Classification of primary and incisional abdominal wall hernias

Purpose

A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable.

Methods

Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias.

Results

To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome.

Conclusions

A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery

PURPOSE

To provide uniform terminology and definition of post-herniorrhaphy groin chronic pain. To give guidelines to the scientific community concerning the prevention and the treatment of chronic groin and testicular pain.

METHODS

A group of nine experts in hernia surgery was created in 2007. The group set up six clinical questions and continued to work on the answers, according to evidence-based literature. In 2008, an International Consensus Conference was held in Rome with the working group, with an audience of 200 participants, with a view to reaching a consensus for each question.

RESULTS

A consensus was reached regarding a definition of chronic groin pain. The recommendation was to identify and preserve all three inguinal nerves during open inguinal hernia repair to reduce the risk of chronic groin pain. Likewise, elective resection of a suspected injured nerve was recommended. There was no recommendation for a procedure on the resected nerve ending and no recommendation for using glue during hernia repair. Surgical treatment (including all three nerves) should be suggested for patients who do not respond to no-surgery pain-management treatment; it is advisable to wait at least 1 year from the previous herniorraphy.

CONCLUSION

The consensus reached on some open questions in the field of post-herniorrhaphy chronic pain may help to better analyze and compare studies, avoid sending erroneous messages to the scientific community, and provide some guidelines for the prevention and treatment of post-herniorraphy chronic pain.

The European hernia society groin hernia classification: simple and easy to remember

After reviewing the available classifications for groin hernias, the European Hernia Society (EHS) proposes an easy and simple classification based on the Aachen classification. The EHS will promote the general and systematic use of this classification for intraoperative description of the type of hernia and to increase the comparison of results in the literature.

EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair

BACKGROUND

Although the repair of ventral abdominal wall hernias is one of the most commonly performed operations, many aspects of their treatment are still under debate or poorly studied. In addition, there is a lack of good definitions and classifications that make the evaluation of studies and meta-analyses in this field of surgery difficult.

MATERIALS AND METHODS

Under the auspices of the board of the European Hernia Society and following the previously published classifications on inguinal and on ventral hernias, a working group was formed to create an online platform for registration and outcome measurement of operations for ventral abdominal wall hernias. Development of such a registry involved reaching agreement about clear definitions and classifications on patient variables, surgical procedures and mesh materials used, as well as outcome parameters. The EuraHS working group (European registry for abdominal wall hernias) comprised of a multinational European expert panel with specific interest in abdominal wall hernias. Over five working group meetings, consensus was reached on definitions for the data to be recorded in the registry.

RESULTS

A set of well-described definitions was made. The previously reported EHS classifications of hernias will be used. Risk factors for recurrences and co-morbidities of patients were listed. A new severity of comorbidity score was defined. Post-operative complications were classified according to existing classifications as described for other fields of surgery. A new 3-dimensional numerical quality-of-life score, EuraHS-QoL score, was defined. An online platform is created based on the definitions and classifications, which can be used by individual surgeons, surgical teams or for multicentre studies. A EuraHS website is constructed with easy access to all the definitions, classifications and results from the database.

CONCLUSION

An online platform for registration and outcome measurement of abdominal wall hernia repairs with clear definitions and classifications is offered to the surgical community. It is hoped that this registry could lead to better evidence-based guidelines for treatment of abdominal wall hernias based on hernia variables, patient variables, available hernia repair materials and techniques.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Prosthetic repair, intestinal resection, and potentially contaminated areas: Safe and feasible?

INTRODUCTION

Prosthetic repair for abdominal wall hernia currently represents the gold standard. However, it is still difficult to identify the correct indication for prosthetic implant in borderline cases. The authors propose evaluating whether a prosthetic implant is absolutely contraindicated in potentially infected operating fields through the review of literature and personal experience.

