The Lichtenstein technique is being used adequately in inguinal hernia repair: national analysis and review of the surgical technique.

INTRODUCTION: it is estimated that approximately 20 million people undergo inguinal hernia surgery annually in the world, with the Lichtenstein technique being the most performed surgical procedure. The objective of this study is to analyze the knowledge of the technical principles used in the Lichtenstein technique. METHOD: Survey-type intersectional study approved by the research ethics committee of São Camilo University Center (CAAE: 70036523.1.0000.0062). During the research period, 11,622 e-mails were sent to members of the main national surgical societies with research on the technical principles of Lichtenstein surgery. The survey was carried out using an electronic form with 10 multiple-choice questions. The form was answered anonymously on the SurveyMonkey and Google Forms platforms. RESULT: 744 responses were received to the electronic form. Based on this number of respondents, our survey has a confidence level of 95% with a margin of error of 3.5%. It was observed that there is no standardization of the technique among the majority of responders (53.4%). Many surgeons still perform digital dissection of the spermatic cord (47%). A small number of interviewees (15.2%) performed sutures with absorbable thread in the region of the internal oblique aponeurosis, while more than half (55.2%) continued to perform sutures with non-absorbable thread. Most surgeons use a small overlap or fix the mesh juxtaposed to the pubic symphysis (51%). CONCLUSION: Our research identified that a small percentage of respondents adequately know the technical principles of Lichtenstein surgery. The result brings us new insights into the need to review Lichtenstein technique.

Endoscopic Mini-or Less-Open Sublay Operation (E/MILOS) in ventral hernia repair: a minimally invasive alternative technique.

The ideal ventral hernia surgical repair is still in discussion1. The defect closure with a mesh-based repair is the base of surgical repair, in open or minimally invasive techniques2. The open methods lead to a higher surgical site infections incidence, meanwhile, the laparoscopic IPOM (intraperitoneal onlay mesh) increases the risk of intestinal lesions, adhesions, and bowel obstruction, in addition to requiring double mesh and fixation products which increase its costs and could worsen the post-operative pain3-5. The eTEP (extended/enhanced view totally intraperitoneal) technique has also arisen as a good option for this hernia repair. To avoid the disadvantages found in classic open and laparoscopic techniques, the MILOS (Endoscopically Assisted Mini or Less Open Sublay Repair) concept, created by W. Reinpold et al. in 2009, 3 years after eTEP conceptualization, allows the usage of bigger meshes through a small skin incision and laparoscopic retro-rectus space dissection, as the 2016 modification, avoiding an intraperitoneal mesh placement6,7. This new technique has been called E-MILOS (Endoscopic Mini or Less Open Sublay Repair)8. The aim of this paper is to report the E-MILOS techniques primary experience Brazil, in Santa Casa de Misericórdia de São Paulo.

Endoscopic Mini-or Less-Open Sublay Operation (E/MILOS) in ventral hernia repair: a minimally invasive alternative technique / Endoscopic Mini or Less Open Sublay Repair (E/MILOS) na correção das hérnias ventrais: uma alternativa técnica minimamente invasiva

ABSTRACT The ideal ventral hernia surgical repair is still in discussion1. The defect closure with a mesh-based repair is the base of surgical repair, in open or minimally invasive techniques2. The open methods lead to a higher surgical site infections incidence, meanwhile, the laparoscopic IPOM (intraperitoneal onlay mesh) increases the risk of intestinal lesions, adhesions, and bowel obstruction, in addition to requiring double mesh and fixation products which increase its costs and could worsen the post-operative pain3-5. The eTEP (extended/enhanced view totally intraperitoneal) technique has also arisen as a good option for this hernia repair. To avoid the disadvantages found in classic open and laparoscopic techniques, the MILOS (Endoscopically Assisted Mini or Less Open Sublay Repair) concept, created by W. Reinpold et al. in 2009, 3 years after eTEP conceptualization, allows the usage of bigger meshes through a small skin incision and laparoscopic retro-rectus space dissection, as the 2016 modification, avoiding an intraperitoneal mesh placement6,7. This new technique has been called E-MILOS (Endoscopic Mini or Less Open Sublay Repair)8. The aim of this paper is to report the E-MILOS techniques primary experience Brazil, in Santa Casa de Misericórdia de São Paulo.

