Nuevo método de operar en la eventración compleja: separación anatómica de componentes con prótesis y nuevas inserciones musculares / New surgical technique in complex incisional hernias: Component Separation Technique (CST) with prosthesis and new muscle insertions

Introducción El objetivo de este trabajo es mostrar a la comunidad quirúrgica una nueva técnica para el tratamiento de eventraciones complejas y catastróficas desarrollada en este equipo: separación anatómica de componentes (SAC) modificada por Carbonell-Bonafé. Material y método Se trató a 100 pacientes con eventración compleja. Se documentó tamaño, contenido y reductibilidad de la eventración (tomografía computarizada preoperatoria), recidivas y técnicas de cierre previas, talla y peso, alteraciones tróficas de la piel y necesidad de neumoperitoneo preoperatorio. Se operó siguiendo un protocolo homogéneo, con medida de presión intraabdominal antes, durante y tras la intervención. Se evaluó al paciente en consulta a los 15 y 30 días, mensualmente durante 3 meses, al sexto mes y anualmente hasta 5 años. Resultados Entre enero de 2003 y mayo de 2008 se intervino a 100 pacientes consecutivos. En el postoperatorio inmediato se tuvo un 12% de seromas, un 8% de isquemia parcial de bordes de la herida y un fallecimiento debido a fallo multiorgánico; en el postoperatorio tardío se tuvo un 6% de algias transitorias en los puntos de anclaje óseo. Los pacientes reanudaron su actividad habitual en una media de 2 meses con gran mejoría en su calidad de vida. No se han encontrado recidivas hasta la fecha. Conclusiones La técnica SAC que esta Unidad ha modificado es un excelente recurso en el tratamiento de grandes eventraciones: garantiza el éxito del cierre con poca morbilidad y, además, reconstruye la biomecánica de la pared abdominal (AU)

Introduction Our goal is to show the surgical community a new technique developed by our team for treating complex and catastrophic ventral hernias: Separation of Anatomical Component (SAC) amended by Carbonell–Bonafé. Materials and methods A total of 100 patients with complex incisional hernias have been treated. The size, content and reducibility of ventral hernia (preoperative CT scan), recurrences and pre-closure techniques, height and weight, trophic skin alterations and need for preoperative pneumoperitoneum were all documented. The operation was performed following a standardised protocol; intra-abdominal pressure (IAP) was measured before, during and after the intervention. Patients were evaluated in the clinic at 15 and 30 days, monthly for 3 months, at sixth months and annually for up to 5 years. Results A total of 100 consecutive patients were operated on between January 2003 and May 2008. In the immediate post-surgical period there were 12% seromas, 8% of partial-ischaemia on the edges of the wound and 1 death due to multi-organ failure. In the later period, 6% had transitional pain in bone anchorage points. They resumed their normal activities after an average of 2 months, with great improvement in their quality of life. There have been no recurrences to date. Conclusions The SAC technique, as modified by our Unit, is an excellent resource in managing large ventral hernias: successfully closing with low morbidity, as well as reconstructing the biomechanics of the abdominal wall (AU)

[New surgical technique in complex incisional hernias: Component Separation Technique (CST) with prosthesis and new muscle insertions]. / Nuevo método de operar en la eventración compleja: separación anatómica de componentes con prótesis y nuevas inserciones musculares.

INTRODUCTION: Our goal is to show the surgical community a new technique developed by our team for treating complex and catastrophic ventral hernias: Separation of Anatomical Component (SAC) amended by Carbonell-Bonafé. MATERIALS AND METHODS: A total of 100 patients with complex incisional hernias have been treated. The size, content and reducibility of ventral hernia (preoperative CT scan), recurrences and pre-closure techniques, height and weight, trophic skin alterations and need for preoperative pneumoperitoneum were all documented. The operation was performed following a standardised protocol; intra-abdominal pressure (IAP) was measured before, during and after the intervention. Patients were evaluated in the clinic at 15 and 30 days, monthly for 3 months, at sixth months and annually for up to 5 years. RESULTS: A total of 100 consecutive patients were operated on between January 2003 and May 2008. In the immediate post-surgical period there were 12% seromas, 8% of partial-ischaemia on the edges of the wound and 1 death due to multi-organ failure. In the later period, 6% had transitional pain in bone anchorage points. They resumed their normal activities after an average of 2 months, with great improvement in their quality of life. There have been no recurrences to date. CONCLUSIONS: The SAC technique, as modified by our Unit, is an excellent resource in managing large ventral hernias: successfully closing with low morbidity, as well as reconstructing the biomechanics of the abdominal wall.

[Prosthetic infection after hernioplasty. Five years experience]. / Infección de la prótesis en la reparación herniaria. Nuestra experiencia en 5 años.

