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BACKGROUND: Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). METHODS: CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago. RESULTS: A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%). CONCLUSIONS: This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951.
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Neoplasias do Colo , Laparoscopia , Mesocolo , Humanos , Colectomia/métodos , Neoplasias do Colo/cirurgia , Neoplasias do Colo/patologia , Laparoscopia/métodos , Excisão de Linfonodo/métodos , Mesocolo/cirurgia , Estudos ProspectivosRESUMO
BACKGROUND: The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been described. This article reports on the European Hernia Society (EHS) Clinical Practice Guideline for RD. METHOD: The Guideline group consisted of eight surgeons. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done in November 2018 and updated in November 2019 and October 2020. Nine Key Questions (KQs) were formulated. RESULTS: Literature reporting on the definition, classification, symptoms, outcomes and treatments was limited in quality, leading to weak recommendations for the majority of the KQs. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is suggested based on the width of muscle separation, postpregnancy status and whether or not there is a concomitant hernia. Impaired body image and core instability appear to be the most relevant symptoms. Physiotherapy may be considered before surgical management. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD with concomitant midline hernias. CONCLUSION: RD should be defined as a separation of rectus muscles wider than 2 cm and a new classification system is suggested.
The management of RD is controversial. These guidelines are intended to provide a consensus about the exact definition, the correct way of measurement and diagnosis, a classification system, the main symptoms, and a systematic review of non-surgical and surgical treatments to achieve the best results for patients with this pathology. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is proposed. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD in those with concomitant midline hernias.
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Hérnia Ventral/diagnóstico , Hérnia Ventral/terapia , Hérnia Umbilical/complicações , Hérnia Ventral/classificação , Hérnia Ventral/complicações , Herniorrafia , Humanos , Modalidades de Fisioterapia , Cuidados Pós-Operatórios , Reto do Abdome/cirurgia , Telas CirúrgicasRESUMO
BACKGROUND: Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis. METHOD: A multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures' materials, interrupted versus running suture and the presence of deep corner suture has been investigated. RESULTS: We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (p = 0.455) and anastomotic leak (p = 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (p = 0.02). About double-layer characteristics, we found a significant reduction of bleedings (p = 0.008) and leaks (p = 0.017) with a running suture; similarly, a reduction of bleedings (p = 0.001) and leaks (p = 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (p = 0.001) and leaks (p = 0.001). We found no significant differences in terms of bleedings (p = 0.245) and anastomotic leak (p = 0.660) comparing sewn versus stapled anastomosis. CONCLUSIONS: Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.
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Anastomose Cirúrgica , Colectomia/métodos , Colo Ascendente/cirurgia , Neoplasias do Colo/cirurgia , Íleo/cirurgia , Técnicas de Sutura , Técnicas de Fechamento de Ferimentos , Idoso , Fístula Anastomótica/cirurgia , Estudos de Casos e Controles , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Procedimentos Cirúrgicos Robóticos , Grampeamento CirúrgicoRESUMO
BACKGROUND: The aim of our study was to evaluate the short-term outcomes of totally laparoscopic right colectomy, in particular to compare the incidence of leakage of the ileocolic anastomosis after either single-layer (SL) or double-layer (DL) enterotomy closure. METHODS: From March 2010 to July 2014, 162 patients underwent laparoscopic right colectomy with intracorporeal ileocolic anastomosis. The enterotomy was closed with either SL (77 patients) or DL technique (85 patients). Short-term outcomes in both groups were retrospectively analyzed. RESULTS: Median time to perform the ileocolic anastomosis was similar in the two groups (17 min in SL versus 20 min in DL, p = 0.109). DL closure was associated with a significantly lower incidence of anastomotic leakage (1.2 % in DL vs 7.8 % in SL, p = 0.044). Shorter hospital stay was also observed in the DL group. CONCLUSIONS: Adoption of DL closure of the enterotomy resulted in significantly improved outcome. We strongly recommend a double-layer closure technique when performing an intracorporeal enterocolic anastomosis.
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Fístula Anastomótica/etiologia , Colo/cirurgia , Íleo/cirurgia , Técnicas de Sutura/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Colectomia/efeitos adversos , Feminino , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos RetrospectivosRESUMO
Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.
