Lateral incisional hernia. EVEREG registry analysis.

BACKGROUND: The aim of this study is to analyze the data collected on lateral incisional hernias (LIH) in the National Incisional Hernia Registry (EVEREG) and assess current practices and outcomes in LIH repair. METHODS: A retrospective cohort study was conducted using LIH data recorded over 10 years (2012-2022). Comorbidities, hernia characteristics, short-term complications, and recurrences were studied, along with their association with the type of approach used, either open or laparoscopic, in elective surgery. RESULTS: 1742 LIH cases were studied. According to the EHS classification, these included L1 409 (23.5%), L2 388 (22.3%), L3 565 (32.4%), L4 150 (8.6%) and combined 230 (13.2%). An open approach was performed in 1528 (87.7%) cases and laparoscopic in 214 (12.3%). The median age was 66 ± 12.45 years, with a majority of males, 934 (53.6%). The median body mass index was 29 ± 5.18 kg/m2. The most observed comorbidity was arterial hypertension (957 patients, 55%). A specialist was present in 638 interventions (56%). The 24-month follow-up was 17.9%, and recurrence in those cases was 27.2%, with a higher incidence when there was no specialist present during the intervention, onlay mesh position, and larger defect size. CONCLUSIONS: Surgery for LIH is common, although laparoscopic approach remains infrequent. Furthermore, it is associated with a high percentage of recurrences that increases when there is no specialist in abdominal wall surgery present.

The evolution of incisional hernia repair in Spain. A comparative analysis of results from the EVEREG registry.

BACKGROUND: The aim of this study was to assess the utility of the EVEREG registry in evaluating the evolution of surgical treatment for incisional hernia and its outcomes in Spain by comparing data from 2 study periods. METHODS: A retrospective comparative analysis of hernia surgeries performed between 2011 and 2015 (first period) and between 2017 and 2022 (second period) was conducted using data collected from the EVEREG registry. RESULTS: Statistically significant differences were observed in the second cohort, including: a decrease in minimally invasive procedures (11.7% vs 8.2%; P < .001), an increase in emergency surgeries for males (31.7% vs 41.2%; P = .017), an increase in trocar hernia repairs (16% vs 26.2%; P < .0001), a reduction in suture repairs (2.8% vs 1.5%; P < .0001), and an increase in retromuscular techniques (36.4% vs 52.4%; P < .001) in open surgery with mesh. In elective surgery, there was a decrease in the average length of stay (4.9 vs 3.8 days; P < .0001), the percentage of complications (27.9% vs 24.0%; P < .0001), reoperations (3.5% vs 1.4%; P < .0001), and mortality (0.6% vs 0.2%; P = .002). Long-term outcomes included a decrease in recurrences after 12 months (20.7% vs 14.5%; P < .0001) and in chronic pain (13.7% vs 2.5%; P < .0001) and chronic infections (9.1% vs 14.5%; P < .0001) after 6 months. CONCLUSION: In recent years, there has been a significant improvement in the outcomes of incisional hernia treatment. The registry serves as a fundamental tool for assessing the evolution of hernia treatment and enables the identification of key areas for improvement and the evaluation of treatment outcomes.

Ventral hernia repair in high-risk patients and contaminated fields using a single mesh: proportional meta-analysis.

PURPOSE: The use of mesh is a common practice in ventral hernia repair (VHR). Lack of consensus on which prosthetic material works better in different settings remains. This meta-analysis aims to summarize the available evidence on hernia recurrence and complications after repair with synthetic, biologic, or biosynthetic/bioabsorbable meshes in hernias grade 2-3 of the Ventral Hernia Working Group modified classification. METHODS: A literature search was conducted in January 2021 using Web of Science (WoS), Scopus, and MEDLINE (via PubMed) databases. Randomized Controlled Trials (RCTs) and observational studies with adult patients undergoing VHR with either synthetic, biologic, or biosynthetic/bioabsorbable mesh were included. Outcomes were hernia recurrence, Surgical Site Occurrence (SSO), Surgical Site Infection (SSI), 30 days re-intervention, and infected mesh removal. Random-effects meta-analyses of pooled proportions were performed. Quality of the studies was assessed, and heterogeneity was explored through sensitivity analyses. RESULTS: 25 articles were eligible for inclusion. Mean age ranged from 47 to 64 years and participants' follow-up ranged from 1 to 36 months. Biosynthetic/bioabsorbable mesh reported a 9% (95% CI 2-19%) rate of hernia recurrence, lower than synthetic and biologic meshes. Biosynthetic/bioabsorbable mesh repair also showed a lower incidence of SSI, with a 14% (95% CI 6-24%) rate, and there was no evidence of infected mesh removal. Rates of seroma were similar for the different materials. CONCLUSIONS: This meta-analysis did not show meaningful differences among materials. However, the best proportions towards lower recurrence and complication rates after grade 2-3 VHR were after using biosynthetic/slowly absorbable mesh reinforcement. These results should be taken with caution, as head-to-head comparative studies between biosynthetic and synthetic/biologic meshes are lacking. Although, biosynthetic/bioabsorbable materials could be considered an alternative to synthetic and biologic mesh reinforcement in these settings.

