[Cholelithiasis: complications and rehabilitation]

The results of laparoscopic cholecystectomy, conducted in 71 patients, suffering cholelithiasis, were analyzed. In early postoperative period an acute cholangitis have occurred in 2 (2.8%) patients, an acute pancreatitis--in 1 (1.4%), postoperative infiltrate--in 14(19.7%), suppuration of postoperative cicatrix--in 6 (8.4%); late compli- cations as a kind of postcholecystectomy syndrome was observed in 29 (40.8%) patients, and abdominal hernia--in 3 (4.2%).

Meckel's diverticulum incarcerated in a transmesocolic internal hernia

Intestinal obstruction is a common complication associated with Meckel's diverticulum in adults. The diverticulum itself or its fibrous band can lead to an intestinal volvulus, intussusceptions, or closed-loop obstructions, which require surgery. The incarceration of Meckel's diverticulum in either inguinal or femoral hernia sacs (Littre's hernia) is another, less common, etiology underlying intestinal obstruction. This case report describes a 45-year-old man who had an obstruction associated with a Meckel's diverticulum that passed through a congenital defect in the mesocolon into the right subphrenic space. The patient, who had not undergone abdominal surgery previously, came to the emergency room with acute onset of intermittent epigastric pain and abdominal distention. Computed tomography images showed the presence of a segment of the small bowel and a diverticulum in the right subphrenic space and paracolic gutter. The twisted mesentery and the dilated loops of the proximal small bowel were indicative of an intestinal volvulus and obstruction. Meckel's diverticulum complicated by a transmesocolic internal hernia was diagnosed, and this condition was confirmed during emergency surgery. The patient's postoperative recovery was uneventful. This case report highlights another presentation of Meckel's diverticulum, that is, in combination with a transmesocolic internal hernia. This etiology may lead to an intestinal volvulus and necessitate early surgery.

[Simplified laparoscopic gastric bypass. Initial experience]

BACKGROUND

Obesity surgery includes various gastrointestinal procedures. Roux-en-Y gastric bypass is the prototype of mixed procedures being the most practiced worldwide. A similar and novel technique has been adopted by Dr. Almino Cardoso Ramos and Dr. Manoel Galvao called "simplified bypass," which has been accepted due to the greater ease and very similar results to the conventional technique. The aim of this study is to describe the results of the simplified gastric bypass for treatment of morbid obesity in our institution.

METHODS

We performed a descriptive, retrospective study of all patients undergoing simplified gastric bypass from January 2008 to July 2012 in the obesity clinic of a private hospital in Mexico City.

RESULTS

A total of 90 patients diagnosed with morbid obesity underwent simplified gastric bypass. Complications occurred in 10% of patients; these were more frequent bleeding and internal hernia. Mortality in the study period was 0%. The average weight loss at 12 months was 72.7%.

CONCLUSION

Simplified gastric bypass surgery is safe with good mid-term results and a loss of adequate weight in 71% of cases.

[The nature of postoperative complications in patients with peritonitis]

We studied the postoperative period in patients with peritonitis. The structure of the most important factors that slow down the healing process and lead to mortality. Among the factors that affect the healing process is the most important character of fluid, and the prevalence of peritonitis (causative factor), which causes complications on the part of the internal organs and wounds.

Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia. A randomized clinical trial

BACKGROUND

Prosthetic repair has become the standard method for hernia repair. Mesh placement for the prevention of trocar site incisional hernia (TSIH) is still a controversial issue. We tested the hypothesis that closure with an intraperitoneal prophylactic mesh of the umbilical trocar after a laparoscopic cholecystectomy can reduce the incidence of a TSIH in high-risk patients.

STUDY DESIGN

A randomized clinical trial was conducted among patients undergoing elective laparoscopic cholecystectomy who presented the following high-risk factors for incisional hernia, according to the literature: age 65 years and older, diabetes mellitus, chronic pulmonary disease, and obesity (ie, body mass index ≥30 kg/m(2)). Patients were assigned to have closure of the umbilical trocar site with either nonabsorbable sutures (group A) or intraperitoneal polypropylene omega-3 mesh (group B). Trocar site incisional hernia, pain, and surgical complications were evaluated at the early postoperative course and at 1, 6, and 12 months after surgery.

