Prophylactic mesh reinforcement for midline incisional hernia prevention: systematic review and updated meta-analysis of randomized controlled trials.

BACKGROUND: Incisional hernia (IH) is a common complication after abdominal surgery. Prevention of IH is matter of intense research. Prophylactic mesh reinforcement (PMR) has been shown to be promising in the minimization of IH risk after elective midline laparotomy. METHODS: Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PMR vs. primary suture closure (PSC). Risk ratio (RR) and standardized mean difference (MD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. RESULTS: Fourteen RCTs (2332 patients) were included. Overall, 1280 (54.9%) underwent PMR while 1052 (45.1%) PSC. Postoperative follow-up ranged from 12 to 67 months. The incidence of IH was reduced for PMR vs. PSC (13.4% vs. 27.5%). The estimated pooled IH RR for PMR vs. PSC is 0.38 (95% CI 0.24-0.58; p < 0.001). Stratified subgroup analysis according to mesh location shows a risk reduction for intraperitoneal (RR = 0.65; 95% CI 0.48-0.89), preperitoneal (RR = 0.18; 95% CI 0.04-0.81), retromuscular (RR = 0.47; 95% CI 0.24-0.92) and onlay (RR = 0.24; 95% CI 0.12-0.51) compared to PSC. The seroma RR was higher for PMR (RR = 2.05; p = 0.0008). No differences were found for hematoma (RR = 1.49; p = 0.34), surgical site infection (SSI) (RR = 1.17; p = 0.38), operative time (OT) (MD = 0.27; p = 0.413), and hospital length of stay (HLOS) (MD = -0.03; p = 0.237). CONCLUSIONS: PMR seems effective in reducing the risk of IH after elective midline laparotomy compared to PSC in the medium-term follow-up. While the risk of postoperative seroma appears higher for PMR, hematoma, SSI, HLOS and OT seems comparable.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life.

BACKGROUND: Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression. OBJECTIVE: To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms. METHODS: Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12 months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used. RESULTS: Overall, 71 patients were included. The median age was 67.1 years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12 month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12 month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved. CONCLUSIONS: LTF for the treatment of PEH is safe and seems to be effective up to 12 month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

Laparoscopic posterior cruroplasty: a patient tailored approach.

BACKGROUND: Different surgical variations have been described for laparoscopic crural repair however, the technique is not standardized and left to the surgeons' preference. OBJECTIVE: The purpose of this study is to describe a standardized "patient tailored" approach for laparoscopic posterior cruroplasty in the setting of elective hiatal hernia repair. METHODS: Retrospective single-center study was conducted (November 2015 to November 2019). The technical aspects of a standardized "patient tailored" laparoscopic posterior crural repair are described. Perioperative outcomes and patients' quality of life, measured with the disease specific Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and generic Short Form-36 (SF-36), were analyzed. RESULTS: One hundred and forty-one patients were treated for symptomatic hiatal hernia according to the described "patient tailored" concept. Overall, 102 (72.3%) patients underwent simple suture repair while simple suture repair buttressed with biosynthetic resorbable U shaped mesh [Phasix ST®-Bard] was used in 39 (27.7%) patients. Toupet fundoplication was fashioned in all patients. The median operative time was 131 min (IQR 55-240). No intraoperative complications or conversion to open surgery occurred. The median postoperative stay was 1.8 days (range 1-7). The overall postoperative complication rate was 4.2%. The median follow-up was 21 months (IQR range 1-34) with 102 patients having a minimum follow-up of 6 months. Recurrent hernia was diagnosed in three patients (2.1%), but none required reoperation. No mesh-related complications occurred. Compared to baseline, the median GERD-HRQL (p = 0.003) and all SF-36 items (p < 0.001) were significantly improved. CONCLUSION: The application of a standardized "patient tailored" concept for laparoscopic posterior cruroplasty seems safe and effective in the medium-term follow-up with promising perioperative outcomes and quality of life improvement. This approach may be valuable to assure procedure reproducibility, standardization, and to uniformly interpret the outcomes.

Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST® mesh: a single-institution experience.

