Trocar site hernia following laparoscopic cholecystectomy: a 10-year single center experience.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the gold standard of treatment for patients with symptomatic cholelithiasis. Compared to open cholecystectomy, LC is associated with significantly lower postoperative complications. Trocar site hernia (TSH) is an uncommon, but potentially dangerous, complication of LC. The aim of this study was to evaluate the incidence of TSH following LC. METHODS: The records of all patients who underwent elective LC between January 2004 and December 2013 were retrospectively reviewed. The open technique with a vertical incision infraumbilically was used to establish pneumoperitoneum. Two or three other skin incisions were made and trocars were inserted. In all cases, only the fascia at the site of infra-umbilical incision was closed. Following hospital discharge, all patients were regularly re-examined 1, 4 and 52 weeks postoperatively and were contacted by phone during November-December 2015. Based on the findings from clinical and telephone follow-ups, the incidence of TSH was recorded. Using univariate/multivariate analysis, we investigated several variables to identify risk factors for TSH development. RESULTS: During the study period, 1172 patients were eligible and included in the final analysis. Seven patients (0.6%) presented TSH at 1-year follow-up. At the end of the study and with a mean follow-up of 65.86 ± 25.19 months, 11 patients (0.94%) presented TSH. Interestingly, all TSHs were developed at the infra-umbilical site. Multivariate analysis identified obesity as an independent risk factor for TSH. CONCLUSION: The incidence of TSH following LC is considerably low. Obesity is an independent risk factor for TSH development, while closure of fascial incision of 10 mm below the xiphoid is not justified.

Lichtenstein technique for inguinal hernia repair using polypropylene mesh fixed with sutures vs. self-fixating polypropylene mesh: a prospective randomized comparative study.

PURPOSE: Chronic postoperative pain is probably the most significant complication of tension-free inguinal hernia repair as its presence can considerably affect the life quality of the patient. Different mesh materials and different surgical techniques for mesh fixation have been applied to reduce chronic postoperative pain, with controversial, nevertheless, results. The aim of this prospective randomized study was to evaluate the effect of a relatively new mesh with self-fixating properties, used to repair inguinal hernia with the Lichtenstein technique, on early and chronic postoperative pain. METHODS: Between June 2009 and June 2010, 50 patients with primary unilateral inguinal hernia were treated using the Lichtenstein technique. Patients were randomly assigned to receive either a polypropylene mesh, fixed with polypropylene sutures (n = 25; group A), or a self-fixating polypropylene mesh with resorbable polylactic acid microgrips (n = 25; group B). Demographic data were recorded. Early and chronic postoperative pain was evaluated using the visual analog scale (VAS). Duration of surgery, complications, length of hospitalization and recurrence were also recorded. RESULTS: No statistical difference was found between the two groups in association to demographic data. Operating time was 53.4 ± 12.5 and 44.4 ± 7.2 min in groups A and B, respectively, and the difference was statistically significant (p < 0.001). No difference was observed between the groups regarding the postoperative complications. The VAS of early postoperative pain was 1.7 ± 1.9 in group A and 1.3 ± 1.6 in group B, with the difference being not statistically significant (p = 0.21). Concerning chronic pain, no remarkable statistically significant difference was observed between the two groups at 3-month, 1- and 2-year follow-up period. At the end of the study, no recurrence was reported in either group. CONCLUSIONS: Self-fixating mesh can be safely and effectively used in inguinal hernia repair with the additional advantage of reducing the operative time compared to the classic Lichtenstein technique. However, its use is not accompanied by reduced rates in early or chronic postoperative pain.

Gastric schwannoma: a case report and literature review.

Schwannomas are generally benign, slow growing tumors, which can originate from any nerve that has a Schwann cell sheath. Digestive tract schwannomas are rare and are usually asymptomatic. We present the case of a 48-year-old woman with a symptomatic submucosal tumour of the gastric antrum. The patient underwent partial gastrectomy and the histological and immunohistochemical findings of the resected specimen established the diagnosis of schwannoma.

Procalcitonin as an early indicator of outcome in sepsis: a prospective observational study.

This study explores the role of procalcitonin (PCT) in predicting the outcome of sepsis. In a prospective multicentre observational investigation, blood was sampled within 24 h of onset of sepsis in 1156 hospitalised patients; 234 were in the intensive care unit (ICU) at the point of presentation of sepsis while 922 were not. PCT was estimated in serum by the ultrasensitive Kryptor assay in a double-blinded fashion. Among patients outside the ICU, mortality was 8% in those with PCT ≤0.12 ng/mL but 19.9% in those with PCT >0.12 ng/mL [P<0.0001, odds ratio (OR) for death: 2.606; 95% confidence interval (CI): 1.553-4.371]. Among patients whose sepsis presented in ICU, mortality was 25.6% in those with PCT ≤0.85 ng/mL but 45.3% in those with PCT >0.85 ng/mL (P=0.002; OR for death: 2.404; 95% CI: 1.385-4.171). It is concluded that PCT cut-off concentrations can contribute to predicting the outcome of sepsis and might be of particular value in identifying patients who would benefit from ICU admission.

