Comparison of intracorporeal and extracorporeal anastomosis in laparoscopic right colectomy: an updated meta-analysis and trial sequential analysis

This meta-analysis was conducted to provide updated evidence regarding perioperative safety and efficacy, of IC and EC anastomosis in laparoscopic right colectomies. In this study, the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines were applied. The study protocol received a PROSPERO registration (CRD42020214596). A systematic literature search of the electronic scholar databases (Medline, Web of Science and Scopus) was performed. To reduce type I error, a trial sequential analysis (TSA) algorithm was introduced. The quality of evidence was evaluated based on the GRADE methodology. In total, 46 studies were included in this meta-analysis, Pooled comparisons and TSA confirmed that IC is superior in terms of incisional hernia (0.29; 95%CI: 0.19, 0.44), open conversion (0.45; 95%CI: 0.30, 0.67), reoperation (0.62; 95%CI: 0.46, 0.84]), LOS (- 0.76; 95%CI: - 1.03, - 0.49), blood loss (- 11.50; 95%CI: - 18.42, - 4.58), and cosmesis (- 1.71; 95%CI: - 2.01, - 1.42). Postoperative pain and return of bowel function were, also, shortened when the anastomosis was fashioned intracorporeally. The grading of most evidence ranged from 'low' to 'high'. Due to the discrepancy in the results of RCTs and non-RCTs, and the proportionally smaller sample size of the former, further randomized trials are required to increase the evidence of this comparison.

Purse-string skin closure versus linear skin closure in people undergoing stoma reversal

BACKGROUND

Stoma reversal is associated with a relatively high risk of surgical site infection (SSI), occurring in up to 40% of cases. This may be explained by the presence of microorganisms around the stoma site, and possible contamination with the intestinal contents during the open-end manipulation of the bowel, making the stoma closure site a clean-contaminated wound. The conventional technique for stoma reversal is linear skin closure (LSC). The purse-string skin closure (PSSC) technique (circumferential skin approximation) creates a small opening in the centre of the wound, enabling free drainage of contaminants and serous fluid. This could decrease the risk of SSI compared with LSC.

OBJECTIVES

To assess the effects of purse-string skin closure compared with linear skin closure in people undergoing stoma reversal.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and three trials registers on 21 December 2022. We also checked references, searched for citations, and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing PSSC and LSC techniques in people undergoing closure of stoma (loop ileostomy, end ileostomy, loop colostomy, or end colostomy) created for any indication.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible studies, extracted data, evaluated the methodological quality of the included studies, and conducted the analyses. The most clinically relevant outcomes were SSI, participant satisfaction, incisional hernia, and operative time. We calculated odds ratios (ORs) for dichotomous data and mean differences (MDs) for continuous data, each with its corresponding 95% confidence interval (CI). We used the GRADE approach to rate the certainty of the evidence.

MAIN RESULTS

Nine RCTs involving 757 participants were eligible for inclusion. Eight studies recruited only adults (aged 18 years and older), and one study included people aged 12 years and older. The participants underwent elective reversal of either ileostomy (82%) or colostomy (18%). We considered all studies at high risk of performance and detection bias (lack of blinding) and four studies at unclear risk of selection bias related to random sequence generation. PSSC compared with LSC likely reduces the risk of SSI (OR 0.17, 95% CI 0.09 to 0.29; I2 = 0%; 9 studies, 757 participants; moderate-certainty evidence). The anticipated absolute risk of SSI is 52 per 1000 people who have PSSC and 243 per 1000 people who have LSC. The likelihood of being very satisfied or satisfied with stoma closure may be higher amongst people who have PSSC compared with people who have LSC (100% vs 89%; OR 20.11, 95% CI 1.09 to 369.88; 2 studies, 122 participants; low-certainty evidence). The results of the analysis suggest that PSSC compared with LSC may have little or no effect on the risk of incisional hernia (OR 0.51, 95% CI 0.07 to 3.70; I2 = 49%; 4 studies, 297 participants; very low-certainty evidence) and operative time (MD -2.67 minutes, 95% CI -8.56 to 3.22; I2 = 65%; 6 studies, 460 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

PSSC compared with LSC likely reduces the risk of SSI in people undergoing reversal of stoma. People who have PSSC may be more satisfied with the result compared with people who have LSC. There may be little or no difference between the skin closure techniques in terms of incisional hernia and operative time, though the evidence for these two outcomes is very uncertain.

