Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis.

INTRODUCTION: Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve. METHODS: Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve. RESULTS: Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications. CONCLUSIONS: This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.

Learning curve in open inguinal hernia repair: a quality improvement multicentre study about Lichtenstein technique.

PURPOSE: Inguinal hernia repair is one of the most performed procedure all over the world with more than 20 million procedures performed each year. Due to the lack of data in literature about the learning curve of the Lichtenstein procedure, we decided to reproduce a research on learning curves with the same methodology proposed in our previous study about laparoscopic hernia repair. The aim of this multicentre study was to analyse how many cases are required to achieve the learning curve for a Lichtenstein procedure. METHODS: We performed a retrospective analysis of the first 100 Lichtenstein procedures performed by 4 trainees from three different institutions and compared them with the same number of procedures performed by 3 senior surgeons from the same institutions. The data about the achieving of learning curve were evaluated with CUSUM and KPSS test. RESULTS: No differences about biometrical features were found between the seven groups of patients. CUSUM analysis showed that the trainees achieve the learning curve after 37-42 procedures, reaching an operative time similar to that one of the senior surgeons. CONCLUSIONS: In conclusion, we have shown that the number of procedures required to reach the learning curve from the beginning of surgical residency is around 40 hernia repairs. This number, produced in a controlled environment under strict supervision, could be the minimum requirement to start the procedure of accreditation and specialization in hernia surgery and is higher and steeper than previously reported.

Heterochromatin characterization and ribosomal gene location in two monotypic genera of bloodsucker bugs (Cimicidae, Heteroptera) with holokinetic chromosomes and achiasmatic male meiosis.

Members of the family Cimicidae (Heteroptera: Cimicomorpha) are temporary bloodsuckers on birds and bats as primary hosts and humans as secondary hosts. Acanthocrios furnarii (2n=12=10+XY, male) and Psitticimex uritui (2n=31=28+X1X2Y, male) are two monotypic genera of the subfamily Haematosiphoninae, which have achiasmatic male meiosis of collochore type. Here, we examined chromatin organization and constitution of cimicid holokinetic chromosomes by determining the amount, composition and distribution of constitutive heterochromatin, and number and location of nucleolus organizer regions (NORs) in both species. Results showed that these two bloodsucker bugs possess high heterochromatin content and have an achiasmatic male meiosis, in which three regions can be differentiated in each autosomal bivalent: (i) terminal heterochromatic regions in repulsion; (ii) a central region, where the homologous chromosomes are located parallel but without contact between them; and (iii) small areas within the central region, where collochores are detected. Acanthocrios furnarii presented a single NOR on an autosomal pair, whereas P. uritui presented two NORs, one on an autosomal pair and the other on a sex chromosome. All NORs were found to be associated with CMA3 bright bands, indicating that the whole rDNA repeating unit is rich in G+C base pairs. Based on the variations in the diploid autosomal number, the presence of simple and multiple sex chromosome systems, and the number and location of 18S rDNA loci in the two Cimicidae species studied, we might infer that rDNA clusters and genome are highly dynamic among the representatives of this family.

Laparoscopic incisional hernia repair by lightweight polypropylene mesh with resorbable coating. Technical notes, preliminary results.

Laparoscopic repair of ventral hernias has gained popularity, since many studies have reported encouraging results. The choice of the mesh and fixation methods are crucial issues in preventing complications and recurrence. 30 laparoscopic ventral hernia repair performed consecutively in 28 patients (11 males, 17 females) for different kinds of incisional hernias from February 2011 to June 2012 were prospectively evaluated. All patients received total laparoscopic incisional hernia repair by the use of the new lightweight polypropylene mesh with resorbable coating (PhysiomeshTM, Ethicon Endo-Surgery, Johnson Johnson, Inc.). No major postoperative complications were reported. Two recurrences were diagnosed after 5 months from the first repair. Both patients received laparoscopic repair by the same kind of mesh. Lightweight polypropylene mesh with resorbable coating, with its properties of easy positioning and bio-compatibility, represents an innovation in laparoscopic incisional hernia repair, and should be considered for clinical intra-operative as well as long term evaluations.

[Unusual cause of acute abdomen in adult patient: gallstone ileus]. / Insolita causa di addome acuto in paziente adulto: l'ileo biliare.

