Long-term patient-reported outcome measures (PROMs) after primary ventral or small midline incisional hernia repair.

BACKGROUND: Ventral hernia repair is a common elective surgical procedure lacking strong evidence for specific operative approaches. This study aimed to evaluate the outcomes of primary suture repair or polypropylene sandwich mesh repair for ventral hernias. The main outcome measures were the rate of hernia recurrence, and evaluation of long-term complications and patient-reported outcomes. METHODS: This retrospective cohort study evaluated patient perceived recurrence and pain in patients who had undergone a primary ventral hernia (epigastric, supraumbilical, or umbilical) repair or small (≤20 mm) midline incisional hernia repair 10 years after the procedure. Short-term follow-up occurred up to 6 weeks after the initial operation, while long-term follow-up included patients who were reviewed clinically or interviewed via telephone at or beyond 3 years after the procedure. RESULTS: Most (75/100, 75.0%) patients had an extra-peritoneal sandwich mesh repair. Short-term follow-up showed minimal pain and normal activities for all patients (97/97, 100%). Long-term follow-up (median 12 years [IQR 11-13]) was achieved in 95.9% (93/97) of patients with only a small number reporting a slight bulge (5/93, 5.4%) and intermittent mild discomfort (8/93, 8.6%). Nine patients (9/97, 9.3%) experienced hernia recurrence, diagnosed at a median of 26 months [interquartile range, IQR, 7-58] post-operatively. CONCLUSIONS: These findings suggest that an open sandwich mesh technique is a safe and effective method for repairing primary ventral hernias and small midline incisional hernias and is associated with favourable long-term patient-reported outcomes.

Comparison of single absorbable tacker vs. conventional method in fixating the mesh in bilateral inguinal hernia undergoing laparoscopic transabdominal preperitoneal (TAPP): A randomized control trial study.

Background: The current study aims to investigate the superior mesh fixation method, single absorbable tacker versus conventional method, in patients undergoing bilateral inguinal hernia repair through the laparoscopic total abdominal preperitoneal (TAPP) approach. Materials and Methods: The current randomized clinical trial has been conducted on 81 patients undergoing bilateral hernia repair through TAPP. The patients were randomly assigned into one of the mesh fixation groups including single absorbable tacker (Group S) (n = 41) and conventional method (Group C) (n = 40). All patients were assessed during the hospital stay and 1 month postoperatively to assess the surgery-associated complications and days for return to daily activity. Eura-Hs questionnaire was applied to assess the quality of life (QOL) after hernia surgery during 12-month follow-up. Results: The duration of bilateral inguinal hernia operation (P = 0.067), postoperative urinary catheterization (P = 0.813), and hospital stay duration (P = 0.779) did not differ between the groups; whereas Group C significantly required a longer time for returning to daily activity (P < 0.001). Only a patient in Group C represented hematoma (P = 0.494). Seroma incidence was not statistically different between the two groups (P = 0.712). Postoperative pain was statistically less in Group S (P < 0.001 for all the assessments). Postoperative QOL within a year after hernia repair revealed an insignificant difference between the groups in general (P > 0.05); however, a pain subscale was significantly less in Group S (P = 0.002). Conclusion: Based on the findings of this study, a single absorbable tacker was generally superior to the conventional method considering its less pre- and postoperative complications. However, the two methods did not differ regarding 1-year follow-up QOL.

Treatment of chronic mini-thoracotomy wound pain and lung herniation with intercostal cryoablation and surgical mesh repair: a case report.