MATERIALS AND METHODS

The authors performed ten prosthetic hernia repairs in potentially contaminated areas, with a preliminary preparation of the retromuscular-preperitoneal space hosting the prosthesis implant, and subsequent performance of the major operation.

RESULTS

There were neither major nor minor complications with a 21-month follow-up (mean period).

DISCUSSION

It is certain that both in noncomplicated inguinal hernia and in abdominal wall hernia repairs, the use of antibiotics can significantly reduce the number of infections. It is very important to underline that the success of the described procedure can be guaranteed only by an accurate preparation of the preperitoneal space: perfect haemostasis, temporary closure of the space with the insertion of iodine gauzes and suturing the edges, local antibiotic treatment, washing of the cavity, and accurate drainage.

CONCLUSIONS

Prosthetic repair is the gold standard for inguinal, incisional, and all abdominal wall hernias and should be used, with the method described, even in potentially contaminated areas. The use of a prosthesis has to be avoided in clearly infected cases.

Open tension-free Lichtenstein repair of inguinal hernia: use of fibrin glue versus sutures for mesh fixation

PURPOSE

To investigate pain and other complications following inguinal hernioplasty performed by the Lichtenstein technique with mesh fixation by fibrin glue or sutures.

METHODS

Five hundred and twenty patients were enrolled in this 12-month observational multicenter study and received either sutures or fibrin glue (Tissucol(®)/Tisseel(®)) based on the preference of the surgeon. Pain, numbness, discomfort, recurrence, and other complications were assessed postoperatively and at 1, 3, 6, and 12 months. Pain intensity was assessed by a visual analog scale (VAS; 0 [no pain] to 10 [worst pain]).

RESULTS

One hundred and seventy-one patients received sutures and 349 received fibrin glue. During the early postoperative phase, 87.4% of patients in the fibrin glue group and 76.6% of patients in the sutures group were complication-free (P = 0.001). Patients who received fibrin glue were also less likely to experience hematoma/ecchymosis than those in the suture group (both P = 0.001). The mean pain score was significantly lower in the fibrin group than the sutures group (2.5 vs. 3.2, P < 0.001). At 1 month, significantly fewer patients in the fibrin glue group reported pain, numbness, and discomfort compared with patients in the sutures group (all P < 0.05). Fibrin glue patients also experienced less intense pain (0.6 vs. 1.2; P = 0.001). By 3 months, the between-group differences had disappeared, except for numbness, which was more prevalent in the sutures group. By 12 months, very few patients reported complications.

CONCLUSIONS

Tissucol fibrin glue for mesh fixation in the Lichtenstein repair of inguinal hernia shows advantages over sutures, including lower incidence of complications such as pain, numbness, and discomfort, and should be considered as a first-line option for mesh fixation in hernioplasty.

Surgical treatment of chronic pain after inguinal hernia repair

BACKGROUND

Chronic groin pain is defined as pain arising 3-6 months after inguinal hernia repair that can compromise the patient's quality of life. Many articles in the literature report clinical presentation, but there are no well-defined indications and protocols of treatment.

METHODS

Forty-six patients underwent surgical treatment for chronic groin pain that consisted of a simultaneous double approach, anterior and posterior, to the inguinal region, with 44 triple neurectomies and 2 iliohypogastric neurectomies. Ilio-inguinal and ilio-hypogastric nerves were resected by anterior approach, while genitofemoral trunk was resected by a posterior pre-peritoneal approach. Mesh was removed in 24 cases, and mesh and plug were removed in 16 cases. A new mesh repair was performed in 42 cases. All the patients were examined 1 week, 1 month and 1 year postoperatively.

RESULTS

In 40 patients, the surgical treatment has obtained good response with improvement or complete resolution of the pain. Two patients referred persistent groin pain different from preoperative and in 4 cases the pain persisted without substantial benefit. Mean VAS value was 7.89 before surgery and 1.89 after surgery.

