Closure of the Peritoneum in Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair (TAPP) With Cyanoacrylate Glue in a Microdroplet Device: A Single Surgeon Prospective Comparison vs. Barbed Suture

Purpose

To describe and compare a peritoneal closure technique using cyanoacrylate glue (Glubran 2®, GEM, Cardiolink SL) with a microdroplet device (Glutack®, GEM, Cardiolink SL) in laparoscopic transabdominal preperitoneal repair (TAPP) of inguinal hernia with the routinely used barbed suture peritoneal closure (V-Lock 3.0, Covidien France).

Materials and methods

From January to August 2022, 60 patients undergoing TAPP repair for uni- or bilateral inguinal hernia were randomized into one of two groups. One using as mesh fixation and peritoneal closure the Glutack® device with Glubran 2® cyanoacrylate glue (Glu-close group) and the other using mesh fixation with cyanoacrylate and peritoneal closure with V-lock 3.0 (Sut-close group), with a follow-up of 12 months. Demographic variables, operative time, peritoneal closure time, main surgical findings and main intra- and postoperative complications were analyzed prospectively.

Results

63 patients were included with no losses to follow-up. The mean operative time was 34 min (range 58.25) for the glu-close group and 40 (range 64.25) for the sut-close group, with no conversion (0%) for either group. The mean flap closure time was 1.18 min (SD 24 0.19) for the glu-close group and 3.24 min (SD 0.78) for the sut-close group, with statistically significant differences (p < 0.001). The intraoperative complication rate was 0 for the glu-close group and 0 for the sut-close group, with no significant difference. The median hospital stay was 0.8 days (range, 0-1) for both groups. The median duration of follow-up was 12 months and none had hernia recurrence. The postoperative VAS score at the first and second check-up at 1 month and 3 months was 2.83 (SD 1.341) and 0.60 (SD 0.621) in the sut-close group and 1.03 (0.984) and 0.24 (SD 0.435) in the glue-close group, with significant differences (p < 0.001 and p < 0.012).

Conclusion

The data demonstrated by the study are that the glue can be used safely to close the peritoneum and that the method provides a small, statistically significant but not clinically relevant reduction in the time to close the peritoneal flap, as well as in postoperative pain after surgery in short and medium term.

Implementing an outpatient surgical management in moderated-high risk patients with groin hernia repair

PURPOSE

There is a growing trend to expand Ambulatory Surgery (AS) criteria in abdominal wall surgery. No Admission (NOADS) circuit. The present study aimed to assess the impact of classification criteria on postoperative results and hospital stays in a NOADS versus a conventional admission circuit to throw some light on surgical circuit inclusion.

METHODS

A retrospective analysis of a prospective;y maintained database was performed comparing groin hernia's interventions in a NOADS vs Admission circuit in our center in 2018-2021. A multiple regression predictive model followed by a retrospective retest were dessigned to assess the impact of each criterion on hospital stay. In total, 743 patients were included, 399 in the Admission circuit (ADC) and 344 in NOADS circuit (NOADS).

RESULTS

There were no statistical differences in complication or readmission rates (p = 0.343 and p = 0.563), nevertheless, a shorter hospital stay was observed in NOADS (p = 0.000). A hierarchical multiple regression predictive model proposed two opposite scenarios. The best scenario, not likely to need admission, was a female patient operated via the laparoscopic approach of a unilateral primary hernia (Estimated Postoperative Stay: 0.049 days). The worst scenario, likely to need admission, was a male patient operated via the open approach of a bilateral and recurrent hernia (Estimated Postoperative Stay: 1.505 Days).

CONCLUSION

Groin hernia patients could safely benefit from a No Admission (NOADS) circuit. Our model could be useful for surgical circuit decision-making, especially for best/worst scenarios.

Laparoscopic vs. Open Approach in Emergent Inguinal Hernia: Our Experience and Review of Literature

There is currently no consensus or homogeneous recommendation about the role of the laparoscopic approach in emergent inguinal hernia surgery. The aim of this manuscript is showing our experience and results of laparoscopic approach for emergent groin hernia repair comparing with open approach. A retrospective review of a prospectively maintained database between January 2011 and December 2021 of acute incarcerated groin hernia that were operated at Virgen del Rocio University Hospital. In this period, they were identified 463 patients with groin hernia that required an emergency repair. 454 patients underwent open surgery (group 1) and 36 patients underwent laparoscopic approach (TAPP procedure) (group 2). Median length stay was 1 day in lap group and 2 days in open approach. Reintervention was necessary in 20 cases (4.40%) from group 1 and one (2.27%) from group 2. In laparoscopic approach, no mortality was described but in open approach, 10 patients (2.20%) died. Globally, 58 cases (12.77%) from group 1 and six patients (16.66%) from group 2 presented any complication. Wound infection was higher in group of open repairs (5.94% vs. 2.77%). Non-surgical complications were higher in open approach (19 vs. 0). There is no statistical significance in any of these items. Laparoscopic approach is a safe, feasible and effective therapeutic option for the treatment of incarcerated groin hernia that require emergency surgery, but prospective and randomized comparative studies are needed to establish the best approach.

