Laparoscopic incisional hernia repair in an ambulatory surgery-extended recovery centre: a review of 259 consecutive cases.

PURPOSE: The high prevalence of incisional hernias and an average stay of 3-10 days for open procedures have made this pathology both a health problem and an economic issue. A protocol was developed for performing this procedure in an Ambulatory Surgery Center (ASC) with extended recovery. METHODS: From January 2000 to December 2011, data about all laparoscopic incisional hernia repairs were gathered prospectively. The patients' clinical features, hernia type, intraoperative and postoperative complications and reasons for hospital admission are studied. RESULTS: A total of 259 patients have been operated for incisional hernia (185) or recurrent hernioplasty (74) in our ASC. Laparoscopic repair was successful in 254 patients (98.07 %). Conversion to open surgery was necessary in five patients (1.93 %). A total of 50 patients (19.69 %) in whom surgery was completed laparoscopically were discharged the same day of surgery, 179 (70.47 %) at 24 h and 25 (9.84 %) required a stay of over 24 h. Postoperative pain was severe in 10 % of patients, moderate in 40 %, and mild in 50 %. Complications, mostly minor and self-limiting, were observed in 25 patients (9.84 %) during hospital stay. Five major complications that occured were: bile peritonitis, an acute peritonitis, due to an inadvertent intestinal perforation, and one intestinal obstruction by partial detachment of the mesh, an intra-abdominal hematoma and a colo-cutaneous fistula. There were no deaths in the series. The mean follow-up of patients was 29.35 months (range 12-129 months). The recurrence rate was 7.03 % (n = 18). Four trocar-site hernias were detected. CONCLUSIONS: It is essential to create a protocol with selection criteria that take into account the patient, his entourage, the anesthetic-surgical procedure, and a team dedicated to surgical laparoscopic surgery in an ASC with extended recovery to achieve good results in terms of morbidity and patient safety.

Hernia de spiegel. Estado actual / No disponible

INTRODUCCIÓN: La hernia de Spiegel es un raro defecto en la pared abdominal anterior. Se revisan las características anatómicas, la etiología y la clínica de estas hernias. La incarceración y estrangulación son complicaciones frecuentes. Se exponen los procedimientos diagnósticos, el diagnóstico diferencial y las alternativas terapéuticas. DISCUSIÓN: El hecho de que esta hernia se localice debajo de la aponeurosis del músculo oblicuo externo, hace que su diagnóstico clínico sea muy difícil. La ecografía es una valiosa prueba complementaria. La tomografía computarizada desempeña un papel destacado en el diagnóstico de las hernias de Spiegel. El tratamiento es quirúrgico, con pocas recidivas. La deficiencia de tejido conectivo en pacientes con hernias justifica el uso de mallas para el refuerzo tisular. El abordaje endoscópico permite una buena visión de las estructuras y hace innecesario abrir la aponeurosis del músculo oblicuo externo, reduciendo el riesgo de recurrencias y de infección postoperatoria. CONCLUSIONES: El diagnóstico de las hernias de Spiegel es a menudo difícil a causa de su sintomatología insidiosa. Estas hernias presentan serias complicaciones en un alto porcentaje de casos. Recomendamos el examen ecográfico en los casos dudosos de dolor abdominal. La tomografía computarizada es superior a la ecografía en demostrar el defecto parietal e identificar el contenido del sacoherniario. El tratamiento es quirúrgico, con excelentes resultados. Antes de aprobar el uso rutinario del abordaje videoendoscópico es esencial evaluar esta técnica con ensayos randomizados y prospectivos, que demuestren mayores beneficios en cuanto a hospitalización más reducida, la analgesia postoperatoria en la infección de la herida quirúgica (AU)

INTRODUCTION: Spigelian hernias are a rare anterior abdominal wall defect. The anatomic characteristics of the region, the etiology and the clinical features of spigelian hernias are described. Incarceration or strangulation are common complications. We present the diagnostic procedures, differential diagnosis and therapeutic alernatives. DISCUSSION: The fact that this hernia is located beneath the aponeurosis of the external oblique muscle makes its clinical diagnosis extremely difficult. Ultrasound examination is avaluable diagnostic tool. Computed tomography plays a primary role in the diagnosis of spigelian hernia. The treatment of spigelian hernia is surgical, with low risk of relapses. The deficiency of connective tissue in patients with (..) (AU)

[Necrotizing infections of the soft tissues. Apropos of 40 cases]. / Infecciones necrosantes de partes blandas. A propósito de 40 casos.

The diagnosis of necrotizing soft tissue infection (NSTI) is based on a high suspicion index and/or clinical experience. Mortality is associated with delayed diagnosis and use of early surgical treatment, and also with the underlying disease and the patient's age. Usually they are mixed infections; therefore, in addition to surgical therapy an adequate antibiotic coverage is required. The latter, in cases of severe renal failure, might consist in monotherapy. All these guidelines can be modified on the basis of bacteriological findings. The Gram stain of a surgical sample can be very useful to select an appropriate empirical therapy. From a clinical point of view, we suggest to pay extreme attention to the findings consistent with NSTI: tenderness and/or crackling of soft tissue, rapid expansion through natural planes, or visualization of gas in the x-ray film of the involved zone, particularly if associated with a rapid deterioration of the general condition of the patient.