Adverse events in thyroid surgery: observational study in three surgical units with high volume/year.

BACKGROUND: Thyroid surgery, performed for benign or malignant pathologies, is one of the most frequently performed procedures and its frequency has even been increasing in recent years. Postoperative bleeding, recurrent laryngeal nerve (RLN) palsy, associated to dysphonia, dysphagia, dyspnea, and hypoparathyroidism represent the most fearful and common complications. We conducted a multicenter, observational study of retrospectively collected data in three high-volume referral centers, enrolling all patients undergone to thyroid surgery between January 2016 and December 2017 in Parma University Hospital, Cagliari University Hospital and Ferrara University Hospital. MATERIALS: Patients were divided into five groups, differentiated thyroid carcinoma, medullary thyroid carcinoma, non-toxic benign pathology, hyperfunctioning benign pathology and NIFTP (Non-invasive Follicular Thyroid neoplasm with Papillary-like nuclear features). A follow up at 7 and 30 days was executed, evaluating the onset of paresthesia, dysphonia and dysphagia. A 6-month follow-up was conducted in cases of early complications. RESULTS: Totally, 1252 patients were eligible for the study: 907 female and 345 male, with a female to male ratio of 2.6:1 and an average age of 53.428. Total thyroidectomy was performed in 1022 cases, lobectomy in 230. After 6 months we recorded paresthesia in 0.5%, dysphonia in 1.8% and dysphagia in 0.5%. CONCLUSION: Our study confirms once again that a share of morbidity escapes the possibilities of prediction and control by the operator, depending on patient anamnestic, pathological or anatomical factors.

Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports.

BACKGROUND: In the presence of a large uterus, total laparoscopic hysterectomy (TLH), always requires morcellation to allow removal of the tissues from the abdominal cavity. However, uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma. Therefore, in-bag extracorporeal morcellation has been developed. However, tissue containment and extraction are extremely challenging, especially when considering the increasing uterine size to be removed through minimally invasive surgery. CASE SUMMARY: Herein, we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH. The study enrolled patients who were planned for TLH for large uteri (weight > 500 g). TLH was performed following the procedure reported in our previous studies. The novel technique has been described step-by-step in a video, which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g, 1700 g, and 3700 g, respectively. The procedures were performed without any complications. The patients had an uneventful postoperative course, and in all cases, the pathology was benign leiomyoma. CONCLUSION: Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies. The technique herein presented may be adopted in surgical practice, by adding it to the other available techniques of contained morcellation. It may represent a valid and feasible alternative, especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.

First-in-man permanent laparoscopic fixation free obliteration of inguinal hernia defect with the 3D dynamic responsive implant ProFlor-E®. Case report.

INTRODUCTION: In the case of inguinal hernia recurrence after primary anterior repair, international guidelines strongly suggest a posterior laparoscopic approach. The 3D dynamic-responsive prosthesis for inguinal hernia repair ProFlor-E® has recently been introduced to the market. The present report describes the results of the first-in-man laparoscopic inguinal hernia repair carried out with ProFlor-E®. PRESENTATION OF CASE: A 71-year-old male Caucasian presented with recurrent inguinal hernia after primary anterior repair. A fixation free TAPP procedure with ProFlor-E® was planned. Implant delivery and placement to obliterate the defect was quick and safe. Postoperatively, starting from 2nd postop day, pain was practically absent allowing quick return to normal activities. During follow up, US and MRI scans confirmed the permanence of ProFlor-E® in the hernial gap. During 16-month follow-up no complications were reported. DISCUSSION: Flat meshes used to reinforce the herniated inguinal area is a well-established concept. Notwithstanding, such static and passive implants leave the defect patent and cause specific complications related to mesh fixation and uncontrolled poor quality fibrotic ingrowth. ProFlor-E® respects the inguinal physiology resolving these issues. Its centrifugal expansion and dynamic responsivity allows for fixation-free defect obliteration, thus avoiding complications, above all tissue tear, bleeding, mesh invagination, discomfort and chronic pain. In accord with the degenerative pathogenesis of hernia disease, by acting as a regenerative scaffold, ProFlor-E® restores the inguinal barrier promoting the regeneration of the typical inguinal components. CONCLUSION: This initial experience seems to prove that ProFlor-E® can also be used with the laparoscopic approach achieving excellent results.

Inguinal Hernia: The Destiny of the Inferior Epigastric Vessels and the Pathogenesis of the Disease.

