Laparoscopic treatment for ventral hernia in obese patients.

AIM: Obese patients generally are not considered good candidates for wall defect repair, because of associated comorbidities, increased surgical risk, and high risk of surgical site infection and recurrence. The purpose of this retrospective study was to evaluate the results of laparoscopic incisional hernia repair in a group of patients with Body Mass Index (BMI)>35 kg/m2. MATERIAL AND METHOD: From January 2016 to October 2018, 15 obese patients, including 11 females (73.3%) with a BMI > 35 kg/m2 underwent laparoscopic repair of an incisional abdominal hernia. Median BMI was 40 (SD±5). No selection related to comorbidities was performed. As primary endpoints, main postoperative general complications and hernia recurrence were taken into account. Secondary endpoints were the incidence of seroma, hematoma, wound infection and length of hospitalization. In addition, a systematic review of the literature on open and laparoscopic repair techniques was carried out. RESULTS: All patients were treated by laparoscopy and no conversions were required. No intraoperative complications were observed, and no patients underwent early re-intervention. Mortality was zero. One patient (6.6%) presented a seroma, conservatively managed, and evaluated over time without the need of re-intervention. One patient (6.6%) suffered a recurrence a year later, also treated by laparoscopy. Average hospital stay was 2.79 days (DS±0.77). CONCLUSIONS: Despite positive data and good results, laparoscopic treatment of wall defects has yet to be standardized. The feasibility of the laparoscopy for ventral hernias in patients with BMI>35 kg/m2 should be considered. The proposed technique is standardizable and easily reproducible. In terms of complications in the short term (perforations, kidney and pulmonary failure, cardiovascular events) and in the long term (relapses, wound infections, seromas) our results justify recommendation of the minimally invasive approach for almost all patients with abdominal wall defects. KEY WORDS: Laparoscopy, Obese, Ventral hernia.

Tailored Surgery in Inguinal Hernia Repair. The Role of Subarachnoid Anesthesia: A Retrospective Study.

Safety and effectiveness evaluation of subarachnoid anesthesia implemented with hyperbaric Prilocaine in reduced dose (30mg) in combination with Fentanyl (20mcg), for the purpose of ensuring an optimal analgesia in open inguinal hernia repair. Although the local anesthesia is the first line treatment for open inguinal hernia repair, a minority of patients is not eligible because of obesity or big groin hernia, requiring a high dose of local anesthetic. Subarachnoid anesthesia implemented with hyperbaric Prilocaine in reduced dose in combination with Fentanyl may be a good alternative. Thirty patients were treated with intrathecal association of Prilocaine 30 mg and Fentanyl 20 mcg (group PF); they were compared to a group of fifty three ones, previously treated with a classic procedure with intrathecal Prilocaine 60 mg (group P). The sensitive blockage remained within an higher limit at T12 level in the patients of PF group, and a lower limit at S1 level 50 minutes after the anesthesia, while in the P group the anesthetic tended to migrate (p<0.0001). In PF group 70 minutes after the anesthesia 21 patients had a Bromage score equal to 0 and 9 patients equal to 9 (in P group, 19 patients had a score equal to 3, 8 to 2 and 3 to 1, p<0.0001). Subarachnoid anesthesia using Prilocaine 30 mg + Fentanyl 20 mcg could be stated as a viable alternative to local anesthesia in selected patients.

Postoperative nausea and vomiting (PONV) in outpatient repair of inguinal hernia.

PURPOSE: Nausea and vomiting are among the most frequent complications following anesthesia and surgery. Due to anesthesia seems to be primarily responsible for post operative nausea and vomiting (PONV) in Day Surgery facilities, the aim of the study is to evaluate how different methods of anesthesia could modify the onset of postoperative nausea and vomiting in a population of patients undergoing inguinal hernia repair. METHODS: Ninehundredten patients, aged between 18 and 87 years, underwent open inguinal hernia repair. The PONV risk has been assessed according to Apfel Score. Local anesthetic infiltration, performed by the surgeon in any cases, has been supported by and analgo-sedation with Remifentanil in 740 patients; Fentanyl was used in 96 cases and the last 74 underwent deep sedation with Propofol . RESULTS: Among the 910 patients who underwent inguinal hernia repair, PONV occurred in 68 patients (7.5%). Among patients presenting PONV, 29 received Remifentanil, whereas 39 received Fentanyl. In the group of patients receiving Propofol, no one presented PONV. This difference is statistically significant (p < .01). Moreover, only 50 patients of the total sample received antiemetic prophylaxis, and amongst these, PONV occurred in 3 subjects. CONCLUSIONS: Compared to Remifentanil, Fentanyl has a major influence in causing PONV. Nonetheless, an appropriate antiemetic prophylaxis can significantly reduce this undesirable complication. Key words: Day Surgery, Fentanyl, Inguinal, Hernia repair, Nausea, Vomiting.

Fondaparinux for intra and perioperative anticoagulation in patients with heparin-induced thrombocytopenia candidates for peripheral vascular surgery: Report of 4 cases.

INTRODUCTION: Intra and perioperative anticoagulation in patients with heparin induced thrombocytopenia (HIT), candidates for peripheral vascular surgery remains a challenge, as the best alternative to heparin has not yet been established. We evaluated the off-label use of fondaparinux in four patients with HIT, undergoing peripheral vascular surgery procedures. PRESENTATION OF CASES: Four patients of whom 3 men of a mean age of 66 years, with proven heparin induced thrombocytopenia (HIT) underwent two axillo-femoral bypasses, one femoro-popliteal bypass and one resection of a splenic artery aneurysm under fondaparinux. No intra or perioperative bleeding or thrombosis of new onset was observed. DISCUSSION: In the absence of a valid alternative to heparin for intra and perioperative anticoagulation in HIT, several other anticoagulants can be used in an off-label setting. However, no general consensus exist on which should be the one of choice. In this small series fondaparinux appeared to be both safe and effective. CONCLUSIONS: These preliminary results seem to justify the off-label use of fondaparinux for intra and perioperative anticoagulation in patients with HIT, candidates for peripheral vascular surgery interventions.