RESUMO O tratamento cirúrgico ideal para correção das hérnias ventrais ainda é motivo de grande discussão1. O fechamento do defeito associado a utilização de telas para reforço da parede abdominal são passos fundamentais da terapia cirúrgica, podendo ser realizados tanto pela via aberta quanto pelas técnicas minimamente invasivas2. A via aberta apresenta maiores taxas de infecção de sítio cirúrgico, enquanto o reparo laparoscópico IPOM (intraperitoneal onlay mesh) acarreta um risco aumentado de lesões intestinais, aderências e obstruções intestinais, além de requerer uso de telas de dupla face e dispositivos de fixação que encarecem o procedimento e não raro aumentam a dor no pós-operatório3-5. A técnica eTEP (extended/enhanced view totally extraperitoneal), tem ganhado importância, mostrando-se uma boa opção para a correção das hérnias ventrais também2. A fim de se evitar as desvantagens das técnicas abertas e laparoscópicas "clássicas" o conceito MILOS (Endoscopically Assisted Mini or Less Open Sublay Repair), desenvolvido por W. Reinpold et al. em 2009, 3 anos antes do advento do eTEP, possibilita ao cirurgião o uso de telas de grandes dimensões no plano retromuscular através de uma pequena incisão na pele e dissecção laparoscópica deste espaço, conforme modificação realizada em 2016, evitando a colocação de uma tela no espaço intraperitoneal6-7. Esta nova técnica passou a se chamar EMILOS (Endoscopic Mini or Less Open Sublay Repair)8 Este artigo tem como objetivo relatar nossa experiência inicial no emprego da técnica E-MILOS no Brasil, na Santa Casa de Misericórdia de São Paulo.

The Lichtenstein technique is being used adequately in inguinal hernia repair: national analysis and review of the surgical technique / A técnica de Lichtenstein está sendo utilizada adequadamente nos reparos das hérnias inguinais: análise nacional e revisão da técnica cirúrgica

ABSTRACT Introduction: it is estimated that approximately 20 million people undergo inguinal hernia surgery annually in the world, with the Lichtenstein technique being the most performed surgical procedure. The objective of this study is to analyze the knowledge of the technical principles used in the Lichtenstein technique. Method: Survey-type intersectional study approved by the research ethics committee of São Camilo University Center (CAAE: 70036523.1.0000.0062). During the research period, 11,622 e-mails were sent to members of the main national surgical societies with research on the technical principles of Lichtenstein surgery. The survey was carried out using an electronic form with 10 multiple-choice questions. The form was answered anonymously on the SurveyMonkey and Google Forms platforms. Result: 744 responses were received to the electronic form. Based on this number of respondents, our survey has a confidence level of 95% with a margin of error of 3.5%. It was observed that there is no standardization of the technique among the majority of responders (53.4%). Many surgeons still perform digital dissection of the spermatic cord (47%). A small number of interviewees (15.2%) performed sutures with absorbable thread in the region of the internal oblique aponeurosis, while more than half (55.2%) continued to perform sutures with non-absorbable thread. Most surgeons use a small overlap or fix the mesh juxtaposed to the pubic symphysis (51%). Conclusion: Our research identified that a small percentage of respondents adequately know the technical principles of Lichtenstein surgery. The result brings us new insights into the need to review Lichtenstein technique.

RESUMO Introdução: estima-se que aproximadamente 20 milhões de pessoas sejam submetidas a cirurgia de hérnia inguinal anualmente no mundo, sendo a técnica de Lichtenstein o procedimento cirúrgico mais realizado. O objetivo desse estudo é analisar o conhecimento dos principios técnicos empregados na técnica de Lichtenstein. Método: estudo tipo levantamento interseccional aprovado pelo comitê de ética em pesquisa do Centro Universitário São Camilo (CAAE: 70036523.1.0000.0062). Durante o período da pesquisa foram encaminhados 11.622 e-mails aos membros das principais sociedades cirúrgicas nacionais com uma pesquisa sobre os princípios técnicos da cirurgia de Lichtenstein. A pesquisa foi realizada por formulário eletrônico com 10 questões de múltipla escolha. O formulário foi respondido de forma anônima nas plataformas SurveyMonkey e Google Forms. Resultado: foram recebidos 744 respostas ao formulário eletrônico. Com base nesse número de respondedores, nossa pesquisa apresenta grau de confiança de 95% com margem de erro de 3,5%. Foi observado que não há padronização da técnica entre a maioria dos respondedores (53.4%). Muitos cirurgiões ainda fazem dissecção digital do funículo espermático (47%). Um pequeno número de entrevistados (15,2%) realizam sutura com fio absorvível na região da aponeurose do obliquo interno, enquanto, mais da metade (55,2%) continua fazendo sutura com fio inabsorvível. A maior parte dos cirurgiões utilizam overlap pequeno ou fixam a tela justaposta a sínfise púbica (51%). Conclusão: nossa pesquisa identificou que uma porcentagem pequena dos entrevistados conhecem adequadamente os princípios técnicos da cirurgia de Lichtenstein. O resultado nos traz novas percepções sob a necessidade de revistar a consagrada técnica de Lichtenstein.