INTRODUCTION: Prosthesis infection is an infrequent but important complication in abdominal wall surgery. The aim of this study is to evaluate the incidence and risk factors for the infection of the prosthesis after hernia repair, as well as the treatment to apply. MATERIAL AND METHOD: Between January 2002 and December 2006, we performed 1055 prosthetic hernia repairs: 761 inguinal hernias (72.1%), 74 umbilical hernias (7%) and 220 ventral hernias (20.9%). We prospectively analysed preoperative, intraoperative and postoperative variables, as well as the incidence of infection of surgical wound and of prosthesis. We used ASA classification for preoperative anaesthetic evaluation. RESULTS: The overall percentage of infection of the prosthesis was 1.3%. Infection was observed in 11 repairs with polypropylene mesh (PPL), in 4 with PTFE mesh, and one case in combined mesh. Risk factors of mesh infection were: obesity (p=0.002), diabetes (p=0.020), the type of repair (p=0.047), emergency surgery (p=0.001), the type and size of mesh (p=0.003; p=0.007) and time of surgery >180 min (p<0.001). Seven of the 11 patients with infection of PPL prosthesis were resolved with conservative treatment, whereas all the cases with PTFE infection or mixed mesh needed removal to solve the problem. CONCLUSIONS: Several factors are involved in producing a prosthesis infection. Whereas antibiotic treatment and surgical drainage of the infection can be sufficient in most PPL mesh infection, PTFE prostheses need to be removed prematurely in order to halt the infection process.

Infección de la prótesis en la reparación herniaria. Nuestra experiencia en 5 años / Prosthetic infection after hernioplasty. Five years experience

Introducción: la infección de la prótesis es una complicación infrecuente pero importante en la cirugía de la pared abdominal. El objetivo de este estudio es valorar la incidencia y los factores de riesgo influyentes en la infección de la prótesis tras la reparación herniaria, así como el tratamiento a aplicar. Material y método: entre enero de 2002 y diciembre de 2006, se realizaron en total 1.055 reparaciones protésicas herniarias: 761 hernias inguinocrurales (72,1%), 74 hernias umbilicales (7%) y 220 eventroplastias (20,9%). Se analizaron de forma prospectiva variables preoperatorias, intraoperatorias y postoperatorias, así como la incidencia de infección de herida quirúrgica y de prótesis. Se utilizó la clasificación ASA para la valoración preoperatoria anestésica. Resultados: el porcentaje de infección del biomaterial en general fue del 1,3%. Observamos infección en 11 reparaciones con prótesis de polipropileno (PPL), en 4 con PTFE-e y 1 caso en prótesis combinada. Fueron factores de riesgo en la infección del biomaterial: la obesidad (p=0,002), la diabetes mellitus (p=0,020), el tipo de reparación (p=0,047), la intervención de urgencia (p=0,001), el tipo y el tamaño de la prótesis (p=0,003 y p=0,007) y el tiempo quirúrgico >180min (p<0,001). De 11 pacientes con infección de prótesis de PPL, 7 respondieron al tratamiento con curas, mientras que todos los casos con infección de PTFE-e o prótesis mixta necesitaron de su extirpación para resolver el problema. Conclusiones: existen numerosos factores de riesgo influyentes en la tasa de infección del biomaterial. Mientras que la terapia antibiótica adecuada y el drenaje quirúrgico de la infección pueden ser suficientes en la mayoría de las infecciones de prótesis de PPL, las de PTFE-e requieren extirpación precoz para acabar con el proceso infectivo (AU)

Introduction: Prosthesis infection is an infrequent but important complication in abdominal wall surgery. The aim of this study is to evaluate the incidence and risk factors for the infection of the prosthesis after hernia repair, as well as the treatment to apply. Material and method: Between January 2002 and December 2006, we performed 1055 prosthetic hernia repairs: 761 inguinal hernias (72.1%), 74 umbilical hernias (7%) and 220 ventral hernias (20.9%). We prospectively analysed preoperative, intraoperative and postoperative variables, as well as the incidence of infection of surgical wound and of prosthesis. We used ASA classification for preoperative anaesthetic evaluation. Results: The overall percentage of infection of the prosthesis was 1.3%. Infection was observed in 11 repairs with polypropylene mesh (PPL), in 4 with PTFE mesh, and one case in combined mesh. Risk factors of mesh infection were: obesity (p=0.002), diabetes (p=0.020), the type of repair (p=0.047), emergency surgery (p=0.001), the type and size of mesh (p=0.003; p=0.007) and time of surgery >180min (p<0.001). Seven of the 11 patients with infection of PPL prosthesis were resolved with conservative treatment, whereas all the cases with PTFE infection or mixed mesh needed removal to solve the problem. Conclusions: Several factors are involved in producing a prosthesis infection. Whereas antibiotic treatment and surgical drainage of the infection can be sufficient in most PPL mesh infection, PTFE prostheses need to be removed prematurely in order to halt the infection process (AU)

Absceso perihepático secundario a cálculo biliar olvidado en cavidad abdominal / Perihepatic abscess due to a gallstone left in the abdominal cavity

No disponible

[Acute cholecystitis and laparoscopic cholecystectomy in the elderly]. / Colecistitis aguda y colecistectomía laparoscópica en el paciente anciano.