BACKGROUND: The incidence of minimally invasive heart surgery via mini-thoracotomy (MT; right anterior thoracotomy) is on the rise, accompanied by an increase in post-MT intercostal nerve neuralgia and the risk of lung herniation through the incision site. While various methods have been proposed to address these issues, none have been commonly effective. In this case report, we attempted to simultaneously address these problems by performing intercostal cryoablation (IC) and mesh repair. CASE PRESENTATION: A 43-year-old male was referred to our hospital for chronic post-thoracotomy neuralgia following heart surgery via MT, involving patch closure of an atrial septal defect and tricuspid annuloplasty. He presented with intercostal nerve neuralgia and lung herniation accompanied by severe pain. Despite medication and lidocaine injections, there was no relief. Consequently, he underwent surgical treatment with IC for chronic MT wound pain and simultaneously underwent mesh repair for a lung hernia. He was discharged from hospital free of complications. Subsequently, he no longer required further pain medication and experienced a favorable recovery. CONCLUSION: Our findings suggest that concurrent IC and mesh repair can effectively relieve chronic post-MT intercostal nerve neuralgia and severe lung herniation pain in patients who underwent MT surgery, leading to a decrease in opioid medication usage.

Preparation of surgical meshes using self-regulating technology based on reaction-diffusion processes.

While reaction-diffusion processes are utilized in multiple scientific fields, these phenomena have seen limited practical application in the polymer industry. Although self-regulating processes driven by parallel reaction and diffusion can lead to patterned structures, most polymeric products with repeating subunits are still prepared by methods that require complex and expensive instrumentation. A notable, high-added-value example is surgical mesh, which is often manufactured by weaving or knitting. In our present work, we demonstrate how the polymer and the biomedical industry can benefit from the pattern-forming capabilities of reaction-diffusion. We would like to propose a self-regulating method that facilitates the creation of surgical meshes from biocompatible polymers. Since the control of the process assumes a thorough understanding of the underlying phenomena, the theoretical background, as well as a mathematical model that can accurately describe the empirical data, is also introduced and explained. Our method offers the benefits of conventional techniques while introducing additional advantages not attainable with them. Most importantly, the method proposed in this paper enables the rapid creation of meshes with an average pore size that can be adjusted easily and tailored to fit the intended area of application.

Anatomical outcomes and complications of sacrocolpopexy using Surelift Uplift mesh: A multicentric observational study.

OBJECTIVE: The study evaluated the anatomical and functional outcomes, as well as the safety data of laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse (POP) using a lightweight macroporous mesh. METHODS: A multicentric observational study was developed including five expert centers between March 2011 and December 2019. Inclusion criteria were female patients with symptomatic ≥stage II POP (POP-Q classification), who underwent a LSC. A lightweight and macroporous mesh device (Surelift Uplift) was used. Baseline anatomical positions were evaluated using POP-Q stage. The anatomical outcomes and procedural complications were assessed during the postoperative period. Primary outcomes were anatomical success, defined as POP-Q stage ≤I, and subjective success, defined as no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse. RESULTS: A total of 325 LSCs were analyzed with a median patient age of 66 (interquartile range [IQR] 61-73). After a median follow-up of 68 months (IQR 46.5-89), anatomical success was found in 88.9%, whereas subjective success was seen in 98.5% of the patients. Recurrent prolapse presented as cystocele (1.5%). Reported complications were bladder (4.6%) or rectum lesions (0.6%), de novo urinary incontinence (12.9%), and mesh extrusion (1.2%). CONCLUSIONS: LSC provides significant clinical improvement and excellent anatomical results, with a low risk of serious complications for women with ≥2 grade POP in a real clinical practice setting.

The long-term impact of vaginal surgical mesh devices on pain clinic and psychological service referrals, anti-inflammatory testing and pelvic scans in UK primary care: A cohort study with the Clinical Practice Research Datalink.

