Use of a bioabsorbable mesh in midline laparotomy closure to prevent incisional hernia: randomized controlled trial.

INTRODUCTION: The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention. MATERIALS AND METHODS: A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n = 167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n = 165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan. RESULTS: At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively. CONCLUSION: The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a "palliative" transient effect for preventing IH in the long-term.

Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis.

BACKGROUND: Incisional hernia is a frequent complication after abdominal surgery. The aim of this study was to assess the efficacy of prophylactic mesh reinforcement (PMR) after midline laparotomy in reducing the incidence of incisional hernia. METHODS: A meta-analysis was conducted following PRISMA guidelines. The primary outcome was the incidence of incisional hernia after follow-up of at least 12 months. Secondary outcomes were postoperative complications. Only RCTs were included. A random-effects model was used for the meta-analysis, and trial sequential analysis was conducted. RESULTS: Twelve RCTs were included, comprising 1815 patients. The incidence of incisional hernia was significantly lower after PMR compared with sutured closure (risk ratio (RR) 0·35, 95 per cent c.i. 0·21 to 0·57; P < 0·001). Both onlay (RR 0·26, 0·11 to 0·67; P = 0·005) and retromuscular (RR 0·28, 0·10 to 0·82; P = 0·02) PMR led to a significant reduction in the rate of incisional hernia. The occurrence of seroma was higher in patients who had onlay PMR (RR 2·23, 1·10 to 4·52; P = 0·03). PMR did not result in an increased rate of surgical-site infection. CONCLUSION: PMR of a midline laparotomy using an onlay or retromuscular technique leads to a significant reduction in the rate of incisional hernia in high-risk patients. Individual risk factors should be taken into account to select patients who will benefit most. [Correction added on 19 February 2020, after first online publication: J. García Alamino has been amended to J. M. Garcia-Alamino].

ANTECEDENTES: La eventración (hernia incisional) es una complicación frecuente de la cirugía abdominal. El objetivo es evaluar la eficacia de la inserción de una malla profiláctica de refuerzo (prophylactic mesh reinforcement, PMR) después de la laparotomía media para reducir la incidencia de eventración. MÉTODOS: Se realizó un metaanálisis siguiendo las recomendaciones PRISMA. La variable principal fue la incidencia de eventración después de un seguimiento mínimo de 12 meses. Las variables secundarias fueron las complicaciones postoperatorias. Solo se incluyeron ensayos controlados aleatorizados. Se utilizó un modelo de efectos aleatorios para el metaanálisis y se realizó un análisis secuencial de los ensayos. RESULTADOS: Se incluyeron 12 ensayos aleatorizados y controlados con 1.815 pacientes. La incidencia de eventración fue significativamente menor después de la PMR en comparación con el cierre simple (riesgo relativo, RR 0,35; i.c. del 95%: 0,21-0,57, P < 0,0001). Hubo una reducción significativa de la tasa de eventración tanto si la PMR se colocó en posición supra-aponeurótica (RR 0,26; i.c. del 95% 0,11-0,67, P = 0,005) como retromuscular (RR 0,28; i.c. del 95% 0,0-0,82, P = 0,02). La aparición de seromas fue mayor en los pacientes con RPM supra-aponeurótica (RR 2,23; i.c. del 95% 1,10-4,52, P = 0,03). La PMR no conllevó una mayor tasa de infecciones de la herida quirúrgica. CONCLUSIÓN: Una PMR en una laparotomía de la línea media, tanto en posición supra-aponeurótica como retromuscular, reduce de forma significativa el desarrollo de eventraciones en pacientes de alto riesgo. Se deben considerar los factores de riesgo individuales para seleccionar a los pacientes que más puedan beneficiarse.

Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters.

BACKGROUND: Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia. METHODS: We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared. RESULTS: During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001). CONCLUSION: Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.

Phytochemical characterization of Borago officinalis L. and Centaurea cyanus L. during flower development.

The present work details the nutritional and chemical compositions of borage and centaurea, at three flowering stages. Water was the main constituent, followed by total dietary fiber. Both flowers showed statistically different (p < 0.05) nutritional and chemical profiles, although in both, polyunsaturated fatty acids (PUFAs) (mainly linoleic and α-linolenic acids), free sugars (3.9-28.9% dw as fructose, glucose, and sucrose), tocopherols (with the major contribution of α-tocopherol from 1.24 to 2.75 mg/100 g dw), carotenoids (0.2-181.4 mg/100 g dw, mainly as lutein), and organic acids (6.1-14.4 g/100 g dw, mainly malic, succinic, and citric acids) were quantified. Concerning flowering, significant differences (p < 0.05) were found for some components, particularly carotenoids; however, no specific trend was observed in either of the two flower species. Thus, the present study shows that each flower species, as well as their flowering stages, may have different phytochemical and nutritional compositions.