Hernia incisional umbilical (M3). ¿Son diferentes las hernias de trócar? Análisis comparativo del registro EVEREG / Umbilical incisional hernias (M3): Are trocar-site hernias different? Comparative analysis of the EVEREG Registry

Introducción La hernia incisional (HI) es una complicación frecuente. El objetivo principal de este estudio es comparar características, complicaciones y recurrencias de las HI producidas por la colocación de un trócar laparoscópico umbilical (M3T) con las de misma localización tras cirugía abierta (M3O); y de forma secundaria, la identificación de factores de riesgo. Método Estudio observacional transversal analizando al registro EVEREG durante el periodo entre julio del 2012 y junio del 2018. Las variables principales fueron recurrencias y complicaciones postoperatorias. Se compararon ambos grupos (M3T y M3O). Se realizó regresión logística múltiple para identificar los factores de riesgo de la cohorte completa. Resultados Se incluyeron un total de 882 casos. El grupo M3O presentó un ASA superior, HI con criterios de mayor complejidad para la reparación, mayor número de recurrencias a los 12 y 24 meses (8,6 vs. 2,5%; p < 0,0001 y 9,3 vs. 2,9%; p < 0,0001, respectivamente) y complicaciones postoperatorias (21,9 vs. 14,6%; p = 0,02). Se identificaron como factores de riesgo para la aparición de complicaciones postoperatorias, la reparación previa, la duración de la intervención y el requerimiento de procedimientos asociados, y para las recidivas: la ausencia de especialista de pared abdominal, la reparación previa y la aparición de complicaciones. El análisis por puntuación de propensión no detectó diferencias significativas en complicaciones y recurrencias. Conclusiones Las HI M3 de trócar umbilical son menos complejas que las originadas por cirugía abierta. La complejidad no se relaciona con el origen de la hernia, sino con sus características y las del paciente (AU)

Introduction Incisional hernia (HI), in open and laparoscopic surgery, is a very frequent complication. HI located in the umbilical region are called M3. The main aim of this study is to compare HI produced by the placement of an umbilical laparoscopic trocar (M3T) with those located in M3 in open surgery (M3O) in terms of basal characteristics, complications and recurrences; and secondarily the identification of risk factors. Method Cross-sectional observational study based on the national prospective registry EVEREG during the period of July 2012 - June 2018. The main variables were recurrences and postoperative complications. Both groups (M3T and M3O) were compared. Multiple logistic regression was performed to identify the risk factors of the entire cohort. Results 882 had a follow-up time longer than 12 months. M3O group presented superior ASA-Class, more complex HI and previous repair. It also presented a higher recurrence rate at 12 and 24 months (8.6 vs. 2.5%; p < 0,0001 and 9.3 vs. 2.9%; p < 0.0001) and higher postoperative complications rate (21.9 vs. 14.6%; p = 0.02). Previous repair, intervention length and associated procedures requirement were identified as risk factors for postoperative complications. Absence of a specialist present during surgery, previous repair, and the absence of complications were identified as risk factors for recurrence. In the PSM analysis no differences were detected in of complications and recurrences. Conclusions HI M3O is more complex than M3T. The complexity is not related to the origin of the hernia but to its characteristics and those of the patient (AU)

European Hernia Society guidelines on management of rectus diastasis.

BACKGROUND: The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been described. This article reports on the European Hernia Society (EHS) Clinical Practice Guideline for RD. METHOD: The Guideline group consisted of eight surgeons. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done in November 2018 and updated in November 2019 and October 2020. Nine Key Questions (KQs) were formulated. RESULTS: Literature reporting on the definition, classification, symptoms, outcomes and treatments was limited in quality, leading to weak recommendations for the majority of the KQs. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is suggested based on the width of muscle separation, postpregnancy status and whether or not there is a concomitant hernia. Impaired body image and core instability appear to be the most relevant symptoms. Physiotherapy may be considered before surgical management. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD with concomitant midline hernias. CONCLUSION: RD should be defined as a separation of rectus muscles wider than 2 cm and a new classification system is suggested.

The management of RD is controversial. These guidelines are intended to provide a consensus about the exact definition, the correct way of measurement and diagnosis, a classification system, the main symptoms, and a systematic review of non-surgical and surgical treatments to achieve the best results for patients with this pathology. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is proposed. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD in those with concomitant midline hernias.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG).