OBJECTIVE: To examine long-term complications in women with stress urinary incontinence (SUI) and pelvic organ prolapse (POP), with and without surgical mesh implants. DESIGN: Longitudinal open cohort study from 1 April 2006 (or 1 April 2012) to 30 November 2018. SETTING: The Clinical Practice Research Datalink (CPRD) Gold database, which is linked to Hospital Episodes Statistics (HES) inpatient data, the HES Diagnostic Imaging Dataset (DID), Office for National Statistics mortality data and Index of Multiple Deprivation socio-economic status data. SAMPLE: Women aged ≥18 years with a diagnostic SUI/POP Read code. METHODS: Rates are estimated using negative binomial regression. MAIN OUTCOME MEASURES: Rates of referrals for: psychological and pain services; urinalysis, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) testing; and pelvic ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) scans. RESULTS: A cohort of 220 544 women were eligible for inclusion; 74% (n = 162 687) had SUI, 37% (n = 82 123) had POP and 11% (n = 24 266) had both. Rates of psychological referrals and CT scans were lower in women with SUI mesh surgery, but this was offset by higher rates of CRP testing in women with SUI or POP mesh, MRI scans in women with SUI mesh, and urinalysis testing and referrals to pain clinics for women with POP mesh. CONCLUSIONS: Our results suggest a higher burden of morbidity in women with SUI/POP mesh surgery, and that these women may require ongoing follow-up in the primary care setting.

Concomitant Panniculectomy in Abdominal Wall Reconstruction: A Narrative Review Focusing on Obese Patients.

The global prevalence of obesity continues to rise, contributing to an increased frequency of abdominal wall reconstruction procedures, particularly ventral hernia repairs, in individuals with elevated body mass indexes. Undertaking these operations in obese patients poses inherent challenges. This review focuses on the current literature in this area, with special attention to the impact of concomitant panniculectomy. Obese individuals undergoing abdominal wall reconstruction face elevated rates of wound healing complications and hernia recurrence. The inclusion of concurrent panniculectomy heightens the risk of surgical site occurrences but does not significantly influence hernia recurrence rates. While this combined approach can be executed in obese patients, caution is warranted, due to the higher risk of complications. Physicians should carefully balance and communicate the potential risks, especially regarding the increased likelihood of wound healing complications. Acknowledging these factors is crucial in shared decision making and ensuring optimal patient outcomes in the context of abdominal wall reconstruction and related procedures in the obese population.

Reparação da parede abdominal com membranas acelulares de pericárdio bovino - Parte I - Achados clínicos e radiológicos / Abdominal wall repair with acellular bovine pericardial membranes - Part I - Clinical and radiological findings

Introdução: Reduzindo os índices de recidiva de forma impactante, o emprego de biomateriais como "telas de reforço" na reparação de diferentes defeitos da parede abdominal tornou-se rotina quase obrigatória para o sucesso dessas reparações. A partir da década de 1990 houve a introdução de matrizes biológicas acelulares, iniciando-se assim uma nova era na reparação dos defeitos da parede abdominal. O objetivo é avaliar a funcionalidade do pericárdio bovino acelularizado em reparações da parede abdominal. Método: Trinta pacientes foram submetidos a reparação de defeitos da parede abdominal, com biopróteses acelulares de pericárdio bovino, perfazendo um total de 40 implantes anatomicamente individualizados. O seguimento médio foi de 31 meses, sendo os pacientes avaliados clinicamente e radiologicamente. Em três casos foram feitas biópsias das áreas implantadas permitindo análise histológica do material. Resultados: Não se observou recidiva das herniações em nenhum dos casos, tanto clinica como radiologicamente. Também não houve registro de hematomas, infecções ou qualquer fenômeno de natureza reacional local ou sistêmica. Radiologicamente, não foi possível visualizar as matrizes no local de implantação em qualquer dos períodos de pós-operatório analisados. Conclusão: As matrizes mostraram similaridade às demais membranas biológicas descritas na literatura internacional. Representando uma importante atualização e evolução conceitual, as membranas acelulares de pericárdio bovino podem ser incorporadas ao arsenal terapêutico nas reparações de parede abdominal.