RESULTS

A total of 106 patients were randomized into the study and 92 patients were finally analyzed, including 47 in group A and 45 in group B. The TSIH rate was higher in group A (31.9%) than in group B (4.4%) (odds ratio = 10.1; 95% CI, 2.15-47.6; p < 0.001)). The wound infection rate was 4.3%; 8.5% in group A and 0% in group B (odds ratio = 2.04; 95% CI, 1.7-2.5; p = 0.045). Median postoperative pain evaluated by a visual analogue scale was 3 in group A and 2 in group B (p = 0.05). No differences were observed in complication rate, operative time, or hospital stay between the groups.

CONCLUSIONS

Prosthetic closure of the umbilical trocar site after laparoscopic surgery could become the standard method for preventing TSIH in high-risk patients.

[Foetal brain damage may follow gastric bypass surgery]

Bariatric surgery is performed on an increasing number of women of childbearing age. During pregnancy they have reduced risk of obesity-related complications but increased risk of bariatric surgery-related complications, including internal hernias. We present a case in which a pregnant woman required acute surgery for internal herniation and later gave birth to a child with cerebral palsy. Before performing bariatric surgery in women of childbearing age, thorough information about risks and benefits related to pregnancy should be given. Special medical attention during pregnancy is required.

The management of abdominal contour defects following TRAM flap breast reconstruction

BACKGROUND

Incisional hernia can develop following breast reconstruction with abdominal tissue regardless of technique, and the management is often challenging.

OBJECTIVES

The authors characterize hernias following transverse rectus abdominis musculocutaneous (TRAM) flap procedures and evaluate outcomes of different strategies for repair.

METHODS

All patients who underwent repair of a TRAM-related hernia or bulge between 2003 and 2011 at a single institution were retrospectively reviewed. A minimum of 2 years' follow-up was required for inclusion in this series. Outcomes of different techniques for repair were compared and risk factors for hernia recurrence identified.

RESULTS

Forty-three patients underwent repair of a TRAM-related hernia or bulge, most often with mesh (74.4%, n=32). At a mean overall follow-up of 5.2 years, 9 patients (20.9%) developed recurrent hernia or bulge. Compared to primary suture closure, the use of mesh was protective against recurrence (odds ratio, 0.05; 95% confidence interval, 0.00-0.65; P=.02), with the best results observed with fascial closure and underlay mesh reinforcement.

CONCLUSIONS

Incisional hernia following TRAM flap breast reconstruction can be a challenging problem. Attention to surgical technique and the use of mesh minimize the risk of recurrence.

[Successful laparoscopic repair of delayed traumatic abdominal wall hernia]

The occurrence of traumatic abdominal wall hernia secondary to blunt trauma is uncommon, and laparoscopic repair of such hernias is very rare. A 53-year-old man, who had sustained injuries to his right thigh and right abdomen 8 months previously, visited a hospital because of a bulge in the right lateral abdomen. An abdominal computed tomography scan revealed a rupture in the lateral abdominal muscle and herniation of the cecum into the subcutaneous space. Accordingly, delayed traumatic abdominal wall hernia was diagnosed, which was successfully repaired laparoscopically. Thus, a laparoscopic tension-free mesh repair was safely and effectively performed for delayed traumatic abdominal wall hernia.

[Dealing with surgical complications after bariatric gastric bypass surgery]

The subject of this article is surgical complications to Roux-en-Y-gastric bypass and how to deal with them. The article addresses doctors, who are on duty in hospitals without bariatric surgery and who often deal with this patient category in the acute situation. Managing complications is challenging due to both the patient's physiognomy and the wide-ranged change in anatomy. The article gives a review of the literature and hands-on-recommendations for treating anastomotic leak, post-operative bleeding, internal herniation, bowel obstruction and biliary complications.