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Colectomia , Laparoscopia , Artéria Mesentérica Superior , Humanos , Colectomia/métodos , Laparoscopia/métodos , Estudos Prospectivos , Itália/epidemiologia , Feminino , Masculino , Artéria Mesentérica Superior/anatomia & histologia , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/cirurgia , Idoso , Pessoa de Meia-Idade , Bases de Dados Factuais , Colo/cirurgia , Colo/irrigação sanguínea , Neoplasias Colorretais/cirurgia , Adulto , Idoso de 80 Anos ou mais , Variação Anatômica , Período IntraoperatórioRESUMO
AIM: Laparoscopic surgery has become recognized as an established technique for colon diseases and many different surgical techniques have been described. The aim of our study is to show the results of a single institution where a standardized operative and perioperative procedure for laparoscopic left hemicolectomy (LLH) has been used. METHODS: Between January 2005 and April 2011, 484 patients underwent LLH for colon diseases. Data collected included age, indication for surgery, ASA class, body mass index, operating time, intra and post-operative complications, conversion rate, length of hospital stay, tumor stage, number of lymph nodes harvested, mortality, and a 30-day readmission rate. RESULTS: We found 299 cancer, 29 large dysplastic polyps and 156 complicated diverticular diseases. Average operation time was 120 minutes. The average hospital stay was 5.7 days. In the cancer group, the average number of lymph nodes harvested was 12.7. The intraoperative and early postoperative complications were 3.3% and 10.7 % respectively. The conversion rate was 3.7%. The 30-day readmission rate was 3%. The 30-day mortality rate was 0.4%. CONCLUSION. The standardization of the LLH technique might reduce the technical difficulties and complications. Its potential benefits include the standardization of surgical instrument sets, the definition of benchmarks for conversion before making any inappropriate investment in time and equipment, low rates of complications and readmission rate.
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Colectomia/normas , Laparoscopia/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Colectomia/métodos , Neoplasias do Colo/cirurgia , Pólipos do Colo/cirurgia , Diverticulose Cólica/cirurgia , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Tempo de Internação/estatística & dados numéricos , Excisão de Linfonodo/métodos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória , Complicações Pós-Operatórias/epidemiologia , Estudos RetrospectivosRESUMO
PURPOSE: Undeniably, in the last 2 decades, surgical approaches in the field of abdominal wall repair have notably improved. However, the best approach to provide a durable repair with low morbidity rate has yet to be determined. The purpose of this study is to outline our long-term results following the Transverse Abdominis Release (TAR) approach in patients with complex ventral hernias, focusing on the incidence of recurrence and overall patient satisfaction following surgery. METHODS: This is a retrospective study on 167 consecutive patients who underwent TAR between January 2015 and December 2021 for primary or recurrent complex abdominal hernias. Of these, 117 patients who underwent the open Madrid approach with the use of a double mesh (absorbable and permanent synthetic mesh) were selected and analyzed. A quality of life questionnaire (EuraHS QoL) comparing the preoperative and the postoperative status was administered. RESULTS: Between January 2015 and December 2021, we successfully treated 117 patients presenting with complex ventral defects using the double mesh technique (absorbable and permanent synthetic mesh). Of these, 26 (22.2%) were recurrent cases. At a median follow-up period of 37.7 months, there had been 1 (0.8%) case of recurrence and 8 cases (6.8%) of bulging. The QoL score was significantly improved when compared to the preoperative status in terms of cosmesis, body perception, and physical discomfort. CONCLUSIONS: The Madrid approach for posterior component separation is associated with both a low perioperative morbidity and recurrence rate. In accordance with other studies, we demonstrated that the TAR with reconstruction according to the Madrid approach provides excellent results in the treatment of complex abdominal wall hernias, even at long-term follow-up.
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PURPOSE: The aim of this study is to present our innovative robotic approach for the treatment of rectus diastasis with concurrent primary or incisional ventral hernias. METHODS: We performed 45 r-TARRD repairs for symptomatic rectus diastasis with concomitant associated ventral/incisional umbilical and/or epigastric hernias between January 2019 and January 2020. Data on patient demographics, type of hernia, operative time, complications, recurrence rate, and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1, 6 months, and 1 year after surgery. RESULTS: 45 patients (13 M, 32 F) underwent r-TARRD repair. Mean age was 54.8 years (range 31-68) and mean BMI was 26.74 kg/m2 (range 21.1-31). Mean ASA was 2.2 (range 1-3). In all patients we used a polypropylene mesh 25 × 15 cm, properly shaped. Mean operative time was 192 min (range 115-260). Mean hospital stay 4.2 days (range 2-7). No conversion to laparoscopy or open surgery and no major complications occurred. At 1-month follow-up one mesh infection (2.22%) was observed and it was treated conservatively. Four recurrences (8.88%) were reported at 1-year follow-up. CONCLUSIONS: Robot-assisted TARRD repair is conceived as a novel alternative minimally invasive procedure for RD with concurrent midline defects ensuring a primary fascial defect closure and mesh implantation in a sublay position with a wide overlap. It is important to better evaluate the suture that should be used to perform the repair, and multicenter studies with standardization of patient's demographics, RD characteristics, and long-term follow-up outcomes are mandatory to assess the effectiveness and durability of r-TARDD repair.
