Dynamic suture less repair of incisional hernia

BACKGROUND AND AIM OF THE STUDY

An incisional hernia is represented by the escape of organs from their physiologic position through an area of weakness on the surgical scar. An original technique, based on a Rives intervention, which is the golden standard in the treatment of incisional hernias, is presented in this study.

METHODS

From January 1995 to December 2003, 93 patients underwent surgery for incisional hernia in our Division. The intervention was performed in 52 cases (Group A) with a classic Rives technique, with apposition of a prolene mesh in the subaponeurotic space, and fixation of the mesh with transcutaneous stitches. In 41 cases (Group B) the intervention was performed with a personal technique, with apposition of an "Hertra 0", a rigid and memory controlled mesh between the rectum abdomini muscle and its posterior fascia, tension free without fixation with stitches.

RESULTS

The mean follow-up was of 23 months. In Group A we observed immediately 3 postoperative cases (5%) of intraparietal haematoma, 2 (4%) of subcutaneous haematoma, 4 (7%) of retrofascial haematoma, 4 (7%) of wound infection (in 1 it was necessary to remove the prosthesis), 3 (6%) of respiratory complications, and 1 case (2%) of cardiovascular complication. In Group B we observed only 3 cases (7%) of subcutaneous seroma. The mean postoperative stay was 6 days in both groups. There was no postoperative mortality or relapses.

CONCLUSIONS

The presented technique seems to offer advantages in the management of incisional hernia; the use of "Hertra 0" mesh simplifies Rives technique, improving its resistance to infections.

[Hand-assisted laparoscopic technique (HALS) in colorectal surgery (Case reports and review of the literature)]

Hand-assisted laparoscopic surgery (HALS) is a new technique in which the surgeon's hand is introduced to the abdominal cavity through a mini-laparotomy, while pneumoperitoneum is maintained. We describe the technique of HALS used successfully in the treatment of two patients of colorectal disease. We describe current literature and our initial clinical experience. Our conclusion is that, besides colorectal surgery, HALS technique may prove useful for other abdominal procedures as well; however its real value should be estimated in prospective randomized trials.

Intraperitoneal macrophages and tumor immunity: A review

The macrophage (Mphi) is considered the first line of defense in immune response to foreign invaders. Increasing evidence suggests that Mphi(s) also play an important role against neoplastic cells. Mphi(s) exposed to supraphysiologic concentrations of CO(2) are suppressed. As surgeons apply newer minimally invasive techniques to oncologic therapies, it is important to evaluate the impact of these techniques on host-tumor interactions. We review the current understanding of Mphi biology with specific attention on cytotoxicity in addition to tumor immunity. Although systemic immune function is better preserved after laparoscopy than laparotomy, peritoneal Mphi(s) show reduced function after CO(2) pneumoperitoneum than exposure to air. Mphi(s) have shown cytotoxicity to syngeneic cancer cells and may play an important role in tumor surveillance. The impairment in Mphi function after CO(2) exposure may have an effect on outcome after oncologic surgery. In our understanding, Mphi(s) help destroy neoplastic cells. As CO(2) impairs Mphi activity, laparoscopy may significantly alter the host-tumor interaction.

Laparoscopic surgery and surgical infection

INTRODUCTION

It has been observed that the metabolic response to surgical injury is less after laparoscopic surgery than after open surgery. However, the effect of laparoscopic surgery on surgical infection has not been given much attention in the surgical literature, even though it may decrease the incidence of infectious complications. The objective of this study was to assess the influence that laparoscopic surgery has on surgical infection and to highlight certain controversial aspects.

METHODS

A review of the literature was undertaken to examine the relationship between laparoscopic surgery and surgical infection. This was achieved primarily by using PubMed Medline as a source of material.

RESULTS AND CONCLUSION

Laparoscopic surgery is associated with better preservation of the immune system than open surgery. This results in a decreased incidence of infectious complications. Although carbon dioxide pneumoperitoneum affects the peritoneal response to injury, it seems to have no harmful effect in terms of intra-abdominal infection. Nevertheless, at laparoscopic operation the virulence of intestinal micro-organisms should be recognized and, while knowing the advantages of minimally invasive surgery, the surgeon should consider the complexity of this technique. Furthermore, maintenance of laparoscopic instruments should be governed by the same norms as those used in open surgery; recommendations offered by the manufacturers should be respected.

Effect of CO(2) gas warming on pain after laparoscopic surgery: a randomized double-blind controlled trial

BACKGROUND

Previous studies have suggested that gas temperature has an influence on postlaparoscopy pain. This trial therefore was conducted to study the effect of gas warming on pain after upper abdominal laparoscopic surgery.

METHODS

Patients who underwent laparoscopic cholecystectomy, fundoplication, or Heller's myotomy were included and randomly allocated to receive either warm or cold gas. Primary end point was shoulder tip pain, and secondary end points were subcostal, trocar wound, and visceral pains, as well as other postoperative events. Criteria of pain assessment were the visual analog scale, verbal rating scale, and amount of analgesics.

RESULTS

A total of 100 patients were suitable for postoperative evaluation. The groups were well matched. Shoulder tip and subcostal pains were significantly more intense after gas warming (p < 0.05). The three assessment criteria showed the same differences. No difference was observed concerning trocar wound and visceral pains and the other secondary end points. Subdiaphragmatic temperature was not significantly different (34.4 degrees with warming vs. 34 degrees without warming).

CONCLUSIONS

Gas warming does not reduce, and probably increases, postoperative shoulder tip and subcostal pains.

[Usefulness of the trans-umbilical incision in laparoscopic surgery]

Most surgeons induces pneumoperitoneum with the Verres' needle via an infra or a supraumbilical route; only a reduced group does it true the umbilicus. This paper reports the authors experience using the trans-umbilical route emphasizing its differences and advantages over the conventional umbilical approach. The files of our last 100 laparoscopic cholecystectomies performed in different hospitals were reviewed. Trans-umbilical route was used in 93 cases. Four patients were found to have an umbilical hernia with no content in its sac and it did not compromised the approach. In 7 cases the semi-open technique had to be used because of previous abdominal surgery. There were no major complications during the induction of the pneumoperitoneoum; no hematomas infections or post-operative umbilical hernias either, just a mild pneumopreperitoneum occurred in 5 patients. Trans-umbilical approach for pneumoperitoneum induction is useful, safe, easy to repair, has a low infection rate, and provide better cosmetic results; scar is almost invisible deep in the umbilicus. This approach has several advantages over the ordinary umbilical approaches by been cautious and by using the authors' technique, mini-invasive procedures can be initiated quick and safely.

Porous diaphragm syndromes

Porous diaphragm syndromes are a group of seemingly disparate clinical symptom complexes involving a wide variety of unrelated medical specialties. However, they are linked by a common anatomical feature, a defect in the diaphragm. They usually present with thoracic symptomatology--pleural effusions, pneumothorax, hemothorax, empyema--mediated by this defect. Management of these syndromes utilizes principles of thoracic surgical practice including thoracotomy and thoracoscopy.