Olive cultivar and maturation process on the oviposition preference of Bactrocera oleae (Rossi) (Diptera: Tephritidae).

The olive fly, Bactrocera oleae (Rossi) (Diptera: Tephritidae), is a key-pest in the main olives producing areas worldwide, and displays distinct preference to different olive cultivars. The present work intended to study oviposition preference towards three Portuguese cultivars (Cobrançosa, Madural, and Verdeal Transmontana) at different maturation indexes. Multiple oviposition bioassays (multiple-choice and no-choice) were conducted to assess cultivar preference. No-choice bioassays were conducted to assess the influence of different maturation indexes (MI 2; MI 3, and MI 4) in single cultivars. The longevity of olive fly adults according to the cultivar in which its larvae developed was also evaluated through survival assays.Cultivar and maturation are crucial aspects in olive fly preference. Field and laboratory assays revealed a preference towards cv. Verdeal Transmontana olives and a lower susceptibility to cv. Cobrançosa olives. A higher preference was observed for olives at MI 2 and MI 3. The slower maturation process in cv. Verdeal Transmontana (still green while the other cultivars are reddish or at black stage) seems to have an attractive effect on olive fly females, thus increasing its infestation levels. Olive fly adults from both sexes live longer if emerged from pupae developed from cv. Verdeal Transmontana fruits and live less if emerged from cv. Cobrançosa. Therefore, olive cultivar and maturation process are crucial aspects in olive fly preference, also influencing the longevity of adults.

EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen.

PURPOSE: To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used. METHODS: The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument. RESULTS: For many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE. RECOMMENDATIONS: When considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.

EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen

To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument. For many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE. When considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.

Commentary on "Prognostic effect of carcinoma in situ in muscle-invasive urothelial carcinoma patients receiving neoadjuvant chemotherapy."

BACKGROUND: Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes. MATERIALS AND METHODS: Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy. RESULTS: A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio = 4.08; 95% CI: 1.19-13.98; P = 0.025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = 0.055) and OS (104.5 vs. 152.3 months; P = 0.091) outcomes similar to those for the pCR patients. CONCLUSION: The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

Heavy metals in the bottom sediments of the Furo of Laura estuary, Eastern Amazon, Brazil.

The Furo of Laura is an economically important river in the Amazon estuary. Thus, in the present study, we evaluated the metal distribution (Al, Cd, Co, Cu, Cr, Fe, Ni, and Mg) in the bottom sediments of this river. The sediments were sampled at four points every 2months for a year with an Ekman-Birge sampler. After microwave acid digestion, the metal levels were determined by optical emission spectrometry with inductively coupled plasma. The particle size and organic matter content influenced the concentration of the metals. The sediments were not enriched by the analyzed metals; the estuary therefore retained the characteristics of an uncontaminated environment, thus serving as a reference environment for comparison.

A PCR-based diagnostic assay for detecting DNA of the olive fruit fly, Bactrocera oleae, in the gut of soil-living arthropods.

Bactrocera oleae (Rossi) (Diptera: Tephritidae) is considered the most devastating pest of the olive tree worldwide. In an effort to develop management and biological control strategies against this pest, new molecular tools are urgently needed. In this study, we present the design of B. oleae-specific primers based on mitochondrial DNA sequences of cytochrome oxidase subunit I (COI) gene. Two pairs of B. oleae-specific primers were successfully designed and named as SBo1-F/SBo1-R and SBo2-F/SBo1-R, being able to amplify 108 and 214 bp COI fragments, respectively. The specificity of designed primers was tested by amplifying DNA from phylogenetically related (i.e. Diptera order) and other non-pest insects living in olive groves from the Mediterranean region. When using these primers on a PCR-based diagnostic assay, B. oleae DNA was detected in the gut content of a soil-living insect, Pterostichus globosus (Fabricius) (Coleoptera: Carabidae). The detection of B. oleae DNA in the guts of arthropods was further optimized by adding bovine serum albumin enhancer to the PCR reaction, in order to get a fast, reproducible and sensitive tool for detecting B. oleae remains in the guts of soil-living arthropods. This molecular tool could be useful for understanding pest-predator relationships and establishing future biological control strategies for this pest.