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Hérnia Ventral , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Telas Cirúrgicas , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Estudos Retrospectivos , Hérnia Ventral/cirurgia , Laparoscopia/métodos , RecidivaRESUMO
PURPOSE: To assess the incidence of incisional hernia (IH) across various type of incisions in colorectal surgery (CS) creating a map of evidence to define research trends, gaps and areas of future interest. METHODS: Systematic review of PubMed and Scopus from 2010 onwards. Studies included both open (OS) and laparoscopic (LS). The primary outcome was incidence of IH 12 months after index procedure, secondary outcomes were the study features and their influence on reported proportion of IH. Random effects models were used to calculate pooled proportions. Meta-regression models were performed to explore heterogeneity. RESULTS: Ninetyone studies were included reporting 6473 IH. The pooled proportions of IH for OS were 0.35 (95% CI 0.27-0.44) I2 0% in midline laparotomies and 0.02 (95% CI 0.00-0.07), I2 52% for off-midline. In case of LS the pooled proportion of IH for midline extraction sites were 0.10 (95% CI 0.07-0.16), I2 58% and 0.04 (95% CI 0.03-0.06), I2 86% in case of off-midline. In Port-site IH was 0.02 (95% CI 0.01-0.04), I2 82%, and for single incision surgery (SILS) of 0.06-95% CI 0.02-0.15, I2 81%. In case of stoma reversal sites was 0.20 (95% CI 0.16-0.24). CONCLUSION: Midline laparotomies and stoma reversal sites are at high risk for IH and should be considered in research of preventive strategies of closure. After laparoscopic approach IH happens mainly by extraction sites incisions specially midline and also represent an important area of analysis.
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Cirurgia Colorretal , Hérnia Incisional , Colectomia/efeitos adversos , Cirurgia Colorretal/efeitos adversos , Herniorrafia/efeitos adversos , Humanos , Hérnia Incisional/epidemiologia , Hérnia Incisional/etiologia , Hérnia Incisional/prevenção & controle , Fatores de RiscoRESUMO
PURPOSE: Reinforced prosthetic crural repair is particularly indicated for giant hiatal hernias. The rationale is to reduce the recurrence rate in the long term. The aim of our study is to evaluate the outcomes of laparoscopic giant hiatal hernia repair using a biosynthetic mesh. METHODS: We retrospectively analyzed 44 patients who underwent laparoscopic mesh-reinforced hiatal closure and fundoplication using a biosynthetic material. Inclusion criterion was large hiatal defects (> 5 cm). Follow-up was scheduled at 6, 12 and 36 months after surgery. RESULTS: 44 patients (29F) with a mean age of 62 years (range 14-85) and mean of BMI 24.5 kg/m2 (range 21-29) underwent successful laparoscopic repair. Twenty-six (59.1%) patients had Nissen-Rossetti fundoplication, whereas 18 (40.9%) had Toupet fundoplication. Six-month questionnaire for the evaluation of symptoms was available for 43 patients (97.7%) and for 40 (90.9%) patients at 12 and 36 months. Mean preoperative symptoms score analysis was 1.68 ± 0.73. Mean scores at each follow-up time were significantly improved compared to baseline (p > 0.05). Barium swallow was available in 37 patients (84.1%) at 1 year after surgery. Radiologic recurrence was observed in two patients (4.5%). No patient had symptoms attributable to recurrence or required revisional surgery. There were no mesh-related complications at 3 years follow-up. CONCLUSIONS: The use of biosynthetic mesh for crural reinforcement is associated with a low incidence of mesh-related complications and with a reasonably low recurrence rate (4.5%) at 36 months. However, additional data with longer follow-up are needed to determine long-term safety and efficacy.
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Hérnia Hiatal , Laparoscopia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fundoplicatura , Hérnia Hiatal/cirurgia , Herniorrafia/efeitos adversos , Humanos , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: Laparoscopic transabdominal preperitoneal (TAPP) is a valid option for bilateral primary groin hernia and recurrent cases. Robotic approach for inguinal hernia is still debated. The aim of this study is to investigate the potential role of robotic-assisted single site-TAPP (RASS-TAPP) reporting our experience. METHODS: We performed 44 RASS TAPP in 32 patients from February 2016 to July 2018. Data on patient demographics, type of hernia, operative time, complications, recurrence rate and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1 week, 4 months and 1 year after surgery. RESULTS: Forty-two hernias were treated in 32 patients (27 M). Mean age was 48.6 years (range 20-67), mean BMI was 26.49 kg/m2 (range 16-34.9). Mean operative time was 54.8 min (range 28-150). In two cases (6%) a conversion to laparoscopy was necessary. At 1 week, two scrotal hematomas and four seromas were observed and treated conservatively. At 4 months follow-up, one patient (3.1%) complained temporary pain. No patient had inguinal recurrence or incisional umbilical hernia and chronic pain at 1-year follow-up. CONCLUSION: RASS TAPP is feasible and safe with a high patient satisfaction. However, the surgeon experiences a technical discomfort due to the conflict of the instrumentation which influences negatively the choice of this approach, despite the better vision and augmented dexterity provided by the robot.
