The reality of general surgery training and increased complexity of abdominal wall hernia surgery.

INTRODUCTION: The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature. METHODS: A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated. RESULTS: All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures. CONCLUSION: A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project.

INTRODUCTION: There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems. METHODS: The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries. RESULTS: The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center. CONCLUSION: Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

The management of sportsman's groin hernia in professional and amateur soccer players: a revised concept.

BACKGROUND: Chronic groin pain appears in athletes with a diverse etiology. In a select few, it can be defined as a sportsman's hernia, that may be related, among other pathologies, to weakness of the posterior inguinal wall and may successfully respond to surgery. HYPOTHESIS: Surgical repair of the sportsman's hernia is associated with good functional outcomes, if the diagnosis is based on meticulous examination and follows a simple selection flowchart. STUDY DESIGN: Prospective case cohort study. METHODS: The study assessed patients recruited from 2006 until the present assessed by a dedicated team with clinical and radiographic features of a sportsman's hernia who had failed a specified period of conservative therapies. Surgery was performed using a tension-free mesh open inguinal hernia repair. RESULTS: Of 246 male patients with chronic groin pain, 51 underwent surgery (mean age 20.7 years, range 14-36 years) with 58 inguinal procedures performed. Of the operated group, seven underwent bilateral surgery with a direct hernia found in 9/58 operated sides (15.5%), an indirect hernial sac in 8/58 (14%) and a direct and indirect hernia being found in 3/58 (5%) of operated sides. There was no post-operative morbidity (median follow-up 36.1 months; range 1-74 months), with two failures (3.45 % of operated sides). All other patients were asymptomatic, returned to full sports activity within 4.3 weeks (range 3-8 weeks) after surgery, and required no analgesics or further treatment. CONCLUSION: Selective surgical hernia repair, based on meticulous anamnesis and physical examination is effective in the management of chronic groin pain in athletes.

Video-assisted open supraclavicular sympathectomy following air embolism.

BACKGROUND: Air embolism is a relatively rare complication of thoracoscopic surgery. METHODS: Open supraclavicular sympathectomy was indicated to overcome the risk of re-embolization. A novel video-assisted technique was performed. conclusions: The previously prevalent open supraclavicular sympathectomy is a good choice for avoiding air embolism. Laparoscopic instrumentation and technology can be used to improve open procedures, especially when exposure and visibility are limited. Sometimes we should remember to use the experience of our teachers.

Volume-controlled vs no/short-term drainage after axillary lymph node dissection in breast cancer surgery: a meta-analysis.

It is unknown whether there are any clinically relevant differences between volume-controlled (<30-50 ml/24h across trials) vs no/short-term drainage after axillary lymph node dissection in breast cancer surgery on outcomes such as seroma formation, wound infection or length of hospital stay. Randomised controlled trials comparing volume-controlled drainage vs no or short-term drainage after axillary lymph node dissection in breast cancer surgery were identified systematically using Pubmed, EMBASE and The Cochrane library. Trial data were reviewed and extracted independently by two reviewers in a standardised unblinded manner. Six randomised controlled trials which included a total of 561 patients fulfilled our inclusion criteria. Patients randomised to volume-controlled drainage were less likely to develop clinically relevant seromas compared to patients randomised to no/short-term drainage. There was, however, no difference in wound infections between patients treated with volume-controlled drainage and patients with no or short-term drainage. Patients randomised to volume-controlled drainage stayed significantly longer in hospital than patients randomised to no/short-term drainage. Based on available evidence, clinically relevant seromas occur more frequently in patients treated with no/short-term drainage. However, no/short-term drainage after axillary lymph node dissection does not lead to an increase in wound infections and is associated with shorter hospital stay.

Magnetic resonance guided focused ultrasound surgery. Ablation of soft tissue at bone-muscle interface in a porcine model.