Neurological complications of acute multifocal placoid pigment epitheliopathy.

Acute multifocal placoid pigment epitheliopathy (AMPPE) is an autoimmune chorioretinal disease that can be complicated by neurological involvement. There is limited information on this potentially treatable condition in the neurological literature. The objective of this patient series is to describe the neurological complications of AMPPE. We retrospectively identified patients with neurological complications of AMPPE seen at Auckland Hospital between 2008 and 2013 and summarised cases in the literature between 1976 and 2013. We identified five patients with neurological complications of AMPPE at Auckland Hospital and 47 reported patients. These patients demonstrated a spectrum of neurological involvement including isolated headache, stroke or transient ischaemic attack, seizures, venous sinus thrombosis, optic neuritis, sensorineural hearing loss and peripheral vestibular disorder. We propose criteria to define AMPPE with neurological complications. A cerebrospinal fluid (CSF) lymphocytosis in a patient with isolated headache may predict the development of cerebrovascular complications of AMPPE. Patients with cerebrovascular complications of AMPPE have a poor prognosis with high rates of death and neurological disability among survivors. Predictors of poor outcome in those who develop neurological complications of AMPPE are a relapsing course, generalised seizures and multifocal infarction on MRI. All patients with neurological complications of AMPPE, including headache alone, should be investigated with an MRI brain and CSF examination. Patients with focal neurological symptoms should receive intravenous (IV) methylprednisolone followed by a tapering course of oral steroids for at least 3months. Patients with AMPPE and an isolated headache with a CSF pleocytosis should be treated with oral steroids.

Feeding preferences and functional responses of Calathus granatensis and Pterostichus globosus (Coleoptera: Carabidae) on pupae of Bactrocera oleae (Diptera: Tephritidae).

Carabid beetles are important predators in agricultural landscapes feeding on a range of prey items. However, their role as predators of the olive fruit fly, Bactrocera oleae (Rossi) (Diptera: Tephritidae), one of the most serious pests of olives, is unknown. In this context, the feeding preferences and the functional responses of two carabid beetle species, Calathus granatensis (Vuillefroy) and Pterostichus globosus (Fabricius), were studied under laboratory conditions. Feeding preference assays involved exposing carabid beetles to different ratios of B. oleae pupae and an alternative prey, the Mediterranean fruit fly, Ceratitis capitata (Wiedemann). Both species fed on B. oleae pupae however, C. granatensis always showed a significant preference for that prey whereas P. globosus switched to C. capitata pupae when the offered ratio was below 0.5. The total prey biomass consumed was significantly higher for P. globosus than for C. granatensis. Functional response curves were estimated based on different densities of B. oleae pupae and both carabid beetle species exhibited a type II functional response using Rogers' random-predator equation. P. globosus showed shorter handling time (1.223 ± 0.118 h) on B. oleae pupae than C. granatensis (3.230 ± 0.627 h). Our results suggest that both species can be important in reducing the densities of B. oleae in olive groves, although P. globosus was more efficient than C. granatensis.

Effect of packaging technology on microbiological and sensory quality of a cooked blood sausage, Morcela de Arroz, from Monchique region of Portugal.

Morcela de Arroz (MA), a popular Portuguese blood sausage, with high pH and water activity (aw), is traditionally commercialized without preservatives and unpacked. This study evaluated the best packaging solution to extend MA shelf life stored at 4±1°C for 44days: without packaging (WP), vacuum (VP) and modified atmosphere packaging (MAP) (80% CO2; 20% N2). Mesophilic (MTVC), psychrotrophic (PTVC), lactic acid bacteria (LAB), pseudomonads, molds and yeasts, Enterobacteriaceae, Listeria monocytogenes, Salmonella spp., Bacillus cereus, Clostridium perfringens, sensory properties, pH, moisture and aw were studied. Moisture and aw decreased (p<0.05) in WP. pH decreased in WP and MAP during storage. MTVC and PTVC counts increased to values around 7logCFU/g at 44days of storage. LAB and Enterobacteriaceae counts were higher (p<0.05) in VP. Pseudomonads were inhibited (p<0.05) by MAP after 8days of storage. Sensory parameters were affected (p<0.05) by packaging and storage time. Globally, MAP performed better.