INTRODUCTION: While many scientific reports deal with inguinal hernia, including treatment methods and prosthetic devices proposed to provide a cure, few studies have sought to deepen our understanding of the etiology of this disease. The genesis of inguinal protrusion seems to be a neglected subject, even though addressing hernia genesis may be helpful for improving techniques and materials for surgical treatment. To clarify the source of inguinal protrusions, macroscopic and histological alterations of the inferior epigastric vessels in the herniated groin have been studied. These vascular structures exhibit significant features that could help to illuminate hernia genesis. MATERIAL AND METHODS: In patients with double ipsilateral inguinal hernia, composed of distinct direct and indirect protrusions, a tissue septum separates the two defects. Macroscopic observation and histological examination of this septal arrangement were carried out in 23 patients to highlight characteristics of the inferior epigastric vessels in the posterior aspect of this anatomical area. RESULTS: The examined inferior epigastric vessels presented notable alterations of the gross anatomy and histologically significant damage, with a typical trait of chronic compressive damage. All degrees of degeneration were observed, including complete disbanding of the vascular structure. CONCLUSIONS: In pantaloon hernias, excised inferior epigastric vessels suffered from chronic compressive degeneration but had no contact with the protrusions. Therefore, protrusion expansion does not produce the degenerative injuries seen in the epigastric vessels. In the inguinal area, there is no source of chronic compression except visceral impact. Consequently, orthostatic visceral impact could be hypothesized to cause structural weakening of the groin, leading to tissue disbanding and visceral protrusion through the weakened inguinal floor.

Neo-nervegenesis in 3D dynamic responsive implant for inguinal hernia repair. Qualitative study.

BACKGROUND: Prosthetic repair of inguinal hernias is one of the most performed surgical procedures. Nevertheless, high rates of complications affect the surgical treatment. Implant fixation, poor-quality tissue ingrowth and mesh shrinkage seem to be involved in postoperative complications, discomfort and chronic pain following inguinal hernia repair. To address these issues a multilamellar shaped 3D dynamic responsive prosthesis has been developed. This new implant, positioned fixation-free to obliterate the hernia opening, thanks its inherent dynamic compliance during inguinal movements, has demonstrated to induce an enhanced biological response. The ingrowth of newly formed muscle fibers, arteries and veins in a surrounding of viable connective tissue could be evidenced into the implant fabric. This appears to be quite different from the fibrotic plaque, typical biologic response of conventional meshes. In addition to myocytes and vessels, newly ingrown nerves have also been detected in the prosthetic structure. MATERIALS AND METHODS: The aim of this investigation was to determine by examining biopsy specimens excised from patients who underwent hernia repair with the 3D dynamic implant, quantity and quality of the neural ingrowth within the implant fabric in the short, medium, and long term post-implantation. RESULTS: Newly formed nervous structures were found in biopsy specimens, from multiple spots of nerve clusters evidenced in the short-term along the increased level of neural maturation in the midterm, until the nerves showed complete in all components in the long-term. CONCLUSION: The development of highly specialized nervous tissue in the 3D prosthesis seems to finalize the regenerative biologic response that is expected for the treatment of a degenerative disease, as, in fact, inguinal hernia is. Re-growth of the typical tissue components of the groin evidenced in the 3D dynamic prosthesis seems to effectively revert the degenerative source of inguinal hernia into regeneration of the vanished tissue components of the groin.

The Septum Inguinalis: A Clue to Hernia Genesis?

Purpose: Double ipsilateral inguinal ("pantaloon") hernias and also the more advanced "combined" inguinal hernia involve disruption of the inguinal floor. In the case of pantaloon hernias, the medial boundary of the internal ring remains intact but in combined hernias this is fully disrupted, producing a single hernial protrusion. Deepening the pathophysiology of these hernias may be helpful in addressing hernia genesis, thus improving strategies for the treatment of this disease. Materials and Methods: A cohort of 22 patients who underwent inguinal hernia repair showed double ipsilateral (pantaloon) hernia, comprising distinct direct and indirect protrusions separated by a tissue septum. In 19 patients, the septal arrangement dividing the 2 hernias showed macroscopically evident structural damages, then excised and histologically studied. Different tissue markers were used for the identification of the structural damages. Results: Macroscopically, the divisor septum represents the boundary between internal ring and Hesselbach's triangle. Anteriorly it is composed by fibers of the internal oblique and transverse muscles, which form a complex with the inferior epigastric vessels on the corresponding posterior side of the inguinal floor. In the patient cohort studied, this anatomical structure showed a progressive sufferance characterized by chronic compressive damage. Conclusion: The anatomical structure which separates the indirect and direct components of a pantaloon hernia, herein referred to as the "septum inguinalis", has been shown progressively alter in both macro- and microscopically until it f undergoes disruption with development of a combined hernia. Understanding of this anatomical concept may help surgeons to perform sound repairs of these complex hernias.

Neomyogenesis in 3D Dynamic Responsive Prosthesis for Inguinal Hernia Repair.