Perforated jejunal diverticulum presenting as acute abdomen.

We present a case of a 66-year-old man, who was admitted with a 6-hour history of severe diffuse abdominal pain of acute onset, accompanied by nausea and flatulence. The patient underwent an exploratory laparotomy, which revealed the presence of multiple diverticules of the jejeunum, one of which was ruptured. The patient was treated with segmental resection of the jejunum carrying the ruptured diverticle. Perforation of a jejunal diverticulum has to be considered in the differential diagnosis of acute abdomen.

Effect of time on risk of perforation in acute appendicitis.

INTRODUCTION: The aim of this study was to quantify the role of time between symptom onset and surgery on the changing risk of perforation, and to evaluate the possible factors leading to delay to the operation. PATIENTS AND METHODS: The files of 169 patients who underwent appendectomy in our clinic over a two-year period (May 2004-June 2006) were reviewed. The relative risk of perforation was calculated according to the "time-table" method. Time was divided into intervals, initially of 12 hours and, later on, of 24 hours. RESULTS: 18 patients were found to have perforated appendicitis. The time from symptom-onset to first examination ("symptom onset to presentation" time, "SOP" time) was longer for patients with perforation than for those without (p = 0.047). On the other hand, the time from initial examination in the emergency department to the operating room ("ER to OR" time) was shorter for patients with perforation than for those without (p = 0.027). Overall time from symptom onset to operating room, showed no statistical difference between patients with rupture and those without. The risk of perforation was negligible within the first twelve hours of untreated symptoms, but then increased to 8% within the first twenty-four hours. It then decreased to approximately 1.3% to 2% during 36 to 48 hours, and subsequently rose again to approximately 6% (7.6% to 5.8%) for each ensuing 24-hour period. In multivariate analysis, neither the "SOP" nor the "ER to OR" time remained significant contributors to the probability of an individual to suffer from appendiceal perforation. CONCLUSION: When time matters and the risk of adverse outcomes can be reduced, we should change our current approach to care. Surgeons should be mindful of delaying surgery beyond 24 hours of symptom onset in patients with assumed appendicitis.

The effect of the type of intraperitoneally implanted prosthetic mesh on the systemic inflammatory response.

BACKGROUND: The purpose of this study was to determine any differences in the systemic inflammatory response after the intraperitoneal implantation of three different types of polypropylene mesh. METHODS: Thirty-two male New Zealand rabbits underwent a 6-cm midline incision and opening of the peritoneal cavity. The animals were randomly divided into four groups. In groups A, B, and C, there was an intraperitoneal placement of polypropylene mesh, titanium-coated polypropylene mesh, and composite polypropylene/e-PTFE mesh, respectively. Group D received a sham operation. Blood was sampled preoperatively and at 6, 24, 48, and 168 h postoperatively to measure white blood cell count (WBC), tumor necrosis factor-alpha (TNF-alpha), and malondialdehyde (MDA). RESULTS: Statistically significant elevations of WBC, TNF-alpha and MDA were observed in all four groups at 6, 24, and 48 h postoperatively (P<0.05). There were no statistically significant differences in WBC, TNF-alpha, and MDA between groups A, B, and C at any time interval. However, a statistically significant elevation of WBC (P<0.05) and TNF-alpha (P<0.05) was observed between each of the groups with mesh implantation and group D at 24 h postoperatively. CONCLUSION: Intraperitoneal mesh implantation induces mild systemic inflammatory response regardless of the type of implanted mesh.

Primary torsion of the greater omentum. An obscure and unusual cause of acute abdomen.

A 36-year-old man was admitted with a 3-day history of severe abdominal pain in the right upper abdomen and was initially diagnosed with acute cholecystitis or acute retrocecal appendicitis. The patient was transferred to the department of surgery for close surgical observation. CT of the entire abdomen was performed just before the operation, which demonstrated inflammation in the omental fat. Surgery revealed primary omental torsion and subsequent resection of the infarcted segment offered a rapid recovery. We report a case of primary segmental omental torsion and discuss the diagnostic and therapeutic implications of this unusual entity.

Appendiceal mucocele. a retrospective analysis of 19 cases.

BACKGROUND: Appendiceal mucocele is an infrequent well-recognized entity that can present in a variety of clinical syndromes or can be asymptomatic and discovered incidentally. PATIENTS AND METHODS: Nineteen patients with a diagnosis of primary appendiceal mucocele treated in our institution between January 1, 1987 and December 31, 2006 were included in this retrospective analysis. RESULTS: The histological examination of the specimens revealed simple and hyperplastic appendiceal mucocele in nine cases (47%), mucinous appendiceal cystadenoma in eight cases (42%), and mucinous appendiceal cystadenocarcinoma in two cases (11%). Thirteen patients (68%) underwent appendectomy, five patients (26%) right colectomy, and two patients (6%) underwent right colectomy for invasive appendiceal cystadenocarcinoma and at the same time right nephrectomy and sigmoidectomy, respectively, for concomitant malignancy. CONCLUSION: Mucocele of the appendix may be related to a benign or malignant appendiceal process, leading to individualized diagnosis and treatment.