Unraveling the impact of chronic exposure to metal pollution through human gallstones

This study aims to explore the impact of chronic metal exposure derived from persistent pollution from mining activity using human gallstones as proxies. The samples were obtained from patients residing in geologically and environmentally contrasting areas in the Province of Huelva, SW Spain, allowing for the evaluation of the regional effect of metal pollution. The study group resides in the Iberian Pyrite Belt characterized by natural and anthropogenic metal pollution from mining activities, whereas the control group resides in the Ossa Morena Zone famous for its natural parks. A total of 68 gallstones were first classified based on their phase composition and structure and subsequently their chemical composition was studied using solution Inductively Coupled Plasma-Mass Spectrometry. The metal concentrations increased in the cholesterol-rich gallstones from pure, to mixed and composite cholesterol stones along with the increasing amount of minor phases, such as bilirubinate, carbonate, and phosphate. These cholesterol stones did not show an evident enrichment tendency. On the contrary, pigment stones, composed of bilirubinate, carbonate, and phosphate phases, were rich in a variety of elements and the regional comparison showed that the pigment stones from the study area were enriched in sulfide-associated metal(loid)s, Mn, Fe, Cu, Zn, Sr, As, Ag, Sb, and Pb with respect to the control group. Inhalation of polluted airborne particulate matter is considered as one of the main exposure routes among the residents of the study area. Additionally, consumption of local water and locally produced food products such as fruit and vegetables and dermal contact may be possible sources of exposure, but no direct connection was observed.

New insights into the metal partitioning in different microphases of human gallstones

Chronic metal exposure, e.g. from metal mining, may cause accumulation of metals in soft and hard tissues, and in developing biomineralizations in the human body. Gallstones are biomineralizations formed in the gallbladder which are able to trap trace elements from the bile. Laser Ablation-Inductively Coupled Plasma-Mass Spectrometry (LA-ICP-MS) was used to analyze gallstone cross-sections to trace the elemental abundances and correlate them with the principal phases constituting gallstones, namely cholesterol, Ca bilirubinate salts, Ca carbonate, and Ca phosphate. Five different types of gallstones (pure, mixed, and composite cholesterol stones, pigment stone, and carbonate stone) were chosen according to a previous classification based on phase characterization by different spectroscopic and microscopic techniques. These data were combined with bulk solution ICP-MS/OES analyses for total elemental concentrations. The results indicated that cholesterol has a zero capacity to retain elements except for Ca. Hence, pure cholesterol stones contained the lowest bulk metal concentrations, and the metals were found in the scarce carbonate and phosphate phases in these calculi. Calcium and trace element concentrations increased in other types of gallstones along with increasing amount of bilirubinate, carbonates and phosphates; pigment stones being the most enriched in metals. Phosphates were the principal carriers of Ca, P, Na, Mg, Mn, Fe, Pb, and Cd, whereas carbonate phases were enriched in Ca, Mg, Na, and Mn in order of decreasing abundance. Bilirubinate on the other hand was enriched in Ca, Cu, Ag, and Ni. The higher trace metal affinities of bilirubinate and phosphate explain the elevated metal concentrations observed in the pigment stones. These results give new insight to the trace metal behavior in the gallstone formation and the metal accumulation in the human body, validating the possible use of these biomineralizations as a proxy for exposure to metal pollution.

Combined microstructural and mineralogical phase characterization of gallstones in a patient-based study in SW Spain - Implications for environmental contamination in their formation

This study explores the environmental impact of metal exposure on humans through detailed phase and structural characterization of gallstones from two environmentally contrasting populations in Huelva Province (SW Spain). A total of 42 gallstone samples, obtained after surgical intervention at the Riotinto Hospital, were studied by powder X-ray diffraction (XRD), Fourier Transformed Infra-Red spectroscopy (FTIR), FTIR-μ-ATR (Attenuated Total Reflection) coupled with an optical microscope, and by Environmental Scanning Electron Microscope with Energy Dispersive X-ray Spectroscopy (ESEM-EDS), and subsequently classified according to their phase composition and structure. Additionally, the patients were enquired for their living habits in order to analyze the source of possible exposure to metal contamination. The gallstones were classified into pure, mixed and composite cholesterol stones, black and brown pigment stones, and carbonate stones. The patients from the study group residing in a region with acknowledged metal contamination of both natural and anthropogenic origin have a higher risk of metal exposure through contaminated soil, particle matter in the air, and consumption of local water and food products. According to our findings, the metal exposure is related to a higher tendency of forming black pigment stones in the study group in comparison to the control group residing in a natural park with nearly pristine environmental conditions. Moreover, the gallstones from the study group showed to contain more abundant metal components, such as Cu, Fe, Ni, and Zn, than those from the control group. To our knowledge this is the first study to examine the regional environmental impact of metal exposure on human gallstones.