Despite undisputed improvements, prosthetics hernia repair continues to be affected by unacceptable rates of complications. Postoperative adverse events such as discomfort and chronic pain represent a subject of increasing concern among the surgical community. Poor quality biologic response, stiff scar plates, and mesh shrinkage, a typical effect of conventional static meshes and plugs, are all indicated as the main reasons for many of the complications related to inguinal hernia repair. Even the conventional concept of treatment based upon a supposed reinforcement of the groin consequent to the fibrotic incorporation of meshes, would appear to be inadequate in the light of the latest scientific evidence concerning the degenerative genesis of inguinal hernia. Following these recent studies, a newly conceived 3D dynamically responsive implant has been developed. It concerns a multilamellar shaped prosthesis, intended to be placed fixation-free to obliterate the hernia defect. This 3D structure has already demonstrated to induce a probiotic biological response with development of viable tissue, instead of the fibrotic plaque typical of conventional meshes. Newly formed elastic fibers, neo-angiogenesis, and neo-nerve genesis in a surrounding of well perfused connective tissue are the typical elements of the biologic response in the newly conceived implant. In addition to these elements, muscle fibers have also been detected in the implant structure. The aim of this research was to determine the ingrowth of muscle fibers in the implant by assessing the quantity and quality of muscle development in the short, medium, and long term post-implantation. Histological examination of biopsy samples excised from patients who underwent dynamic hernia repair with the 3D dynamic implant showed the presence of muscular elements that in the short term could be described as multiple spots of myocytes in the early stage of development. Over the mid- to long-term, muscle fibers increased in number and level of maturation, assuming the typical aspect of standard muscle bundles in the final phase. Effectively, long term, myocytes histologically evidenced the distinctive arrangement of the muscle structure, with nuclei and striated elements being similar to normal muscle elements. The development of this highly specialized connective tissue in the 3D dynamic responsive implant seems to document the finalization of an enhanced biologic response leading to the ingrowth of typical tissue components of the groin. Reverting degenerative pathogenesis into effective regeneration recognized in the newly conceived 3D prosthesis would appear to represent a significant concept change in the repair of inguinal hernias.

Long-Term Results of Fixation-Free Incisional Hernia Repair Using a Tentacle-Shaped Implant.

INTRODUCTION: The fixation and the overlap of the mesh represent an open issue in incisional hernia repair. An exclusively designed prosthesis has been developed to assure a suture-free repair and a broader coverage of the abdominal wall. This study describes the long-term results of incisional hernia procedures carried out positioning a tentacle-shaped implant through a specifically developed surgical technique. MATERIALS AND METHODS: A proprietary symmetrically-shaped flat mesh constituted by a large central body with integrated radiating arms was used to repair incisional hernias in 68 patients. The prosthesis was placed in preperitoneal/retromuscular sublay. The friction of the straps passing through myotendineal structures of the abdomen was intended to assure an adequate grip to firmly hold the device in place with a broad overlap of the hernia defect in a fixation-free fashion. All tentacle straps were positioned through a special needle passer crossing the abdominal wall laterally from the defect borders then cut short in the subcutaneous layer. RESULTS: In a long-term follow-up of 12 to 96 months (mean 58 months), 11 seromas occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence have been reported. CONCLUSIONS: The tentacle strap system of the prosthesis effectively ensured reduced skin incision and an easier implant placement avoiding the need for suturing the mesh. Regularly performed computed tomography (CT) and ultrasound (US) investigations proved that the arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences, even in the long-term.

Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series.

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.

Assessing RET/PTC in thyroid nodule fine-needle aspirates: the FISH point of view.

RET/PTC rearrangement and BRAF(V600E) mutation are the two prevalent molecular alterations associated with papillary thyroid carcinoma (PTC), and their identification is increasingly being used as an adjunct to cytology in diagnosing PTC. However, there are caveats associated with the use of the molecular approach in fine-needle aspiration (FNA), particularly for RET/PTC, that should be taken into consideration. It has been claimed that a clonal or sporadic presence of this abnormality in follicular cells can distinguish between malignant and benign nodules. Nevertheless, the most commonly used PCR-based techniques lack the capacity to quantify the number of abnormal cells. Because fluorescence in situ hybridization (FISH) is the most sensitive method for detecting gene rearrangement in a single cell, we compared results from FISH and conventional RT-PCR obtained in FNA of a large cohort of consecutive patients with suspicious nodules and investigated the feasibility of setting a FISH-FNA threshold capable of distinguishing non-clonal from clonal molecular events. For this purpose, a home brew break-apart probe, able to recognize the physical breakage of RET, was designed. While a ≥3% FISH signal for broken RET was sufficient to distinguish nodules with abnormal follicular cells, only samples with a ≥6.8% break-apart FISH signal also exhibited positive RT-PCR results. On histological analysis, all nodules meeting the ≥6.8% threshold proved to be malignant. These data corroborate the power of FISH when compared with RT-PCR in quantifying the presence of RET/PTC in FNA and validate the RT-PCR efficiency in detecting clonal RET/PTC alterations.

The surgical treatment of a rare complication: gallstone ileus.

The authors describe 3 cases of gallstone ileus observed in two different hospitals and evaluate the current rarity of this complication of the biliary lithiasis and/or of cholangiocarcinomas. There were two cases of stones at the ileal level and one case in the left colon. In one case a single surgical intervention was carried out while in the other a two-step strategy was adopted. Notwithstanding the fact that the correct strategy to adopt is still controversial in literature, the authors discuss the single and double step strategies and propose that the second intervention of the 2-step strategy should not be performed in high risk surgical patients.