Parastomal hernia repair according to Modified Stapled Mesh Stoma Reinforcement Technique (mSMART): which are the results ?

INTRODUCTION: Parastomal hernia repair is a real surgical challenge because of the high rate of recurrence. The Stapled Mesh Stoma Reinforcement Technique (SMART) is a keyhole-like technique in which the mesh is stapled to the fascia using a circular mechanical stapler. METHODS: A prospective study from January 2021 to February 2023 was conducted including all patients operated with the SMART technique. Primary endpoint was the recurrence rate during the follow-up. Secondary endpoints were reoperation, Surgical site Occurrence (SSO) and deep (mesh) surgical site infection (SSI) within 30 days postoperatively. RESULTS: Sixteen patients operated on SMART procedures were included. The mean follow-up was 11.3 ± 9.2 months. The SSO rate was 18.7% (n = 3). A seroma was drained radiologically (IIIa), one haematoma was evacuated surgically (IIIb) and one patient presented a postoperative lesion of a ureter after a parastomal Bricker's hernia repair. In addition, there was one death due to multiple organ failure (V). There was no SSI. The recurrence rate was 57.1% during the follow-up. CONCLUSION: This study shows disappointing results for this SMART technique, with a high recurrence rate.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study.

INTRODUCTION: Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair. METHODS: A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1 month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program. RESULTS: One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9 days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5 days for group 3 (p < 0.005). CONCLUSION: Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

Incisional hernia repair with a slowly absorbable P4HB mesh: what happens after the mesh disappears? A retrospective longitudinal clinical study.

PURPOSE: To analyze the incisional hernia recurrence rate at a long-term follow-up using a biosynthetic long-term absorbable mesh in patients with a higher risk of surgical infection in a contaminated surgical field. METHODS: This was a retrospective multicentric study. All patients undergoing incisional hernia repair between 2016 and 2018 at 6 participating university centers were included. Patients were classified according to the Ventral Hernia Working Group (VHWG). All consecutive patients who underwent abdominal wall repair using biosynthetic long-term absorbable mesh (Phasix®) in contaminated fields (grade 3 and 4 of the VHWG classification) were included. Patients were followed-up until September 2021. Preoperative, operative, and postoperative data were collected. All patients' surgical site infections (SSIs) and surgical site occurrences (SSOs) were recorded. The primary outcome of interest was the clinical incisional hernia recurrence rate. RESULTS: One hundred and eight patients were included: 77 with VHWG grade 3 (71.3%) and 31 with VHWG grade 4 (28.7%). Median time follow-up was 41 months [24; 63]. Twenty-four patients had clinical recurrence during the follow-up (22.2%). The SSI and SSO rates were 24.1% and 36.1%, respectively. On multivariate analysis, risk factors for incisional hernia recurrence were previous recurrence, mesh location, and postoperative enterocutaneous fistula. CONCLUSIONS: At the 3 year follow-up, the recurrence rate with a biosynthetic absorbable mesh (Phasix®) for incisional hernia repair in high-risk patients (VHWG grade 3 and 4) seemed to be suitable (22.2%). Most complications occurred in the first year, and SSI and SSO rates were low despite high-risk VHWG grading.

Why and how to implement an electronic resident's surgical logbook to improve operating-room training? First 5-year feedback from a French center.

INTRODUCTION: The evaluation of general surgery residents' operating room (OR)-training and technical skills progression may be difficult in the absence of a standardized evaluation tool. The aim of this study was to evaluate the impact of the implementation of an electronic "surgical logbook" for general surgery residents. METHODS: A prospective single center study was conducted between May 2015 and October 2020. An electronic logbook was filled by all residents immediately after each surgical procedure and data were prospectively collected and analyzed. RESULTS: Fifty-five students (34 men/21 women) reported their participation to 6917 surgical procedures, which corresponded to 55.5% of all procedures performed in our department. Residents performed the entire procedure as the operating surgeon in 28.5% of cases (n=1963), parts of the procedure as operating surgeon in 32.5% of cases (n=2230) and as operating-assistant in 38.5% (n=2672). Residents were more likely an operating surgeon for the entire procedure when they were assisted by a fellow or a practicing physician than an associate professor or a clinical professor (P<0.001). There was no significant difference in the major morbidity rate between different resident's contribution to the procedure (P=0.14). CONCLUSION: We present here a simple, useful and cost efficient tool which offers easy data collection and reporting that could help improve OR-training, OR-supervision and certification at a local or national level.