ARE THERE DIFFERENCES IN CHRONIC PAIN AFTER LAPAROSCOPIC INGUINAL HERNIA REPAIR USING THE TRANSABDOMINAL TECHNIQUE COMPARING WITH FIXATION OF THE MESH WITH STAPLES, WITH GLUE OR WITHOUT FIXATION? A CLINICAL RANDOMIZED, DOUBLE-BLIND TRIAL.

BACKGROUND: Regarding postoperative pain, it remains unclear whether non-fixation of the polypropylene prosthesis in transabdominal preperitoneal inguinal hernia repair produces the same outcomes as mesh fixation with glue or tackers. In addition, hernia recurrence is another aspect to be assessed in the comparison between non-fixation and mesh-fixation techniques (tackers and glue). AIMS: This study aimed to evaluate the incidence, quality of pain, and recurrence in patients undergoing laparoscopic inguinal hernioplasty (transabdominal preperitoneal) technique, comparing the fixation of the mesh with tackers versus with glue versus without fixation. METHODS: This is a prospective, double-blind study in which 63 patients presenting with primary unilateral inguinal hernia underwent laparoscopic transabdominal preperitoneal inguinal hernia repair and were randomized into three groups: no mesh fixation (n=21), mesh tacked (n=21), and mesh fixed with fibrin glue (n=21). Patients also responded to questionnaires in order to assess pain and pain quality and were followed up for 2 years. RESULTS: Neither mesh-fixation nor non-fixation techniques were found to affect postoperative chronic pain (p=0.535), but patients undergoing tacker fixation reported more pain descriptors (p=0.0021) and a higher pain index (p=0.002) on the McGill scale in the first 15 postoperative days (T0 and T1). No hernia recurrences were observed. CONCLUSIONS: Both mesh-fixation techniques (tackers and glue) used with the transabdominal preperitoneal approach did not influence the onset of inguinodynia, but tacker fixation was more likely to increase patient sensitivity to pain. Mesh placement without fixation produced the same pain and recurrence outcomes as mesh-fixation techniques. Also, no recurrence was observed in patients without mesh fixation in this study. Consequently, it has become an alternative therapy deserving consideration for hernia repair.

Prospective study of the Iliac Bicrest Pubic Angle through the 3D reconstruction of the bone pelvis and the correlation with giant incisional hernia.

OBJECTIVE: to describe and measure the Bicrista Iliaca Pubo Angle (APBCI) as a new anthropometric parameter. Correlate the measurement with patients with giant incisional hernia (HIG), in the midline of the anterior abdominal wall (AAW). METHODS: measurement of APBCI, through 3D reconstruction from computed tomography (CT). Measurements performed by two observers, R and C, in 246 women and 60 men, normal adults, in order to obtain the APBCI measurement and its correlation in patients with HIG of the AAW. RESULTS: after sample calculations, the measurement of APBCI in men: 92.5+6.3º to 93.8+6.7º; in women: 90+6.7° to 94.3+6.8° [p-value 0.337(R)/0.628(C)]. The mean age was 57.9+15.9 years (22 to 91 years). Female gender 57+15.7 years (22 to 91 years) and male 61.7+16.5 years (23 to 89 years) p=0.067. As for the distribution of the ranges from 5 to 5 degrees, there is no difference in the distribution of the angle [p-value 0.455(R)/0.672(C)]. The correlation between age and angle showed that the higher the age, the higher the APBCI. There was no variability between angle measurements: 0.97 (95% CI 0.97; 0.98). In men with HIG, the average is between 108.3+5.37º (102.92º to 113.67º), and in women, 107.8+6.64 (101.16º to 114.44º). CONCLUSION: the study allowed us to conclude that HIG is not just an isolated AAW defect. Determines skeletal changes, as the APBCI is influenced by the distance of the iliac crests.

Robotic re-TAPP: a minimally invasive alternative for the failed posterior repair.

OBJECTIVE: to describe the use of the robotic platform in inguinal hernia recurrence after a previous laparoscopic repair. METHODS: patients with recurrent inguinal hernias following a laparoscopic repair who have undergone robotic transabdominal preperitoneal between December 2015 through September 2020 were identified in a prospectively maintained database. Outcomes of interest included demographics, hernia characteristics, operative details and rates of 30-day surgical site occurrence, surgical site occurrences requiring procedural interventions, surgical site infection and hernia recurrence were abstracted. RESULTS: nineteen patients (95% male, mean age 55 years, mean body mass index 28) had 27 hernias repaired (N=8 bilateral). Average operative time was 168.9 ± 49.3min (range 90-240). There were two intraoperative complications all of them were bleeding from the inferior epigastric vessel injuries. Three SSOs occurred (N=2 seromas and N=1 hematoma. After a median 35.7 months follow-up (IQR 13-49), no recurrence has been diagnosed. One patient developed chronic postoperative inguinal pain. CONCLUSIONS: on a small number of selected patients and experienced hands, we found that the use of the robotic platform for repair of recurrent hernias after prior laparoscopic repair appears to be feasible, safe and effective despite being technically demanding. Further studies in larger cohorts are necessary to determine if this technique provides any benefits in recurrent inguinal hernia scenario.