Impact of parastomal hernia on colostomy costs at 1 year: Secondary analysis of a randomized clinical trial (STOMAMESH)

BACKGROUND AND AIMS

Parastomal hernia (PSH) is a common complication after the creation of a colostomy, with a prevalence of approximately 50%. Despite the high frequency, little is known how PSH affects the cost of colostomy care.The hypothesis in this study was that PSH increases the cost of colostomy care compared with not having a PSH.

METHODS

Two groups with (N = 61) and without (n = 147) PSH were compared regarding costs of stoma appliances and visits. The population from a large randomized trial comparing construction of colostomy with or without prophylactic mesh (STOMAMESH) was used and cross-matched with health economic data from the National Pharmaceutical Register, 1 year after initial surgery.

RESULTS

Patients with and without a PSH were similar in basic demographic data. No difference in cost of stoma appliances (with PSH 2668.3 EUR versus no PSH 2724.5 EUR, p = 0.938) or number of visits to a stoma therapist (p = 0.987) was seen, regardless of the presence or not of a PSH.

CONCLUSIONS

PSH appears not to affect costs due to colostomy appliances or the need to visit a stoma therapist, in the first year. The lesson to be learnt is that PSHs are not a driver for costs. Other factors may be determinants of the cost of a colostomy, including manufacturers' price and persuasion, means of procurement, and presence of guidelines.

Development and pilot testing of a patient-reported outcome measure to assess symptoms of parastomal hernia

AIM

The aim was to develop and pilot a patient-reported outcome measure (PROM) to assess symptoms of parastomal hernia (PSH).

METHODS

Standard questionnaire development was undertaken (phases 1-3). An initial list of questionnaire domains was identified from validated colorectal cancer PROMs and from semi-structured interviews with patients with a PSH and health professionals (phase 1). Domains were operationalized into items in a provisional questionnaire, and 'think-aloud' patient interviews explored face validity and acceptability (phase 2). The updated questionnaire was piloted in patients with a stoma who had undergone colorectal surgery and had a computed tomography scan available for review. Patient-reported symptoms were examined in relation to PSH (phase 3). Three sources determined PSH presence: (i) data about PSH presence recorded in hospital notes, (ii) independent expert review of the computed tomography scan and (iii) patient report of being informed of a PSH by a health professional.

RESULTS

For phase 1, 169 and 127 domains were identified from 70 PROMs and 29 interviews respectively. In phase 2, 14 domains specific to PSH were identified and operationalized into questionnaire items. Think-aloud interviews led to three minor modifications. In phase 3, 44 completed questionnaires were obtained. Missing data were few: 5/660 items. PSH symptom scores associated with PSH presence varied between different data sources. The scale with the most consistent differences between PSH presence and absence and all data sources was the stoma appearance scale.

CONCLUSION

A PROM to examine the symptoms of PSH has been developed from the literature and views of key informants. Although preliminary testing shows it to be understandable and acceptable it is uncertain if it is sensitive to PSH-specific symptoms and further psychometric testing is needed.

Short-term outcomes after open versus robot-assisted repair of ventral hernias: a nationwide database study

PURPOSE

The robotic platform is widely implemented; however, evidence evaluating outcomes of robotic ventral hernia repair is still lacking. The aim of the study was to evaluate the short-term outcomes after open and robot-assisted repair of primary ventral and incisional hernias.

METHODS

Nationwide register-based cohort study with data from the Danish Ventral Hernia Database and the National Danish Patients Registry was from January 1, 2017 to August 22, 2022. Robot-assisted ventral hernia repairs were propensity score matched 1:3 with open repairs according to the confounding variables defect size, Charlson comorbidity index score, and age. Logistic regression analyses were performed for factors associated with length of stay > 2 days, readmission, and reoperation within 90 days.

RESULTS

A total of 528 and 1521 patients underwent robot-assisted and open repair, respectively. The mean length of hospital stay in days was 0.5 versus 2.1 for robot-assisted and open approach, respectively (P < 0.001) and open approach was correlated with risk of length of stay > 2 days (OR 23.25, CI 13.80-39.17, P < 0.001). The incidence of readmission within 90 days of discharge was significantly lower after robot-assisted repair compared to open approach (6.2% vs. 12.1%, P < 0.001). Open approach was independently associated with increased risk of readmission (OR 21.43, CI 13.28-39.17, P = 0.005, P < 0.001).

CONCLUSION

Robot-assisted ventral hernia repair is safe and feasible and associated with shorter length of stay and decreased risk of readmission compared with open ventral hernia repair.

