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   Table of Contents - Current issue
October-December 2020
Volume 3 | Issue 4
Page Nos. 117-161

Online since Monday, November 30, 2020

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Incisional hernia formation can be reduced following hyperthermic intraperitoneal chemotherapy with increased suture length to wound length ratio fascial closure p. 117
Joseph A Lewcun, Eric M Pauli, Colette Pameijer
INTRODUCTION: Incisional hernia (IH) is a common postsurgical complication of laparotomy. The impact of hyperthermic intraperitoneal chemotherapy on fascial healing has not been evaluated. The aim of this study is to determine whether utilizing a 4:1 suture length to wound length ratio (SL:WL) during fascial closure reduces the risk of IH following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS-HIPEC). METHODS: A retrospective review of patients who underwent HIPEC between 2013 and 2019 at a single institution was performed. Demographics and IH rates were compared between patients closed with a 4:1 SL:WL and patients with standard fascial closure (SFC). Hernias were detected on physical examination or on cross-sectional imaging studies. RESULTS: Eighty-six patients who underwent HIPEC were included in the study. A 4:1 SL:WL was utilized in 26.7% (n = 23) of HIPEC cases and the remaining 73.3% (n = 63) of patients received SFC methods. Three patients in the 4:1 SL:WL group developed hernias, whereas 22 patients in the SFC group had hernias (13.0% vs. 34.9%, P = 0.048). The incidence of IHs was similar across the body mass index, smoking status, and operative time categories. CONCLUSION: Utilizing a 4:1 SL:WL during fascial closure may reduce the rates of IH in the HIPEC population, but larger sample sizes and longer follow-up are required to determine the statistical significance of this intervention.
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Sports rehabilitation after laparoscopic hernioplasty p. 122
Osvaldo Santilli, Hernan Santilli, Nicolas Nardelli, Daniel Tripoloni, Hernan Etchepare
INTRODUCTION: The development of minimally invasive procedures and analgesic drug evolution has contributed to reduce the rest period after inguinal hernia repair; nevertheless, there is still no scientific evidence to establish optimal postsurgery rest time and sequence for resuming activity until reaching full performance. Early and controlled rehabilitation by physical therapists has proven beneficial in postsurgery for athlete groups, although no publications are available on experiences in nonathlete patients. OBJETIVE: The aim was to analyze the results of a rehabilitation program applied to post-transabdominal preperitoneal (TAPP) hernioplasty in non-athletic patients. PATIENTS AND METHODS: The first 1,000 nonathlete patients who performed the postoperative sports rehabilitation plan from January 2012 to December 2016. We used TAPP laparoscopic hernioplasty. Postsurgery exercise program guided by objectives and supervised by physical therapists in four growing-intensity phases. Postsurgery complications, hernia recurrence, pain intensity (numeric scale) while exercising at 2 and 10 days after surgery; start time and duration for the first phase in the rehabilitation plan; and timing of return to work were evaluated. RESULTS: The objectives of the first phase were reached by 92% of the patients on the 7th day. Work activities started in 97% of the patients before the 5th day. CONCLUSIONS: Application of a sports rehabilitation program does not increase the recurrence rate nor complications and may speed up the return to full physical activity in nonathletic patients.