CONCLUSIONS

Choice of the adequate therapy of chronic groin pain after inguinal hernia repair is still controversial. Our surgical approach turned out to be a safe and effective procedure. In this way, an accurate exploration of the whole inguinal region can be performed along with the identification of the nerves involved. Anyway in a certain number of cases, the resolution of pain cannot be achieved; this suggests a possible involvement of differences in the single personality and tolerances of pain in the different patients.

Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation

PURPOSE

Diastasis recti abdominis (DRA) or rectus diastasis is an acquired condition in which the rectus muscles are separated by an abnormal distance along their length, but with no fascia defect. To data there is no consensus about risk factors for DRA. The aim of this article is to critically review the literature about prevalence and risk factor of DRA.

METHOD

A total of 13 papers were identified.

RESULTS

The real prevalence of DRA is unknown because the prevalence rate varies with measurement method, measurement site and judgment criteria, but it is certainly an extremely frequent condition. Numbers of parity, BMI, diabetes are the most plausible risk factors. We identified a new anatomical variation in cadaveric dissection and in abdominal CT image evaluation: along the semilunar line the internal oblique aponeurosis could join the rectus sheath with only a posterior layer, so without a double layer (anterior and posterior) as usually described. We conducted a retrospective review of abdominal CT images and the presence of the posterior insertion only could be considered as a risk factor for DRA.

CONCLUSION

Further studies with large sample size, including nulliparous, primiparous, pluriparous and men too, are necessary for identify the real prevalence.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project

INTRODUCTION

There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems.

METHODS

The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries.

RESULTS

The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center.

CONCLUSION

Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

Prosthetic abdominal wall hernia repair in emergency surgery: from polypropylene to biological meshes

The use of nonabsorbable prosthetic materials such as polypropylene, polyester, and ePTFE, have expanded and are now widely used in reparative surgery for abdominal wall hernias.There are still difficulties to find correct indication for prosthetic implant in emergency hernia surgery: as a matter of fact there is still a great debate if to use non-absorbable prostheses in potentially or truly infected operating fields [e.g. after intestinal resections].All these problems can be avoided with the use of absorbable prosthetic materials such as those composed of lactic acid polymers or lactic and glycolic acid copolymers: however, the use of these absorbable prosthesis exposes the patient to a rapid and inevitable hernia recurrence.It is important to remember that prosthetic repair has been proven to have a significant less risk of recurrence than repair with direct sutures.Recently, new "biologic" prosthetic materials have been developed and proposed for the clinical use in infected fields. These materials can be called "remodeling" for the way by which they are replaced after their placement within the patient. The "remodeling" process is made possible through a process of incorporation, where a reproduction of a site-specific tissue similar to the original host tissue is created.

Organic No-Till with Roller Crimpers: Agro-ecosystem Services and Applications in Organic Mediterranean Vegetable Productions

<p>In sustainable/organic farming systems, Agro-ecological Service Crops (ASC) may provide many beneficial ecosystem services, when they are introduced as buffer zones, living mulches or break crops. This outlook paper focuses on: i) the role of ASC genotype and mixtures as catch crops for soil mineral nitrogen (NO₃^-) surplus, which is returned to the system after their termination; ii) living mulches and break crops management strategies, particularly comparing ploughing under (green manure) with termination by roller crimper; iii) summary of three recent case studies that have assessed the effectiveness of ASC management by no-till with roller crimper for tomato, zucchini and melon crops, under Mediterranean conditions. Recently, in central Italy yield and quality results on organic tomato indicated that this crop was suitable following termination of leguminous ASC by roller crimping. Similarly, this ASC management increased yield by about 70% compared to green manure in zucchini crop. In southern Italy, no substantial differences were found in the ASC management and organic fertilizer interactions in organic melon, confirming the suitability of matching these strategies to sustain crop production. More studies should be encouraged to further empower the use of ASC in a wide range of agro-climatic conditions. Furthermore, additional studies on the roller crimper should be performed, mainly to understand the dynamic of N mineralisation in the soil-mulch interface and synchronisation of N release with cash crop N requirements. Finally, Decision Supporting Systems (DSS) for ASC introduction into vegetable cropping systems should be developed.</p>

