Small and Laterally Placed Incisional Hernias Can be Safely Managed with an Onlay Repair.

INTRODUCTION: In meta-analyses and systematic reviews, clear advantages have been identified for the sublay versus onlay technique for treatment of incisional hernias. Nonetheless, an expert panel has noted that the onlay mesh location may be useful in certain settings. MATERIALS AND METHODS: First, unadjusted analysis of data from the Herniamed Registry was performed to compare 6797 sublay operations with 1024 onlay operations for repair of incisional hernias. Then, using propensity score matching to account for the influence of variables age, gender, ASA score, BMI, risk factors, preoperative pain, defect size, and defect localization, 1016 pairs were formed and compared with each other. RESULTS: Unadjusted analysis revealed that the onlay operation was used significantly more often for small defects, lateral defect localization, and in women. After comparing the propensity score-matched pairs, no significant difference was found between the sublay and onlay technique in the outcome criteria intra- and postoperative complications, general complications, complication-related reoperations, pain at rest, pain on exertion, chronic pain requiring treatment, and recurrence on 1-year follow-up. But that was true only for this carefully selected patient collective. CONCLUSION: In a selected patient collective with small and lateral incisional hernias and with a large proportion of women, outcomes obtained for the onlay and sublay techniques do not differ significantly.

Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial).

BACKGROUND: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). METHODS: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). RESULTS: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25-265) vs. 55 min (range 22-185); P < 0.001]. There were no significant differences in hospital length of stay or pain VAS scores between the two groups. An incisional hernia developed within 1 year in six patients in the SPC group and in three in the MPC group (P = 0.331). Patients were more satisfied with aesthetic results after SPC, whereas surgeons rated the aesthetic results higher after MPC. No difference in quality of life scores, as measured by the gastrointestinal quality of life index at 60 days after surgery, was observed between the two groups. CONCLUSIONS: In selected patients undergoing cholecystectomy for benign gallbladder disease, SPC is non-inferior to MPC in terms of safety but it entails a longer operative time. Possible concerns about a higher risk of incisional hernia following SPC do not appear to be justified. Patient satisfaction with aesthetic results was greater after SPC than after MPC.

Self-Gripping Meshes for Lichtenstein Repair. Do We Need Additional Suture Fixation?

BACKGROUND: The Lichtenstein repair is a frequently used treatment of inguinal hernias. In recent years, there has been an increasing tendency to apply self-gripping meshes (s.g). In many cases, additional suture of the mesh is carried out; however, it is uncertain what the benefits or potential risks of this actually are. METHODS: The evaluation was undertaken on the basis of the Herniamed register, and covered all unilateral Lichtenstein operations between 01.09.2009 up to 30.09.2013. The analysis only included patients with whom s.g. meshes with resorbable micro hooks had been used (Progrip(®), Covidien) and who had undergone a full 1-year follow-up examination (80.15 %). RESULTS: In total, 2095 patients were suitable for analysis, of which 816 (38.95 %) cases received an additional suture fixation (Fix). With increasing hernia size, more frequent fixation took place (29.97 % of hernias <1.5 cm vs. 46.65 % of hernias >3 cm, p < 0.001). The recurrence rates 1 year after surgery did not show any significant differences (Fix. 0.86 % vs. No Fix. 1.17 %; p = 0.661) with and without fixation, even when being adjusted for covariables. Likewise, no differences were noted in terms of postoperative complications (Fix. 5.15 % vs. No Fix. 5.08 %; p = 1.0). In addition, the numbers of patients needing to be treated after 1 year for chronic pain were also comparable (Fix. 2.33 % vs. No Fix. 2.97 %; p = 0.411). CONCLUSION: Within the group that did not have additional suture fixation of self-gripping meshes (No Fix.), the length of operations was on average 8 min shorter (p < 0.001). No differences could be observed in terms of postoperative complications, treatment requiring chronic pain and recurrence rates.

Changes in the Surgical Management of Parastomal Hernias Over 15 Years: Results of 135 Cases.

BACKGROUND: Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures. METHODS: From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences. RESULTS: One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12-146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured. CONCLUSION: The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p < 0.001).

Metals in Human Gall, Bladder, and Kidney Stones Based on an Electron Microprobe Investigation.

Several particles of copper accompanied by a few particles of nickel, lead, and a compound composed of selenium containing minor Ni, Si, Cu, and Co were found in human gall, kidney, and bladder stones. The investigated particles occur as tiny grains, <10 µm in size, that are irregularly dispersed in the stones. Therefore, they were studied by scanning electron microscopy and qualitatively analyzed by energy dispersive system. One grain of copper contained a small amount of Ni and Zn, and some grains of nickel proved to contain Cr as trace element. Most of the discovered metals formed a single-phase grain. However, a few grains found in two gallstones were associated with inclusions of calcium and apatite. Based on the results presented in this contribution, we argue that most of the studied metals can be classified as endogenous particles, i.e., directly precipitated from the same fluids that formed their host human stones. This observation suggests that the precipitation and accumulation of metals in some human stones can be considered an efficient way to eliminate them from the human body.