Efeito da lactulose sobre os teores séricos de ureia, creatinina, cálcio e fósforo em cães não azotêmicos / Effect of lactulose on serum urea, creatinine, calcium and phosphorus in non-azothemic dogs

The present study evaluated serum levels of urea, creatinine, calcium and phosphorus in non-azothemic dogs by continued use of lactulose orally. Serum levels of urea, creatinine, calcium and phosphorus were determined in Beagle dogs, clinically healthy and without biochemical changes (non-azothemic), undergoing oral treatment with lactulose (n = 6), for a period of 30 days. The prebiotic showed no significant lowering effect on serum urea and creatinine, but the values of calcium and phosphorus, as well as their relation, were modified with reduced serum phosphorus levels in animals treated with lactulose compared to controls, with a significant difference...

High sensitivity C-reactive protein concentrations, birthweight and cardiovascular risk markers in Brazilian children.

BACKGROUND/OBJECTIVES: High sensitivity C-reactive protein (hs-CRP) and low birthweight have emerged as predictors of cardiovascular diseases (CVDs). In studies involving adults, higher concentrations of hs-CRP have been associated with low birthweight. This study assessed the relationship between hs-CRP and birthweight, and other risk markers for CVDs in childhood. SUBJECTS/METHODS: A total of 459 Brazilian children aged 5-8 years were included in the study. hs-CRP was measured by particle-enhanced immunonephelometry. The nutritional status of the children was assessed by BMI and waist circumference. Total cholesterol and fractions, triglycerides and glucose were measured by enzymatic methods. Insulin sensitivity was determined by the homeostasis model assessment (HOMA) method. Blood pressure was measured by the HDI/Pulse Wave CR-2000 equipment (Hypertension Diagnostics, Eagan, MN, USA). A multivariate linear regression analysis investigated the association between hs-CRP and birthweight, and risk markers for CVDs. RESULTS: There were positive associations between hs-CRP and gender (P=0.001), waist circumference (P<0.001) and systolic blood pressure (SBP) (P=0.03), and negative associations between hs-CRP and age (P<0.001), and high-density lipoprotein cholesterol (HDL-c) (P=0.005) (R²=0.14). Abnormal values of hs-CRP, waist circumference, HDL-c and SBP, respectively, were observed in 27.7, 26.4, 14.4 and 34.7% of the children. CONCLUSIONS: Opposite to studies involving adults, there was no association between hs-CRP and birthweight, implying that time may strengthen the relationship, considering that hs-CRP-concentration-associated metabolic changes increase from childhood to adulthood. The associations between hs-CRP and waist circumference, HDL-c and SBP in very young ages is a matter of concern, especially in females, in view of the large number of children with abnormal values of these measurements.

Maternal stress and distress and child nutritional status.

BACKGROUND/OBJECTIVE: To assess the relationship between maternal stress and distress in pregnancy and 5-8 years postpartum and child nutritional status. SUBJECTS/METHODS: Longitudinal cohort study carried out in Jundiai city, Southeast Brazil, involving 409 women followed throughout pregnancy to 5-8 years postpartum, and respective children. Measures of stress and distress were obtained three times in pregnancy (at gestational ages lower than 16 weeks, from 20 to 26 weeks and from 30 to 36 weeks) and 5-8 years postpartum by the Perceived Stress Scale (PSS), General Health Questionnaire (GHQ) and the State-Trait Anxiety Inventories (STAI). The nutritional status of the children was assessed by the World Health Organization body mass index (BMI) z-score for age. The relationship between child BMI z-score for age and scores of the PSS, GHQ and STAI was evaluated by multivariate linear regression, controlling for confounding variables. RESULTS: BMI z-score for age of the children was negatively associated with maternal scores of the PSS 5-8 years postpartum and scores of the GHQ in the second trimester of pregnancy. BMI of the children was positively associated with maternal BMI and birthweight (R(2)=0.13). There was -0.04 (confidence interval -0.07 to -0.9 × 10(-2)) decrease in child BMI per score unit of the PSS increase, and -0.09 (confidence interval -0.18 to -0.6 × 10(-3)) decrease in child BMI per score unit of the GHQ increase. CONCLUSIONS: This study detected a relationship between maternal mental and nutritional status and child nutritional status, implying that if the mother is not physically or mentally well, her capacity for caring for her child may be impaired.

