTC) as opposed to barium enema (BEDC) when the colonoscopy was incomplete or impossible to perform. PATIENTS AND METHOD: Group A: 50 patients with colorectal cancer with subsequent incomplete colonoscopy and BEDC. Group B: 40 patients with colorectal cancer with subsequent incomplete colonoscopy and CTC. As gold standard to match the tests, we carried out the pathological study of the surgical piece and the colonoscopy 3 months after surgery. In addition, we studied the degree of satisfaction, indirect effect and cost by test. RESULTS: There were no synchronous tumors. For the detection of colonic polyps, we obtained for the CTC the following values: Sensitivity = 85.7%, Specificity = 96.1%, PPV = 92.3%, NPV = 92.6%, CPP = 21,97 and CPN =0,15. And for BEDC, the values were: Sensitivity = 23.5%, Specificity = 92.8%, PPV = 80%, NPV = 71.7%, CPP = 3.26 and CPN = 0.82 (p < 0.001). The degree of satisfaction was greater with CTC than with BEDC (p < 0.05). There were no differences as far as indirect effect was concerned. The cost of CTC was 33.18 Euros and it was 42.42 Euros for BEDC. CONCLUSION: CTC is better than BEDC both to confirm the presence of polyps in colon and to rule out the absence of them in patients in whom a complete the study of the colon by colonoscopy has not been possible.

Obturator hernia as a cause of chronic pain after inguinal hernioplasty: elective management using tomography and ambulatory total extraperitoneal laparoscopy.

Obturator hernia is a rare variety of pelvic hernia. Preoperative diagnosis is still uncommon and influences treatment and prognosis. Clinical suspicion and tomography are fundamental for establishing a preoperative diagnosis. Subsequently, elective treatment via the total extraperitoneal laparoscopic approach seems to offer the best results for both the patient and the hospital. This management might reduce the high rates of associated morbidity and mortality. We present the case of a patient with chronic pelvic pain after hernia surgery in whom tomography confirmed the existence of a bilateral obturator hernia. Details are given of diagnostic and therapeutic management using ambulatory total extraperitoneal laparoscopy. We recommend ruling out obturator hernia as a possible cause of chronic pain after hernia repair.

Randomized clinical trial of fixation vs nonfixation of mesh in total extraperitoneal inguinal hernioplasty.

HYPOTHESIS: Mesh fixation in the extraperitoneal space during endoscopic total extraperitoneal inguinal hernioplasty might be related to an increase in postoperative pain, morbidity rate, and hospital costs. DESIGN: Randomized clinical trial. SETTING: University teaching hospital. PATIENTS: From January 1999 to December 2001, 170 patients with inguinal hernia were invited to participate; 85 patients were randomized to each group. INTERVENTION: Total extraperitoneal inguinal hernioplasty with or without mesh fixation using staples. MAIN OUTCOME MEASURES: Operating time, morbidity rate, chronic pain, recurrences, and hospital cost were analyzed. Follow-up was considered complete when it included a physical examination at 24 months (mean, 36 +/- 12 months). RESULTS: The statistical study showed no significant differences with regard to epidemiological factors, hernia type, operating time, morbidity, or recurrences when the mesh was stapled, although the total cost of the process was higher (P<.001). CONCLUSIONS: Stapling the mesh in total extraperitoneal inguinal hernioplasty offers no advantages and increases the cost of the process. Our results suggest the possibility of limiting the use of mesh fixation in total extraperitoneal inguinal hernioplasty to cases of direct bilateral hernias.

Vólvulo gástrico por hernia diafragmática crónica / Gastric volvulus due to chronic diaphragmatic hernia

Objetivo: Presentar un caso de vólvulo gástrico obstructivo. Caso clínico: Presentamos el caso de una paciente que inició con un episodio de obstrucción intestinal por una volvulación gástrica. El antecedente de otro episodio antiguo y la radiología de tórax alertaron de una posible hernia diafragmática crónica. La buena respuesta al tratamiento médico inicial permitió un estudio completo y una cirugía programada mediante abordaje laparoscópico.

Aim: To present a patient with gastric volvulus. Case report: A case of a female patient who started with an episode of intestinal obstruction due to gastric volvulus. The history of a former episode and chest radiology alerted us to a possible chronic diaphragmatic hernia. The patient's good response to initial medical treatment allowed a complete study and laparoscopic intervention.