Introduction: Reducing recurrence rates significantly, the use of biomaterials as "reinforcement meshes" in the repair of different abdominal wall defects has become an almost mandatory routine for the success of these repairs. From the 1990s onwards, acellular biological matrices were introduced, thus beginning a new era in the repair of abdominal wall defects. The objective is to evaluate the functionality of the acellularized bovine pericardium in abdominal wall repairs. Method: Thirty patients underwent repair of abdominal wall defects using acellular bovine pericardium bioprostheses, making a total of 40 anatomically individualized implants. The average follow-up was 31 months, with patients being evaluated clinically and radiologically. In three cases, biopsies were taken from the implanted areas, allowing histological analysis of the material. Results: No recurrence of herniations was observed in any of the cases, both clinically and radiologically. There were also no records of bruises, infections or any phenomenon of a local or systemic reaction nature. Radiologically, it was not possible to visualize the matrices at the implantation site in any of the postoperative periods analyzed. Conclusion: The matrices showed similarity to other biological membranes described in the international literature. Representing an important update and conceptual evolution, acellular bovine pericardial membranes can be incorporated into the therapeutic arsenal in abdominal wall repairs.

Effect of Functionalization of Texturized Polypropylene Surface by Silanization and HBII-RGD Attachment on Response of Primary Abdominal and Vaginal Fibroblasts.

Soft tissue defects, such as incisional hernia or pelvic organ prolapse, are prevalent pathologies characterized by a tissue microenvironment rich in fragile and dysfunctional fibroblasts. Precision medicine could improve their surgical repair, currently based on polymeric materials. Nonetheless, biomaterial-triggered interventions need first a better understanding of the cell-material interfaces that truly consider the patients' biology. Few tools are available to study the interactions between polymers and dysfunctional soft tissue cells in vitro. Here, we propose polypropylene (PP) as a matrix to create microscale surfaces w/wo functionalization with an HBII-RGD molecule, a fibronectin fragment modified to include an RGD sequence for promoting cell attachment and differentiation. Metal mold surfaces were roughened by shot blasting with aluminum oxide, and polypropylene plates were obtained by injection molding. HBII-RGD was covalently attached by silanization. As a proof of concept, primary abdominal and vaginal wall fasciae fibroblasts from control patients were grown on the new surfaces. Tissue-specific significant differences in cell morphology, early adhesion and cytoskeletal structure were observed. Roughness and biofunctionalization parameters exerted unique and combinatorial effects that need further investigation. We conclude that the proposed model is effective and provides a new framework to inform the design of smart materials for the treatment of clinically compromised tissues.

Surgical management of sternal tumours-a decade of experience from a tertiary care centre in India.

Tumours of the sternum can be either primary or secondary with malignancy being the most common etiology. Wide local excision of these tumours results in a midline defect which pose a unique challenge for reconstruction. As limited data on the management of these tumours exists in the literature, we hereby report 14 consecutive patients who were treated at our institute between January 2009 to December 2020. Most of them were malignant with majority of them, 11 (78%) patients, with manubrial involvement requiring partial sternectomy. Overall, the average defect size was 75 cm2. Reconstruction of the chest wall defect was done using a semi-rigid fixation: mesh and suture stabilization in 3 (21%) or suture stabilization in 7 (50%) and without mesh or suture stabilization in 3 (21%) patients. Rigid fixation with polymethyl methacrylate (PMMA) was done for one patient (7%). Pectoralis major advancement flap was most commonly used for soft tissue reconstruction with flap necrosis noted in one patient (7%). There was no peri-operative mortality and one patient required prolonged post-operative ventilation. On a median follow-up of 37.5 months, one patient (7%) had a recurrence. Sternal defects after surgical resection reconstructed with semi-rigid fixation and suture stabilization render acceptable post-operative outcomes.

Vertical Ridge Augmentation with Customized Titanium Mesh Using a 3D-Printing Model: A Prospective Study in Humans.