Effect of different surgical techniques on postoperative wound infection in patients with uterine prolapse: A meta-analysis

The assumption is that a number of controlled trials have been conducted to assess the impact of uterus retaining or hysterectomy on wound and haemorrhage, but there is no indication as to which method would be more beneficial for wound healing. This research is intended to provide a comprehensive overview of the availability of wound healing in case studies of both operative methods. From inception to October 2023, four databases were reviewed. The odds ratio (OR) and the mean difference (MD) for both groups were computed with a random effect model, as well as the corresponding 95% confidence intervals. A total of five studies were carried out in the overall design and enrolled 16 972 patients. No statistical significance was found in the rate of postoperative wound infection among the two treatments (OR,1.46; 95% CI,0.66,3.22 p = 0.35); The rates of bleeding after surgery did not differ significantly from one procedure to another (OR,1.41; 95% CI,0.91,2.17 p = 0.12); two studies demonstrated no statistical significance for the rate of incisional hernia after surgery (OR,2.58; 95% CI,0.37,18.05 p = 0.34). Our findings indicate that there is a similar risk between uterine preservation and hysterectomies for the incidence of wound infection, haemorrhage and protrusion of incision.

Efficacy of laparoscopic surgery for loop colostomy: a propensity-score-matched analysis

PURPOSE

Colostomy is a common procedure for fecal diversion, but the optimal colostomy approach is unclear in terms of surgical outcomes and stoma-related complications. The purpose of this study was to examine the efficacy and feasibility of laparoscopic loop colostomy.

METHODS

This retrospective cohort study included patients who underwent loop colostomy at Shizuoka Cancer Center in Japan between April 2010 and March 2022. Patients were divided into two groups based on surgical approach: the laparoscopic (LAP) and open (OPEN) groups. Surgical outcomes and the incidences of stoma-related complications such as stomal prolapse (SP), parastomal hernia (PSH), and skin disorders (SD) were compared with and without propensity score matching.

RESULTS

Of the 388 eligible patients, 180 (46%) were in the LAP group and 208 (54%) were in the OPEN group. The male-to-female ratio was 5.5:4.5 in the Lap group and was 5.3:4.7 in the OPEN group, respectively. The median age was 68 years (range, 31-88 years) in the LAP group and 65 years (range, 23-93 years) in the OPEN group, respectively. The LAP group, compared with the OPEN group, had a shorter operative time and lower incidences of surgical site infection (3.9% versus 16.3%, respectively; p < 0.01) and SD (11.7% versus 24.5%, respectively; p < 0.01). There was no significant difference between the LAP and OPEN groups in the incidence of SP (17.3% versus 17.3%, respectively) or PSH (8.9% versus 6.7%, respectively). After propensity score matching, the incidences of surgical site infection and SD were significantly lower in the LAP group than in the OPEN group, while there were no significant differences in the operative time or the incidences of SP and PSH.

CONCLUSION

Our results suggest that laparoscopic surgery could be beneficial and feasible in loop colostomy.

A novel self-gripping long-term resorbable mesh providing temporary support for open primary ventral and incisional hernia

A novel synthetic fully long-term resorbable self-gripping mesh has been recently developed to reinforce soft tissue where weakness exists during ventral hernia repair open procedures. This resorbable mesh is a macroporous, knitted, poly-L-lactide, poly-trimethylene carbonate copolymer monofilament mesh with the ProGrip™ technology, providing grips on one side of the mesh. A new poly-L-lactide, poly-trimethylene copolymer was developed to provide the required features for mechanical support during at least 20 weeks covering the critical healing period, including resistance to fatigue under cyclic loading conditions, as it occurs in patients. The yarns and mesh initial physical and biomechanical properties were characterized. Then, the mesh mechanical strength was evaluated over time. The mechanical properties of the proposed mesh were found to be above the generally recognized threshold value to mechanically support the repair site of a hernia over a 20-week period during in-vitro cyclic loading test. The mesh performance was evaluated in vivo using a published preclinical porcine model of hernia repair at 4-, 12- and 20-weeks post implantation. The burst strength of the hernia repair sites reinforced with the new mesh were higher at 4 & 12 weeks and comparable at 20 weeks to the one of the native abdominal walls. At all time points, the mesh was well tolerated with moderate inflammation and was fast integrated in the abdominal wall at 4 weeks. Particularly, the grips were nicely engulfed in the newly formed connective tissue. They must facilitate the anchoring of the mesh by their extension from the mesh and their mushroom shape. The preclinical data of the self-gripping resorbable mesh suggests that it has all the favorable characteristics for future clinical use during ventral hernia repair open procedures.

Percutaneous Pigtail Catheter Drainage of Spontaneous Intestinal Perforation in Premature Infants

INTRODUCTION

Peritoneal drainage is an established management strategy for spontaneous intestinal perforation (SIP) in premature infants. We sought to evaluate the safety and efficacy of percutaneous pigtail catheter placement as an alternative to drain insertion via a lower quadrant incision.