AIM: To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients. METHODS: All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed. RESULTS: During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m2. ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004). CONCLUSION: CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

¿Es la apendicectomía un tratamiento válido en las neoplasias mucinosas apendiculares de bajo grado? / Is appendectomy a valid treatment in low-grade appendiceal mucinous neoplasms (lamn)?

Introducción: las neoplasias mucinosas apendiculares de bajo grado son una patología infrecuente, cuyo manejo quirúrgico ha variado en los últimos anos. Métodos: estudio retrospectivo de pacientes con diagnostico anatomopatologico de neoplasias mucinosas apendiculares de bajo grado. Resultados: se incluyeron 28 pacientes con una edad mediana de 63 años. La clínica predominante de presentación fue la apendicitis aguda en 11 pacientes (39,3%). El 35,7% se abordaron mediante laparoscopia. En el 39,3% se describe perforación apendicular y el 25% presentan moco libre en la cavidad abdominal. En el 60,7% se realizo de inicio una apendicectomia, presentando el estudio anatomopatologico afectación de los bordes en 5 pacientes. En 4 de los 5 se amplió la resección, sin evidencia de enfermedad residual. Conclusiones: la apendicetomía es el tratamiento recomendado en las neoplasias mucinosas de bajo grado. Si existen márgenes afectos se debe individualizar el tratamiento, valorando el seguimiento como una opción a considerar

Introduction: low-grade appendiceal mucinous neoplasms are an infrequent pathology, whose surgical management has varied in recent years. Methods: retrospective study of patients with anatomopathological diagnosis of low grade appendiceal mucinous neoplasms. Results: twenty-eight patients with a median age of 63 years were included. The main clinical presentation was acute appendicitis in 11 patients (39.3%). 35.7% were approached by laparoscopy. In 39,3% patients is described appendicular perforation and 25% present free mucus in the abdominal cavity. In 60,7% patients was performed an appendectomy, presenting the pathological study the border affected in 5 patients. In 4 of the 5 resection was extended, without evidence of residual disease. Conclusions: appendectomy is the recommended treatment in low grade mucinous neoplasms. If there borders are affected, treatmentshould be individualized, assessing follow-up as an option to be considered

EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen.

PURPOSE: To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used. METHODS: The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument. RESULTS: For many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE. RECOMMENDATIONS: When considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.

EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen

To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument. For many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE. When considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.

Initial surgical experience in laparoscopic total mesorectal excision for middle and lower third rectal cancer: short-term results

INTRODUCTION: Total mesorectal excision (TME) of the rectum has been advocated as the gold standard surgical treatment of middle and lower third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in terms of safety and its oncological adequacy. OBJECTIVE: To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients. METHODS: One hundred and thirty-two patients with middle or inferior rectal cancer were admitted to our unit and underwent TME from December 1998 to February 2008. Eighty-nine patients were approached with laparoscopy. Patients staged cT3/4 cTxN+ or uTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcomes were registered. RESULTS: In the laparoscopic group 80 anterior resections (including 4 intersphincteric resections and manual colo- anal anastomosis) and 9 abdominal-perineal resections were performed. 33.3% of patients were enrolled in "long-course" neoadjuvant chemo-radiotherapy (partial and complete response rates 88.2% and 11.8%, respectively). Protective lateral ileostomy was performed in 72% of patients. Mean operative time was 254.3+/-38.3 min and mean blood loss was 215+/-180 ml. Conversion rate was 12.7%. Morbidity rate was 39.3% without mortality. The rate of anastomotic leaks was 13.48%, reoperation rate 13.48%, recovery rate 3.1+/-1.4 days and hospital stay 10.4+/-4.6 days. Concerning adequacy of oncologic resection, mean distance of the tumour from the anal verge was 4.3+/-2.2 cm. Nodal sampling of 12.4+/-4.8 were obtained. Six patients (6/89, 6.74%) had a R1 margin: 3 distal and 3 circumferential. Median follow-up was 29 months and local recurrence rate was 5.79%. Four-year cumulative overall survival was 78% and disease-free survival was 63% (Kaplan-Meier method). CONCLUSIONS: Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is oncologically safe (AU)

[Urachal sinus: an unusual cause of recurrent umbilical discharge in adults]. / Uracosinus: una causa poco frecuente de onfalitis recurrente en adultos.

Urachal sinus is a rare congenital anomaly due to incomplete closure the urachus in the umbilical region, it is very rare in adults. 47-year-old male who arrived at our Emergency Department with recurrent umbilical discharge. Not response medical treatment (oral antibiotic and drainage). Abdominal computerized tomography scan confirmed the urachal sinus with omphalitis. Surgical complete excision with omphalectomy was performed. Any complications in the postoperative was observed.