PURPOSE: To evaluate the usefulness of ridge augmentation using a customized titanium mesh (CTM) that was preformed by trimming and bending the commercial titanium mesh on a virtually reconstructed 3D acrylic resin model using clinical, radiologic, histologic, and histomorphometric analyses. MATERIALS AND METHODS: This study was designed prospectively for patients who required vertical ridge augmentation using a staged approach before implant surgery. After installation of the CTM, grafting was performed using deproteinized porcine bone mineral covered with an absorbable membrane. Computed tomography was performed preoperatively and 6 months after simultaneous/staged guided bone regeneration to measure planned, reconstructed, and lacking bone volume, and the reconstruction rate was calculated based on these values. Clinical complications were also recorded, particularly the mesh exposure rate. At re-entry, the bone core was obtained using a trephine bur, and histologic and histomorphometric analyses were performed. RESULTS: A total of 10 sites in eight patients were used for the study analysis. The mean planned bone volume was 1.15 cm3 (range: 0.78 to 1.56 cm3), mean lacking bone volume was 0.13 cm3 (range: 0 to 0.59 cm3), and mean reconstructed bone volume was 1.02 cm3 (range: 0.56 to 1.43 cm3). The exposure rate was 30% (3 out of 10 sites). The reconstruction rate was over 80%, except for one case that showed suppuration. From histomorphometric analysis, 27.52% ± 16.87% of new bone, 7.62% ± 5.19% of residual graft, and 64.86% ± 23.76% of connective tissue were observed. The core biopsy samples demonstrated different pseudoperiosteum layer appearances based on the healing stage of the augmented sites. In the premature bone, the inner osteogenic layer consisted of multiple layers of osteoblast cells with adjacent large blood vessels. However, in the mature augmented site, there was no specific inner osteogenic layer, and the outer fibrous layer was dominant. CONCLUSIONS: The fabrication of CTM based on the application of the 3D-printing technique makes vertical ridge augmentation easier and can reduce complications and achieve target bone acquisition. In addition, it is expected that quantitative analysis of the pseudoperiosteum layer will be facilitated using the CTM.

Robotic sacrocolpopexy.

Pelvic organ prolapse (POP) is a common cause of gynecological disease in elderly women. The prevalence of POP has increased with an aging society. Abdominal sacrocolpopexy (ASC) is safer and more effective than the vaginal approach in patients with apical compartment POP because it has a higher anatomical cure rate, a lower recurrence rate, less dyspareunia, and improved sexual function. Laparoscopic sacrocolpopexy (LSC) has replaced ASC. Robotic sacrocolpopexy (RSC) also helps overcome the challenges of LSC by facilitating deep pelvic dissection and multiple intracorporeal suturing. The RSC is technically easy to apply, has a steep learning curve, and offers many advantages over the LSC. However, insufficient data led us to conclude that the LSC is superior overall, especially in terms of costeffectiveness. The present review provides insights into different aspects of RSC, highlighting the most common benefits and concerns of this procedure. We searched for eligible articles discussing this issue from January 2019 to March 2022 to reveal the outcomes of RSC.

Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair.

PURPOSE: With this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery. METHODS: Clinical records before and after mesh revision surgery from 221 patients with chronic postoperative inguinal pain (CPIP) and 59 patients with pain after pelvic organ prolapse (POP) surgery were collected at two experienced tertiary referral centers. Primary outcome was patient reported improvement of pain after revision surgery. A multivariable logistic regression model was used to specify predictors for pain reduction. RESULTS: The multivariable logistic regression was performed for each patient group separately. Patients with CPIP had higher chances of improvement of pain when time between mesh placement and mesh revision surgery was longer, with an OR of 1.19 per year. A turning point in chances of risks and benefits was demonstrated at 70 months, with improved outcomes for patients with revision surgery ≥ 70 months (OR 2.86). For POP patients, no statistically significant predictors for reduction of pain after (partial) removal surgery could be identified. CONCLUSION: A longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.

The Use of Platelet-Rich Fibrin and Polypropylene Mesh in Repair of Nasal Septal Perforation.