BACKGROUND: Hernia recurrence after laparoscopic repair is a perplexing problem. In an effort to reduce anatomical and clinical recurrences, different type of meshes have been used to bolster the esophageal hiatus. OBJECTIVE: The aim of this study was to assess safety, medium-term efficacy, and quality of life improvement after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (Phasix-ST®). METHODS: Observational single-center retrospective single-arm cohort study (November 2015-February 2021). We included all adult patients (> 18 years old) who underwent laparoscopic paraesophageal hernia repair with Phasix-ST® mesh and Toupet fundoplication. RESULTS: Sixty-eight patients were included. The median postoperative stay was 3.2 days (range 2-9) and the postoperative complication rate was 11.7%. The median follow-up time was 27 months (range 1-53). No mesh-related complications were detected. Hernia recurrence was diagnosed in six patients (8.8%). The recurrence-free probability at 34 months was 0.89 (95% CI 0.807-0.988) while at 60 months was 0.86 (95% CI 0.76-0.97). Hernia recurrences were mostly observed between 21 and 36 months after the operation. None of the patients required surgical revision and all were managed with PPI. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 2.9% of patients. Compared to baseline, both the GERD-HRQL (15.2 ± 6.2 vs. 3.2 ± 3.1; p = 0.026) and all SF-36 items were significantly improved (p < 0.001). CONCLUSIONS: Laparoscopic crura augmentation with Phasix-ST® mesh combined with a Toupet fundoplication is safe and seems effective in the medium-term follow-up. Phasix-ST® crural reinforcement resulted in low hernia recurrence rate with a sustained symptoms and quality of life improvement.

Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation.

PURPOSE: Diastasis recti abdominis (DRA) or rectus diastasis is an acquired condition in which the rectus muscles are separated by an abnormal distance along their length, but with no fascia defect. To data there is no consensus about risk factors for DRA. The aim of this article is to critically review the literature about prevalence and risk factor of DRA. METHOD: A total of 13 papers were identified. RESULTS: The real prevalence of DRA is unknown because the prevalence rate varies with measurement method, measurement site and judgment criteria, but it is certainly an extremely frequent condition. Numbers of parity, BMI, diabetes are the most plausible risk factors. We identified a new anatomical variation in cadaveric dissection and in abdominal CT image evaluation: along the semilunar line the internal oblique aponeurosis could join the rectus sheath with only a posterior layer, so without a double layer (anterior and posterior) as usually described. We conducted a retrospective review of abdominal CT images and the presence of the posterior insertion only could be considered as a risk factor for DRA. CONCLUSION: Further studies with large sample size, including nulliparous, primiparous, pluriparous and men too, are necessary for identify the real prevalence.

A non-coding cancer mutation disrupting an HNF4α binding motif affects an enhancer regulating genes associated to the progression of liver cancer.

BACKGROUND: Somatic mutations in coding regions of the genome may result in non-functional proteins that can lead to cancer or other diseases, however cancer mutations in the non-coding regions have rarely been studied and the interpretation of their effects is difficult. Non-coding mutations might act by breaking or creating transcription factor binding motifs in promoters, enhancers or silencers resulting in altered expression of target gene(s). A high number of mutations have been reported in coding and non-coding regions in cells of liver cancer. Hepatocyte nuclear factor 4α is a transcription factor that regulates the expression of several genes in liver cells, while the motifs it binds are frequently mutated in promoters and enhancers in liver cancer. AIM: The aim of the study is to evaluate the genetic effects of a non-coding somatic mutation frequently observed in liver cancer. MATERIALS AND METHODS: We evaluated experimentally the effects of a somatic mutation frequently reported in liver cancer as a motif-breaker for the binding of hepatocyte nuclear factor 4α. The effects of the mutation on protein binding and enhancer activity were studied in HepG2 cells via electrophoresis mobility shift assay and dual luciferase reporter assays. We also studied genome-wide promoter-enhancer interactions performing targeted chromosome conformation capture in liver tissue to identify putative target genes whose expression could be altered by the mutation. RESULTS: We found that the mutation leads to reduced protein binding and a decrease in enhancer activity. The enhancer harboring the mutation interacts with the promoters of ANAPC13, MAP6D1 and MUC13, which have been implicated in liver cancer. CONCLUSIONS: The study highlights the importance of non-coding somatic mutations, vastly understudied, but likely to contribute to cancer development and progression.

Educational value of surgical videos on transabdominal pre-peritoneal hernia repair (TAPP) on YouTube.