METHODS

Patients less than 32 weeks gestational age who underwent peritoneal drain placement for SIP at two neonatal intensive care units between 2011 and 2022 were identified. Incisional drainage (ID) or percutaneous pigtail catheter drainage (PD) was used based upon the usual practices of the surgeons. ID (n = 19) was performed via a 5-mm right lower quadrant incision into which a one-fourth-inch Penrose or red rubber catheter was placed. PD (n = 18) was accomplished using a Seldinger technique by which a 6.0 or 8.5 F pigtail catheter was passed through the left lower quadrant. Demographics and physiological parameters at the time of drainage were recorded and short-term and long-term outcomes were evaluated.

RESULTS

Thirty seven infants were identified. There were no differences in demographics or physiological derangement between the groups. Patients who underwent ID had more frequent stool drainage, a greater transfusion requirement, and a longer time to full feedings (60.6 v 37.7 d, P = 0.04). Incisional hernias (n = 3, 16%) only developed after ID. The duration of drain placement, length of stay, and time to resolution of pneumoperitoneum were similar with ID and PD as was the incidence of premature drain dislodgement and subsequent laparotomy.

CONCLUSIONS

Percutaneous drain placement provided effective drainage in infants with SIP and was associated with more rapid feeding advancement and no incidence of incisional hernia.

Small bite versus large bite stitching technique for midline laparotomy wound closure: A systematic review and meta-analysis

Mass closure with a continuous suture using large bite stitching technique has been widely accepted for midline laparotomy wound closures. However, emerging evidence suggests the use of small bite technique to reduce rates of incisional ventral hernia, surgical site infection (SSI) and burst abdomen. This meta-analysis aims to compare small versus large bite stitching techniques to assess complication rates in midline laparotomy wound closures. A comprehensive multi-database search (OVID EBM Reviews, OVID Medline, EMBASE, Scopus) was conducted from database inception to 11th October 2021 according to PRISMA guidelines. We included studies comparing post-operative complication rates of small bite versus large bite stitching techniques for midline laparotomy wound closure. Extracted data was pooled for meta-analysis evaluating rates of incisional ventral hernia, SSI and burst abdomen. We included five randomized controlled trials (RCT) in the meta-analysis and three prospective cohort studies for qualitative analysis. A total of 1977 participants composed of 961 small bite and 1016 large bite technique patients were included from the five RCTs. There was a significant reduction in the rates of incisional ventral hernia and SSI with the small bite stitch technique with odds ratios (OR) of 0.39 (95% CI [0.21-0.71]) and 0.68 (95% CI [0.51-0.91]) respectively, and a trend in favour of reduced incidence of burst abdomen with OR of 0.60 (95% CI [0.15-2.48]). Small bite stitch technique in midline laparotomy wound closure may be superior over conventional mass closure using the large bite stitch technique, with statistically significant lower rates of incisional ventral hernia and SSI.

A Standardized Protocol for Opioid Prescribing After Surgery Decreases Total Morphine Equivalents Prescribed

INTRODUCTION

Perioperative opioid analgesia has been extensively reexamined during the opioid epidemic. Multiple studies have demonstrated over prescription of opioids, demonstrating the need for change in prescribing practices. A standard opioid prescribing protocol was implemented to evaluate opioid prescribing trends and practices.

OBJECTIVES

To evaluate opioid use after primary ventral, inguinal, and incisional hernia repair and to assess clinical factors that may impact opioid prescribing and consumption. Secondary outcomes include the number of refills, patients without opioid requirement, difference in opioid use based on patient characteristics and adherence to prescribing protocol.

METHODS

This is a prospective observational study examining patients undergoing inguinal, primary ventral and incisional hernias between February and November 2019. A standardized prescribing protocol was implemented and utilized for postoperative prescribing. All data was captured in the abdominal core health quality collaborative (ACHQC) and opioid use was standardized via morphine milligram equivalents (MME).

RESULTS

389 patients underwent primary ventral, incisional, and inguinal hernia repair, with a total of 285 included in the final analysis. 170 (59.6%) of patients reported zero opioid use postoperatively. Total opioid MME prescribed and high MME consumption were significantly higher after incisional hernia repair with a greater number of refills were required. Compliance with prescribing protocol resulted in lower MME prescription, but not actual lower MME consumption.

CONCLUSIONS

Implementation of a standardized protocol for opioid prescribing after surgery decreases the total MME prescribed. Compliance with our protocol significantly reduced this disparity, which has the potential for decreasing abuse, misuse, and diversion of opioids by better estimating actual postoperative analgesic requirements.