Vacuum with mesh is a feasible temporary closure device after fascial dehiscence

INTRODUCTION

The open abdomen is a challenging condition and a temporary abdominal closure device is required in order to protect the intra-abdominal viscera. We aimed to evaluate the feasibility of a recent device: vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) after fascial dehiscence focusing on fascial closure rate, mortality and procedure-related complications.

MATERIAL AND METHODS

We performed a retrospective study on 18 patients treated with VAWCM after fascial dehiscence who were consecutively admitted to the Department of Surgery, Slagelse Hospital, between October 2008 and October 2012.

RESULTS

The 18 patients had a median age of 64 (29-90) years. 80% (12/15) obtained delayed primary abdominal closure. The in-hospital mortality was 17% (3/18). The median treatment period with VAWCM and vacuum-assisted wound closure were 18 (7-34) and 21 (7-53) days, respectively, with a median of six (1-11) tightenings. One patient developed an intra-abdominal abscess. Three patients survived until discharge without having obtained delayed primary closure. In two of these patients, the fascial edges were adapted with a prosthetic mesh and one patient was left with a planned ventral hernia. We performed a retrospective follow-up with a median duration of 21 months 21% developed an incisional hernia. Two patients died within 60 days after closure of the abdomen.

CONCLUSION

We found and that VAWCM is a safe and useful technique for delayed primary closure of the open abdomen after fascial dehiscence. We stress the need for more studies on temporary abdominal closure devices in selected groups of patients.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

European Hernia Society classification of parastomal hernias

Purpose

A classification of parastomal hernias (PH) is needed to compare different populations described in various trials and cohort studies, complete the previous inguinal and ventral hernia classifications of the European Hernia Society (EHS) and will be integrated into the EuraHS database (European Registry of Abdominal Wall Hernias).

Methods

Several members of the EHS board and invited experts gathered for 2 days to discuss the development of an EHS classification of PH. The discussions were based on a literature review and critical appraisal of existing classifications.

Results

The classification proposal is based on the PH defect size (small is ≤5 cm) and the presence of a concomitant incisional hernia (cIH). Four types were defined: Type I, small PH without cIH; Type II, small PH with cIH; Type III, large PH without cIH; and Type IV, large PH with cIH. In addition, the classification grid includes details about whether the hernia recurs after a previous PH repair or whether it is a primary PH. Clinical validation is needed in the future to assess if the classification allows us to differentiate the treatment strategy and if the classification impacts outcome in these different subgroups.

Conclusion

A classification of PH divided into subgroups according to size and cIH was formulated with the aim of improving the ability to compare different studies and their results.

[The effect of laparoscopic hernioplasty using various types of allotransplants on the quality of life in patients with postoperative abdominal wall hernia]

The quality of life (QL) dynamics during 6 mo after laparoscopic hernioplasty (LH), using the Proseed and polytetrafluoroethylene (PTFE) net, pulled over nitinol carcase (NC), was studied in 67 patients, suffering postoperative abdominal hernias (POAH). These patients were divided into two groups in accordance to two kinds of allotransplants used. They have had answered the SF-36 questionnaire questions while discharging from stationary and also in 1 and 6 months after LH. The results obtained witness, that LH with intraperitoneal allotransplant placement certainly impacts QL in the patients, suffering POAH, but its indices completely restore up to 6 mo postoperatively. In the patients, for whom PTFE with NC was applied the pain intensity was lesser while discharge from stationary and in 1 mo after discharge from the hospital. Restoration for this criterion in both groups of patients was registered up to sixth postoperative month. In the patients with the PTFE and NC nets applied the indices of physical and psychiatric blocks of QL in 1 mo postoperatively have appeared normal. While in the patients with the Proseed nets applied in 6 mo after LH the restoration of components of physical health was only noted.

Late post liver transplant protein losing enteropathy: Rare complication of incisional hernia

Development of oedema and hypoproteinaemia in a liver transplant recipient may be the first signs of graft dysfunction and should prompt a full assessment. We report the novel case of a patient who, years after liver transplantation developed a functional blind loop in an incisional hernia, which manifested as oedema and hypoproteinaemia secondary to protein losing enteropathy. After numerous investigations, the diagnosis was made by flurodeoxyglucose positron emmision tomography (FDG-PET) imaging. Surgical repair of the incisional hernia was followed several months later by resolution of the protein loss, and confirmed at a post operative FDG-PET scan at one year.