Slowly absorbable mesh in contaminated incisional hernia repair: results of a French multicenter study.

PURPOSE: To analyze the postoperative morbidity and 1-year recurrence rate of incisional hernia repair using a biosynthetic long-term absorbable mesh in patients at higher risk of surgical infection in a contaminated surgical field. METHODS: All patients undergoing incisional hernia repair in a contaminated surgical field with the use of a biosynthetic long-term absorbable mesh (Phasix®) between May 2016 and September 2018 at six participating university centers were included in this retrospective cohort and were followed-up until September 2019. Regarding the risk of surgical infection, patients were classified according to the modified Ventral Hernia Working Group classification. Preoperative, operative and postoperative data were collected. All patients' surgical site infections (SSIs) and occurrences (SSOs) and recurrence rates were the endpoints of the study. RESULTS: Two hundred and fifteen patients were included: 170 with mVHWG grade 3 (79%) and 45 with mVHWG grade 2 (21%). The SSI and SSO rates at 12 months were 22.3% and 39.5%, respectively. According to the Dindo-Clavien classification, 43 patients (20.0%) had at least one minor complication, and 57 patients (26.5%) had at least one major complication. Among the 121 patients (56.3%) having at least 1 year of follow-up, the clinical recurrence rate was 12.4%. Multivariate analysis showed that a concomitant gastrointestinal procedure was an independent risk factor for surgical infection (OR = 2.61), and an emergency setting was an independent risk factor for major complications (OR = 11.9). CONCLUSION: The use of a biosynthetic absorbable mesh (Phasix®) is safe in a contaminated surgical field, with satisfying immediate postoperative and 1-year results. TRIAL REGISTRATION: The study is registered on Clinical Trial ID: NCT04132986.

Intra-operative fluorescence angiography is reproducible and reduces the rate of anastomotic leak after colorectal resection for cancer: a prospective case-matched study.

AIM: Intra-operative fluorescence angiography (IOFA) with indocyanine green provides information on tissue perfusion that may help prevent an anastomotic leak (AL). The aim of this study was to assess the impact of IOFA on outcomes after left-sided colonic or low anterior resection with anastomosis for colorectal cancer. METHODS: All patients with left-sided colonic or rectal cancer, operated between June 2017 and December 2018, were prospectively included. IOFA has been routinely implemented since May 2018. Reproducibility of IOFA, after a 1:1 matching for relevant clinical risk factors of AL, was studied in patients with IOFA (IOFA+) and without IOFA (IOFA-). Outcomes were compared in terms of postoperative events such as clinically relevant AL as the primary end-point. RESULTS: In the IOFA+ group, changing of the initially planned colon transection due to inadequate perfusion occurred in five out of 46 patients (10.9%). Agreement between intra-operative assessment and postoperative blind review of IOFA was deemed strong (Cohen's kappa index 0.893, 95% CI 0.788-0.998, P < 0.001). Among 111 patients, 42 matched patients were included in each group. There was significantly more clinically relevant AL in the IOFA- group compared to the IOFA+ group (16.7% vs 2.4%, P = 0.026) involving significantly more anastomotic dehiscence which required re-intervention (19% vs 2.4%, P = 0.014). Additionally, more descending colon ischaemia/necrosis was observed in the IOFA- group compared with the IOFA+ group (9.5% vs 0%, P = 0.040). CONCLUSION: In this prospective case-matched study, IOFA decreased the occurrence of clinically relevant AL due to necrosis of the descending colon or anastomosis. Upon blind review, perfusion assessment using IOFA was reproducible.

Extraskeletal Ewing's Sarcoma: insight into a ten years follow-up.

Extraskeletal Ewing's sarcoma is a rare malignant soft tissue tumor, classified within the Ewing's Sarcoma Family Tumors. While the classical Ewing's Sarcoma affects mainly the bone during youth, the Extraskeletal histotype differs for age incidence, primary location and prognosis. Peak incidence and typical location are during adolescence and in the extremities respectively. We report a 30 year old woman case with a positive outcome after ten years from first diagnosis of Extraskeletal Ewing's sarcoma. Treatment was achieved through surgical resection plus adjuvant chemoradiotherapy derived from EW93 and IRS III trials. Conclusion. Our report represents an unusual case due to age of presentation, neoplasm location and long survival reached. In last decades several trials results demonstrated that long survival could be achieved by combined surgery and adjuvant multi-drug treatment.