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Inguinal and femoral hernia repair in octogenarians and nonagenarians – A population-based analysis p. 128
Joana Pina-Vaz, Philippe Glauser, Henry Hoffmann, Philipp Kirchhoff, Ralph Staerkle, Marco von Strauss und Torney
PURPOSE: Our primary aim was to evaluate the inhospital mortality (IHM) of elderly patients undergoing inguinal or femoral hernia repair (groin hernia repair GHR), since this growing population is associated with increased perioperative risks. MATERIALS AND METHODS: Totally 179,806 patients undergoing GHR between 2005 and 2015 in Switzerland were divided into three cohorts: <80, 80–89, and ≥90 (years). IHM for each was compared and stratified according to: type of admission, hernia, surgical approach, and whether a bowel resection was performed. A multivariate analysis controlling for age, gender, type of hernia, admission, and comorbidities was performed. RESULTS: The elderly (>80 years) represent 8.86% (n = 15,750) of our sample. The IHM for elective GHR in these patients is low (0.15% for octogenarians and 0.8% for nonagenarians). For emergency surgery, it increases substantially (4.1% and 7.5%, respectively). In emergency cases with a combined bowel resection (n = 755), the IHM has a fivefold increase for nonagenarians when compared to the younger population. The IHM was significantly higher with femoral hernia repair, especially in the elderly (4.75% – octogenarians and 11.4% – nonagenarians). When adjusting for other variables, there is a twofold risk of death with femoral hernia repair. Patients with a Charlson Comorbidity Index (CCI) ≥2 have a 7.5 times higher risk of dying after GHR. All of these results were statistically significant (P < 0.0001). CONCLUSIONS: This retrospective analysis highlights the increased operative risk in emergency compared to elective GHR in the elderly. This should be considered when opting for watchful waiting in minimally symptomatic octo- and nonagenarians.
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Large scrotal hernias: Totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair? p. 138
Virinder Kumar Bansal, Om Prakash, Asuri Krishna, Subodh Kumar, Mayank Jain, Mahesh Chandra Mishra
INTRODUCTION: Large scrotal hernias are rare, constituting <2% of all hernias repairs. Few of these large scrotal hernias become massive or giant due to neglect in treatment for many years. Conventionally, open surgery was advocated for these hernias, but with experience, laparoscopic repairs have been performed in the recent years for these hernias. PATIENTS AND METHODS: We reviewed our experience of patients with large scrotal hernias (L3, M3, or R) undergoing either totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP). Demographic profile, clinical characteristics of hernia, and intra- and postoperative outcomes were recorded. RESULTS: There were 144 patients with large hernias, of which 10 were massive hernias. TEP repair was attempted in 85 patients and TAPP repair in 59 patients. In 25 patients (7 in TEP and 18 in TAPP), laparoscopic-assisted approach was used. TEP repair successful in 64 patients (75.3%) and converted to TAPP in 15 patients (17.6%) and to open in 6 patients (7.1%). TAPP was successful in 53 patients (89.8%) and was converted to open repair in 6 patients (10.2%). Seroma was noted in 42 patients, spermatic cord edema in 26 patients, and scrotal hematoma in 14 patients at 1st week. The mean follow-up was 2 years. Two patients had recurrence and TAPP repair was done. None of the patients developed mesh infection or chronic groin pain. CONCLUSION: We believe that TEP and TAPP repair are complementary and hernia surgeons should be adept at both techniques. TAPP repair has advantages in large irreducible hernias and should be preferred.
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Laparoscopic intraperitoneal onlay mesh repair (intraperitoneal onlay mesh plus) in 429 patients – Our experience p. 144
Paritosh Gupta, Kanu Kapoor, Dhruv Kundra, Aman Priya Khanna, Chinmay Arora, Aakanksha Agarwal
INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) was first described in 1992 by Karl Leblanc and has increasingly gained popularity in this current era of minimal access surgery, hereby establishing itself as a well-accepted option for the treatment of these hernias. OBJECTIVE: To assess; if the repair of Symptomatic Ventral hernia using Laparoscopic IPOM-PLUS is an effective modality in the treatment of such hernias or not. AIM: The study reviews our experience in Laparoscopic Intraperitoneal Onlay Mesh repair (IPOM- PLUS) of symptomatic ventral hernia in a single surgical unit at Artemis Hospital, Gurgaon. METHODS: A Prospective observational study was conducted where in we analysed the electronic medical records of 429 patients who underwent Laparoscopic Ventral Hernia Repair between July 2012 to January 2020 at Artemis Hospital, Gurgaon, Haryana. A Follow up period of 24 months was undertaken . RESULTS: Four hundred and twenty nine patients underwent Laparoscopic IPOM in a span of 8 years. All patient's with a defect size of more than 2 cm were included in the study. Average BMI of the cohort was between 28.42 ± 4.8 kg/m2. Primary closure of all hernias greater than 2 cm was done (Trans-fascial sutures taken using Prolene No.1). Dual mesh was used as prosthesis and it was fixed using non absorbable tacking device. Hernia recurrence was found to occur in 2 of the 429 patient's (0.4%) where in one had chronic cough on account of COPD and the other showed excessive weight gain of 12 kg during the follow up period of 24 Months. CONCLUSION: Laparoscopic IPOM- PLUS is a safe, highly efficacious and accepted method for ventral hernia repair with a very low recurrence rate.