Minimal Invasive Linea Alba Reconstruction for the Treatment of Umbilical and Epigastric Hernias with Coexisting Rectus Abdominis Diastasis.

INTRODUCTION: Patients with umbilical or epigastric hernias benefit from mesh- based repairs, and even more so if a concomitant rectus diastasis (RD) is present. The ideal technique is, however, still under debate. In this study we introduce the minimal invasive linea alba reconstruction (MILAR) with the supraaponeurotic placement of a fully absorbable synthetic mesh. MATERIALS AND METHODS: Midline reconstruction with anterior rectus sheath repair and mesh augmentation by an open approach is a well-known surgical technique for ventral hernia repair. Between December 1, 2016, and November 30, 2017, 20 patients with symptomatic umbilical and/or epigastric hernias, and coexisting RD underwent a minimally invasive complete reconstruction of the midline through a small access route. The inner part of both incised and medialized anterior rectus sheaths was replaced by a fully absorbable synthetic mesh placed in a supraaponeurotic position. RESULTS: Patients were hospitalized for an average of 4 days and the mean operating time was 79 minutes. The mean hernia defect size was 1.5 cm in diameter and the mean mesh size was recorded as 15.8 cm in length and 5.2 cm in width. Two patients sustained surgical postoperative complications in terms of symptomatic seroma occurrences with successful interventional treatment.The early results (mean follow-up period of 5 months) showed no recurrences and only 1 patient reported occasional pain following exertion without rest. DISCUSSION: MILAR is a modification of the recently published endoscopic linea alba reconstruction restoring the normal anatomy of the abdominal wall. A new linea alba is formed with augmentation of autologous tissue consisting of the plicated anterior rectus sheaths. Supraaponeurotic placement of a fully absorbable synthetic mesh eliminates potential long-term mesh-associated complications. Regarding MILAR, there is no need for endoscopic equipment due to the uniquely designed flexible lighted retractors, meaning one assistant less is required.

Fast Early Recovery After Transabdominal Preperitoneal Repair in Athletes with Sportsman's Groin: A Prospective Clinical Cohort Study.

BACKGROUND: Current literature on chronic groin pain suggests that laparoscopic mesh repair on athletes enables a faster recovery and subsequent return to unrestricted athletic activities. The aim of this study was to evaluate the role of transabdominal preperitoneal (TAPP) mesh repair in athletes resistant to conservative therapy. METHODS: A multidisciplinary approach with tailored physiotherapy. Thirty-nine professional athletes with chronic groin pain were referred to surgery at a single clinic. A full assessment was carried out on each, including medical history, physical examination, dynamic ultrasound, and pelvic magnetic resonance imaging. TAPP repair was performed using a polypropylene mesh and fibrin glue fixation on 30 athletes who had exhibited typical symptoms, shown resistance to conservative therapy, not benefited from accompanying physiotherapy, and had ceased training in the 3 to 6 months prior. The outcome measures were early postoperative recovery of 6 weeks and full resumption of athletic activities. RESULTS: Mean duration of symptoms from onset to surgical repair was 7 months. Conservative treatment had improved symptoms temporarily or to some extent in 7 athletes, while 2 ceased competing altogether. Twenty-three athletes exhibited unilateral and 16 bilateral groin pain. Laparoscopy confirmed posterior wall deficiency in 24 and true inguinal hernia in 6 athletes. Mild scrotal hematoma occurred in 2 athletes postoperatively; all were discharged within 24 hours of surgery. Twenty-one (70%) returned to sports activities after 6 weeks of convalescence. Persistent mild pain was experienced by 5 athletes postoperatively for up to 1 year, yet did not interfere with normal daily activity. Twenty-five participants (85%) reported full satisfaction with the procedure 1 year after treatment; all returned to the same or even higher level of athletic performance. CONCLUSION: The study confirms that the endoscopic placement of retropubic mesh is an efficient, safe, and minimally invasive treatment that enables fast early recovery.

Single-port parastomal hernia repair by using 3-D textile implants.

BACKGROUND: Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall. METHODS: We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications. RESULTS: From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively. CONCLUSION: We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.

Splenic decapsulation after gastroscopy.

Sanguineous splenic complications in elective treatment procedures remain a potentially life-threatening complication in patients of all age groups. In this case, the patient, as per her past medical history, underwent a laparoscopic appendectomy when she was admitted to the clinic. One of the diagnostic procedures to find the reason for the epigastric pain, a gastroscopy, can retrospectively be held responsible for decapsulation of the spleen.