Uracosinus: una causa poco frecuente de onfalitis recurrente en adultos / Urachal sinus: an unusual cause of recurrent umbilical discharge in adults

El uracosinus es una anomalía congénita poco frecuente secundaria a la obliteración incompleta del uraco en su porción infraumbilical, que puede aparecer a cualquier edad. Presentamos un paciente de 47 años que acudió al servicio de urgencias por supuración umbilical persistente que no había respondido al tratamiento médico (antibioterapia y curas). El TAC confirmó la existencia de un sinus del uraco con cambios de onfalitis. La cirugía consistió en la resección en bloque del mismo con onfalectomía. El postoperatorio transcurrió sin incidencias

Urachal sinus is a rare congenital anomaly due to incomplete closure the urachus in the umbilical region, it is very rare in adults. 47-year-old male who arrived at our Emergency Department with recurrent umbilical discharge. Not response medical treatment (oral antibiotic and drainage). Abdominal computerized tomography scan confirmed the urachal sinus with omphalitis. Surgical complete excision with omphalectomy was performed. Any complications in the postoperative was observed

[Clinical and functional results after Laparoscopic fundoplication. Prospective evaluation]. / Resultados clínicos y funcionales después de funduplicatura laparoscópica. Evaluación prospectiva.

OBJECTIVE: To prospectively assess the medium- and long-term clinical and functional results in consecutive patients undergoing laparoscopic procedures for gastroesophageal reflux. PATIENTS AND METHOD: The series included the interventions performed or assisted by the first author in 325 patients referred for surgical evaluation between December 1992 and June 2000. Forty patients were excluded from the study because they did not fulfil the inclusion criteria for laparoscopic surgery. A further 20 patients who underwent laparoscopic surgery were excluded because they required conversion to open surgery. Thus, 265 patients were included in the study. One hundred ninety-six total fundoplications (Nissen-Rossetti) and 69 partial fundoplications(42 posterior-Toupet and 27 anterior-Dor) were performed. The surgical technique employed was a slight modification of that described by Dallemagne et al with five-trocars. Preoperative evaluation was established by clinical features, endoscopy with biopsy, barium contrast radiography, esophageal manometry and esophageal pH monitoring. RESULTS: The mean follow-up was 47.1 3.3 months (range: 4-92 months). Heartburn, regurgitation, and dysphagia were relieved in 92.5%, 97.7%, and 88.1% of patients respectively. Complete relief of symptoms was achieved in all patients who presented preoperative respiratory symptoms as a complication of gastroesophageal reflux. Esophagitis healed in 98.2% of patients with preoperative esophagitis. Correction of lower esophageal sphincter pressure and lower esophageal sphincter length were statistically significant compared with preoperative status (p = 0.006 and p = 0.003, respectively). Pre- and postoperative differences in the percentage of patients with a pH < 4 in 24-hour ambulatory esophageal pH monitoring were also significant (p = 0.005), confirming correction of acid reflux. Morbidity appeared in 6.7% of patients and there was no mortality. Conversion to open procedures was required in 7.5%. The mean operative time was 115 6.3 minutes. CONCLUSIONS: These preliminary results suggest that when performed by experienced surgeons laparoscopic fundoplication provides an excellent alternative in selected patients with gastroesophageal reflux. Both medium- and long-term clinical and functional results, as well as morbidity, were satisfactory and were similar to those of open fundoplication.

Survival after prehospital advanced life support in severe trauma.

The aim of this study was to assess the influence of prehospital advanced life support (PALS) on the survival of victims of severe trauma in our hospital. During a period of 24 months, 46 patients with severe trauma were admitted to our Emergency Department after receiving PALS; this included endotracheal intubation and ventilatory support (IVS) in 35 cases, and cardiopulmonary resuscitation (CPR) in 11. The severity of the trauma in this group of patients was confirmed by assessing the clinical condition on admission and the Glasgow Coma Scale score (mean = 4.0, median = 3), the Revised Trauma score (mean = 4.1, median = 4) and the Injury Severity Score (mean = 44.5 and median = 41 in blunt trauma; mean = 58.3 and median = 75 in penetrating trauma). The overall survival was 41%. The survival rate was 48% in patients with prehospital IVS rate and 18% in those receiving CPR. We conclude that PALS in severe trauma was able to save the lives of many patients at high risk of dying before reaching hospital.

[Massive rectal hemorrhage caused by nonspecific colonic ulcers]. / Rectorragia masiva por úlceras cólicas inespecíficas.

Nonspecific colon ulcers are a rare disease which may produce lower gastrointestinal bleeding. A history of previous nonsteroidal anti-inflammatory drugs ingestion may be recorded in most patients. The right colon is the main location, being the cecum the most frequent site. However, they may be distributed in all the large intestine, including the rectum. We present a case of lower massive gastrointestinal hemorrhage produced by nonspecific colic ulcers requiring emergency total colectomy. Although infrequent, they have to be considered in every patient with lower gastrointestinal bleeding and previous nonsteroidal anti-inflammatory drugs ingestion.