PURPOSE: Transabdominal pre-peritoneal hernia repair (TAPP) is a worldwide performed surgery. Surgical videos about TAPP uploaded on the web, with YouTube being the most frequently used platform, may have an educational purpose, which, however, remains unexplored. This study aims to evaluate the 20 most viewed YouTube videos on TAPP through the examination of four experienced surgeons and assess their conformity to the guidelines on how to report laparoscopic surgery videos. METHODS: On April 1st 2019, we searched for the 20 most viewed videos on TAPP on YouTube. Selected videos were evaluated on their overall utility and quality according to the Global Operative Assessment of Laparoscopic Skills-Groin Hernia (GOALS-GH) and the Laparoscopic surgery Video Educational Guidelines (LAP-VEGaS). RESULTS: Image quality was poor for 13 videos (65%), good for 6 (30%) and in high definition for 1 (5%). Audio and written commentary were present in 55% of cases, while no video presented a detailed preoperative case description. Only 35% of the videos had a GOALS-GH score > 15, indicating good laparoscopic skills. Overall video conformity to the LAP-VEGaS guidelines was weak, with a median value of 12.5% (5.4-18.9%). Concordance between the examiners was acceptable for both the overall video quality (Cronbach's Alpha 0.685) and utility (0.732). CONCLUSIONS: The most viewed TAPP videos available on YouTube in 2019 are not conformed to the LAP-VEGaS guidelines. Their quality and utility as a surgical learning tool are questionable. It is of upmost importance to improve the overall quality of free-access surgical videos due to their potential educational value.

An extraperitoneal approach for complex flank, iliac, and lumbar hernia.

PURPOSE: The aim of this paper is to propose our four-step technique, an open extraperitoneal approach for complex flank, lumbar, and iliac hernias. METHODS: A big polypropylene mesh is placed, covering and reinforcing all the lateral abdominal wall in an extraperitoneal space. Its borders are retroxiphoid fatty triangle and the costal arch cranially and the retropubic space caudally, psoas muscle, and paravertebral region posteriorly and contralateral rectus muscle medially. Mesh dimensions do not depend from the defect size, but prosthesis has to cover all the lateral abdominal wall. RESULTS: No major complications have been reported. The mean length of stay is 4.8 days (range 3-11). Mean follow-up is 44.8 months (range 5-92). One recurrence (4.5%) has been reported at the 1-year clinical evaluation. CONCLUSION: In conclusion, we believe that regardless size and location of the defect, every complex lateral hernia requires the same extensive repair because of the critical anatomy of the region with a big medium-heavyweight polypropylene mesh placed in an extraperitoneal plane, the only one that allows adequate covering of the visceral sac. Our technique is a safe, feasible, and reproducible treatment for this challenging surgical problem.

Operating Room Efficiency measurement made simple by a single metric.

Operating room (OR) efficiency is a hot topic in OR management studies. Benefits of OR efficiency maximization include financial savings, improved patient safety, greater satisfaction for patients and health workers, and increased productivity. However, how to measure the efficiency of an OR suite still remains a pending question. Many performance indicators have been developed (1) and one of the most frequent approaches consists of choosing a set of indicators to create a dashboard for the monitoring of surgical activities. Macario proposed a scoring system based on eight performance indicators (2). A similar approach was used in The Canadian Paediatric Surgical Wait Times Project (3). Although the use of dashboards and scoring systems allows for a wide and in-depth understanding of the numerous factors that contribute to efficiency, it may also raise problems. The use of multiple indicators involves gathering large amounts of data that are not routinely available in every context and are subject to different interpretations if metrics show divergent trends. Moreover, it is not possible to properly establish relative weights among metrics. We propose a different approach, based on a single and overall indicator that can be used as a proxy for OR efficiency. We considered four elements as a minimum set for composing our indicator: raw utilization (RU), turn-over time (TT), preparation time (PT) and case cancellation (CC) (4). RU formed the basis for our considerations, as it is one of the most common and widespread performance indicators. RU represents the percent of time that patients spend in OR during resource hours.

Restructuring the surgical process after regional reform in Emilia-Romagna: an action-research project at Rizzoli Orthopedic Institute.