Purse string closure of perineal defects after abdominoperineal excision

PURPOSE

The aim of this study was to describe a new technique of perineal closure following abdominoperineal excision (APE) using purse-string perineal skin closure (PSPC).

MATERIAL AND METHODS

Between January 2016 and May 2021, 15 consecutives patients who had an APE procedure were included in this retrospective single-center study. All indications of APE were considered, as well as all types of APE. We analyzed the patient characteristics and peri-operative features, including overall (Clavien 1 to 5) and severe (Clavien 3 and 4) postoperative morbidity, length of stay (LOS), and long-term results (median time to perineal wound closure and rate of perineal incisional hernia).

RESULTS

The patients included 11 men and four women, with a mean age of 64 ± 13 [33-80] years. The indication of APE was an epidermoid carcinoma of the anal canal (n = 5) or an adenocarcinoma of the rectum (n = 10). The mean operating time was 220 ± 88.64 [70-360] min. The overall morbidity rate was 60%, the severe morbidity rate 26%, and reoperation rate 26%. The median length of stay was 9 ± 6.5 days. After a mean follow-up of 23.5 ± 20.3 months, the median time to perineal wound closure was 96 ± 60 days, the persistent perineal sinus rate was 6% (n = 2), and one patient developed a perineal incisional hernia.

CONCLUSION

Purse-string closure of perineal wounds is a safe and effective technique for perineal wound closure after APE. The short LOS allowed an early return home.

A Surgical Technique for Closure of 10 mm and Larger Laparoscopic Port Fascial Defects Using a Graham's Nerve Hook

Background and Objectives

In order to avoid potential complications from incisional hernias in patients undergoing laparoscopic or robotic procedures with 10 mm or larger ports, a surgeon closes the fascial defects using various techniques. We compared several different techniques of port site closure, which uses the open technique that can be performed with or without laparoscopic visualization. We modified the technique initially described by Dr. H. Aziz. We are introducing a new surgical technique to close the larger port site using Graham's nerve-hook. This new technique is easy to learn, replicate and implement for all body types.

Methods

We use the commonly available Graham's nerve-hook and two S-retractors to visualize the entire layers of fascia and peritoneum and to pull up both layers to close the larger port site safely and securely with 0 polyglactin absorbable suture. We illustrated this new Lee's port site closure technique with eight separate drawings in this paper.

Results

We performed 493 consecutive laparoscopic cases using this new technique. Four years follow up revealed only one incisional hernia using this technique. The patients are routinely followed in one month and six months and a year after the operation. However, not all of the patients are seen after six months unless there was a specific complaint.

Conclusion

The new port site closure technique introduced in this paper is found to be easy to learn, fast, and very cost effective due to the reusable, commonly found S-retractors and Graham's nerve hook. After four years of consistent use, this new technique was found to be safe and effective in closure of 10 mm or larger port sites.

[Strangulated postoperative diaphragmatic hernia]

We present a rare case of postoperative diaphragmatic hernia in a patient with colon infringement 3 years after surgery for cardioesophageal cancer accompanied by extensive diaphragmotomy. The diagnosis of diaphragmatic hernia with colon infringement was based on a combination of anamnestic, clinical and radiological data, as well as results of diagnostic pleural puncture. This clinical case is of interest due to small incidence of disease and difficult interpretation of clinical and diagnostic data.

[Treatment of ventral hernias in patients with morbid obesity]

The review is devoted to the treatment of ventral hernias in patients with morbid obesity. This issue is important due to significant number of such patients and no unambiguous clinical recommendations. The advantages of simultaneous surgery (with bariatric intervention) are obvious, i.e. lower risk of postoperative hernia incarceration and no need for re-hospitalization with another intervention. High risk of bariatric population makes it necessary to minimize surgery time and surgical trauma. A staged approach with reducing body weight surgically or conservatively before hernia repair is often chosen. Hernia repair should be performed using laparoscopic or robotic techniques with obligatory use of mesh implants. Panniculectomy or abdominoplasty as the main surgery is a valid option. Currently, it is necessary to develop clear criteria for selecting patients with morbid obesity for staged and simultaneous treatment of ventral hernias.