BACKGROUND: Pain management treatments of patients with bone metastases have either efficacy problems or significant side effects. Percutaneous radiofrequency ablation has recently proved to be of palliative value. Magnetic resonance guided focused ultrasound surgery (MRgFUS) uses focused ultrasonic energy to non-invasively create a heat-coagulated lesion deep within the body in a controlled, accurate manner. The surgeon can monitor and control energy deposition in real time. This technology represents a potential treatment modality in oncological surgery. We investigated the ability of two MRgFUS methods to accurately and safely target and ablate soft tissue at its interface with bone. MATERIALS AND METHODS: Heat-ablated lesions were created by MRgFUS at the bone-muscle interface of 15 pigs. Two different methods of energy delivery were used. Temperature rise at the target adjacent to bone was monitored by real time MR thermal images. Results were evaluated by MRI (magnetic resonance imaging), nuclear scanning and by histopathological evaluation. RESULTS: Soft tissue lesion sizes by both methods were in the range of 1-2 cm in diameter. Targeting the focus 'behind' the bone, achieved the same result with a single sonication only. Follow up MRI and histopathological examination of all lesions showed focal damage at its interface with bone and localized damage to the outer cortex on the side closer to the targeted tissue. There was no damage to non-targeted tissue. CONCLUSION: MRgFUS by both energy deposition methods can be used to produce controlled well-localized damage to soft tissue in close proximity to bone, with minimal collateral damage.

MR-guided focused ultrasound surgery (MRgFUS) for the palliation of pain in patients with bone metastases--preliminary clinical experience.

BACKGROUND: Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a noninvasive thermal ablation technique, shown to be clinically effective in the treatment of uterine fibroids and is being evaluated as a method of thermal ablation of benign and malignant breast tumors. To evaluate the safety and initial efficacy of MRgFUS for the palliation of pain caused by bone metastases, in patients for whom other treatments are either not effective or not feasible. MATERIALS AND METHODS: Thirteen patients suffering from symptomatic bone metastases underwent MRgFUS procedure. Treatment safety was evaluated by assessing the incidence and severity of device-related complications up to 6 months after treatment. Effectiveness of pain palliation was evaluated by visual analog scale, pain questionnaires and changes in the patients' medication. RESULTS: Fifteen procedures were carried out. Mean follow-up was 59 days. Twelve patients received adequate treatment and were available for follow-up. Two patients died due to disease progression during the first month after treatment. No severe adverse events were recorded. The remaining 10 patients reported prolonged improvement in pain score and/or reduced analgesic dosage. CONCLUSION: MRgFUS may provide a safe and effective noninvasive alternative for the palliation of pain, caused by bone metastases.

History of sympathetic surgery.

The first reported operation on the upper sympathetic system was performed by Alexander in 1889. The initial indications (epilepsy, exophthalmic goiter, idiocy, glaucoma) are obsolete. For some subsequent indications (angina pectoris, vasospastic disorders, and painful conditions) sympathectomy has still a limited application. The main indications today are hyperhidrosis (since 1920) and blushing. Renewed attempts to perform the operation for psychological conditions have been reported. The technique of sympathectomy has been modified over the century, with a trend to minimize the extent of surgery: from open to endoscopic approaches; from resection of ganglia to thermoablation, thermotransection, and clipping. The sequelae of the operation (mainly compensatory hyperhidrosis) present a major problem in a small percentage of operated patients. Techniques of reversal (by nerve grafting and unclipping) have been proposed. Meticulous follow-up studies are required to evaluate the merits of these techniques. Improved knowledge of the functions and interrelations of the autonomic nervous system is required to understand the mechanism of these sequelae and learn how to avoid or treat them.

Upper thoracic sympathetic surgery. Open surgical techniques.

Four open surgical approaches have been used to perform upper thoracic sympathectomy. The posterior approach requires access through the posterior muscles of the back, and rib transection. It is a painful operation that has been practically abandoned in favor of the other techniques. The anterior transthoracic approach consists of a formal thoracotomy and never gained popularity. The supraclavicular approach involves dissection of several important anatomical structures. It requires excellent surgical dexterity, but ensures the easiest postoperative recovery. The last approach involves a small transaxillary thoracotomy. Technically, it is the easier procedure. Both the supraclavicular and the transaxillary approaches were widely used until the advent of thoracoscopic surgery. The results (rate of success, recurrences, and sequelae) were similar for all techniques, depending on the procedure performed on the sympathetic chain, not on the access route. Open approaches for upper dorsal sympathectomy are not used any more except in the very rare cases in which thoracoscopy is unfeasible.

The pathophysiology of cervical and upper thoracic sympathetic surgery.