Prospective study of the Iliac Bicrest Pubic Angle through the 3D reconstruction of the bone pelvis and the correlation with giant incisional hernia / Estudo prospectivo do Ângulo Pubo Bicrista Ilíaca através da reconstrução 3D da pelve óssea e a correlação com a hérnia incisional gigante

ABSTRACT Objective: to describe and measure the Bicrista Iliaca Pubo Angle (APBCI) as a new anthropometric parameter. Correlate the measurement with patients with giant incisional hernia (HIG), in the midline of the anterior abdominal wall (AAW). Methods: measurement of APBCI, through 3D reconstruction from computed tomography (CT). Measurements performed by two observers, R and C, in 246 women and 60 men, normal adults, in order to obtain the APBCI measurement and its correlation in patients with HIG of the AAW. Results: after sample calculations, the measurement of APBCI in men: 92.5+6.3º to 93.8+6.7º; in women: 90+6.7° to 94.3+6.8° [p-value 0.337(R)/0.628(C)]. The mean age was 57.9+15.9 years (22 to 91 years). Female gender 57+15.7 years (22 to 91 years) and male 61.7+16.5 years (23 to 89 years) p=0.067. As for the distribution of the ranges from 5 to 5 degrees, there is no difference in the distribution of the angle [p-value 0.455(R)/0.672(C)]. The correlation between age and angle showed that the higher the age, the higher the APBCI. There was no variability between angle measurements: 0.97 (95% CI 0.97; 0.98). In men with HIG, the average is between 108.3+5.37º (102.92º to 113.67º), and in women, 107.8+6.64 (101.16º to 114.44º). Conclusion: the study allowed us to conclude that HIG is not just an isolated AAW defect. Determines skeletal changes, as the APBCI is influenced by the distance of the iliac crests.

RESUMO Objetivo: descrever e medir o Ângulo Pubo Bicrista Iliaca (APBCI) como novo parâmetro antropométrico. Correlacionar a medida com portadores de hérnia incisional gigante (HIG), da linha média da parede anterior do abdome (PAA). Métodos: medida do APBCI, através de reconstrução 3D a partir de tomografia computadorizada (TC). Realização de medidas por dois observadores, R e C, em 246 mulheres e 60 homens, adultos normais, afim de obter a medida do APBCI e sua correlação em portadores de HIG da PAA. Resultados: após cálculos de amostra, a medida do APBCI nos homens: 92,5+6,3º a 93,8+6,7º; nas mulheres: 90+6,7º a 94,3+6,8º [p-valor 0,337(R)/0,628(C)]. A média de idade foi de 57,9+15,9 anos (22 a 91 anos). Gênero feminino 57+15,7 anos (22 a 91 anos) e o masculino 61,7+16,5 anos (23 a 89 anos) p=0,067. Quanto à distribuição das faixas de 5 em 5 graus, inexiste diferença na distribuição do ângulo [p-valor 0,455(R)/0,672(C)]. A correlação idade e o ângulo demonstrou que quanto maior a idade, maior o APBCI. Não houve variabilidade entre as medidas do ângulo: 0,97 (IC95% 0,97; 0,98). Nos homens com HIG, a média está entre 108,3+5,37º (102,92º a 113,67º), e nas mulheres 107,8+6,64 (101,16º a 114,44º). Conclusão: o estudo permitiu concluir que a HIG não é apenas um defeito da PAA isolado. Determina alterações esqueléticas, na medida que o APBCI sofre a influência quanto ao afastamento das cristas ilíacas.

Robotic re-TAPP: a minimally invasive alternative for the failed posterior repair / re-TAPP robótico: uma alternativa minimamente invasiva para falha da via posterior

ABSTRACT Objective: to describe the use of the robotic platform in inguinal hernia recurrence after a previous laparoscopic repair. Methods: patients with recurrent inguinal hernias following a laparoscopic repair who have undergone robotic transabdominal preperitoneal between December 2015 through September 2020 were identified in a prospectively maintained database. Outcomes of interest included demographics, hernia characteristics, operative details and rates of 30-day surgical site occurrence, surgical site occurrences requiring procedural interventions, surgical site infection and hernia recurrence were abstracted. Results: nineteen patients (95% male, mean age 55 years, mean body mass index 28) had 27 hernias repaired (N=8 bilateral). Average operative time was 168.9 ± 49.3min (range 90-240). There were two intraoperative complications all of them were bleeding from the inferior epigastric vessel injuries. Three SSOs occurred (N=2 seromas and N=1 hematoma. After a median 35.7 months follow-up (IQR 13-49), no recurrence has been diagnosed. One patient developed chronic postoperative inguinal pain. Conclusions: on a small number of selected patients and experienced hands, we found that the use of the robotic platform for repair of recurrent hernias after prior laparoscopic repair appears to be feasible, safe and effective despite being technically demanding. Further studies in larger cohorts are necessary to determine if this technique provides any benefits in recurrent inguinal hernia scenario.