BACKGROUND: Hospitals performing surgery in Italy underwent important transformations in recent years, with decreasing economic resources and higher expected standards of care. Regional authorities acted differently across the country to adapt to the new scenario, generating heterogeneous outcomes. The Rizzoli Orthopedic Institute (ROI) in the Emilia-Romagna region started its reorganization in 2017, after the issue of new regional regulations about surgical activity. Aim of this paper is to describe the actions taken at ROI and discuss their outcomes. STUDY DESIGN: Action-research. METHODS: From 2017 to 2019 an action-research project was developed to introduce organizational changes within ROI and close the existing gaps between regional requirements and actual features of the Institute. Four areas of intervention were identified: surgical scheduling, appropriateness of surgical setting, monitoring and management of the surgical path and accountability. Progress was monitored through the collection of performance indicators and qualitative investigation of the organizational culture. RESULTS: Changes were implemented in all areas of intervention. Key features were the introduction of Operating Room Management (ORM) skills and the establishment of multiprofessional teams to drive the changes. Performance indicators showed a positive trend in the comparison between 2017 and 2018. Improvements were observed in terms of productivity, scheduling, and respect of standard waiting time, while case-mix did not significantly change. CONCLUSIONS: Effective ORM and collaborative practices can successfully drive the change towards a more efficient surgical process without increasing resources consumption.

Open mesh vs. suture umbilical hernia repair: systematic review and updated trial sequential meta-analysis of randomized controlled trials.

PURPOSE: To examine the updated evidence on safety, effectiveness, and outcomes of mesh versus suture elective umbilical hernia (UH) repair and to explore the timely tendency variations favouring one treatment over another. METHODS: MEDLINE and CENTRAL databases were consulted. A systematic review, pairwise meta-analysis, and trial sequential analysis (TSA) were conducted. RESULTS: Six RCTs were included for a total of 742 patients. Overall, 383 (51.6%) underwent mesh, while 359 (48.4%) underwent suture repair. The estimated pooled postoperative recurrence RR was 0.27 (95% CI 0.13-0.53; p < 0.001). The TSA showed a statistically significant timely tendency in favour of mesh repair with a boundary cross curve (Z = 1.96) before reaching the information size. The estimated pooled seroma, haematoma, and wound infection RR were 1.45 (p = 0.368), 0.54 (p = 0.196), and 0.71 (p = 0.375), respectively. The TSA for wound-related complications showed partial, non-significant results. CONCLUSIONS: Elective UH mesh repair seems to be associated with reduced risk of postoperative recurrence compared to simple suture repair with a statistically significant timely trend endorsed by the TSA. Definitive considerations concerning the cumulative effect for seroma, haematoma, and wound infection are premature. Further studies are warranted to endorse these results and deeply investigate the timely tendency variations.

Variation in boldness and novelty response between rural and urban predatory birds: The Chimango Caracara, Milvago chimango as study case.

The study of traits that enable species to thrive in urban habitats is critical to a better understanding the evolution of urban ecosystems. Here, we examined variation in boldness, neophobia, and exploratory behavior in a generalist raptor, the Chimango Caracara, Milvago chimango, occurring in areas with different urbanization level. We also focused on the relationship between object exploration and neophobia in rural and urban population of this species. The results showed that birds from more urbanized habitats showed more tolerance to humans than rural raptors, without any effect of age and sex in this trait. Rural birds were also more neophobic and were slower to explore than urban raptors, though they dedicated a similar amount of time to exploring novel objects, indicating a non-correspondence between the speed to approach and contact these objects and the amount of exploration performed. Finally, we found a correlation between exploration speed and neophobia in rural birds, whereas for urban raptors this correlation was not observed. Our results show that urbanization not only influences the expression of risk-taking behaviors and novelty responses in the chimango, but can also modify the relationship between exploration and neophobia.

Original concepts in anatomy, abdominal-wall surgery, and component separation technique and strategy.

