The effect of mesh fixation on migration and postoperative pain in laparoscopic TEP repair: prospective randomized double-blinded controlled study

PURPOSE

The development of chronic pain is one of the major post-surgery problems after inguinal hernia repair. Although the possibility of chronic pain formation decreases with laparoscopic methods, pain may develop due to the staples used. It is thought that absence of mesh fixation in total extra-peritoneal (TEP) repair does not increase the recurrence rate. This study aims to investigate the absence of mesh fixation in the TEP on the development of postoperative pain, mesh displacement, and recurrence rate.

METHODS

Between December 2019 and December 2020, 100 patients who underwent TEP repair due to unilateral inguinal hernia in the General Surgery Clinic of Hitit University were included in the study. Study was registered at http://Clinicaltrials.gov (NCT05152654). Patients were divided into two groups as repairs in which the mesh was fixed with a tacker and no-fixation (NF) was used. The mesh is marked with radiopaque clips. Patients were compared in terms of postoperative pain, mobilization time, hospital stay, return to work, chronic pain, early-late mesh displacement, and recurrence.

RESULTS

While there was no significant difference between the groups in terms of mesh displacement and recurrence, it was observed that the NF group developed significantly less pain in the early and late postoperative period compared to the other group. The time-dependent reduction rate of postoperative pain was higher in NF group than in other group. In addition, operation time was shorter in the NF group.

CONCLUSION

While the absence of mesh fixation in TEP hernia repair does not increase the recurrence rate, it can be used safely, because it causes less acute and chronic pain.

TRAIL REGISTRATION

Clinicaltrials number: NCT05152654.

The predictive value of platelet/mean platelet volume ratio in predicting colon diverticulitis relapse

OBJECTIVE

Diverticulitis is a health problem that has increased in frequency recently. It has a wide spectrum from simple inflammation to fecal peritonitis, sepsis and even mortality. Thus, it is important to predict diverticulitis, especially recurrent diverticulitis, and take measures to prevent it. In this study, we investigated the predictive value of the PLT/MPV ratio, which is an inflammation marker in predicting the recurrence of diverticulitis disease.

PATIENTS AND METHODS

In this study, 132 patients diagnosed with diverticulitis were analyzed retrospectively. Patients' gender, age, localization of diverticulitis, number of diverticula in computed tomography (CT), hospitalization status, length of hospitalization, control colonoscopies, polyps' number and localizations in colonoscopies, presence of malignancy, need for surgery, and recurrences were not reported. White blood cell (WBC), Neutrophil (NE), Lymphocyte (LY), Hemoglobin (Hb), PLT, MPV, Albumin, Creatine Kinase (CK) and C-reactive protein (CRP) levels were examined. The patients were divided into two groups as those who did not relapse concerning diverticulitis and those who did, and statistical analysis was performed between the two groups about related parameters.

RESULTS

Among all patients, recurrence was seen in 11 (10.1%) patients. The patients were divided into two groups according to their recurrence status and statistical significance was sought between the data. The calculated PLT/MPV ratio of patients who did not relapse was 25.61±8.05 and 34.98±11.37 for those who had a relapse (p=0.006). The sensitivity for MPV was 81.8%, a specificity of 57.1% and a cut-off of 9.85. The cut-off value for PLT was 207.5 with 100% sensitivity and 33.7% specificity. A cut-off value of 25.11 was found for PLT/MPV with 100% sensitivity and 49% specificity.

CONCLUSIONS

PLT/MPV ratio was significantly higher in relapsed cases. Since it is easily accessible and inexpensive, it will guide physicians for diagnosis concerning early detection of relapse cases and initiation of appropriate treatment.

Malignant Tumors Misdiagnosed as Liver Hemangiomas

Background and Aim: To derive lessons from the data of patients who were followed for various periods with the misdiagnosis of liver hemangioma and eventually found to have a malignancy.

Material and Methods: The records of 23 patients treated between 2003 and 2018 were analyzed retrospectively.

Results: Twelve patients were men and 11 were women; median (range) age was 55 (35–80). The principal diagnostic modality for the initial diagnosis was ultrasonography (n:8), magnetic resonance imaging (MRI) (n:13), and computed tomography (CT) (n:2). At our institution, MRI was performed in 16 patients; the diagnosis was made with the available MRI and CT studies in five and two patients, respectively. In other words, the ultrasonography interpretations were not confirmed on MRI; in others, the MRI or CT examinations were of low quality or they had not been interpreted properly. Fifteen patients underwent surgery; the other patients received chemotherapy (n:6) or chemoembolization (n:2). The misdiagnosis caused a median (range) 10 (0–96) months delay in treatment. The final diagnoses were hepatocellular carcinoma in 12 patients, cholangiocarcinoma in four patients, metastatic mesenchymal tumor, metastasis of colon cancer, metastatic neuroendocrine carcinoma, sarcomatoid hepatocellular carcinoma, angiosarcoma, thoracic wall tumor, and metastatic tumor of unknown primary in one patient each.

Conclusions: High-quality MRI with proper interpretation and judicious follow up are vital for the accurate differential diagnosis of liver lesions.

Comparison of Primary Midline Closure, Limberg Flap, and Karydakis Flap Techniques in Pilonidal Sinus Surgery

Background

Pilonidal sinus (PS) is a common disease of the sacrococcygeal-natal region. There are many treatment options, but there is still no consensus on the ideal treatment. We compared the results of our PS patients who were treated with primary midline closure (PMC), Limberg flap repair (LFR), and Karydakis flap (KF).

Material/Methods

The data for 924 PS patients from 2013 to 2017 were retrospectively examined. Demographic data, surgical procedures, schedules, and recurrence rates were examined.

Results

The mean age was 28.4 years (14–77 years), 82.5% were male (n=762), and 17.5% were female (n=162). PMC was performed on 53.7% (n=496) of the patients, 32.5% (n=300) received LFR, and 13.9% (n=128) underwent KF. PMC was the first choice among females but LFR was the first choice in recurrent patients. The recurrence rate was 10.8% in the PMC group, 8% in the LFR group, and 3.1% in the KF group. In Short Form Survey-36 (SF-36) scores, the best cosmetic outcomes were observed in cases of PMC (p<0.05). Overall, wound dehiscence (WD) was observed in 7.5%, surgical site infection (SSI) in 2.4%, and seroma in 8.5% of all patients. The KF group had the lowest complication rates (p<0.01).

Conclusions

According to the results of this study, the reason for preferring PMC among women is cosmetic concerns. PMC still remains important for treatment, but it should be noted that the recurrence rates due to inadequate excision are mostly observed in cases of PMC. Considering their low recurrence rates, LFR or KF should be considered first. When low recurrence rates, patient comfort, and cosmetic results are evaluated together, KF in particular emerges as a method preferred by physicians and patients.

Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome

INTRODUCTION

Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique.

PRESENTATION OF CASE

A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal.

DISCUSSION

There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients.

CONCLUSION

J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.