RESUMO Objetivo: descrevemos nossa experiência com uso da plataforma robótica no tratamento das recidivas operadas previamente por laparoscopia, mantendo assim uma proposta minimamente invasiva a esses pacientes, apesar de haver uma predileção pela via anterior e aberta nestes casos. Métodos: foram incluídos pacientes submetidos a hernioplastia inguinal robótica transabdominal pré-peritoneal como tratamento de recidiva e que foram operados previamente por laparoscopia, entre dezembro de 2015 e setembro de 2020 e mantidos em uma base de dados ambulatorial prospectiva. Variáveis de interesse incluíram dados demográficos, características herniárias, detalhes operatórios, ocorrências do sítio cirúrgico em 30 dias (com ou sem necessidade de intervenção), infeção do sítio cirúrgico, tempo de seguimento e taxa de recidiva. Resultados: dezenove pacientes (95% masculino, média de idade de 55 anos, média de índice de massa corporal 28kg/m2) e 27 hérnias operadas (N=8 bilaterais). Média de tempo cirúrgico 168.9±49.3 min (variando 90-240). N=2 complicações intraoperatórias por lesão de vasos epigástricos inferiores. N=2 seromas e N=1 hematoma foram identificados no pós-operatório; N=1 paciente apresentou dor crônica pós operatória. Após um tempo de seguimento médio de 35.7 meses (intervalo entre quartis 13-49), nenhuma recidiva foi diagnosticada. Conclusões: o uso da plataforma robótica parece ser seguro e efetivo no tratamento das recidivas operadas previamente laparoscopia, nesse pequeno grupo de pacientes selecionados, apesar de requerer expertise em cirurgia robótica. Outros estudos com maiores casuísticas são necessários para estabelecer o papel desta técnica no cenário das hérnias inguinais recidivadas.

Are there differences in chronic pain after laparoscopic inguinal hernia repair using the transabdominal technique comparing with fixation of the mesh with staples, with glue or without fixation? a clinical randomized, double-blind trial / Há diferenças na dor crônica pós-hernioplastia inguinal videolaparoscópica pela técnica transabdominal comparando fixação da tela com grampos, com cola ou sem fixação? ensaio clínico randomizado duplo-cego

ABSTRACT BACKGROUND: Regarding postoperative pain, it remains unclear whether non-fixation of the polypropylene prosthesis in transabdominal preperitoneal inguinal hernia repair produces the same outcomes as mesh fixation with glue or tackers. In addition, hernia recurrence is another aspect to be assessed in the comparison between non-fixation and mesh-fixation techniques (tackers and glue). AIMS: This study aimed to evaluate the incidence, quality of pain, and recurrence in patients undergoing laparoscopic inguinal hernioplasty (transabdominal preperitoneal) technique, comparing the fixation of the mesh with tackers versus with glue versus without fixation. METHODS: This is a prospective, double-blind study in which 63 patients presenting with primary unilateral inguinal hernia underwent laparoscopic transabdominal preperitoneal inguinal hernia repair and were randomized into three groups: no mesh fixation (n=21), mesh tacked (n=21), and mesh fixed with fibrin glue (n=21). Patients also responded to questionnaires in order to assess pain and pain quality and were followed up for 2 years. RESULTS: Neither mesh-fixation nor non-fixation techniques were found to affect postoperative chronic pain (p=0.535), but patients undergoing tacker fixation reported more pain descriptors (p=0.0021) and a higher pain index (p=0.002) on the McGill scale in the first 15 postoperative days (T0 and T1). No hernia recurrences were observed. CONCLUSIONS: Both mesh-fixation techniques (tackers and glue) used with the transabdominal preperitoneal approach did not influence the onset of inguinodynia, but tacker fixation was more likely to increase patient sensitivity to pain. Mesh placement without fixation produced the same pain and recurrence outcomes as mesh-fixation techniques. Also, no recurrence was observed in patients without mesh fixation in this study. Consequently, it has become an alternative therapy deserving consideration for hernia repair.

