Optimum mesh and port sizes for laparoscopic incisional hernia repair.

PURPOSE: Since incisional hernia repair was introduced into laparoscopic surgical practice it has been recognized that larger meshes can be problematic to successfully insert through laparoscopic ports. This study aims to facilitate the choice of mesh and port by documenting the minimum port sizes realistically needed for insertion of different types and sizes of onlay mesh. It also aims to evaluate the optimal insertion techniques. MATERIALS AND METHODS: Using four specified insertion techniques--simple roll, a tight roll along the longest edge; diagonal roll, a tight roll along the longest axis; roll and bind, the optimal roll with an additional vicryl tie as binding; and unprepared, grasped by the corner, the diagonal length of the mesh is presented head-on to the port--two independent investigators attempted insertion of different sizes of four onlay meshes--DualMesh (1 mm and 1.5 mm), Surgisis Gold, and Permacol--down 10- to 18-mm Endopath and Versaport ports positioned within a sham abdomen. The maximum mesh sizes used were DualMesh, 34 x 26 cm; Surgisis Gold, 22 x 13 cm; and Permacol, 10 x 10 cm. Two types of ports were used, Endopath ports which have an integral seal and Versaport ports with a removable seal. RESULTS: The largest mesh widths successfully passed down 18-, 12-, 11-, and 10-mm ports, respectively, were: DualMesh 1 mm--26, 17, 15, and 13 cm; Surgisis Gold--13, 13, 13, and 10 cm; DualMesh 1.5 mm--26, 15, 12, and 9 cm; and Permacol--10, 10, 10, and 7 cm. The novel roll and bind insertion technique showed improved insertion than the simple roll technique alone for the biological meshes. CONCLUSION: Small differences in mesh size and type can lead to marked changes in optimal port size. The availability of a guide such as the one produced by this study in the operating room will help surgeons to plan and select appropriate combinations of ports and meshes, potentially reducing intraoperative delays.

Transanal endoscopic microsurgery: where are we now?

AIMS: This review of literature aimed to assess the role and establish the current status of transanal endoscopic microsurgery (TEM) in the management of benign and malignant rectal lesions. METHODS: A review of the literature was undertaken through the Medline database and by cross-referencing previous publications, thus identifying 54 relevant publications on TEM in the management of rectal lesions. Aggregated results of various parameters were calculated but statistical comparisons deemed unsuitable due to heterogeneity of data. RESULTS: The TEM procedure is associated with good functional results, morbidity of 4% and zero procedure-related mortality. The local recurrence rates after TEM excision is 4.5% (range 0-14) for benign rectal lesions, 6% (0-13) for T(1) cancers, 14% (range 0-50) for T(2) cancers and 20% (range 14-67%) for T(3) cancers. Local recurrences after TEM can be surgically salvaged with good disease free survival rates. CONCLUSIONS: The TEM procedure clearly offers the benefits of good exposure of the operative field allowing extremely precise dissection and access to high rectal lesions unresectable by other methods. For pTis and low risk pT(1) lesions, the oncological results are comparable to the more traditional formal resection. The routine use of TEM for high-risk pT(1) and higher stage lesions is not an oncologically sound choice at the present moment.