Laparoscopic antireflux surgery: are old questions answered? mesh hernioplasty / Cirurgia laparoscópica anti-refluxo: as antigas perguntas são respondidas? hernioplastia com tela

ABSTRACT Hiatal hernias are at high risk of recurrence. Mesh reinforcement after primary approximation of the hiatal crura has been advocated to reduce this risk of recurrence, analogous to mesh repair of abdominal wall hernias. However, the results of such repairs have been mixed, at best. In addition, repairs using some type of mesh have led to significant complications, such as erosion and esophageal stricture. At present, there is no consensus as to (1) whether mesh should be used, (2) indications for use, (3) the type of mesh, and (4) in what configuration. This lack of consensus is likely secondary to the notion that recurrence occurs at the site of crural approximation. We have explored the theory that many, if not most, "recurrences" occur in the anterior and left lateral aspects of the hiatus, normally where the mesh is not placed. We theorized that "recurrence" actually represents progression of the hernia, rather than a true recurrence. This has led to our development of a new mesh configuration to enhance the tensile strength of the hiatus and counteract continued stresses from intra-abdominal pressure.

RESUMO As hérnias hiatais têm alto risco de recidiva. O reforço com tela após a aproximação primária dos pilares hiatais tem sido defendido, para reduzir esse risco de recidiva, análogo ao reparo com tela de hérnias da parede abdominal. No entanto, os resultados de tais reparos foram variados, na melhor das hipóteses. Além disso, os reparos com algum tipo de tela levaram a complicações importantes, como erosão e estenose esofágica. Atualmente, não há consenso sobre 1) se a tela deve ser usada, 2) indicações para uso, 3) o tipo de tela e 4) em qual configuração. Essa falta de consenso provavelmente é secundária à noção de que a recidiva ocorre no local da aproximação crural. Exploramos a teoria de que muitas, se não a maioria, das recidivas ocorrem nas faces anterior e lateral esquerda do hiato, normalmente onde a tela não é colocada. Nós teorizamos que a "recidiva" na verdade representa a progressão da hérnia, em vez de uma verdadeira recidiva, levando ao desenvolvimento de uma nova configuração da tela, para aumentar a resistência à tração do hiato e neutralizar as tensões contínuas da pressão intra-abdominal.

Observations on multi-generational interactions in academic surgical practice and education

SUMMARY Although there is a natural passage of responsibilities and duties from one generation to the next in any organization, academic or otherwise, managing intergenerational differences is challenging. In academic surgery, in which there are duties to patients, institutional administrators, faculty colleagues, resident trainees, and medical students are faced with multi-generations of individuals who have their own perspectives of what is "required" of them and what is "fulfilling" to them. The purpose of this essay is to relate our observations of the challenges and opportunities to manage these relationships from the perspective of North and South America in all levels involved with surgical care and teaching.