RESUMO RACIONAL: Em relação à inguinodinia, há que se perguntar se a não fixação da tela pela técnica da hernioplastia inguinal videolaparoscópica transbadominal pré-peritoneal teria os mesmos resultados em relação à fixação de telas com cola ou grampos. Além disso, a recorrência de hérnia é outro aspecto a ser avaliado na comparação entre as técnicas de não fixação e de fixação com tela (grampos e cola). OBJETIVOS: Avaliar a incidência, qualidade da dor e recorrência em pacientes submetidos à técnica de hernioplastia inguinal laparoscópica (transbadominal pré-peritoneal), comparando a fixação da tela com grampos vs. com cola vs. sem fixação. MÉTODOS: Este é um trabalho prospectivo, duplo-cego, em que 63 doentes portadores de hérnia inguinal submetidos à hernioplastia inguinal videolaparoscópica pela técnica transbadominal pré-peritoneal foram randomizados em três grupos: no primeiro a tela não foi fixada; no segundo foi fixada por grampos; e no terceiro foi fixada com cola. Estes pacientes foram submetidos a questionários para avaliação de dor, sendo acompanhados por dois anos. RESULTADOS: O método de fixação da tela, assim como a não fixação dela não interferiu no aparecimento da dor crônica pela Escala Visual Analógica; porém, os que foram submetidos à fixação por grampos tiveram mais descritores e índice de dor pela escala de McGill. Não foram observadas recidivas herniárias. CONCLUSÕES: O método de fixação da tela na técnica transbadominal pré-peritoneal não influencia no aparecimento da inguinodinia. A não fixação teve os mesmos resultados em termos de dor e recidiva, tornando-se alternativa terapêutica a ser considerada, pois não acarretou recidivas.

Reversal of unstable atrial fibrillation after surgical correction of hiatus hernia: A case report.

INTRODUCTION: The presence of Atrial Fibrillation (AF) with herniation of abdominal content through the esophageal hiatus can be explained by the compression of the cardiac tissue by the viscera and, consequently, of its electrical transmission network, compromising the correct propagation of stimuli. Due to the causal relationship, hernia correction is almost always able to reverse the arrhythmic picture. PRESENTATION OF THE CASE: A 75-year-old male with atrial fibrillation with a large hiatal hernia causing clinical decompensation was successfully treated after a laparocopic correction- primary closure of the defect was made with barbed surgical thread plus and placing a biological mesh (porcine small intestine submucosa, non-cross-linked), fixed with cyanoacrylate; after the procedure, he was discharged asymptomatic and with sinus heart rhythm. DISCUSSION: It is noticed that for cases in which the patient presents with a type IV hiatal hernia associated with atrial fibrillation, the laparoscopic correction of hernia using a mesh for the correction of the defect has good results in the literature. In the present case, it is noted that despite the severity of the condition denoted by hemodynamic instability and the need for electrical cardioversion, the surgical correction of the hiatal hernia was able to reverse the arrhythmic picture definitively. CONCLUSION: the concomitance of AF and hiatal hernia can explain the difficulty to control the arrhythmic picture and is necessary to consider, as soon as possible, the surgical correction of the defect as part of the treatment.

Autoimmune [auto-inflammatory] syndrome induced by adjuvants (ASIA): Case report after inguinal hernia repair with mesh.

INTRODUCTION: There has been a great advance in the treatment of inguinal hernias with a significant reduction in recurrences with the use of polypropylene mesh. Local complications such as infections, rejection, and chronic pain are widely studied and reported in the literature. The Autoimmune [Auto-inflammatory] Syndrome Induced by Adjuvants (ASIA) is little known and can be triggered by using polypropylene mesh. PRESENTATION OF THE CASE: 33-year-old female patient, married, and an administrative manager. History of smoking, previous breast surgery with silicone prosthesis, appendectomy. One year and four months ago, she underwent bilateral inguinal hernioplasty by laparoscopy. Shortly after the inguinal hernia surgery, systemic, urinary symptoms, and chronic local pain appeared. She reported low back pain, fatigue, memory loss, and mood swings associated with limiting pelvic pain, dysuria, and dyspareunia. We performed a robotic surgical procedure to remove the meshes bilaterally. Three days after surgery, the patient was discharged with adequate pain control, without the need for opioids. During outpatient follow-up, there was a significant improvement in symptoms, both local and systemic. DISCUSSION: Local complications with the use of polypropylene mesh to repair inguinal hernias are well described in the literature, highlighting chronic postoperative pain that can affect 10-20% of patients. Recently, polypropylene prostheses have been found to act as adjuvants and may be the trigger for an exacerbated immune response adaptive to an autoantigen. Thus, being capable of causing an autoimmune disease variant of the Autoimmune [Auto-inflammatory] Syndrome Induced by Adjuvants (ASIA), described by Shoenfeld and Agmon-Levin in 2011. CONCLUSION: In addition to local complications, systemic symptoms related to the use of polypropylene mesh can also occur. In the Autoimmune [Auto-inflammatory] Syndrome Induced by Adjuvants (ASIA), systemic symptoms, for being nonspecific, make diagnosis difficult and are often not attributed to the use of mesh.

