Sutures in general surgery. New materials and advice.

The suture thread used in digestive surgery must have several characteristics, including resistance to tension until the anastomosis coalescence, rapid absorption to avoid complications, biocompatibility and ease of handling. The preference is for monofilament polymers as they offer greater guarantees in biliary-digestive anastomoses. Suturing with synthetic polymers and mechanical devices such as staplers are the most suitable techniques. It is believed that staplers may become the gold standard technique in robotic surgery based on their experience and experimental data. In general, the goal is to use materials that minimize the risk of post-operative complications and offer maximum reliability in the anastomosis. KEY WORD: Suture material, Stapler.

The influence of preoperative MRI in early breast cancer: gold standard.

BACKGROUND: Aim of this study was to evaluate the impact of presurgical breast MRI on the surgical management of selected patients with early-stage breast cancer, who were candidates for BCT. MATERIALS AND METHODS: The trial was built up according to the major European Breast Society. In additional foci classified as BI-RADS 3-4 (4a, 4b, and 4c), a targeted second-look US study was performed. RESULTS: A total of 123 patients underwent presurgical breast MRI. Therapeutic strategy established based on MRI was appropriate in 83.8% of cases. Analysis carried out on the subgroup of patients with dense breast showed that additional foci were found in 41.9% and a greater local extension of the index lesion in 6.4%. CONCLUSION: The results obtained in the subgroup of patients with high breast density suggest the importance of a sensitive tool such as MRI in the local staging of breast cancer before treatment planning. KEY WORDS: Breast cancer, BI-RADS, Histological diagnosis, Mammography MRI.

Groin hernia containing bladder diverticula Report of two cases and review of the literature.

We report two cases of groin herniation of bladder diverticula with different clinical presentation and evolution; bladder diverticula are rarely involved in the pathogenesis of groin hernias. A differential diagnosis is to be made mainly with a common groin hernia. A correct anamnesis, a careful physical examination and a correct diagnostic pattern, including cystography, CT and US scans, are needed. Surgery is recommended when specific symptoms appear, or if an urothelial cancer grows within a diverticulum. KEY WORDS: Diverticulum, Groin hernia, Uretheral cancer.

Laparoscopic resection with intracorporeal anastomosis for colon carcinoma located in the splenic flexure.

BACKGROUND: Treatment of splenic flexure (SF) colon cancer is not standardized. A laparoscopic approach is considered a challenging procedure. METHODS: This review examines a single-institution experience with laparoscopic colon resection for cancer of the SF. Intraoperative, pathologic, and postoperative data of patients who underwent laparoscopic SF resection were reviewed to assess for oncologic safety as well as early- and medium-term outcomes. RESULTS: Between September 2004 and January 2009, laparoscopic SF resection was performed for 15 patients with SF. Two cases of conversion were reported, and for three patients, colonic resection was robot assisted. In all cases, the anastomosis was completed intracorporeally. The distal margin was 3.8 +/- 2.5 cm, and the proximal margin was 7.8 +/- 3.7 cm from the tumor site. The mean number of harvested nodes was 9.2 +/- 5.3. The mean operative time was 183.6 +/- 45 min, and the blood loss was 98 +/- 33 ml. No major morbidity was recorded. CONCLUSIONS: Laparoscopic partial resection seems to be feasible and safe for the treatment of early-stage and locally advanced SF cancer.

Laparoscopic incisional hernia mesh repair with the "double-crown" technique: a case-control study.

BACKGROUND: Incisional hernia is a main complication of abdominal surgery. Laparoscopic hernia mesh repair has been demonstrated to be as effective as open repair. However, the mesh fixation method is, to date, a matter of debate, and there are few clinical studies evaluating a single technique. This was a case-control study to assess the "double-crown" fixation method. METHODS: From March 2000 to November 2005, we prospectively collected operative and outcome data on 94 laparoscopic mesh repairs of large incisional hernias performed by using the double-crown technique. The data were compared with those from a retrospective review of 87 matched open incisional hernia repairs done from January 1995 to January 2000. RESULTS: The open and laparoscopic repair groups were comparable in patient age, sex, and hernia size. Operative time was significantly longer in the laparoscopic group; the duration of hospitalization and number of early postoperative complications (e.g., wound infection and prolonged ileus) were significantly greater in the open group. Recurrence rate after a mean follow-up of 38 months (range, 12-72) was 2.1% in the laparoscopic group and 6.9% in the open repair group (mean follow-up, 8 years; range, 5-10) (P > 0.05). CONCLUSIONS: Medium-term results indicate that laparoscopic incisional hernia repair with the double-crown technique has a low complication rate and a comparable recurrence rate to open repair.