BACKGROUND: The abdominal wall can be considered comprised of two compartments: an anterior and a posterior compartment. The anterior compartment includes the anterior rectus sheath and the rectus muscle. The posterior compartment comprises the posterior rectus sheath, the transversalis fascia, and the peritoneum. When a large defect in the anterior compartment has to be corrected, for example, a rectus diastasis or large incisional hernia, an action on the anterior compartment is necessary; therefore, an anterior component separation has to be considered. If a loss of substance is present in the posterior compartment, a trasversus abdominis release should be accomplished. METHODS: We propose an original anterior compartment mobilisation, by a posterior approach. Dissection of the posterior rectus sheet proceeds until the linea semilunaris is reached. Incision of the anterior rectus sheath permits a mobilisation of the anterior compartment by a posterior approach. A mesh is placed in a sublay position. If the abdominal wall presents a loss of substance of the posterior compartment, a transversus abdominis release (TAR) can be performed in the same time. RESULTS: No hernia recurrences, no wound infection, and no mesh infection have been reported. CONCLUSIONS: The anterior compartment mobilization permits mobilization towards the midline of rectus muscle and restoration of anterior compartment, with low morbidity rate; it can be easily associated to a large sublay mesh placement, it allows the preservation of the neurovascular bundles and rectus muscle trophism, and it can be associated with a concomitant TAR procedure for the restoration of the PC, if necessary.

Is the inferior occlusal plane a reliable anatomic landmark for inferior alveolar nerve block? A study on dry mandibles of Brazilian adults.

PURPOSE: To investigate the relationship between the mandibular foramen (MF) and the inferior occlusal plane (IOP) of anatomic specimens, in order to guide clinicians in the inferior alveolar nerve block (IANB). METHOD: Eighty-two dry mandibles (totally or partially toothed) of Brazilian adults were selected, totalizing 66 left and 66 right antimeres. A flat plate of rigid PVC plastic was placed on the occlusal surfaces of posterior teeth and pressure was then manually applied to simulate the IOP. Following, the perpendicular distance from the IOP to the lowest point of the MF was measured by the use of a digital caliper, adopting negative values inferiorly and positive values superiorly. RESULTS: Regarding the antimeres, the majority of the lowest limits of the MF was below the IOP (right: 86.4%, left: 81.8%) with a mean of -4.2mm (±4.8) in the right and -4.1mm (±4.8) in the left ones, without any statistical significance. Considering both sexes, no statistically significant difference was obtained between them. CONCLUSION: The IOP seems not to be a good anatomical landmark to localize the MF and, its turn, to guide clinicians during the IANB for Brazilian adults, given the marked topographic variations.

Robotic inguinal hernia repair: is technology taking over? Systematic review and meta-analysis.

PURPOSE: To examine the current evidence on the therapeutic role and outcomes of robotic Transabdominal Preperitoneal Inguinal hernia repair (rTAPP) to better define its risk-benefit ratio and guide clinical decision-making. METHODS: PubMed, EMBASE, and Web of Science were consulted. A Frequentist single-arm study-level random effect meta-analysis was performed. RESULTS: Twelve studies published between 2015 and 2018 met the inclusion criteria (1645 patients). Patients' age ranged from 16 to 96, the BMI ranged from 19 to 35.6 kg/m2, and 86.1% were males. Unilateral hernia repair was performed in 69.6% while bilateral hernia repair was performed in 30.4% of patients. The operations were all conducted using the da Vinci Xi or Si robotic system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). The rTAPP was successfully completed in 99.4% of patients and the operative time ranged from 45 to 180.4 min. The postoperative follow-up ranged from 16 to 368 days. The estimated pooled prevalence of intraoperative complications and conversion were 0.03% (95% CI 0.00-0.3) and 0.14% (95% CI 0.0-0.5%), respectively. The estimated pooled prevalence of urinary retention, seroma/hematoma, and overall complications were 3.5% (95% CI 1.6-5.8%), 4.1% (95% CI 1.6-7.5%), and 7.4% (95% CI 3.4-10.9%). The estimated pooled prevalence of hernia recurrence was 0.18% (95% CI 0.00-0.84%). CONCLUSIONS: Robotic technology has been progressively entering surgical thinking and gradually changing surgical procedures. Based on the results of the present study, the rTAPP seems feasible, safe, and effective in the short term for patients with unilateral and bilateral inguinal hernias. Further prospective studies and randomized controlled trials are needed to validate these findings.

Primary inguinal hernia: systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair.

PURPOSE: The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair. METHODS: PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed. RESULTS: Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50-1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32-1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39-1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37-2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27-1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48-1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63-3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57-1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65-1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63-2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45-2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay. CONCLUSIONS: This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.

Primary unilateral not complicated inguinal hernia with an effective, cheap, less invasive, and easy operation: the Trabucco repair.