[Enterostomy based on abdominal wall tension and fascial locking: a theory of preventing stoma complications and parahernia]

No consensus on standardized technique of enterostomy creation has been made meanwhile high heterogeneity of surgical procedure exists in 'stoma creation' chapters of textbooks or atlases of colorectal surgery. The present article reviews the anatomy of tendinous aponeurotic fibers which is crucial for abdominal wall tension and integrity. Through empirical practice we hypothesize a procedure of enterostomy creation basied on abdominal wall tension plus anchor suture for fascia fixation which could theoretically decrease short-term stoma complication rates and long-term parastomal hernia rates. Surgical techniques are as followed: (1) preoperative stoma site mark for de-functioning ileostomy should be positioned at the lateral border of rectus abdominis muscle (RAM) to decrease the difficulty of stoma reversal and for permanent colostomy should be placed overlying the RAM to promote adhesion; (2)Optimal circular removal or lineal opening of skin, and avoid dissection of subcutaneous tissue; (3) Lineal dissection of natural strong fascia (rectus sheath) at stoma site and blunt separation of muscular fibers. The tunnel of the fascia should be made with appropriate size without undue tension. To prevent the formation of dead space, additional suturing at fascia layer is unnecessary. (4) Anchor suture for fascia fixation at two ends of fascia opening could be considered to avoid delayed fascia disruption and parastomal hernia. (5) After pull-through of ileum or colon loop, 4-8 interrupted seromuscular sutures could be placed to attach loop to skin. For ileostomy, self-eversion of mucosa can be successful in vast majority of cases and a Brooke ileostomy is not necessary. The efficacy and safety of this procedure should be tested in future trials.

[Surgical strategy for stoma creation in the challenging patients]

Stoma is a commonly used surgical procedure in clinic practice. However, for obese patients with thick abdominal wall, short and thickened mesentery, and for patients with intestinal obstruction and abdominal distension (difficult stoma), establishing a tension- free and well blood-supplied stoma is still a great challenge. Careful preoperative planning, including stoma location marking, careful consideration of all alternatives and attention to technical details, will help to make an optimal stoma under challenging conditions. For enterostomy of obese patients, the pullout intestine must be free of tension and must have sufficient blood supply, the structure of the abdominal wall should be incised vertically, and the intestine should be pulled out vertically as well. For enterostomy of patients with intestinal obstruction, the diameter of the stoma incision should not exceed 3 cm to avoid parastomal hernia, which commonly occurs after bowel retraction.

The Use of Minimal Invasive Surgery versus Open Approach in Hospitalized Cases

Backgtound: The progress in development and application of Minimal Invasive Surgery (MIS) requires clinical and managerial decisions that must be evidence based; the current available scientific evidence for the Romanian medical practice is missing. Our study aims to analyze the use of MIS and open surgery in Romania and the impact of the type of surgery on the hospitalization. Methodology: A cross-sectional study analyzed the activity of the Romanian hospitals reporting primary Diagnostic Related Group (DRG) data at the patient level in the period 2008-2018; all episodes of abdominal and thoracic surgical interventions which may be performed either by MIS or an open approach were extracted from the DRG National database (www.drg.ro). A comparative analysis in terms of the volume of activity and their impact on the hospital average length of stay (ALOS) has been performed. Results: The pattern of use for MIS and open surgery interventions was changed in 2008-2018; MIS procedures doubled while open surgery interventions did not follow the same growth rate; ALOS for the MIS procedures decreased annually at a faster rate as compared to the ALOS for the open surgery and the gap between the two gradually increased in favour of the MIS interventions. The most pronounced shortening of ALOS after MIS procedures has been found for Gallbladder Surgery (by 7.95 days), Gastric Surgery (by 5.64 days) and Incisional Hernia surgery (by 4.33 days). Meanwhile, the reimbursement level for the MIS versus open surgery interventions did not changed over the analyzed period. Conclusions: MIS is significantly reducing the ALOS in Romania with a potential positive influence on the national healthcare budget. However, the pattern of use for MIS interventions is not financial incentives based and calls for in-depth analysis on other factors belonging rather to specific pathology, technology or medical practice (experience in using MIS, endowment, safety, efficacy, surgical approach area etc.) is urgently required.

High Rates of Incisional Hernia After Laparoscopic Right Colectomy With Midline Extraction Site

BACKGROUND

Laparoscopic surgery aims at reducing wound complications and improving cosmetics, among other advantages. High rates of postoperative ventral hernia (POVH) are observed after laparoscopic-assisted colectomies.

MATERIALS AND METHODS

In a 2011 to 2016 retrospective study of all patients at Rabin Medical Center, we examined POVH prevalence after right hemicolectomy for neoplasia and correlation to specimen extraction site. We also compared laparoscopic-assisted colectomy to hand-assisted laparoscopic colectomy. Included were patients who had postoperative abdominal computed tomography or magnetic resonance imaging scan as part of their routine oncological follow-up to 6 months postsurgery. Patients were excluded for conversion to laparotomy, and prior abdominal surgeries after right colectomy and before follow-up computed tomography/magnetic resonance imaging scan. Demographic and surgical data were collected from patient electronic records, and scans reviewed for POVH by a designated radiologist.