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Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems. METHODS: The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries. RESULTS: The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center. CONCLUSION: Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.
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Acreditação/normas , Certificação/normas , Herniorrafia/normas , Hospitais Especializados/normas , Consenso , Europa (Continente) , Herniorrafia/métodos , Humanos , Curva de Aprendizado , Cirurgiões/normasRESUMO
INTRODUCTION: The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature. METHODS: A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated. RESULTS: All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures. CONCLUSION: A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.
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Parede Abdominal/cirurgia , Cirurgia Geral/educação , Hérnia Abdominal/cirurgia , Herniorrafia/educação , Cirurgia Geral/normas , Hérnia Abdominal/complicações , Herniorrafia/normas , Humanos , Laparoscopia , Curva de Aprendizado , Recidiva , Sistema de Registros , Resultado do TratamentoRESUMO
BACKGROUND: Solid pancreatic pseudopapillary tumors are a rare neoplasms, about 1-3% of all pancreatic neoplasms. This cancer mainly affects women between the third and fourth decade of life. They are not well known; the molecular origins represent a low degree of malignancy, in which the complete resection is curative. We report our experience with a case report of SPT in a young man. PRESENTATION OF CASE: Thirty-six years old male patient with a mass about 10â¯cm in the pancreatic tail and splenic ilum. After following CT and MR, the patient was subjected to surgery. Histophatological result was solid tumor pseudopapillary of pancreas with no pathological lymph nodes. DISCUSSION AND CONCLUSION: Solid pseudopapillary neoplasm shows histological characteristic solid and pseudopapillary proliferation. Immunohistochemistry detects, among the causes of tumor development, a correlation between the Beta-catenin mutations, alteration of the E-cadherin. In the most cases, therapy is surgical treatment with laparoscopic.
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BACKGROUND: International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project. METHODS: The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants. RESULTS: End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed. CONCLUSION: An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.
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Hérnia Ventral/terapia , Herniorrafia/métodos , Estomia/efeitos adversos , Estomas Cirúrgicos/efeitos adversos , Hérnia Ventral/diagnóstico , Hérnia Ventral/etiologia , Humanos , Laparoscopia , Telas CirúrgicasRESUMO
After reviewing the available classifications for groin hernias, the European Hernia Society (EHS) proposes an easy and simple classification based on the Aachen classification. The EHS will promote the general and systematic use of this classification for intraoperative description of the type of hernia and to increase the comparison of results in the literature.
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Hérnia Inguinal/classificação , Europa (Continente) , Hérnia Inguinal/patologia , Hérnia Inguinal/cirurgia , Humanos , Guias de Prática Clínica como Assunto , Sociedades MédicasRESUMO
BACKGROUND: In the past decade, laparoscopy has shown its efficacy also for advanced surgery. In this report, the authors retrospectively review their experience with the distal pancreas. METHODS: From April 1999 to October 2004, 19 patients underwent a laparoscopic procedure for pathologies of the distal pancreas. The authors performed one distal pancreatectomy (DP) with conservation of the spleen and section of the splenic vessels, four distal splenopancreatectomies (DSP), one DSP plus a left adrenalectomy, two enucleations, seven DPs with conservation of the spleen and the splenic vessels, and four cystojejunostomies. RESULTS: One procedure was converted to open surgery because of a hemorrhagic complication. No other significant intraoperative complications occurred. The postoperative course was characterized by one bleed managed conservatively, two pancreatic fistulas (one requiring a second operation), one abscess drained under echographic view, and one reactive pancreatitis. The mean postoperative stay was 8.5 days. The histologic report showed 16 benign diseases and 3 malignant tumors. The mean follow-up period was of 42 months. The patient who had DP spleen preservation with section of the splenic vessels reported mild pain in the left hypochondrium, probably attributable to chronic splenic ischemia, during the first 3 postoperative months. One incisional hernia occurred in the patient who underwent conversion to an open procedure, and one patient affected by adenocarcinoma died 10 months after the operation. CONCLUSIONS: The authors can affirm that laparoscopy for the distal pancreas is a successful procedure in terms of results and surgical feasibility. Prospective studies are necessary to confirm their positive impression.