Pancreatoduodenal Artery Aneurism rupture post colonoscopy - Case report.

INTRODUCTION: Complications related to colonoscopy is considered low and in most cases involves intestinal perforation. Vascular complications involving aneurysm rupture are rare in the literature and may occur after colonoscopy. PRESENTATION OF THE CASE: We report a case of a 58-year-old male patient that ruptured pancreatoduodenal artery aneurysm after colonoscopy, successfully submitted to endovascular treatment. DISCUSSION: Colonoscopy is frequently used as a diagnostic procedure. The risk of complication inherent to the procedure is considered low, and intestinal perforation is one of the most frequent. Other complications may present similar clinical symptoms, and it is necessary to complement the diagnostic investigation to offer the most appropriate treatment for the patient. Among the complications, there is one report of aneurysm rupture after performing colonoscopies and no case involving aneurysm rupture of pancreatoduodenal artery has been reported to date. CONCLUSION: A patient with ruptured pancreatoduodenal artery aneurysm is a rare entity that can be adequately treated with endovascular intervention. This is the first report of rupture related to colonoscopy.

Biomechanical and adhesion comparison of linea alba prophylactic reinforcement with coated and uncoated three-dimensional T-shaped mesh in rabbits.

PURPOSE: Incisional hernia (IH) is a frequent complication of median laparotomy. The use of prophylactic mesh to reduce IH incidence has gained increasing attention. We hypothesized that in an animal model, linea alba prophylactic reinforcement with a three-dimensional T-shaped polypropylene mesh results in greater abdominal wall resistance. METHODS: Study was performed in 27 rabbits. After abdominal midline incision, animals were divided into three groups according to the laparotomy closure method used: (1)3D T-shaped coated mesh; (2)3D T-shaped uncoated mesh; and (3) closure without mesh. After 4 months, each animal's abdominal wall was resected and tensiometric tests were applied. Results included IH occurrence, adhesions to the mesh, and wound complications. RESULTS: There was no significant difference between the groups in maximum tensile strength (p=0.250) or abdominal wall elongation under maximum stress (p=0.839). One rabbit from the control group developed IH (p=1.00). Small intestine and colon adhesions occurred only in the uncoated mesh group (p<0.001) and the degree of adhesions was higher in this group compared to the coated mesh group (p<0.05). CONCLUSION: Use of the current 3D T-shaped prophylactic mesh model did not result in a significant difference in tensiometric measurements when compared with simple abdominal wall closure in rabbits.

COVID-19 and Cytomegalovirus Co-infection: A Challenging Case of a Critically Ill Patient with Gastrointestinal Symptoms.

COVID-19 is a severe disease that has reached pandemic status. To the best of our knowledge, we describe the first case of COVID-19 and cytomegalovirus (CMV) co-infection in a critically ill patient. We discuss the challenge of establishing the diagnosis as well as the management of tissue-invasive gastrointestinal CMV infection (TI-GI CMV) simulating vascular involvement and intestinal obstruction in a critically ill patient. LEARNING POINTS: We describe a case of COVID-19 and cytomegalovirus (CMV) co-infection in a critically ill patient.Clinical symptoms simulated mesenteric vascular involvement and intestinal obstruction.The successful management of invasive CMV colitis in a patient with COVID-19 with atypical symptoms is described.

Biomechanical and adhesion comparison of linea alba prophylactic reinforcement with coated and uncoated three-dimensional T-shaped mesh in rabbits

Abstract Purpose: Incisional hernia (IH) is a frequent complication of median laparotomy. The use of prophylactic mesh to reduce IH incidence has gained increasing attention. We hypothesized that in an animal model, linea alba prophylactic reinforcement with a three-dimensional T-shaped polypropylene mesh results in greater abdominal wall resistance. Methods: Study was performed in 27 rabbits. After abdominal midline incision, animals were divided into three groups according to the laparotomy closure method used: (1)3D T-shaped coated mesh; (2)3D T-shaped uncoated mesh; and (3) closure without mesh. After 4 months, each animal's abdominal wall was resected and tensiometric tests were applied. Results included IH occurrence, adhesions to the mesh, and wound complications. Results: There was no significant difference between the groups in maximum tensile strength (p=0.250) or abdominal wall elongation under maximum stress (p=0.839). One rabbit from the control group developed IH (p=1.00). Small intestine and colon adhesions occurred only in the uncoated mesh group (p<0.001) and the degree of adhesions was higher in this group compared to the coated mesh group (p<0.05). Conclusion: Use of the current 3D T-shaped prophylactic mesh model did not result in a significant difference in tensiometric measurements when compared with simple abdominal wall closure in rabbits.