[Appendiceal carcinoid tumors. Evaluation of long-term outcomes in a tertiary level]

BACKGROUND

Appendiceal tumors are found in about 1% of appendectomies performed and 0.5% of intestinal neoplasias. Appendiceal carcinoids are the predominant histology in this group and are usually casual after appendectomy for other reasons. The prognosis is excellent and survival is 95% at 5 years after surgery.

METHODS

Retrospective analysis of all patients with appendiceal carcinoid surgery in our hospital for 20 years (1990-2010) and survival at 5 years. We also discuss the need for additional treatment and testing for follow-up visits.

RESULTS

42 patients underwent surgery for appendiceal carcinoid tumor. 38 of them were operated on urgently, mostly for suspected acute appendicitis, without having reached the carcinoid tumor diagnosed preoperatively in any of them. The predominant symptomatology at admission was abdominal pain. Surgical treatment was appendectomy in 34 patients (12 laparoscopic), 7 patients required colon resections over intraoperatively by colonic involvement; only one patient required reoperation to complete right hemicolectomy. 2 patients had disseminated disease at diagnosis (liver metastases). The 5-year survival is over 95%, with no recurrence.

CONCLUSIONS

The appendiceal carcinoid tumor is difficult to diagnose preoperatively. Appendectomy surgical treatment is usually sufficient, although colonic resections may be needed for dissemination. The 5-year survival is over 95%.

[Obstructive jaundice secondary to hepatic artery aneurysm]

BACKGROUND

Aneurysm of the hepatic artery is relatively infrequent, representing 16-20% of aneurysms of the visceral arteries. Clinical presentation is nonspecific and may include abdominal pain, upper digestive system hemorrhage, or obstructive jaundice, as in the case presented here.

CLINICAL CASE

We present the case of a 47-year-old patient referred to our service due to obstructive jaundice, verifying that the pathology was caused by an aneurysm of >7 cm in diameter in the hepatic artery. Despite elective treatment and intensive collaboration of different surgical specialists, the patient's prognosis was poor.

DISCUSSION

These types of aneurysms occur infrequently and with an uncertain prognosis. Therefore, individualized treatment for each case is necessary.

CONCLUSIONS

We must carefully select the approach that fits the needs of our patient. The endovascular route is often currently used. However, because of the complexity of the location of the injury, in some cases it is impossible and surgical intervention is necessary with trained hepatobiliary and vascular surgeons.

Role of fibrin glue in the prevention of peritoneal adhesions in ventral hernia repair

PURPOSE

The aim of this study was to investigate the effects of fibrin glue on the prevention of postoperative peritoneal adhesion to prosthetic materials used in ventral hernia repair.

METHODS

Ten pigs were included in this study. The abdomens of the animals were opened by means of a median subumbilical laparotomy to place four prostheses that were cut into square pieces of 4 x 4 cm. The two prostheses in the most cephalic position were polypropylene meshes, and the other two prostheses in a more caudal position were expanded polytetrafluoroethylene prostheses (Dualmesh Plus Corduroy). The prostheses on the right side of each animal were previously impregnated with fibrin glue. After 5 weeks, the animals were reoperated on to assess the quantity and quality (consistency) of the adhesions.

RESULTS

There were fewer intraperitoneal adhesions and they were more labile in the case of prostheses impregnated with fibrin glue. Moreover, we also observed that in many of the animals the polypropylene mesh did not show any adhesions, although polypropylene has been considered to be a typical adhesion producing material.

CONCLUSIONS

Fibrin glue reduces both the quantity and consistency of adhesions, even in the case of polypropylene meshes.

[Role of malnutrition in intestinal anastomosis collagenization: an analysis of procollagen (PINP) and carboxyterminal telopeptide (ICTP) by radioimmunoassay]

INTRODUCTION

some clinical, anatomo-pathological, and technical factors influence the correct healing of intestinal suture following an intestinal resection. One of the most influential factors is patient nutritional status.

OBJECTIVES

to evaluate the influence of malnutrition on the viability of primary intestinal anastomosis by the analysis of collagen I deposition.

METHODS

40 Wistar rats, radioimmunoassay material. We used 2 groups of rats, 20 animals in each group: a control group (A) and a "malnutrition" group (B).

RESULTS

there was a decrease in PINP (procollagen) deposition in the colon of group B rats as compared to the colon of group A (0.3620 and 0.4340 mg/g respectively) (p = 0.032). There is an increase in ICTP (carboxyterminal telopeptide) in the colon of group B (0.9545 as against 0.8460 mg/g in group A) (p = 0.875). In anastomoses of group B there was a decrease in PINP synthesis as compared to group A (0.376 and 0.468 mg/g respectively, p = 0.002). As regards ICTP, there was an increase in group B (p = 0.330). In relation to the control group no differences were observed in ICTP increases in group B (p = 1).

CONCLUSIONS

colonic anastomosis increases the levels of PINP and ICTP in healed tissue (p = 0.000); malnutrition reduces collagenization in anastomoses (p = 0.000).