Inguinal hernia recurrence: classification and approach

We reviewed case reports, updated to January 2005, of 2,468 operations for groin hernia in 2,350 patients, including 277 recurrent hernias. The data obtained, following a simple anatomo-clinical classification into three types that could be used to orient surgical strategy, were: type R1--first recurrence of "high" oblique external reducible hernia with small (<2 cm) defect in non-obese patients after pure tissue or mesh repair; type R2--first recurrence of "low" direct reducible hernia with small (<2 cm) defect in non-obese patients after pure tissue or mesh repair; and type R3--all other recurrences, including femoral recurrences, recurrent groin hernia with large defect (inguinal eventration), multi-recurrent hernias, non-reducible contralateral primary or recurrent hernia, and situations compromised by aggravating factors (e.g. obesity) or otherwise not easily included in R1 or R2 after pure tissue or mesh repair.

Giant inguinal hernia: the challenging hug technique

PURPOSE

Giant inguinoscrotal hernia are a real challenge for every kind of surgeon. The technique that we adopt is suggested as a good option to deal with this cases. We report our experience in five cases of giant inguinoscrotal hernia with loss of domain from 2005 to 2012.

METHOD

Five patients with hernia that descended below the knees in the standing position, with an anteroposterior diameter not inferior to 30 cm and a laterolateral diameter of about 50 cm. Penis was not visible. We did the same procedure for all the five patients: single pararectus incision extended to groin region until proximal half of scrotum, isolation of the entire large sac out of the scrotal cavity, paying attention to not opening it, progressive reduction of the viscera without opening the sac with the hug technique, as shown in the video, placement of a heavyweight polypropylene meshes in the preperitoneal space, scrotal skin reductive plastic. In three of our five cases we obtained restoration of herniated viscera without resection of them. Orchiectomy was performed in all cases.

RESULTS

No general neither wound complications were recorded. Long term follow up ranges from 8 years to 18 months: we did not record recurrence or chronic groin pain and scrotal size is normal in each patient.

CONCLUSION

The technique proposed permits to treat with success giant inguinaoscrotal hernia, avoiding the use of further specific procedure such as the preoperative progressive pneumoperitoneum. All our patients were satisfied with the surgeries and their quality of daily life had definitely improved.

Spigelian Hernia

We report on the evolution in concept and techniques that allowed us to improve the treatment of spigelian hernia, operable in day surgery in 90% of cases and through a preperitoneal and recently a preperitoneal and subfascial prosthetic repair (PHS).

BACKGROUND DATA

We propose an innovative use of the PHS mesh for spigelian hernia repair. With this new implementation, we confront the standard surgical technique and its postoperative period.

METHODS

From January 1992 to March 2004, we performed 2,500 hernia surgical operations, including 32 spigelian hernia repairs (1.3% of total case series). The first surgical approach used for 20 of these 32 patients (62.5% of total spigelian hernias), all electively operated on, was a classical preperitoneal repair (Wantz), performed when possible by size of defect and weight (Body Mass Index) of the patient, under local anesthesia and on a day-surgery basis. Our new modified technique takes place through the insertion of a PHS large-type mesh, whose bottom underlay portion lies flat in the preperitoneal space with the connector obliterating the hernial orifice and with the overlay portion lying on the internal oblique muscle, covered by the aponeurosis of the external oblique muscle.

RESULTS

Our modification to the classical technique consisted only in the application of a product, such as the PHS, in a hernia defect, which presented with an orifice of the size of the connector and, therefore, was easily repairable with the use of the PHS device. This approach is easier than the preperitoneal approach, it's always suitable for local anaesthesia, and it gives a more comfortable postoperative period. The surgical approach may be performed completely in day surgery.