INTRODUCTION: Gallstone ileus is a rare complication of cholecystolithiasis. It causes 1-3% of the mechanical obstructions of the small bowel. It often affects patients between 63 and 85 years old. Pre-operative diagnosis is usually delayed 1-10 days because there is not a specific symptomatology. CASE REPORT: The authors report the case of a 50 year-old man with diagnosis of mechanical obstruction of the small bowel caused by a voluminous gallstone. Ileal occlusion was showed by CT. The patient underwent to one-stage emergency surgery with enterolithotomy, cholecystectomy and duodenal fistula repair. Patient's recovery was regular and he was discharged fourteen days after surgery. DISCUSSION: In our case gallstone ileus was diagnosed with a delay of 5 days. Ultrasonography was not able to show the gallbladder. Diagnosis was made by CT, which is the diagnostic gold standard. CONCLUSION: Patient's performance status influences surgical strategy. In our experience, the patient underwent one-stage surgery because he was considered at low risk. Instead staged procedure with enterolithotomy and delayed cholecystectomy and fistula repair, is performed only in patients at high risk.

[Umbilical primary endometrioma. Case report]. / Endometriosi primitiva ombelicale. Caso clinico.

Umbilical primary endometrioma is a rare extra-uterine localization of endometriosis with a documented neoplastic risk. It is often difficult to distinguish primary umbilical endometriosis from other benign and malignant tumors of the abdominal wall. The Authors report a case of umbilical endometriosis in a 36-year old female. Endometriosis was suspected because of the presence of the typical cyclic bleeding and swelling. Abdominal CT excluded the presence of other endometriotic localizations. The umbilical mass was widely excised together with umbilicus, fascia and peritoneum. The tissue defect was primary closed without prosthetic mesh. Histological examination of the specimen showed the presence of endometrial glands with stromal component, compatible with the diagnosis of endometriosis. The Authors suggest that surgery should be performed in the first 3-4 days of the follicular phase, to minimize the risk of diffusion of endometriotic cells. Moreover, the excision should be wide in order to prevent local recurrence.

[Host plants of Cerambycidae (Coleoptera) from northwest and central Argentina]. / Plantas hospedadoras y biogeografía de Cerambycidae (Coleoptera) del noroeste y centro de la Argentina.

Seventy four species of Cerambycidae (Coleoptera) were reared from forty eight host plants found into Yungas, Chaco and Prepuna phytogeografical provinces. The host plants belong Anacardiaceae, Asclepiadaceae, Bignoniaceae, Cactaceae, Cucurbitaceae, Euphorbiaceae, Juglandaceae, Leguminosae sensu lato (Caesalpinaceae, Fabaceae, Mimosaceae), Loranthaceae, Rhamnaceae, Rutaceae, Salicaceae, Sapindaceae, Solanaceae, Ulmaceae and Vitaceae. Some species of Cerambycidae and their host plants show similar distribution patterns: from northeastern Brazil through Paraguay and reach the Argentina at both sides of the Chaco Provine: at the east, along the river systems through Buenos Aires, and the at the west into forests of the Yungas Province or into North Sierra Chaco, a probably relictual community. Others species are restricted to the South America area of Prosopis, that comprise the Chaco, Monte and Espinal biogeographical provinces, and live in host plants of chaquenian lineage mainly Leguminosae sensu lato and Ulmaceae.

[Host plants of Cerambycidae (Coleoptera) species in Espinal and Buenos Aires Province, Argentina]. / Plantas hospedadoras de Cerambycidae (Coleoptera) en el Espinal periestépico y en la provincia de Buenos Aires, Argentina.

The host plants of Cerambycidae (Coleoptera) in the Province of Espinal (Chaquenian Dominion) and the province of Buenos Aires are mainly exotics, cultivated or naturalized, the last ones growing spontaneously and forming little forests. Forty two species of Cerambycidae are reported using these plants and other native species as hosts. Hylotrupes bajulus, originally introduced and a serious pest of furniture, is reported for first time in spontaneous pine forests in Sierra de la Ventana, south of the province of Buenos Aires.

[Host plants of Cerambycidae (Coleoptera) in the northeast of Argentina]. / Plantas hospedadoras de Cerambycidae (Coleoptera) en el noreste de Argentina.

New host plants and localities are recorded for 84 species of Cerambycidae of Chaco Province (Chaquenian Dominion) and Paranaense Province (Amazonian Dominion) in northeastern Argentina and Brazil. Host plants belong to Anacardiaceae, Asclepiadaceae, Apocynaceae, Bignoniaceae, Bombacaceae, Cactaceae, Caesalpinaceae, Capparidaceae, Casuarinaceae, Fabaceae, Mimosaceae, Moraceae, Nyctaginaceae, Polygonaceae, Rhamnaceae, Rutaceae, Sapindaceae, Sapotaceae and Ulmaceae. First records for Argentina and host plants: Compsocerus barbicornis Serville 1834, Desmiphora lenkoi (Lane 1959), Neocompsa serrana (Martins 1962) and Trachysomus dromedarius (Voet 1778). First host plants records of rare or uncommon Argentine species of Cerambycidae are Methia tubuliventris Gounelle 1913, Paraleptidea femorata Gounelle 1913 and Oncideres pepotinga Martins 1981.