Pre-operative assessment of internal mucosal rectal prolapse in internal hemorrhoids: technical details and results from a single institution.

BACKGROUND: The aim of the study was to assess safety and efficacy of pre-operative assessment for internal mucosal rectal prolapse (IMRP) in internal hemorrhoids, in order to achieve a tailored transanal stapled surgery. METHODS: All consecutive patients (January 2011 to December 2014; age 18-80 years), affected by prolapses with II-IV degrees hemorrhoids that underwent Longo procedure with EEA® Auto Suture stapler (Covidien) were included in the present study. RESULTS: A total of 100 consecutive patients (38 females) were enrolled in the study. Preoperative Visual Analogue Scale pain assessment was 7.33±2.68. The mean duration of the procedure was 34.1±17.8 min, and the median hospital stay was 2 days (range 2-6). No major complication occurred, including relapses of mucosal prolapse. Preoperative prolapse measurement with EEA® EEA® Auto Suture stapler (2.3±0.5 cm) was well correlated direct assessment (2.4±0.6, p<0.001), but a proportional bias was identified, with significant preoperative underestimation of IMRP, particularly for lesions larger than 3 cm (around 10% of actual extent). CONCLUSIONS: EEA® Auto Suture stapler seems to be safe and effective for a tailored approach to anorectal prolapse due to hemorrhoids. However, it reasonable that its actual impact may have been overestimated, beneficing of the repetitive, direct assessment of the operatory field guaranteed by preoperative IMRP measurement.

Comparison between self-gripping, semi re-absorbable meshes with polyethylene meshes in Lichtenstein, tension-free hernia repair: preliminary results from a single center.

Even tough inguinal hernia repair is among the commonest operations in general surgery, the choice for an optimal approach continues to be a controversial topic. Because of the low recurrence rates and low prevalence of complications, tension-free mesh augmented operation has become the standard technique in inguinal hernia surgery, significantly reducing hernia recurrence rates. On the contrary, prevalence of chronic postoperative groin pain (CPGI) i.e. pain beyond a three month-postoperative period still remains significant: as rates of CPGI may range between 15% and 53%, surgical approaches aimed to avoid chronic post-hernioplasty pain have been extensively debated, and the avoidance of CPGI has become one of the primary endpoints of surgical research on inguinal hernia repair). Recently, a sound base of evidence suggested that the entrapment of peripheral nervous fibers innervating part of the structures in the inguinal canal and stemming from ilioinguinal (Th12), iliohypogastric (L1) nerves as well as from the genital branch of the genito-femoral nerve (L1, L2), may eventually elicit CPGI (1-10). Consequently, innovative fixation modalities (e.g. self-gripping meshes, glue fixation, absorbable sutures), and new material types (e.g. large-pored meshes) with self-adhesive sticking or mechanical characteristics, have been developed in order to avoid penetrating fixings such as sutures, clips and tacks. However, some uncertainties still remain about the pros and cons of such meshes in terms of chronic pain, as new, innovative mesh apparently does not significantly reduce the rate of CPGI. Parietex ProGrip® (MedtronicsTM) is a bicomponent mesh comprising of monofilament polyester and a semi re-absorbable polylactic acid gripping system that allows sutureless fixation of prosthetic mesh to the posterior inguinal wall. As ProGrip® does not requires additional fixation, inguinal canal may be closed within minutes after adequate groin dissection, ultimately shortening operating time. In other words, ProGrip® has the potential for significant savings, in terms of surgical and post-operating costs as well (10). The aim of our study is therefore to compare the results of the same technique with two different mesh materials (ProGrip® mesh vs. polyethylene mesh), in terms of operative time, post-operative pain, complications, and recurrence rates.

Vaginal cuff dehiscence resulting in small-bowel evisceration. A case report.

Vaginal cuff dehiscence is a rare complication of hysterectomies which seems to be more frequent after surgery with laparoscopic suture of the cuff. We present a clinical case of evisceration of the small bowel emerging from vaginal cuff dehiscence, successfully repaired by positioning a low profile polypropylene ePTFE mesh*.

Totally laparoscopic right colectomy: theoretical and practical advantages over the laparo-assisted approach.