BACKGROUND: In modern abdominal wall hernia surgery, the achievement of the most effective tailored repair for each specific defect with the less possible invasiveness, the quicker recovery, the lower costs and the fewer risk of local occurrences, recurrences and chronic pain is the most desirable and cutting-edge goal. METHODS: Since 1989 about 4219 primary unilateral not complicated inguinal hernias have been treated with specific indications with a sutureless and minimally invasive anterior open approach. The great majority of these procedures were performed under local anaesthesia in a day surgery regimen, with a systematic and careful nerve sparing, preservation of cremasteric muscle, and with a 3-5 cm skin incision. RESULTS: The minimally invasive sutureless nerve sparing open approach has shown a very low rate of seromas (0.45%), haematomas (0.24%) and infections (0.07%) while the width of skin incision challenges even laparoscopy. A significant reduction of both postoperative pain (2.7%) and chronic neuralgia (0.047%) has led to excellent outcomes in patients, also in terms of quality of life. Compared to the Lichtenstein's tension-free technique, which is at now the gold standard open treatment for primary inguinal hernia worldwide, there are no significant differences in the observed recurrence rate (well below 1%). CONCLUSION: In our experience of almost 30 years we have been able to experiment and refine more and more the sutureless technique proposed by Trabucco for the treatment of primitive inguinal hernia, peer to peer, improving the local anaesthesia and the ability to detect hidden defects during the repair (Spigelian included), reducing the width of the incisions and tractions on the tissues, introducing the concept of a gentle and bloodless "finger surgery" according to a minimally invasive, extremely anatomic, safe, inexpensive, very effective anterior open approach.

The effects of land use and topographic changes on sediment connectivity in mountain catchments.

Understanding the evolution of sediment connectivity associated with different land use and topographic changes is a prerequisite for a better understanding of sediment budgets and sediment transport processes. We used the Index of Sediment Connectivity (IC) developed by Cavalli et al. (2013) based on the original approach by Borselli et al. (2008) to study the effects of decadal-scale land use and topographic changes on sediment connectivity in mountain catchments. The input variables of the IC (i.e. land cover and topography) were derived from historical aerial photos using Structure from Motion-Multi View Stereo algorithms (SfM-MVS). The method was applied in different sub-catchments of the Upper River Cinca Catchment (Central Pyrenees), representative of three scenarios: (a) Land cover changes; (b) Topographic changes in agricultural fields (terracing); and (c) Topographic changes associated with infrastructure (road construction). In terms of land cover changes, results show that although connectivity is increased in some areas due to the establishment of new field crops, for most of the study area connectivity decreased due to afforestation caused by rural abandonment. Topographic changes due to the establishment of agricultural terraces affected connectivity to a larger degree than land cover changes. Terracing generally reduced connectivity due to the formation of flat areas in step-slopes, but in certain points, an increase in connectivity caused by the topographic convergence produced by terraces was observed. Finally, topographic changes associated with road construction greatly modified surface flow directions and the drainage network, resulting in changes in connectivity that may affect erosional processes nearby. The methodology used in this paper allows to study the effects of real decadal-scale land use and topographic changes on sediment connectivity and also evaluating and disentangling those changes. Furthermore, this approach can be a useful tool to identify potential risks associated with morphological and land use changes, involving road infrastructures.

The role of habituation in the adjustment to urban life: An experimental approach with burrowing owls.

Birds exhibit variation in fear behaviour in response to an approaching human within and between species and across different habitat contexts. We analyze urban and rural burrowing owls' variation in risk perception along separate but consecutive days (Treatment 1) and risk perception within the same day (Treatment 2). Fear behaviour was measured as flight initiation distances (FIDs) and aggressiveness level when a pedestrian approached repeatedly to an owl individual. We predict that the attenuation in fear response along treatments should add support to the habituation hypothesis (decrease the response to a repeatedly stimulus after verifying that it is irrelevant) while consistency in behaviour might be indicative of a personality trait. We found that FID decreased for measurements made on both treatments in rural owls and also in urban owls for Treatment 2. These results are compatible with a habituation process. We found that aggressiveness remained invariable along treatments in both habitats suggesting that different mechanisms underlie these behavioural responses. Our results suggest that owls' risk perception to humans can be adjusted based on environmental risk perception and that individuals are able to recognize and learn when a stimuli stops being a threat.