Incidence of port site hernias and/or dehiscence in robotic-assisted procedures in gynecologic oncology patients

OBJECTIVES

The incidence of port site hernia and/or dehiscence using bladeless trocars is 0-1.2%. Robotic surgery uses additional port sites and increases manipulation of instruments, raising the concern for more complications. We sought to characterize the incidence of port site complications following robotic surgery when fascia was not routinely closed.

METHODS

Robotically-assisted (RA) procedures performed for suspected gynecologic malignancy between 1/2006 and 12/2011 were retrospectively reviewed. Bladeless 12 mm and 8mm robotic trocars were used. Fascial closure was not routinely performed except after specimen removal through the port site. The decision to close the fascia remained at the discretion of the surgeon.

RESULTS

Data from 842 procedures were included. Mean patient age was 55.6 years. Mean Body Mass Index was 33.6 kg/m(2). RA-total laparoscopic hysterectomy (TLH)± unilateral or bilateral salpingo-oophorectomy (BSO)± lymphadenectomy (LND) accounted for 91.6% of procedures. Final pathology confirmed malignancy in 58.6% of cases, primarily endometrial cancer. In 35 cases, the specimen was removed through the port site; fascia was closed in 54.3% of them and no port site hernias or dehiscences occurred. Only one patient underwent a RA-TLH/BSO/LND for endometrial adenocarcinoma and had a port site dehiscence of the 8mm trocar site. No port site hernias occurred.

CONCLUSION

Port site hernias and dehiscences are rare in RA gynecologic oncology procedures. When bladeless dilating trocars are used, routine closure of even up to a 12 mm port site is unnecessary, even in cases requiring removal of the specimen through the trocar sites.

Paediatric abdominal wall hernia following handlebar injury: should we diagnose more and operate less?

Traumatic abdominal wall hernia following handlebar injury can be easily missed and is thus underreported. A 12-year-old boy presented with handlebar injury to the left upper quadrant of his abdomen. Except for a localised swelling, thought to be related to a haematoma, he was haemodynamically stable. CT revealed an abdominal wall defect with herniating fat that was not evident clinically and was also missed on immediate ultrasound examination. As there were no associated injuries and the abdominal wall defect was small without any herniating bowel loops, masterly inactivity was observed. After 6 weeks, the swelling has disappeared completely and there is progressive reduction in the size of the defect.

Reinforcement of closure of stoma site using a biological mesh

Incisional hernia at the site of stoma closure is an under-reported problem, having been recently shown to occur in up to 30 % of patients. This technical note describes a technique for the placement of intraperitoneal biological mesh to prophylactically reinforce stoma closure sites. Seven consecutive patients underwent mesh placement as part of a pilot study. Following closure of the stoma through a trephine incision, 6 anchoring sutures were placed between the peritoneum/deep fascia and the edges of the mesh circumferentially. The mesh was delivered into the peritoneal cavity and parachuted up against the abdominal wall, and the sutures tied. If closure was performed through a midline laparotomy, the anchoring sutures were placed in a similar fashion through the midline incision. The fascia above the mesh and soft tissues was then closed. The mesh was successfully placed in all 7 patients. Follow-up at 30 days showed one superficial wound infection. An ultrasound scan of this patient revealed that the mesh was still in place and that the infection did not breach the fascia. No other early adverse events occurred. Prophylactic biological mesh reinforcement of stoma closure sites is technically feasible and safe in the short term. Longer-term results from a prospective randomised trial are needed, including clinical and radiological assessment for hernia rates, to establish what if any are the realisable benefits of this technique.

Atypical clinical presentation of internal herniation after laparoscopic Roux-en-Y gastric bypass

A 60-years old women with history of Roux-en-Y gastric bypass presented with progressive abdominal pain, mainly at the left loin. Imaging was aspecific. Exploratory laparoscopy showed an internal herniation trough the Petersen space.