CONCLUSIONS

We believe that spigelian hernia surgical repair should always be performed by means of a preperitoneal prosthesis under local anaesthesia when the patient's clinical and physical conditions allow for it, always in day surgery, and using the PHS mesh when the hernia defect size fits with the connector diameter. This last possibility seems to be easier and more comfortable for the patient in the postoperative period.

Organ culture in 3-dimensional matrix: in vitro model for evaluating biological compliance of synthetic meshes for abdominal wall repair

A new in vitro method to evaluate the early critical interactions between synthetic prosthetic materials and growing tissues is reported. The correct spatial organization and proper cell to cell interaction required to mimic the in vivo environment was obtained in a 3-dimensional (3-D) embryo organ culture. The clot formed by plasma and chick-embryo extract provided a natural 3-D extracellular matrix that was able to support the growth and differentiation of intestinal tissue dissected from 12-day-old chick embryos. Different materials used for the repair of abdominal wall defects were taken as standards; all the prosthetic materials were devoid of any evident cytotoxic potential over a 10-day culture period, so they did not interfere with the organogenesis process. A polyglactin mesh (Vicryl) was fully incorporated into the growing tissue, but early signs of its degradation were detectable. The biologically inert materials polyethylene terephthalate (Mersilene) and polypropylene (Marlex, Prolene, and Herniamesh) retained their structural integrity when incubated with cultured tissue at 37 degrees C, and they did not hinder cellular proliferation or fibroblast migration. However, the outgrowth behavior was very different while the connective tissue invaded the interstices of the polyethylene terephthalate mesh; the explants and the migrating cells were repelled by hydrophobic polypropylene meshes. These findings are in agreement with other reported results in in vivo studies. Therefore, this method can be considered as reliable and predictable for the evaluation of biopolymers.

Long-term impact of farm management and crops on soil microorganisms assessed by combined DGGE and PLFA analyses

In the present study, long-term organic and conventional managements were compared at the experimental field of Monsampolo del Tronto (Marche region, Italy) with the aim of investigating soil chemical fertility and microbial community structure. A polyphasic approach, combining soil fertility indicators with microbiological analyses (plate counts, PCR-denaturing gradient gel electrophoresis [DGGE] and phospholipid fatty acid analysis [PLFA]) was applied. Organic matter, N as well as some important macro and micronutrients (K, P, Mg, Mn, Cu, and Zn) for crop growth, were more available under organic management. Bacterial counts were higher in organic management. A significant influence of management system and management x crop interaction was observed for total mesophilic bacteria, nitrogen fixing bacteria and actinobacteria. Interestingly, cultivable fungi were not detected in all analyzed samples. PLFA biomass was higher in the organic and Gram positive bacteria dominated the microbial community in both systems. Even if fungal biomass was higher in organic management, fungal PCR-DGGE fingerprinting revealed that the two systems were very similar in terms of fungal species suggesting that 10 years were not enough to establish a new dynamic equilibrium among ecosystem components. A better knowledge of soil biota and in particular of fungal community structure will be useful for the development of sustainable management strategies.

New "biological" meshes: the need for a register. The EHS Registry for Biological Prostheses: call for participating European surgeons

Non-absorbable prosthetic materials in hernia surgery can cause relatively rare complications, which include chronic pain, a feeling of stiffness with reduced compliance of the abdominal wall, prosthetic erosion/fistulisation and an increased risk of persistent deep infection. Recently, to avoid these problems, new "biological" prosthetic materials have been developed and proposed for clinical use. These materials are all essentially composed of an extracellular matrix stripped of its cellular components, and differ substantially only in their source (porcine small intestine submucosa, porcine dermis or cadaveric human dermis). Because of the numerous variables involved, it is very difficult to conduct a randomised controlled trial. Therefore, the European Hernia Society (EHS) has decided to start the EHS Registry for Biological Prostheses (ERBP). This is a prospective registry in Europe on the use of collagen meshes in (potentially) contaminated circumstances or clean surgical fields. The registry intends to collect some preoperative data on the patient and indication, intraoperative data and outcome data.

