Differences in the learning curve of robotic transabdominal preperitoneal inguinal hernia repair according to surgeon's robotic experience

PURPOSE

In this study, we aim to analyze the learning curve of each step of robotic transabdominal pre-peritoneal inguinal hernia repair (rTAPP) in two surgeons with varying degrees of expertise with the robotic platform but no experience with laparoscopic hernia repair.

METHODS

Data on 124 rTAPP cases performed by two surgeons were retrospectively reviewed. Cumulative sum (CUSUM) analysis was applied to visualize the learning curve of rTAPP on operation time of each step of the procedure [the peritoneal flap creation (T1), the completion of the critical view of the myopectineal orifice (T2), the mesh application (T3) and the peritoneal flap closure (T4)]. Each intraoperative and postoperative outcome was compared according to surgeon's experience with the robotic platform and learning phase. The robotic surgeon mentored the surgeon-in-training and was present during all surgeries in his learning period.

RESULTS

The surgeon in training with the robotic platform showed a learning phase till the 20th procedure followed by a gradual improvement in performances. The expert surgeon showed a learning phase till the 35th procedure after which a constant decrease of operative time was recorded till the last procedure included. The operative times of each step of the procedures of both surgeons were significantly improved after the learning phase. In the late phase, the surgeon in training could achieve operative times in T2 and T3, which are similar to those of an experienced robotic surgeon with no experience with TAPP before the completion of the learning phase.

CONCLUSIONS

In conclusion, the learning phase of rTAPP surgery may vary between 20 and 35 cases, depending on the surgeon's experience in robotic surgery.

Use of prosthetic mesh in complicated incisional hernias

BACKGROUND

Incisional hernia (IH) repair with conventional techniques is associated with high recurrence rate. Surgical repair using prosthetic biomaterials is becoming increasingly popular. On the basis of the good results an increasing number of surgeons have begun to use this technique. However prosthesis use in contaminated fields is still debated. In complicated IH contaminating surgical procedure are often performed and the use of meshes can be hazardous. The aim of this study was to report our experience about the treatment of complicated IH with prosthetic materials in an emergency surgery setting.

METHODS

From November 1995 to November 2001 55 patients were submitted to emergency surgical treatment for complicated IH. Eleven patients were treated using a prosthetic device. Patients mean age was 71.3 (range 38-91). About 70% of patients had concomitant major cardiac or pulmonary diseases.

RESULTS

Thirty-two IH were strangulated, 23 were incarcerated. In all patients a viscerolysis was carried out. In 6 patients a small bowel resection was done and in 4 subjects a large bowel resection was performed. Eight patients were submitted to omental resection. There were not differences in morbidity and mortality between the studied group. Recurrence rate was significantly lower in prosthetic treated group.

CONCLUSIONS

We concluded that prosthetic repair of complicated IH is feasible in selected cases allowing abdominal wall anatomy re-establishment.

[Emergency surgery of colorectal cancer in patients older than 80 years of age]

AIM

In elderly people colorectal cancer has an high incidence of emergency presentation. In this article we report our experience on colorectal emergency surgery for cancers in patients older than 80 yrs.

METHODS

From October 1995 to December 2000 323 patients were submitted to emergency surgical procedure for colorectal cancer at the Dpt of Emergency Surgery of University of Bologna. 37 (11%) subjects were over 80 years of age. A retrospective analysis was performed: the data collected included the mode of presentation of the patients, the location and Dukes' classification of the tumors, the incidence of radical and palliative operations, the causes of death and 30-day mortality.

RESULTS

The most common emergency presentation was an intestinal occlusion (21 cases); the other different presentations were peritonitis (7 cases) and hemorrhage (9 cases). 22 patients underwent resection of the primary growth and anastomosis and 11 subjects had palliative intervention by creating a stoma only or bypass anastomosis without resection, 2 patients had an explorative laparotomy and 2 were inoperable. Our overall postoperative mortality was 14.2% and we registered 1 anastomotic leakage.

DISCUSSION AND CONCLUSIONS

Emergency surgery for colorectal cancer in patients over 80 years of age can be performed safely without restrictions related to the age.

Acute Meckel's diverticulum in a senior patient

Meckel's diverticulum is the most common congenital abnormality of the intestinal tract, occurring in 2% of autoptic studies. The case of an 85-year-old man referred to the Emergency Surgery Unit for intestinal obstruction and lower gastrointestinal tract bleeding is reported. Surgical exploration revealed a complicated Meckel's diverticulum full of coproliths, immersed in pus and blood. Examination of the resected diverticulum showed necrotic diverticulitis in the absence of ectopic gastric or pancreatic tissues.