Celiac artery with a pulmonary branch in dog: a rare variation

Hepatic, lienal and left gastric arteries are the "classical branches" of the celiac artery in dogs. This report describes a rare case in which the celiac artery emitted a branch to the caudal lobe of the right lung in an adult male mongred dog. The celiac artery and its proximal branches were dissected in situ, and measured with a digital pachymeter.This vascular variation was not previously known in the canine species. The knowledge about the presence of the celiac artery variations in dogs will contribute to a better understanding of the anatomical alterations that can occur in the vascularization of the abdominal region in dogs. The report is also important for angiographic, surgical and clinical procedures that involve this region.

An ergonomic study of single-port versus multi-port laparoscopic mesh insertion for ventral hernia repair.

PURPOSE: To assess the mental effort and physical discomfort of placement of a prosthetic mesh into the abdominal cavity with single-incision laparoscopic surgery (SILS) or multi-port laparoscopic access for incisional ventral hernia repair. METHODS: A total of 10 surgeons with previous experience in conventional laparoscopic surgery performed four surgical tasks through a multi-port laparoscopic access and a SILS access in a porcine model during a first 4-hour working session and a second 2-hour working session. These tasks included (a) introduction of a prosthetic mesh for abdominal wall surgery, (b) manipulation of the mesh inside the abdomen, (c) manipulation of the laparoscopic instruments and (d) mesh insertion to the intraperitoneal abdominal wall and fixation with tackers. The level of mental effort was assessed with the Subjective Mental Effort Questionnaire (SMEQ) and physical discomfort with the Local Experienced Discomfort Scale (LED). RESULTS: Seventy percent were men, with a mean age of 45 years and a mean of 18 years of experience in practicing surgery. The SMEQ questionnaire showed a median physical effort of 24.4 (range 9-36.1) points for the multi-port laparoscopic access and 107.4 (range 74.7-128.4) for SILS (p < 0.01). Statistically significant differences between multi-port laparoscopic surgery and SILS were consistently demonstrated in all tasks as well as in both the 4-hour and 2-hour working sessions. The median (interquartile range) score of the LED scale was 12.5 (2-34.5) for tasks during multi-port laparoscopic surgery and 53.5 (29-89.2) for SILS (p < 0.001). All individual tasks were associated with a significantly higher physical effort for SILS than for conventional laparoscopic access, which were also independent of being performed during the 4-hour or 2-hour working periods. CONCLUSIONS: Placement and manipulation of a prosthetic mesh for incisional ventral hernia repair is more difficult with SILS than using multi-port laparoscopic access, independently of previous experience with standard laparoscopic techniques. This greater difficulty was observed both in terms of mental effort and physical discomfort. More experimental and clinical studies are needed to define specific training aspects and clinical advantages of incisional ventral hernia repair through SILS.

17-AAG mediated targeting of Hsp90 limits tert activity in peritoneal sarcoma related malignant ascites by downregulating cyclin D1 during cell cycle entry.

AIM: Peritoneal or retro-peritoneal sarcomatosis related malignant ascites formation is a rare but serious consequence of the locoregional metastatic event. The present work aimed to study the effect of the Hsp90 inhibitor (17-AAG), an ansamycin analog, on cell cycle and DNA replication specific chaperone-clients interaction in the event of peritoneal sarcoma related malignant ascites formation in mouse model at the late stage of malignant growth. METHODS: We administered 17-AAG, an Hsp90 inhibitor, divided doses (330 µg/kg b.w./day for first five days then next ten days with166 µg/kg b.w./day) through intra-peritoneal route of inbred Swiss albino mice bearing full grown peritoneal malignant ascites of sarcoma-180. Our study was evaluated by peripheral blood hemogram analysis, malignant ascitic cytology, cell viability test, survival time and mitotic indexing. Furthermore, flowcytometric HSP90, TERT, CyclinD1, PCNA and GM-CSF expression analysis has been considered for special objective of the study. RESULTS: Our experimental efforts reduced the aggressive proliferation of malignant ascites by drastic downregulation of TERT and cyclin D1 on the verge of cell cycle entry along with DNA replication processivity factor PCNA by directly modulating their folding machinery - heat shock protein 90. Consequently, we observed that malignant ascitic cells became error prone during the event of karyokinesis and produced micronucleus containing malignant cells with low viability. Peripheral neutrophilia due to over-expression of GM-CSF by the peritoneal malignant ascites were also controlled by the treatment with 17-AAG and overall, the treatment modality improved the median survival time. CONCLUSION: Finally we can conclude that 17AAG administration might serve as a prospective pharmacological agent for the management of peritoneal sarcoma related malignant ascites and throws light towards prolonged survival of the patients concerned.