Guidelines of the Brazilian Hernia Society (BHS) for the management of inguinocrural hernias in adults. / Orientações da Sociedade Brasileira de Hérnia (SBH) para o manejo das hérnias inguinocrurais em adultos.

Inguinal hernias are a frequent problem and their repair is the most commonly performed procedure by general surgeons. In the last years, new principles, products and techniques have changed the routine of surgeons, who need to recycle knowledge and perfect new skills. In addition, old concepts regarding surgical indication and risk of complications have been reevaluated. In order to create a guideline for the management of inguinal hernias in adult patients, the Brazilian Hernia Society assembled a group of experts to review various topics, such as surgical indication, perioperative management, surgical techniques, complications and postoperative guidance.

As hérnias inguinais são um problema frequente e o seu reparo representa a cirurgia mais comumente realizada por cirurgiões gerais. Nos últimos anos, novos princípios, produtos e técnicas têm mudado a rotina dos cirurgiões que precisam reciclar conhecimentos e aperfeiçoar novas habilidades. Além disso, antigos conceitos sobre indicação cirúrgica e riscos de complicações vêm sendo reavaliados. Visando criar um guia de orientações sobre o manejo das hérnias inguinais em pacientes adultos, a Sociedade Brasileira de Hérnias reuniu um grupo de experts com objetivo de revisar diversos tópicos, como indicação cirúrgica, manejo perioperatório, técnicas cirúrgicas, complicações e orientações pós-operatórias.

Orientações da Sociedade Brasileira de Hérnia (SBH) para o manejo das hérnias inguinocrurais em adultos / Guidelines of the Brazilian Hernia Society (BHS) for the management of inguinocrural hernias in adults

RESUMO As hérnias inguinais são um problema frequente e o seu reparo representa a cirurgia mais comumente realizada por cirurgiões gerais. Nos últimos anos, novos princípios, produtos e técnicas têm mudado a rotina dos cirurgiões que precisam reciclar conhecimentos e aperfeiçoar novas habilidades. Além disso, antigos conceitos sobre indicação cirúrgica e riscos de complicações vêm sendo reavaliados. Visando criar um guia de orientações sobre o manejo das hérnias inguinais em pacientes adultos, a Sociedade Brasileira de Hérnias reuniu um grupo de experts com objetivo de revisar diversos tópicos, como indicação cirúrgica, manejo perioperatório, técnicas cirúrgicas, complicações e orientações pós-operatórias.

ABSTRACT Inguinal hernias are a frequent problem and their repair is the most commonly performed procedure by general surgeons. In the last years, new principles, products and techniques have changed the routine of surgeons, who need to recycle knowledge and perfect new skills. In addition, old concepts regarding surgical indication and risk of complications have been reevaluated. In order to create a guideline for the management of inguinal hernias in adult patients, the Brazilian Hernia Society assembled a group of experts to review various topics, such as surgical indication, perioperative management, surgical techniques, complications and postoperative guidance.

Robotic Transversus Abdominis Release (TAR): is it possible to offer minimally invasive surgery for abdominal wall complex defects?

We describe the preliminary national experience and the early results of the use of robotic surgery to perform the posterior separation of abdominal wall components by the Transversus Abdominis Release (TAR) technique for the correction of complex defects of the abdominal wall. We performed the procedures between 04/2/2015 and 06/15/2015 and the follow-up time was up to six months, with a minimum of two months. The mean surgical time was five hours and 40 minutes. Two patients required laparoscopic re-intervention, since one developed hernia by peritoneal migration of the mesh and one had mesh extrusion. The procedure proved to be technically feasible, with a still long surgical time. Considering the potential advantages of robotic surgery and those related to TAR and the results obtained when these two techniques are associated, we conclude that they seem to be a good option for the correction of complex abdominal wall defects.

Descrevemos a experiência preliminar nacional na utilização da cirurgia robótica para realizar a separação posterior de componentes da parede abdominal pela técnica transversus abdominis release (TAR) na correção de defeitos complexos da parede abdominal e seus resultados precoces. As cirurgias foram realizadas entre 02/04/2015 e 15/06/2015 e o tempo de acompanhamento dos resultados foi de até seis meses, com tempo mínimo de dois meses. O tempo cirúrgico médio foi de cinco horas e 40 minutos. Dois pacientes necessitaram reintervenção por laparoscopia, pois um desenvolveu hérnia por migração peritoneal da tela e um teve escape da tela. A cirurgia provou ser factível do ponto de vista técnico, com um tempo cirúrgico ainda elevado. Tendo em vista as vantagens potenciais da cirurgia robótica e aquelas relacionadas ao TAR e os resultados obtidos ao se associar essas duas técnicas, conclui-se que elas parecem ser uma boa opção para a correção de defeitos complexos da parede abdominal.