Abdominal Wall Reconstruction Utilizing the Combination of Absorbable and Permanent Mesh in a Retromuscular Position: A Multicenter Prospective Study.

BACKGROUND: Optimal mesh reinforcement for abdominal wall reconstruction (AWR) in complex hernias remains questionable. Use of biologic, absorbable and synthetic meshes has been described. The idea of using an absorbable mesh (AM) under a permanent mesh (PM) in a retromuscular position may help in these challenging situations. METHODS: Between 2011 and 2016, consecutive patients undergoing open AWR utilizing an AM as posterior layer reinforcement and configuration of a large PM were identified in a multicenter prospectively maintained database in four hospitals. Main outcomes included demographics, ventral hernia classifications, perioperative data, complications and recurrences. RESULTS: A total of 169 complex incisional hernias were analyzed. Mean age was 60.9, with mean body mass index 30.7 (range: 20-46). Location of incisional hernias (IH) was: 80 midline, 59 lateral and 30 midline and lateral. 78% were grade I and II in Ventral Hernia Working Group classification. 52% of patients were discharged with no complication. There were 19% seromas, 13% hematomas, 12% surgical-site infection and 10% skin dehiscence. Only partial mesh removal was necessary in one patient. After a mean follow-up of 26 months (range 15-59), there were five (3.2%) recurrences. Reoperations on patients showed a band of fibrosis separating the peritoneum from the PM. CONCLUSION: The combination of AM with very large PM in the same retromuscular position in AWR seems to be safe. The efficacy with recurrence rates below 4% in complex midline and lateral IH may be explained by the use of larger PMs that are extended and configured with the support of AMs. Reoperations on patients have confirmed the previous experimental reports on the use of the AM.

Revisión de las perforaciones duodenales tras colangiopancreatografía retrógrada endoscópica en el Hospital Puerta de Hierro de 1999 a 2014 / Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014

Introducción: la colangiopancreatografía retrógrada endoscópica (CPRE) sigue siendo la prueba de elección para el diagnóstico y el tratamiento de la patología biliar y pancreática, pero cuenta con una tasa de morbimortalidad no desdeñable, por lo que se proponen algoritmos para el manejo y tratamiento de sus complicaciones. Objetivo: revisar las perforaciones post-CPRE tratadas en el Servicio de Cirugía General del Hospital Puerta de Hierro de 1999 a 2014, evaluando los resultados en función del tipo de perforación y el tratamiento. Métodos y resultados: se ha realizado un estudio descriptivo y observacional de todas las perforaciones post-CPRE comunicadas y tratadas por el Servicio de Cirugía General del Hospital Puerta de Hierro de 1999 a 2014, en relación a la indicación de la prueba y hallazgos, el tipo de perforación (clasificación de Stapfer), el tiempo hasta el diagnóstico y el método de diagnóstico, el tiempo hasta la intervención y la técnica empleada, las complicaciones posteriores, así como la evolución y el tiempo de ingreso. Los resultados se han evaluado en función del tipo de perforación (Stapfer) y del tipo de tratamiento realizado. Se comunicaron 36 perforaciones (21 de tipo I, ocho de tipo II, dos de tipo III y cinco de tipo IV), lo que supone una incidencia menor del 1%. El diagnóstico fue inmediato (en las primeras 24 horas) en el 67% de los casos, siendo las de tipo I las más frecuentes. Se intervino a 28 de los 36 pacientes (77,7%), realizándose en la mayoría una colecistectomía seguida, siempre que fue posible, de sutura, colangiografía intraoperatoria y exploración de la vía biliar y drenaje. Fallecieron cuatro pacientes (dos intervenidos y dos manejados de manera conservadora), todos con perforaciones de tipo I. La complicación más frecuente fue la colección/fístula, que apareció en el 21,42% de los pacientes intervenidos. Conclusiones: el tratamiento de las perforaciones periduodenales secundarias a CPRE debe orientarse en función de los hallazgos clínicos y radiológicos. Según nuestra experiencia, las perforaciones de tipo I requieren una intervención quirúrgica inmediata, mientras que las perforaciones tipo II y III permiten, en algunos casos, un manejo conservador, siempre ante la ausencia de complicaciones como colecciones abdominales asociadas y/o signos de sepsis o de irritación peritoneal. Las perforaciones tipo IV responden bien al manejo conservador

Introduction: endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications. Objective: to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment. Methods and results: this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery. Conclusions: periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management

Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014.

INTRODUCTION: endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications. OBJECTIVE: to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment. METHODS AND RESULTS: this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery. CONCLUSIONS: periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management.

How we do it: down to up posterior components separation.

BACKGROUND: Posterior component separation with transversus abdominis release technique is increasingly being used for abdominal wall reconstruction in complex abdominal wall repair. The main purpose of this study is to present a modification of the surgical technique originally described that facilitates the surgical procedure and offers additional advantages. METHODS: Based on the knowledge of the anatomy of the retromuscular space and the preperitoneal aerolar tissue distribution, we start the incision on the posterior rectus sheath from the arcuate line in a down to up direction. The posterior rectus sheath is incised 0,5-1 cm medial to the linea semilunaris and cut longitudinally as far as the fibers of transversus abdominis muscle that are divided in the superior part of the abdomen. It is also possible to avoid cutting the fibers of this muscle if we incise the posterior rectus sheath in an oblique direction to the midline from the umbilical area. Since 2012 to 2016, 69 consecutive patients with down to up TAR have been prospectively followed. Main outcome measures included demographics, perioperative details, wound complications, and recurrences. RESULTS: Between 2012 and 2016, we have operated 69 patients with down to up TAR technique. Mean operative time was 251 (range 65-566) minutes. Mean hospital stay was 9,8 (2-98) days. 10 patients presented surgical site events (14,5%): 6 patients had superficial site infection, 3 deep and 1 organ space. During follow-up, 3 patients (4,3%) presented incisional hernia recurrence. CONCLUSIONS: This novel modification allows a simpler dissection of the preperitoneal retromuscular space and makes the TAR technique easier to perform. It also enables to incise only the insertion of the transversalis fascia cranially.

Duodenectomía total con preservación pancreática como tratamiento de la poliposis duodenal / Total duodenectomy with panceratic preservation for duodenal polyposis

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Hernia de Garengeot: hernia crural incarcerada conteniendo el apendice. Revisión de la literatura a proposito de 2 casos / De Garengeot's hernia: Incarcerated femoral hernia containing the vermiform appendix. Report of two cases and literature review

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Colecistitis hemorrágica perforada / Perforated hemorrhagic cholecystitis

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