The main effect of upper thoracic sympathectomy is sudomotor. To abolish sweating of the palms, T(2) ganglionectomy (often with the addition of T(3)) was invariably performed. To prevent axillary sweating, additional T(4) ablation was recommended. Sympathectomy produces a vasodilatatory cutaneous effect. The circulation in the muscles, however, is unaltered or may even be reduced. It also appears that improved skin blood flow is on the thermoregulatory, not nutritive level. It seems that chronic surgical sympathectomy does not cause major changes in the vascular function of the forearm. Although the exact pathophysiological mechanism of blushing is still obscure, bilateral upper dorsal sympathectomy alleviates this phenomenon. T(2)-T(3) ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy. Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.

Intrapleural analgesia following thoracoscopic sympathectomy for palmar hyperhidrosis: a prospective, randomized trial.

BACKGROUND: Reports on intrapleural analgesia (IPA) are conflicting. The current study assessed the effect of a single-dose thoracoscopic bilateral intrapleural anesthetic administration on the immediate postoperative recovery room and 24-h pain control. METHODS: Fifty patients with primary palmar hyperhidrosis were randomly classified into two groups to receive either 20 ml of 0.5% bupivacaine and 5 mg/ml epinephrine or 0.9% NaCl in each thoracic cavity at the end of thoracoscopic T2-T3 sympathectomy. The degree of early postoperative pain was estimated by visual analog scale (VAS). The 24-h parenteral opioid analgesic requirement was recorded. RESULTS: The immediate postoperative VAS score (1.46 +/- 0.41 vs 2.0 +/- 0.61, p = 0.03), opioid consumption (0.42 +/- 0.36 vs 0.65 +/- 0.28, p = 0.0133), and 24-h opioid consumption (1.02 +/- 0.80 vs 1.48 +/- 0.84, p = 0.05) were significantly reduced following IPA compared to those of the control group. CONCLUSION: IPA is a simple and effective means for postoperative pain control following thoracoscopic upper dorsal sympathectomy.

Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis. The use of harmonic scalpel versus diathermy.

BACKGROUND: Upper dorsal thoracoscopic sympathectomy, the treatment of choice for primary palmar hyperhidrosis, is not devoid of long-term complications, like Horner's syndrome and postoperative neuralgia. It has been postulated that propagation of heat induced by diathermy may be responsible for some of these sequelae. To assess this hypothesis, a study was undertaken to evaluate the use of harmonic scalpel, which does not dissipate heat. METHOD: Sixteen patients with primary palmar hyperhidrosis underwent upper dorsal thoracoscopic sympathectomy using the harmonic scalpel on one side and diathermy on the other. Follow-up was made two years postoperatively. RESULTS: The length of the procedure with each instrument was similar. There was no localization of postoperative pain, which could be attributed to either device. No Horner's syndrome or postoperative neuralgia occurred. CONCLUSION: The present study proved the safe use of harmonic scalpel for upper dorsal thoracoscopic sympathectomy, but did not detect any important advantage of either instrument over diathermy.

Impact of intraoperative sonography on resection and cryoablation of liver tumors.

PURPOSE: We retrospectively analyzed the impact of intraoperative sonography (IOUS) on the management of patients referred for resection of liver tumors. METHODS: Forty patients underwent IOUS with a 7-MHz curved-array sector transducer; in selected cases, a 5-MHz linear-array transducer attached to a color Doppler unit was also used. The number, size, and location of tumors on IOUS, including tumor proximity to or invasion of major vessels or invasion of the diaphragm, were compared to findings on preoperative imaging studies. The effect of these findings on surgical management was assessed. Unresectable lesions were treated by cryoablation under ultrasound guidance. RESULTS: IOUS detected preoperatively unsuspected lesions in 7 patients (18%). Metastases suspected on CT arterial portography were ruled out in 2 patients (5%), and indeterminate lesions were diagnosed as cysts by IOUS in 2 other patients (5%). Vascular proximity or vascular or diaphragmatic invasion detected by IOUS rendered lesions unresectable in 4 patients (10%). Cryoablation under IOUS guidance and monitoring was attempted in 11 patients (28%) and performed successfully in 10. CONCLUSIONS: IOUS changed the management in 38% of patients and guided cryoablation in 28% of patients. IOUS performed by an experienced sonologist is invaluable for the accurate assessment of liver tumor resectability; the detection of additional, preoperatively unknown lesions; and the guidance of cryoablation of unresectable tumors.

Thoracoscopic sympathectomy for palmar hyperhidrosis. Ablate or resect?