Comparing fibrin sealant with staples for mesh fixation in laparoscopic transabdominal hernia repair: a case control-study.

BACKGROUND: Laparoscopic hernia repair is not as popular as cholecystectomy. We have performed more than 3,000 laparoscopic herniorrhaphies using the trans-abdominal (TAPP) technique. To prevent recurrences we fix the polypropylene mesh with staples. The use of fibrin glue for graft fixation is a possible alternative. METHODS: We have performed 3,130 laparoscopic hernia repairs over 14 years. For mesh fixation we used titanium clips and observed a small number of complications. In July 2003 we started using fibrin glue (Tissucol(R)). The purpose of this retrospective longitudinal study was to evaluate if the use of fibrin sealant was as safe and effective as conventional stapling and if there were differences in post-operative pain, complications and recurrences. RESULTS: From July 2003 to June 2006 we performed 823 laparoscopic herniorrhaphies. Fibrin glue (Tissucol(R)) was used in 88 cases. Two homogeneous groups of 68 patients (83 cases) treated with fibrin glue and 68 patients (87 cases) where the mesh was fixed with staples, were compared. Patients with relevant associated diseases or large inguino-scrotal hernias were excluded. Operative times were longer in the group treated with fibrin glue with a mean of 35 minutes (range 22-65 mins) compared to the group treated with staples (25 minutes, range 14-50 mins). The time of hospital stay was the same (24 hours). Post-operative complications, that were more frequent in the stapled group, included trocar site pain, hematomas, intra-operative bleedings and incisional hernias. No significant difference was observed concerning seromas, chronic pain and recurrence rate. CONCLUSIONS: Less post-operative pain, and a faster return to usual activities are the main advantages of laparoscopic repair compared to the traditional approach. The use of fibrin sealant reduces in our experience the risk of post- and intra-operative complications such as bleeding and incisional hernia; recurrence rates are similar, but the operative time is longer.

Comparison of changes in lipid profile after bilio-intestinal bypass and gastric banding in patients with morbid obesity.

BACKGROUND: The presence of hypercholesterolemia is currently not considered a selection criteria for performing gastric restrictive or diversionary bariatric surgery. METHODS: We prospectively investigated the effects of the bilio-intestinal bypass (BI-bypass) with a wide cholecysto-jejunal anastomosis and of adjustable gastric banding (AGB) on blood lipid concentrations in obese patients. To clarify the mechanism of the hypocholesterolemic effect of the BI-bypass, daily fecal sterol excretion was measured by gas-liquid chromatography (GLC). RESULTS: At 1 year after BI-bypass compared to baseline, the hypercholesterolemic (n=18) and the normocholesterolemic (n=19) patients significantly reduced total (-38% and -27%, respectively), LDL (-47% and -24%, respectively) and HDL (-11% and -13%, respectively) cholesterol and total / HDL cholesterol ratio (-25% and -13%, respectively). At 1 year after AGB, the total / HDL cholesterol ratio was significantly decreased (-11%) compared to baseline in hypercholesterolemic (n=12) but not in normocholesterolemic (n=6) patients, while total and LDL cholesterol were not affected in both groups. At 3 years after BI-bypass compared to baseline, the hypercholesterolemic (n=9) and the normocholesterolemic (n=11) patients significantly reduced total (-43% and -28%, respectively) and LDL (-53% and -29%, respectively) cholesterol and total / HDL cholesterol ratio (-38% and -21%, respectively). The BI-bypass induced a significant (P <0.005; n=7) 6-fold increase in mean fecal cholesterol output. CONCLUSIONS: The BI-bypass but not the AGB leads to a persistent and marked beneficial effect on blood LDL cholesterol associated with an increased cholesterol fecal output. BI-bypass but not AGB is indicated in morbidly obese patients with hypercholesterolemia.