Implantación de un programa de tratamiento integral de la pared abdominal: hernia incisional y abdominoplastia Resultados preliminares / Implementation of a program of integral treatment of the abdominal wall: incisional hernia and abdominoplasty. Preliminary results

Introducción. Las vías clínicas son planes asistenciales sistematizados para determinados procesos hospitalarios, que constituyen una herramienta que coordina a múltiples profesionales implicados en un objetivo común. La abdominoplastia es una de las operaciones que con mayor frecuencia practican el cirujano plástico y el cirujano general, pero no existe ningún consenso sobre cómo debe hacerse cuando existe una hernia incisional o quirúrgica asociada. En el presente trabajo se presenta el proceso de elaboración de la vía clínica del proceso "hernia incisional y abdominoplastia". Metodología. La elaboración de la vía clínica se ha llevado a cabo mediante reuniones semanales durante tres meses. El grupo implicado ha estado formado por cirujanos, anestesiólogos, enfermeros y coordinadores de calidad de cirugía y enfermería. Se hizo un análisis de una serie previa y, además, una revisión bibliográfica con gradación de la evidencia científica, tanto del proceso "hernia incisional", como de otras vías clínicas publicadas. Con ello, se elaboraron los documentos principales de la vía clínica, los cuales se discutieron con los miembros del servicio de cirugía y las unidades de enfermería. Resultados. Se presentan todos los documentos y protocolos de asistencia previos y posteriores a la hospitalización de los pacientes con eventración. Conclusión. La eventración puede ser sistematizada en una vía clínica que pretende estandarizar los cuidados y mejorar los resultados futuros.

Introduction: Clinical pathways are standard care plans for certain processes. They are specially useful in those procedures that are frequent and with nonjustified variability. In addition it is advisable to initiate the way of the clinical pathways with processes that have a predictable clinical course. Clinical pathways constitute a tool that coordinates all the implied professionals, so the joint work of doctors and nurses is fundamental. Abdominoplasty is one of the operations most commonly performed by plastic surgeon and the general surgeon, but there is no consensus about how it should be done if there is a ventral hernia associated. The objective of this work is to present the elaboration and evaluation of the clinical pathway of the incisional hernioplasty. Methodology: The elaboration of the clinical pathway has been carried out by means of weekly meetings of all the group during 3 months. The group was made by surgeons, anaesthetists, nurses of the different implied units and the quality coordinators of surgery and nursery. A bibliographical search with scientific evidence as well as of other published clinical routes has been performed. Then the main documents of the clinical pathway were elaborated and discussed with the members of the service of surgery and units of nursery. Results: The protocols of attendance in the pre- and postoperative period, as well as the main documents of the clinical pathway are presented. Conclusion: The incisional hernia repair is a suitable process to initiate the systematization of the clinical pathways.

[General surgeons and varicose vein surgery]. / Los cirujanos generales frente a la cirugía de las varices.

Chronic venous insufficiency is a highly prevalent condition, with significant health and economic repercussions. Although important therapeutic developments have been introduced in recent years, the majority are dealt with by general surgeons in national health hospitals. These surgeons do not have the required and continuous training, and continue to perform classic surgery techniques. Also, their presence at scientific, organisational meetings and training is almost nil. We present an update on developments in phlebology, and tapping into the preliminary results of a national survey, we reflect on the current status of phlebology and beyond for those general surgeons who should have a role in this field.

[How to avoid burnout syndrome in a general surgical service]. / Cómo evitar "quemarse" (o padecer el síndrome de burnout) en un servicio de cirugía general.

Burnout syndrome may affect >50% of physicians and is characterized by feelings of emptiness and negative attitudes towards work and life. The work of surgeons presented some specific causal factors that determine that the physician (as a professional) can "burn out" and suffer from this disease with the consequent social/laborial impact, affecting also the rest of the surgical service. These may include external factors linked to the health organization or to internal factors that are directly dependent on the type of work performed by the hospital surgeon. This study analyzes these causal factors of burnout and offers some simple coping strategies in order to improve the health of professionals.

[Gastric rupture and massive pneumoperitoneum after cardiopulmonary resuscitation by lay persons]. / Rotura gástrica y neumoperitoneo masivo tras resucitación cardiopulmonar por personal no sanitario.

Iatrogenic gastric rupture is a rarely reported complication of cardiopulmonary resuscitation. Rupture can occur during chest compressions or imperfect ventilation. We present the case of 1 patient with a tension pneumoperitoneum after cardiopulmonary resuscitation by lay persons.

Cómo evitar quemarse (o padecer el síndrome de burnout) en un servicio de cirugía general / How to avoid burnout syndrome in a general surgical service

El síndrome de burnout puede afectar a más de 50 % de los médicos y se caracteriza por sentimiento de vacío y actitudes negativas hacia el trabajo y la vida. La actividad laboral de los cirujanos presenta factores causales específicos que determinan que el profesional pueda padecer esta enfermedad, con la consiguiente repercusión sociolaboral y para el resto del servicio. Estos factores pueden ser externos, ligados a la organización sanitaria, o internos, que dependen de la actividad laboral del cirujano en el hospital. En este trabajo se analizan dichos factores causales de burnout y se proponen algunas estrategias de afrontamiento para mejorar la salud de los profesionales.

Burnout syndrome may affect >50% of physicians and is characterized by feelings of emptiness and negative attitudes towards work and life. The work of surgeons presented some specific causal factors that determine that the physician (as a professional) can "burn out" and suffer from this disease with the consequent social/laborial impact, affecting also the rest of the surgical service. These may include external factors linked to the health organization or to internal factors that are directly dependent on the type of work performed by the hospital surgeon. This study analyzes these causal factors of burnout and offers some simple coping strategies in order to improve the health of professionals.