BACKGROUND: Upper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques. METHODS: A Medline search was performed for the years 1974-99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis. RESULTS: In all, 33 studies were identified and divided into two groups-ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p = 0.00001). Palmar sweating recurred in 0% of patients treated via resection and -4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p = 0.017). CONCLUSIONS: Resection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner's syndrome, and because resympathectomy eventually overcomes initial failure.

Cryohemostasis of uncontrolled hemorrhage from liver injury.

Uncontrolled hemorrhage is the primary cause of death in both blunt and penetrating liver trauma. Cryohemostasis was attempted in the past for elective liver surgery but did not gain popularity. During past decades, cryoequipment was refined and successfully used for tumor ablation. The purpose of the present study was to assess the efficacy of cryosurgery as a potential adjuvant hemostatic technique in the treatment of grades III-IV liver injuries. A standard liver crush-evulsion injury was created in pigs. In the control group, the liver was left to bleed freely. In the experimental group, the severed liver surface was immediately frozen to -160 degrees C for 10 min, spontaneously thawed, and left to bleed thereafter. Blood pressure, pulse rate, urine output, and serum lactate were monitored. The total blood loss was measured 180 min after liver injury was inflicted. The volume of frozen liver parenchyma was measured. For further laboratory evaluation, three additional experimental animals were not sacrificed and recovered. Cryohemostasis significantly reduced blood loss and substantially attenuated hemorrhagic shock. The frozen liver parenchyma underwent necrosis but did not jeopardize survival. Cryosurgery may be an efficient adjuvant technique in the early control of hemorrhage in grades III-IV liver injury.

The effect of upper dorsal thoracoscopic sympathectomy on the total amount of body perspiration.

Thoracoscopic T2-T3 sympathectomy is the treatment of choice for primary palmar hyperhidrosis (PPH); however, compensatory hyperhidrosis (CH) is a disturbing sequela of this operation, the mechanism of which is poorly understood. This study was conducted to evaluate the effect of heat stress on total body perspiration after thoracoscopic T2-T3 sympathectomy, and determine its correlation with CH. A total of 17 patients with PPH who underwent bilateral T2-T3 sympathectomy were subjected to heat stress induced by a 10-min sauna bath (ambient temperature 70 degrees C), 1 day before and 1 month after surgery. The naked body weight was recorded before and immediately following the sauna bath, and the patients were followed up to assess whether CH had developed and the degree of its severity. Postoperatively, the amount of perspiration increased in 13 patients and decreased in 1. The amount of perspiration induced by the sauna bath ranged from 60 to 480 g, with a mean value of 185.29 +/- 125.80 g, before the operation, and from 60 to 540 g, with a mean value of 265.88 +/- 154.05 g, after the operation (P = 0.0113). There was no correlation between the degree of alteration in total body perspiration and the development of CH. Performing thoracoscopic T2-T3 sympathectomy for PPH affects the total body sweating response to heat; however, the development of CH does not correlate with this alteration.

The treatment of primary palmar hyperhidrosis: a review.

Primary palmar hyperhidrosis (HH) is a pathological condition of overperspiration caused by excessive secretion of the eccrine sweat glands, the etiology of which is unknown. This disorder affects a small but significant proportion of the young population all over the world. Neither systemic nor topical drugs have been found to satisfactorily alleviate the symptoms. Although the topical injection of botulinum has recently been reported to reduce the amount of local perspiration, long-term results are required before a definitive evaluation of this method can be made. Hypnosis, psychotherapy, and biofeedback have been beneficial in a limited-number of cases. While radiation achieves atrophy of the sweat glands, its detrimental effects prohibit its use. Iontophoresis has attained some satisfactory results but it has not been assessed long term. Percutaneous computed tomography-guided phenol sympathicolysis achieves excellent immediate results, but its long-term failure rate is prohibitive. Furthermore, percutaneous radiofrequency sympathicolysis may be an effective procedure, but its long-term results are not superior to surgical sympathectomy. On the other hand, surgical upper dorsal (T2-T3) sympathectomy achieves excellent long-term results and the thoracoscopic approach has supplanted the open procedures. Despite some sequelae, mainly in the form of neuralgia and compensatory sweating which cannot be predicted and may be distressing, surgical sympathectomy remains the best treatment for palmar hyperhidrosis.