ddRAD sequencing-based genotyping for population structure analysis in cultivated tomato provides new insights into the genomic diversity of Mediterranean 'da serbo' type long shelf-life germplasm

Double digest restriction-site associated sequencing (ddRAD-seq) is a flexible and cost-effective strategy for providing in-depth insights into the genetic architecture of germplasm collections. Using this methodology, we investigated the genomic diversity of a panel of 288 diverse tomato (Solanum lycopersicum L.) accessions enriched in 'da serbo' (called 'de penjar' in Spain) long shelf life (LSL) materials (152 accessions) mostly originating from Italy and Spain. The rest of the materials originate from different countries and include landraces for fresh consumption, elite cultivars, heirlooms, and breeding lines. Apart from their LSL trait, 'da serbo' landraces are of remarkable interest for their resilience. We identified 32,799 high-quality SNPs, which were used for model ancestry population structure and non-parametric hierarchical clustering. Six genetic subgroups were revealed, clearly separating most 'da serbo' landraces, but also the Spanish germplasm, suggesting a subdivision of the population based on type and geographical provenance. Linkage disequilibrium (LD) in the collection decayed very rapidly within <5 kb. We then investigated SNPs showing contrasted minor frequency allele (MAF) in 'da serbo' materials, resulting in the identification of high frequencies in this germplasm of several mutations in genes related to stress tolerance and fruit maturation such as CTR1 and JAR1. Finally, a mini-core collection of 58 accessions encompassing most of the diversity was selected for further exploitation of key traits. Our findings suggest the presence of a genetic footprint of the 'da serbo' germplasm selected in the Mediterranean basin. Moreover, we provide novel insights on LSL 'da serbo' germplasm as a promising source of alleles for tolerance to stresses.

Impact of drying techniques, seasonal variation and organic growing on flavor compounds profiles in two Italian tomato varieties

The industrial transformation of tomato (Lycopersicon esculentum Mill.) produces processed foods, such as dried tomatoes. In this study two varieties (SaAb and PerBruzzo), grown in three cropping systems (one conventional and two organic ones), were processed by two types of small-scale drying (oven or sun drying), over two years of production. The dried samples were analyzed for their non-volatile and volatile composition, relating the results with sensory analysis. The multivariate analysis performed on collected data allowed a detailed comparison of the effects of processing, year-to year variation and cropping systems. Results indicated that drying methods mainly influenced the composition and flavor profile, also affected by the production year. The cropping system significantly influenced some quality indices, such as the acid and sugar amounts, and the aldehydes, respectively higher and lower in organic samples. The comprehensive PCA analysis allowed discrimination of drying methods and, to a lesser extent, cropping systems.

Genome wide association mapping for agronomic, fruit quality, and root architectural traits in tomato under organic farming conditions

BACKGROUND

Opportunity and challenges of the agriculture scenario of the next decades will face increasing demand for secure food through approaches able to minimize the input to cultivations. Large panels of tomato varieties represent a valuable resource of traits of interest under sustainable cultivation systems and for genome-wide association studies (GWAS). For mapping loci controlling the variation of agronomic, fruit quality, and root architecture traits, we used a heterogeneous set of 244 traditional and improved tomato accessions grown under organic field trials. Here we report comprehensive phenotyping and GWAS using over 37,300 SNPs obtained through double digest restriction-site associated DNA (dd-RADseq).