RESULTS

Of 370 patients, 138 (mean age 70.09 y, 58 males) were included: 54 (39.1%) were diagnosed with POVH, 42/72 (58.3%) at midline extraction site, and 12/66 (18.8%) at off-midline extraction sites (P<0.0001). Surgical site infections and patients positive for tumor metastasis were associated with higher POVH rates. Most (74%) POVHs were identified within 18 months postsurgery (P<0.0001). Body mass index, age, sex, diabetes mellitus, smoking, tumor size, lymph nodes positive for metastasis, and hand-assisted laparoscopic colectomy were not associated with POVH prevalence.

CONCLUSION

High rates of radiologically diagnosed POVH were found after laparoscopic-assisted colectomy, with association to midline extraction site, surgical site infections, and positive tumor distant metastasis.

Effect of photobiomodulation therapy on trunk flexor performance after incisional hernia repair: a randomized controlled trial

To investigate the effect of two photobiomodulation approaches on trunk flexor performance after incisional hernia repair and to compare the effects of both wavelengths. Forty-five patients were randomly distributed after isokinetic trunk flexor assessments into infrared laser, red laser, and placebo groups. Each patient received laser treatment followed by a traditional physical therapy program. In laser treatment, 24 points in both recti were irradiated by infrared or red laser light with the following parameters; 0.6 J per point, 214.28 J/cm² as energy density, and 17.85 W/cm² as intensity, while the control group received a placebo approach. All groups received clinical treatments at a rate of 3 sessions per week for 4 weeks; in addition, the physical therapy program was continued on other days for all groups. Isokinetic trunk flexor strength was measured before treatment and 4 weeks after treatment as in each measurement, fatigue protocol was designed, and the trunk flexor strength was measured before fatigue test while the trunk flexor resistance to fatigue was measured after fatigue test. After 4 weeks, pre-and post-fatigue trunk flexor strengths in both laser groups were significantly increased compared to pre-and post-fatigue trunk flexor strength in the placebo group, respectively, and there was no significant difference between the two laser groups. Photobiomodulation approaches enhance trunk flexor response to exercise after incisional hernia repair. This enhancement leads to greater strength and more fatigue resistance for the trunk flexors in photobiomodulation groups compared to the placebo group and no difference between the two photobiomodulation effects.

Scar endometriosis diagnosed as incisional hernia before surgery

Scar endometriosis is a rare condition highly related to history of abdominal surgery. Due to the low incidence, it is often misdiagnosed. A woman presented to the surgery outpatient clinic with a mass near her C-section scar. Physical examination and ultrasound suggested Incisional Hernia while intraoperative finding revealed a mass suggestive of endometriosis which later confirmed by pathology examination. Scar endometriosis is a common subtype of extra-pelvic endometriosis. Iatrogenic transplantation is speculated to be its etiopathogenesis. Preoperatively, it is challenging to differentiate endometriosis from another abdominal masses. The definitive diagnosis is based on laparoscopy or surgery with histological verification. Chronic pain is complex and often involves multiple factors beyond simply a diagnosis of endometriosis, but it is important to think of endometriosis on women patients presenting with a mass and cyclic pain with history of surgery involving a large amount of endometrial cell.

Laparotomy Closure: A Review of Available Education Training Models

INTRODUCTION

As studies continue to provide advanced knowledge concerning abdominal wall closure after laparotomy, there have been many improvements in surgical techniques and recommended closure materials. However, there continues to be a high rate of incisional hernias following exploratory laparotomies. The goal of this review is to provide a comprehensive assessment of available educational models for laparotomy closure.

MATERIAL AND METHODS

A comprehensive literature review was made using PubMed, Cochrane, and NCBI MeSH databases to find the most relevant articles associated with various abdominal closure models using specific keywords.

RESULTS

Human cadaver, animal, synthetic, and virtual reality models were reviewed. Strengths and limitations of each model were described.

CONCLUSION

Each model has practical benefits in its ability to mimic in vitro anatomy and the experiential similarities to actual laparotomy closure. However, there are also limitations and potential cost-prohibitive factors for individual models. Overall, while there have been some advances in synthetic and virtual models, human cadaver and porcine models remain the most similar to human abdominal wall closures.