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Evaluation of oxidative stress response in endoscopic and Lichtenstein hernia repair: A randomized control study p. 148
Rahul Saini, Lovenish Bains, Niladhar Shankarrao Hadke, Bidhan Chandra Koner, Rajdeep Singh, Pawan Lal
BACKGROUND: The extent of inflammatory and oxidative stress response varies with different surgical procedures. The aim of the study was to compare the same between total extraperitoneal repair and Lichtenstein repair for inguinal hernia. MATERIALS AND METHODS: Men, aged 18–60 years with an ASA score of 1, presenting with primary unilateral indirect inguinal hernia were randomized to total extraperitoneal repair (TEP) and Lichtenstein repair. Blood samples were collected an evening before surgery and postoperatively at 2, 24, and 48 h to compare the levels of highly sensitive C-reactive protein (hs-CRP), malondialdehyde (MDA), and neutrophil: lymphocyte ratio between the two modes of repair. RESULTS: Both modalities of repair cause a significant inflammatory response in the body (P < 0.05). The rise in the level of serum hs-CRP and neutrophil: lymphocyte ratio was significantly more in the open surgery group as compared to the TEP group at 2, 24, and 48 h postoperatively (P < 0.05). The levels of serum MDA were distinctively higher (P = 0.042) only at 2 h after surgery in the former group. CONCLUSION: Endoscopic repair is associated with a significantly lesser oxidative response than Lichtenstein repair based on this study (P < 0.05). Although this might be one of the bases for lesser postoperative pain and earlier return to activity in TEP repair, more randomized studies are required to draw a definitive conclusion.
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Inside-out: Spontaneous bowel evisceration, a rare complication of the ventral hernia p. 155
Ee Wen Lim, Sabrina Ngaserin, Fung Joon Foo
Spontaneous nontraumatic bowel evisceration from a ruptured long-standing abdominal wall hernia is a rare occurrence. Sporadic case reports exist describing bowel evisceration from long-standing ventral herniae, whereby baseline increased intra-abdominal pressure was rendered more pronounced due to sudden increase and/or trauma. Morbidity and mortality rates are significant, and treatment can be technically complex. We present a case of spontaneous small bowel evisceration from rupture of a recurrent ventral hernia in a patient with liver cirrhosis, who was managed with emergent surgical mesh repair and discuss the spectrum of relevant surgical techniques for this unique group of patients.
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Recurrent and late esophageal mesh extrusion after paraesophageal hiatoplasty: A case report and review of the literature p. 158
Sonia Fernandez.Ananin, David Sacoto, Carmen Balagué, Carlos Guarner, Eduardo M Targarona
The most accepted management for symptomatic paraesophageal hernias (PEHs) is the closure of the hiatal gap associated with an antireflux procedure. When the defect of the hiatus is particularly wide or the consistency of the pillars is weak, a prosthetic mesh may be used to cover the suture cruroplasty. Nevertheless, the use of mesh in PEHs repair is a subject of ongoing debate, due to the local risk of complications that a foreign body located in this area can lead. We present the case of a 77-year-old female who underwent PEH surgery with placement of polypropylene mesh twice. On both occasions, the prosthesis migrated late through the wall of the esophagus and could be removed by endoscopy. We consider that this case is exceptional, not only due to the multiple and late extrusion of the mesh in the lumen of the esophagus but also due to the absence of symptoms that this event caused to the patient.
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