RESULTS

A wide range of phenotypic diversity was observed in the studied collection, with highly significant differences encountered for most traits. A variable level of heritability was observed with values up to 69% for morphological traits while, among agronomic ones, fruit weight showed values above 80%. Genotype by environment analysis highlighted the strongest genotypic effect for aboveground traits compared to root architecture, suggesting that the hypogeal part of tomato plants has been a minor objective for breeding activities. GWAS was performed by a compressed mixed linear model leading to 59 significantly associated loci, allowing the identification of novel genes related to flower and fruit characteristics. Most genomic associations fell into the region surrounding SUN, OVATE, and MYB gene families. Six flower and fruit traits were associated with a single member of the SUN family (SLSUN31) on chromosome 11, in a region involved in the increase of fruit weight, locules number, and fruit fasciation. Furthermore, additional candidate genes for soluble solids content, fruit colour and shape were found near previously reported chromosomal regions, indicating the presence of synergic and multiple linked genes underlying the variation of these traits.

CONCLUSIONS

Results of this study give new hints on the genetic basis of traits in underexplored germplasm grown under organic conditions, providing a framework for the development of markers linked to candidate genes of interest to be used in genomics-assisted breeding in tomato, in particular under low-input and organic cultivation conditions.

Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST® mesh: a single-institution experience

BACKGROUND

Hernia recurrence after laparoscopic repair is a perplexing problem. In an effort to reduce anatomical and clinical recurrences, different type of meshes have been used to bolster the esophageal hiatus.

OBJECTIVE

The aim of this study was to assess safety, medium-term efficacy, and quality of life improvement after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (Phasix-ST^®).

METHODS

Observational single-center retrospective single-arm cohort study (November 2015-February 2021). We included all adult patients (> 18 years old) who underwent laparoscopic paraesophageal hernia repair with Phasix-ST^® mesh and Toupet fundoplication.

RESULTS

Sixty-eight patients were included. The median postoperative stay was 3.2 days (range 2-9) and the postoperative complication rate was 11.7%. The median follow-up time was 27 months (range 1-53). No mesh-related complications were detected. Hernia recurrence was diagnosed in six patients (8.8%). The recurrence-free probability at 34 months was 0.89 (95% CI 0.807-0.988) while at 60 months was 0.86 (95% CI 0.76-0.97). Hernia recurrences were mostly observed between 21 and 36 months after the operation. None of the patients required surgical revision and all were managed with PPI. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 2.9% of patients. Compared to baseline, both the GERD-HRQL (15.2 ± 6.2 vs. 3.2 ± 3.1; p = 0.026) and all SF-36 items were significantly improved (p < 0.001).

CONCLUSIONS

Laparoscopic crura augmentation with Phasix-ST^® mesh combined with a Toupet fundoplication is safe and seems effective in the medium-term follow-up. Phasix-ST^® crural reinforcement resulted in low hernia recurrence rate with a sustained symptoms and quality of life improvement.

Variations in the phytochemical contents and antioxidant capacity of organically and conventionally grown Italian cauliflower (Brassica oleracea L. subsp. botrytis): results from a three-year field study

A three-year field study (2009-2011) was performed to evaluate phytochemicals and antioxidant capacities of two genotypes (HF1 Emeraude and the local variety, Velox) of green cauliflower grown under organic and conventional management. The conventional system increased yield, but had little effect on the dry matter, whereas the organic system increased the soluble solids. Phytochemicals and antioxidant capacity showed significant year-to-year variability. During the third year, the scarce rainfall determined a significant increase of total glucosinolates and a general decrease of antioxidants in all samples. Interestingly, in the same year organic plants were less affected by the unfavorable climatic conditions, as they increased ascorbic acid, polyphenols, and carotenoids with respect to conventional ones. The overall results for the three years showed that the two genotypes responded differently. Compared to the conventional system, Velox showed 24, 21, 13, 48, and 44% higher content of ascorbic acid, polyphenols, carotenoids, volatiles, and antioxidant capacity, respectively. In contrast, no significant increase in the phytochemicals or the antioxidant potential was found in organic Emeraude, with the exception of total volatiles (+41%). These findings suggest that organic cultivation may be highly effective for particular cauliflower genotypes.