[Closure of an emergency midline laparotomy]

Closure of an emergency abdominal midline laparotomy is related to potentially serious complications. Main concerns are surgical site infection, wound dehiscence and incisional hernia. In this review, new studies and guidelines are summed up to a set of recommendations applicable to the Danish surgical departments. Surgical strategies concerning primary closure of an emergency laparotomy as well as a strategy towards wound dehiscence are suggested. Suture techniques, negative pressure wound therapy and reinforcement of the abdominal wall with mesh are the topics reviewed.

Novel Technique for Full-Thickness Abdominal Wall Closure in Laparoscopic Ventral Hernia Repair

Laparoscopic ventral hernia repair incorporating a prosthetic mesh underlay, first described in 1993, has demonstrated a lower long-term recurrence rate versus open non-mesh repair. However, over the past 25 years, the laparoscopic approach to ventral/incisional hernias is utilized in only approximately 30% of cases. One of the reasons that prevents it from being utilized more often is the inability to readily, reliably, and easily close the fascial defect. A novel technique has been developed for full-thickness abdominal wall closure in laparoscopic ventral hernioplasty, utilizing puncture sites to place multiple self-locking ligature straps. Introduction of the straps into the abdominal cavity in orthogonal orientation to the skin surface, followed by subcutaneous retrieval of the contralateral tip of the strap, achieves incorporation of full-thickness abdominal wall on either side of the defect. The self-locking property of each strap allows tension to be applied in sequential fashion. Incremental tension application facilitates re-apposition of the borders in large defects. The increased width of the strap compared with conventional suture serves to resolve the force exerted upon tissue during the acute phase of defect closure. The instrumentation was tested in six ventral hernias created in resected porcine belly walls. Subsequent tests were conducted in three swine with large congenital umbilical hernias. One of the test animals was re-examined laparoscopically 30 days post repair, with full healing and no recurrence exhibited upon re-examination. We anticipate that the simplicity and functionality of this technique will translate to clinical utility in the significant cohort of human ventral hernia patients.

[A low risk of ileus, incisional hernia and impact on female fertility after appendectomy]

Appendicitis is a common condition, which is often seen by the general practitioners as well as in the emergency departments. It is normally treated with laparoscopic appendectomy. This review gives an overview of the long-term surgical complications ileus and incisional hernia and of the impact of appendicitis and appendectomy on female fertility. The literature shows, that there is a low risk of ileus and incisional hernia after appendectomy, and that there is no change in female fertility after appendectomy, not even in cases where the appendix was perforated.

[Postoperative ventral hernia - unsolved issues of surgical tactics]

Currently, there is no unified opinion on some problematic issues of surgical treatment of postoperative ventral hernias. Current approaches and surgical aspects of primary and recurrent postoperative ventral are reviewed in the article.

Laparoscopic Stapled Sublay Repair With Self-Gripping Mesh: A Simplified Technique for Minimally Invasive Extraperitoneal Ventral Hernia Repair

INTRODUCTION

Minimally invasive laparoscopic and robotic techniques for ventral hernia repair have evolved to achieve the benefits and minimize the limitations of both the open Rives-Stoppa sublay mesh repair and laparoscopic intraperitoneal onlay mesh (IPOM) repair. By combining the principles of a retromuscular repair with the benefits of a minimally invasive approach, these techniques attempt to decrease recurrence, increase functionality, exclude mesh from the viscera, limit infection and wound complications, and minimize pain. The difficult ergonomics, challenging dissection, and extensive suturing make traditional laparoscopic sublay repair technically challenging and has led to increased robotic utilization to overcome these limitations. We describe a laparoscopic extraperitoneal sublay mesh repair technique using an endoscopic stapler to facilitate reapproximation of the linea alba and creation of the retromuscular space, and self-gripping mesh to position and fixate the prosthetic.

MATERIALS AND METHODS

Between January and June 2016, 10 patients with midline ventral and incisional hernias underwent laparoscopic extraperitoneal stapled sublay mesh repair with self-gripping mesh. Three of these cases included a laparoscopic posterior component separation with myofascial release of the transversus abdominis muscle to facilitate midline closure. Intraoperative and perioperative complications, early recurrence, pain, and narcotic usage were measured.

RESULTS

There were no significant intraoperative complications or conversions to open surgery. Patients were discharged at 1.2 days on average. Early postoperative complications included a hernia site seroma in one patient, which resolved without intervention. There were no early postoperative infections or recurrences. Compared with traditional laparoscopic IPOM repair, there was less acute postoperative pain and use of analgesics.

CONCLUSIONS

Laparoscopic extraperitoneal stapled sublay mesh repair is a safe and effective method for the treatment of medium- to large-sized ventral and incisional hernias. This extraperitoneal stapled approach using self-gripping mesh facilitates a minimally invasive sublay repair and abdominal wall reconstruction using traditional laparoscopic tools.