OBJECTIVE: In this study, we aimed to investigate the effectiveness of the use of polypropylene mesh and platelet-rich fibrin (PRF) in nasal septal perforation (NSP) repair. STUDY DESIGN: Prospective experimental study. SETTING: Laboratory. METHODS: Twenty-four adult male New Zealand rabbits were used in our study. In all subjects, a 10 × 10 mm perforation was created in the septum. The subjects were divided into 3 equal groups according to the different methods used in perforation closure. The bilateral mucosal flap was used in the control group, polypropylene mesh + bilateral mucosal flap in the mesh group, and polypropylene mesh + bilateral mucosal flap + PRF in the mesh + PRF group. RESULTS: NSP treatment success rate was found to be significantly higher in the mesh (4/6, 66.7%) and mesh + PRF (6/6, 100%) groups compared to the control group (0/6, 0%). Re-epithelialization score was higher in the mesh + PRF group and the control group compared to the mesh group. While the necrosis, neutrophil, and abscess scores were highest in the mesh group, they were similar to the control group in the mesh + PRF group. CONCLUSIONS: While polypropylene mesh significantly increases the success rate in NSP repair, it causes severe inflammatory responses. However, when polypropylene mesh is combined with PRF, it both increases the rate of perforation closure and significantly reduces the complications associated with the use of mesh.

Soft, Long-Lived, Bioresorbable Electronic Surgical Mesh with Wireless Pressure Monitor and On-Demand Drug Delivery.

Current research in the area of surgical mesh implants is somewhat limited to traditional designs and synthesis of various mesh materials, whereas meshes with multiple functions may be an effective approach to address long-standing challenges including postoperative complications. Herein, a bioresorbable electronic surgical mesh is presented that offers high mechanical strength over extended timeframes, wireless post-operative pressure monitoring, and on-demand drug delivery for the restoration of tissue structure and function. The study of materials and mesh layouts provides a wide range of tunability of mechanical and biochemical properties. Dissolvable dielectric composite with porous structure in a pyramidal shape enhances sensitivity of a wireless capacitive pressure sensor, and resistive microheaters integrated with inductive coils provide thermo-responsive drug delivery system for an antibacterial agent. In vivo evaluations demonstrate reliable, long-lived operation, and effective treatment for abdominal hernia defects, by clear evidence of suppressed complications such as adhesion formation and infections.

Malignant Chest Wall Tumors: Complex Defects and Their Management-A Review of 181 Cases.

BACKGROUND: Chest wall tumors are a heterogeneous group of tumors that are managed by surgeons from diverse specialties. Due to their rarity, there is no consensus on their diagnosis and management. MATERIALS: This retrospective, descriptive analysis includes patients with malignant chest wall tumors undergoing chest wall resection. Tumors were classified as primary, secondary, and metastatic tumors. The analysis includes clinicopathological characteristics, resection-reconstruction profile, and relapse patterns. RESULTS: A total of 181 patients underwent chest wall resection between 1999 and 2020. In primary tumors (69%), the majority were soft tissue tumors (59%). In secondary tumors, the majority were from the breast (45%) and lung (42%). Twenty-five percent of patients received neoadjuvant chemotherapy, and 98% of patients underwent R0 resection. Soft tissue, skeletal + soft tissue, and extended resections were performed in 45%, 70%, and 28% of patients, respectively. The majority of patients (60%) underwent rib resections, and a median of 3.5 ribs were resected. The mean defect size was 24 cm2. Soft tissue reconstruction was performed in 40% of patients, mostly with latissimus dorsi flaps. Rigid reconstruction was performed in 57% of patients, and 18% underwent mesh-bone cement sandwich technique reconstruction. Adjuvant radiotherapy and chemotherapy were given to 29% and 39% of patients, respectively. CONCLUSIONS: This is one of the largest single-institutional experiences on malignant chest wall tumors. The results highlight varied tumor spectra and multimodality approaches for optimal functional and survival outcomes. In limited resource setting, surgery, including reconstructive expertise, is very crucial.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT / Posição da Sociedade Brasileira de Hérnia e Parede Abdominal sobre o tratamento de grandes hérnias de hiato

Large hiatal hernias (LHH) besides being more prevalent in the elderly, have different clinical presentation: fewer reflux, more mechanical symptoms and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease (GERD-related), sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index (BMI above 35), age over 70 years and presence of comorbidity. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, case-by-case analysis of surgical risk factors such as age, obesity and comorbidities, should be taken under consideration. One should also pay attention to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual workers, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of LHH in high-volume centers, with experienced surgeons.