INTRODUCTION: The aim of this study was to assess the influence of age in laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis by determining the benefits and postoperative complications in patients older than 65 years. MATERIAL AND METHOD: Between January 2003 and March 2006, we performed 134 urgent LC for acute cholecystitis: 58 patients older than 65 years (group 1) were compared with 76 patients younger than 65 years (group 2). Preoperative, intraoperative and postoperative variables were compared between groups 1 and 2. ASA score was used in the preoperative anesthetic evaluation. RESULTS: A total of 31.2% of patients in group 1 had high surgical risk (24% ASA III and 9.2% ASA IV). The conversion rate was 24.1% in group 1 versus 11.3% in group 2 (p = 0.04), due to difficulty in surgical dissection and advanced cholecystitis. The mean length of postoperative hospital stay was 4.7 +/- 3.2 days in group 1 versus 3.3 +/- 2.4 days in group 2 (p = 0.001). The overall rate of postoperative complications was 33.1% and 18.7% respectively, with a predominance of infectious complications. CONCLUSIONS: Although age should not be an exclusion factor for LC, the conversion rate, postoperative complications and length of hospital stay are increased in the elderly. Higher morbidity due to the underlying disease and longer disease duration with more advanced cholecystitis complicate the laparoscopic approach in these patients.

Colecistitis aguda y colecistectomía laparoscópica en el paciente anciano / Acute cholecystitis and laparoscopic cholecystectomy in the elderly

Introducción. El objetivo de este estudio es valorar la influencia de la edad en la colecistectomía laparoscópica (CL) para el tratamiento de la colecistitis aguda (CTTA), determinando los beneficios y complicaciones postoperatorias en los pacientes mayores de 65 años. Material y método. Entre enero de 2003 y marzo de 2006, se practicó un total de 134 CL por CTTA en el área de urgencias: 58 pacientes tenían edades superiores a 65 años (grupo 1) y se los comparó con 76 pacientes más jovenes (grupo 2). Se analiza las variables preoperatorias, intraoperatorias y postoperatorias en el grupo 1 y se las compara con el resto de la serie. Se utilizó la clasificación ASA para valoración preoperatoria anestésica. Resultados. El grupo 1 presentó en un 31,2% alto riesgo quirúrgico (un 24%, ASA III y el 9,2%, ASA IV). La tasa de conversión a colecistectomía abierta fue del 24,1%, frente al 11,3% en el grupo 2 (p = 0,04), debido a dificultad en la disección quirúrgica y hallazgo de vesícula colecistítica muy evolucionada. La estancia media postoperatoria fue de 4,7 ± 3,2 días en el grupo 1 y de 3,3 ± 2,4 días en el grupo 2 (p = 0,001). La tasa general de complicaciones postoperatorias fue del 33,1 y el 18,7%, respectivamente, y prevalecieron las de tipo infeccioso. Conclusiones. Aunque la edad no debe ser un factor excluyente para la CL, la tasa de conversión, las complicaciones postoperatorias y la estancia hospitalaria son mayores en estos pacientes que en el resto de la población. Son características la mayor morbilidad por la enfermedad de base, y una evolución más larga del cuadro con hallazgos más frecuentes de colecistitis evolucionada, que complican el abordaje laparoscópico en estos pacientes (AU)

Introduction. The aim of this study was to assess the influence of age in laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis by determining the benefits and postoperative complications in patients older than 65 years. Material and method. Between January 2003 and March 2006, we performed 134 urgent LC for acute cholecystitis: 58 patients older than 65 years (group 1) were compared with 76 patients younger than 65 years (group 2). Preoperative, intraoperative and postoperative variables were compared between groups 1 and 2. ASA score was used in the preoperative anesthetic evaluation. Results. A total of 31.2% of patients in group 1 had high surgical risk (24% ASA III and 9.2% ASA IV). The conversion rate was 24.1% in group 1 versus 11.3% in group 2 (p = 0.04), due to difficulty in surgical dissection and advanced cholecystitis. The mean length of postoperative hospital stay was 4.7 ± 3.2 days in group 1 versus 3.3 ± 2.4 days in group 2 (p = 0.001). The overall rate of postoperative complications was 33.1% and 18.7% respectively, with a predominance of infectious complications. Conclusions. Although age should not be an exclusion factor for LC, the conversion rate, postoperative complications and length of hospital stay are increased in the elderly. Higher morbidity due to the underlying disease and longer disease duration with more advanced cholecystitis complicate the laparoscopic approach in these patients (AU)