Perceived quality in Day Surgery Units Proposal of an enquiry postoperative questionnaire.

INTRODUCTION: Assessing patient satisfaction could be particularly useful in Day Surgery Units, as it helps maintaining and increasing medical care demand. Moreover, it provides feedback that turns out useful for improving quality in departments, and for assessing competence and skill of the whole staff. Background and aim - The purpose of this study was to evaluate the quality perceived in a day surgery unit through a questionnaire, covering the 10 main aspects of the care pathway. MATERIALS AND METHODS: The results of a questionnaire filled by patients undergoing Day Surgery between January 2007 and December 2012 were retrospectively reviewed. Patients undergoing surgery between 2007 and 2009 filled up the questionnaire at the time of the discharge, whereas those operated on between 2009 and 2012 filled up the same questionnaire 30 days after discharge. RESULTS: The results were good in terms of number of returned questionnaires, underlining its comprehensibility and suitability to be filled out. The questionnaires' scores were good in both groups, although quality perceived by the group that completed it in 30 days after surgery were lightly better than the other group's. CONCLUSIONS: The advantages of the questionnaire consisted of an overall improvement of the quality of care, whereas limitations consisted of the difficulty in setting up the questionnaire accurately, interpreting patients' answers correctly, and dispensing the questionnaire in a timely fashion, in order to evaluate the quality perceived by the patients without any bias related to delay, pain and anxiety. KEY WORDS: Day Surgery, Nursing, Questionnaire, Quality.

Outpatient repair for inguinal hernia in elderly patients: still a challenge?

BACKGROUND: Elective inguinal hernia repair as a day case is a safe and suitable procedure, with well-recognized feasibility. The increasing number of elderly patients requiring inguinal hernia repair leads clinicians to admit a growing number of outpatients. The aim of the current study was to analyze the outcomes (feasibility and safety) of day case treatment in elderly patients. METHODS: Eighty patients >80 years of age and 80 patients ≤55 years of age underwent elective inguinal hernia repairs under local anesthesia. RESULTS: There were no mortalities or major complications in the elderly undergoing inguinal herniorraphies as outpatients, and only one unanticipated admission occurred in the younger age group. CONCLUSIONS: Elective inguinal hernia repair in the elderly has a good outcome, and age alone should not be a drawback to day case treatment.

The Lynch syndrome: a management dilemma.

The case of a familial Lynch syndrome is reported. The criteria for early diagnosis, management and surveillance are briefly reviewed. A germline mutation of genes responsible for mismatch repair is at the basis of the Lynch syndrome. Carriers are predisposed to colorectal cancer and other tumors. Two members of the presently reported family developed colorectal cancer, whereas two others developed other neoplasms. The syndrome was confirmed in members of the same family with appropriate genetic workup. Clinical examination and endoscopy were consequently scheduled once-a-year. Given the high risk of neoplastic disease, such yearly controls can be proposed as the standard follow-up of this condition.

Conventional (CH) vs. stapled hemorrhoidectomy (SH) in surgical treatment of hemorrhoids. Ten years experience.

INTRODUCTION: Interest about hemorrhoids is related to its high incidence and elevated social costs that derive from its treatment. Several comparative studies are reported in Literature to define a standard for ideal treatment of hemorrhoidal disease. Radical surgery is the only therapeutic option in case of III and IV stage haemorrhoids. Hemorrhoids surgical techniques are classified as Open, Closed and Stapled ones. OBJECTIVE: We report our decennial experience on surgical treatment focusing on early, middle and late complications, indications and contraindications, satisfaction level of each surgical procedure for hemorrhoids. METHODS: Four hundred forty-eight patients have been hospitalized in our department fom 1st January to 31st December 2008. Of these 241 underwent surgery with traditional open or closed technique and 207 with the SH technique according to Longo. This retrospective study includes only patients with symptomatic hemorrhoids at III or IV stage. RESULTS: There were no differences between CH and SH about both pre and post surgery hospitalization and intraoperative length. Pain is the most frequently observed early complication with a statistically significant difference in favour of SH. We obtain good results in CH group using anoderma sparing and perianal anaesthetic infiltration at the end of the surgery. In all cases, pain relief was obtained only with standard analgesic drugs (NSAIDs). We also observed that pain level influences the outcome after surgical treatment. No chronic pain cases were observed in both groups. Bleeding is another relevant early complication in particular after SH: we reported 2 cases of immediate surgical reintenvention and 2 cases treated with blood transfusion. Only in SH group we report also 5 cases of thrombosis of external haemorrhoids and 7 perianal hematoma both solved with medical therapy There were no statistical significant differences between two groups about fever, incontinence to flatus, urinary retention, fecal incontinence, substenosis and anal burning. No cases of anal stenosis were observed. About late complications, most frequently observed were rectal prolapse and hemorrhoidal recurrence, especially after SH. DISCUSSION AND CONCLUSION: Our experience confirms the validity of both CH and SH. Failure may be related to wrong surgical indication or technical execution. Certainly CH procedure is more invasive and slightly more painfull in immediate postoperative period than SH surgery, which is slightly more expensive and has more complications. In our opinion the high risk of possible early and immediate complications after surgery requires at least a 24 hours hospitalization length. SH is the gold standard for III grade haemorrhoids with mucous prolapse while CH is suggested in IV grade cases. Hemorrhoidal arterial ligation operation (HALO) technique in III and IV degree needs further validations.