Incisional hernia surgery: report on 283 cases.

BACKGROUND AND OBJECTIVES: Despite the improvement of the surgical technique and several experiences reported in literature about prosthetic incisional hernioplasty, the prevalence rate of recurrence and of the classic complications has not changed over the years. We analyze our caseload, establishing some technical cornerstones in order to reduce their occurrence. PATIENTS AND METHODS: 283 patients underwent incisional hernioplasty in our Department of Surgery in the decade 1999-2008. They were retrospectively divided into four groups (A-D) according to the surgical technique adopted for a comparative analysis: A, 37 primary direct closure; B, 207 Rives-Stoppa procedures; C, 9 Chevrel procedures; D, 30 intraperitoneal repairs. The outcomes were considered in terms of postoperative surgical complications. RESULTS: In total, we observed 11 cases of hernia recurrence (3.9%), 13 cases of infections (4.6%), 7 cases of seroma/hematoma (2.4%) and one case of acute respiratory insufficiency. DISCUSSION: The Rives-Stoppa procedure is, among all those practised, the treatment of choice in incisional hernioplasty. Thanks to the introduction of some simple modifications to this technique and preventing the postoperative infections, we obtained excellent results in terms of recurrence rate (only 1 case on 207 patients, 0.48%) and morbidity.

[Cervico-thoracic liposarcoma in an HIV patient]. / Liposarcoma dorsocervicale in un paziente HIV-positivo.

Association between cervico-thoracic liposarcoma and HIV infection is uncommon. The etiopathology remains unclear and clinical symptoms can be various, often not very evident or absolutely absent. Preoperative diagnosis is based on modern imaging techniques. In selected cases, the ideal procedure is surgical treatment which allows good long-term results. A case of cervico-thoracic liposarcoma in HIV patient is presented.

[Integrated treatment of breast cancer: review of our experience]. / Trattamento integrato del carcinoma della mammella: revisione della nostra esperienza.

In the industrialized West countries the breast cancer represents the most frequent malignant neoplasia in the women. From over 30 years we have a progressive increase of frequency of breast carcinoma. Mortality is substantially unchanged. The Authors, on the base of casuistry accumulated in five years of activity, trace a diagnostic-therapeutic run to the purpose to favour a line of behavior, practice and actual, for the management of breast cancer.

[Complications of the Lichtenstein inguinal hernioplasty]. / L'ernioplastica secondo Lichtenstein: a proposito delle complicanze.

The Lichtenstein inguinal hernioplasty in the original version or with small variations currently allows good results both from the surgical point of view and in terms of reduction of the sanitary expenses. "Tension free" repair and diffusion of local anesthesia allow a drastic reduction of the hospital stay, a early time of the working activity and the diffusion of the admission to the Day Hospital. The authors introduce the own casuistic that comprise 1116 inguinal hernioplasty in 1,034 patients and on the base of two studies, a retrospective one and another prospective, they conclude that a greater attention in the behavior of the intervention and a more accurate preparation of the patients represent fundamental moments to obtain even more satisfactory results.

[Leiomyosarcoma of brachiocephalic vein: case report]. / Leiomiosarcoma del tronco brachiocefalico: a proposito di un caso clinico.

Primary leiomyosarcoma of venous origin is a rare but frequently lethal disease. Clinical symptoms can be different, often not much evident or absolutely absent. Preoperative diagnosis is difficult also with modern imaging and only pathological examination can identify this malignant tumor. Successful therapy requires early surgery but the long-term survival is poor. A case of leiomyosarcoma arising from veins has been presented.

[The clinical significance of lymph node micrometastases and of concept of sentinel lymph node]. / Significato biologico delle micrometastasi linfonodali e del concetto di linfonodo sentinella.

Micrometastases, (metastases smaller than 2 mm), had benn subject of several studies. In literature is documented a prognostic worsening due to their presence. Research of micrometastases in sentinel lymph node is of great interest and can allow a clinical application with profitable cost efficacy ratio. The Authors discuss about clinical, prognostical and therapeutical implicationes in case of micrometastases into sentinel lympho nodes.