As grandes hérnias de hiato (HHG), além de serem mais prevalentes em idosos, têm apresentação clínica diferente: menos refluxo, mais sintomas mecânicos e maior possibilidade de complicações agudas e potencialmente fatais, como vólvulo gástrico, isquemia e perfuração mediastinal visceral. Assim, as indicações cirúrgicas são distintas das hérnias de hiato por deslizamento, relacionadas à doença do refluxo gastroesofágico (DRGE). A azia tende a ser menos intensa, enquanto os sintomas de dor no peito, tosse, desconforto e cansaço são relatados com maior frequência. Queixas de vômitos e disfagia podem sugerir a presença de volvo gástrico associado. São encontrados sinais de deficiência de ferro e anemia. A indicação cirúrgica ainda é controversa e foi anteriormente baseada na alta mortalidade relatada em cirurgias de emergência para volvo gástrico. A mortalidade pós-operatória está especialmente relacionada a três fatores: índice de massa corporal (IMC acima de 35), idade superior a 70 anos e presença de comorbidades. A cirurgia eletiva minimamente invasiva deve ser oferecida a indivíduos sintomáticos, com desempenho bom ou razoável, independentemente da faixa etária. Em pacientes assintomáticos e oligossintomáticos, além de obviamente identificar o desejo do paciente, deve-se levar em consideração a análise caso a caso dos fatores de risco cirúrgico, como idade, obesidade e comorbidades. Deve-se atentar também para situações de maior dificuldade técnica e riscos de migração aguda por aumento da pressão abdominal (abdominoplastia, trabalhos manuais, doenças espásticas). Alternativas técnicas como fundoplicatura parcial e gastropexia anterior podem ser consideradas. Ressaltamos a importância da realização de procedimentos cirúrgicos nos casos de GHH em centros de grande volume, com cirurgiões experientes.

Quantifying mesh textile and effective porosities: A straightforward image analysis procedure for morphological analysis of surgical meshes.

BACKGROUND AND OBJECTIVES: Surgical meshes have demonstrated greater reliability compared to suture repair for abdominal wall hernia treatment. However, questions remain regarding the properties of these devices and their influence on surgical outcomes. Morphological properties, including pore size and porosity, play a crucial role in mesh integration and encapsulation. In this study, we introduce a straightforward image analysis procedure for accurately calculating both textile porosity and effective porosity. The latter specifically considers pores that prevent bridging, providing valuable insights into mesh performance. METHODS: A photographic setup was established to capture high-quality images of the meshes, accompanied by calibration images necessary for computing the effective porosity. The developed image analysis procedure comprises seven steps focused on improving the binarization process's quality, followed by the computation of textile and effective porosities. To facilitate usability, an app called "poreScanner" was designed using MATLAB app designer, guiding users through the algorithm described herein. The app was used to compute both porosities on 24 meshes sourced from various manufacturers, by averaging seven measurements obtained from as many images. The app's measurement stability was validated computing the coefficient of variation for both textile and effective porosity, for a total of 36 results (24 for the textile porosity and 12 for the effective one). Additionally, different operators independently tested one heavy and one light mesh, confirming the measurement's operator independence. RESULTS: The results on the coefficient of variation indicated values below 5 % in 34 out of 36 cases, regardless of the mesh density. Similarly, the same parameter was computed to assess the independence of the procedure from different operators, yielding a maximum value of 1.84 %. These findings confirm the robustness and user-independence of the measurement procedure. CONCLUSIONS: The procedure presented in this study is straightforward to replicate and yields dependable results. Its adoption has the potential to standardize the computation of surgical mesh porosity, enabling consistent determination of this crucial morphological parameter.