BACKGROUND: The improvement in intracorporeal anastomotic techniques and the consequent switch from a laparo-assisted (LA) to a totally laparoscopic (TL) right colectomy seem to have overcome the initial concerns, giving rise to the widespread use of such a procedure. By comparing the LA and TL approaches, our study was aimed at verifying the possible advantages of the more recent technique, while also focusing on some technical implications for the surgeon. SUBJECTS AND METHODS: We prospectively collected and matched data from 27 consecutive LA right colectomies and 28 consecutive TL right colectomies (TLRCs). Clinical, biochemical, pathological, and cosmetic parameters were examined. Operating times were recorded and analyzed, in order to evaluate the learning curve for the different phases of the procedure. RESULTS: The LA and TL groups were homogeneous for demographic and pathological features. We had no mortality, and surgical complication rates were similar (3.6% versus 3.7%). The TLRC group presented a significantly shorter laparotomy (4.8 cm versus 7.2 cm, P=.002), whereas no significant difference was recorded for outcome parameters. Operating time for carrying out anastomosis was significantly longer for the TL group (55.6 minutes versus 20.6 minutes, P<.0001). A rapid decrease in anastomosis time throughout the series attests to a short learning curve for intracorporeal ileotransverse anastomosis. CONCLUSIONS: Further studies are needed to demonstrate possible clinical advantages of TLRC over the LA approach. The cosmetic benefit for patients along with safety and the prospective usefulness for surgeons (practice in intracorporeal suturing techniques) would seem to justify an inclination toward this technical development.

Laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis: a new step in the treatment of slow-transit constipation.

BACKGROUND: Subtotal colectomy with antiperistaltic cecorectal anastomosis (SCCRA) has proved to be an effective alternative to total colectomy for the treatment of severe slow-transit constipation. The laparoscopic approach has made this procedure even more attractive. This is the first controlled trial on laparoscopic SCCRA. The study compares the laparoscopic and the open approach. METHODS: Since 2001, all SCCRAs have been performed laparoscopically at our institution. Only severely symptomatic patients are offered surgery, after stringent patient selection. Laparoscopic SCCRA was performed following the same steps that we first described for the open approach, by utilizing a five-trocar technique. Outcome parameters were prospectively collected every 3 and 6 months. Wexner constipation and incontinence scales (WCS, WI) and gastrointestinal quality of life index (GIQLI) were adopted for functional results. We conducted a case-control study of 15 consecutive patients who underwent laparoscopic SCCRA (VL) and 15 patients previously operated on by the open approach (Op) to compare postoperative and functional outcomes. RESULTS: The VL group had better postoperative outcomes (pain, ileus) while complication rates were similar. Resolution of constipation was impressive in both groups, with no significant difference at follow-up. The VL group presented with a higher number of bowel movements at 3 months (3.8 vs. 2.8, p = 0.039), resulting in a significantly higher incontinence rate at 3 months (WI 6.4 vs. 2.73, p = 0.004), although the difference was no longer significant at 1-year follow-up. The quality of life was good for both groups; the VL group showed a significant improvement at 1-year follow-up (64.18 vs. 114.79, p < 0.01). CONCLUSIONS: Laparoscopic SCCRA confirmed the good functional results of the open approach, with no increase in morbidity rate and a faster postoperative recovery. An early higher incontinence rate did not affect quality of life.

Subtotal colectomy with antiperistaltic cecorectal anastomosis in the treatment of slow-transit constipation: long-term impact on quality of life.

BACKGROUND: The aim of the study was to evaluate the effectiveness of subtotal colectomy with cecorectal anastomosis (SCCA) in the treatment of slow-transit constipation, not just in terms of symptom resolution but also the overall impact on patients' quality of life. METHODS: Between 1991 and 2005, 43 patients underwent SCCA at our institution, 22 for slow-transit constipation (STC) and 21 for other types of colic diffuse disease (non-slow-transit constipation: NSTC), the latter being considered controls. A total of 29 patients (17 affected by STC) were administered a 50-item telephonic questionnaire, including the Gastrointestinal Quality of Life Index (GIQLI), the Wexner constipation and incontinence scale (WC, WI), and individual willingness to repeat the procedure. Questionnaire data and other parameters such as age, sex, length of follow-up, complications, and length of hospital stay were analyzed and compared, in order to evaluate possible correlations between the parameters and their related impact on quality of life, procedural effectiveness in terms of symptomatic regression, qualitative differences related to pathology (constipation versus non-constipation), and surgical approach (laparotomy versus video-laparo-assisted procedure). RESULTS: There were no procedure-related deaths in this series (mortality: 0%); however, we found two complications in the STC group (9.1%), one requiring reoperation. The GIQLI mean score for the STC group was 115.5 +/- 20.5 (mean score for healthy people 125.8 +/- 13), and the WC mean score passed from a preoperative value of 20.3 to a postoperative value of 2.6. Regression analysis revealed a significant correlation between GIQLI and urgency and abdominal pain, and abdominal pain correlated significantly with pathology (STC). A high number of patients (88.2% in STC) expressed a willingness to repeat the procedure given the same preoperative conditions. CONCLUSIONS: Comparing our results to those of the most homogeneous literature data, SCCA does not appear to be inferior to subtotal colectomy with ileorectal anastomosis (IRA) in terms of therapeutic effectiveness, postoperative mortality and morbidity, or overall impact on quality of life.