Laparoscopic Repair of Boundary Incisional Hernia in a Kidney Transplant Patient: A Safe Tacks-Fibrin Glue Combined Mesh Fixation Technique.

BACKGROUND: Incisional hernia in renal transplant patients is a complication that negatively affects the global outcome of transplant and quality of life. The repair of this condition was classically made by open repair with mesh. Increasing evidence suggests that laparoscopic repair could be advocated as the technique of choice in these patients with optimal results. However, the fixation of mesh should be performed by a mixed combination of fibrin sealant (lateral margin of wall defect) and tacks (medial margin). The tacks fixation of the mesh along the lateral margin of the wall defect, close to the graft, is generally difficult for the small size of the remaining aponeurotic plane and dangerous for the underlying presence of the graft. MATERIALS AND METHODS: A case of incisional hernia in a kidney transplant recipient was repaired by laparoscopic mesh technique. The polypropylene-polyglycolic acid composite mesh was fastened with a mixed technique of absorbable tacks for medial margin of the defect and fibrin sealant for the lateral side in contiguity with graft surface. RESULTS: The patient was discharged after 4 days. The 6-month follow-up did not show mesh displacement or recurrence of hernia. CONCLUSIONS: The laparoscopic mesh repair may become the criterion standard for kidney transplant patients affected by incisional hernia. The difficulties of mesh fixation close to the graft can be overcome by the combination of fibrin sealant glue and absorbable tacks at different margins of the wall defect. This technique may offer advantages for this population of patients.

[Risk factors' analysis of transient and permanent hypoparathyroidism after thyroidectomy].

AIMS: This review evaluates those main risk factors that can affect patients undergoing thyroidectomy, to reach a better pre- and post-operative management of transient and permanent hypoparathyroidism. DISCUSSION: The transient hypoparathyroidism is a potentially severe complication of thyroidectomy, including a wide range of signs and symptoms that persists for a few weeks. The definitive hypoparathyroidism occurs when a medical treatment is necessary over 12 months. Risk factors that may influence the onset of this condition after thyroidectomy include: pre- and post-operative biochemical factors, such as serum calcium levels, vitamin D blood concentrations and intact PTH. Other involved factors could be summarized as follow: female sex, Graves' or thyroid neoplastic diseases, surgeon's dexterity and surgical technique. The medical treatment includes the administration of calcium, vitamin D and magnesium sometimes. CONCLUSIONS: Although biological and biochemical factors could be related to iatrogenic hypoparathyroidism, the surgeon's experience and the used surgical technique still maintain a crucial role in the aetiology of this important complication.

Electrospun Polyhydroxyethyl-Aspartamide-Polylactic Acid Scaffold for Biliary Duct Repair: A Preliminary In Vivo Evaluation.

Tissue engineering has emerged as a new approach with the potential to overcome the limitations of traditional therapies. The objective of this study was to test whether our polymeric scaffold is able to resist the corrosive action of bile and to support a cell's infiltration and neoangiogenesis with the aim of using it as a biodegradable tissue substitute for serious bile duct injuries. In particular, a resorbable electrospun polyhydroxyethyl-aspartamide-polylactic acid (90 mol% PHEA, 10 mol% PLA)/polycaprolactone (50:50 w/w) plate scaffold was implanted into rabbit gallbladder to assess the in vivo effects of the lytic action of the bile on the scaffold structure and then as a tubular scaffold to create a biliary-digestive anastomosis as well. For the above evaluation, 5 animals were used and killed after 15 days and 5 animals after 3 months. At 15-day and 3-month follow-ups, the fibrillar structure was not digested by lytic action bile. The fibers of the scaffold were organized despite being in contact with bile action. A new epithelial tissue appeared on the scaffold surface suggesting the suitability of this scaffold for future studies of the repair of biliary tract injuries with the use of resorbable copolymer on biliary injuries.

The medical and surgical treatment in secondary and tertiary hyperparathyroidism. Review.

INTRODUCTION: Hyperparathyroidism is an alteration of the pathophysiological parathyroid hormone (PTH) secretion due or an independent and abnormal release (primary or tertiary hyperparathyroidism) by the parathyroid or an alteration of calcium homeostasis that stimulates the excessive production of parathyroid hormone (secondary hyperparathyroidism). AIMS: There is not a standard, clinical or surgical, treatment for hyperparathyroidism. We review current diagnostic and therapeutic methods. DISCUSSION: In secondary hyperparathyroidism (2HPT) there is a progressive hyperplasia of the parathyroid glands and an increased production of parathyroid hormone. Several causes are proposed: chronic renal insufficiency, vitamin D deficiency, malabsorption syndrome. The tertiary hyperparathyroidism (3HPT) is considered a state of excessive autonomous secretion of PTH due to long-standing 2HPT and it's usually the result of a lack of suppression in the production of PTH. The pathophysiological implications are both skeletal and extraskeletal: it damages the cardiovascular system, nervous system, immune, hematopoietic and endocrine system. The introduction of new drugs has improved the survival of these patients, allowing the inhibition of the synthesis of PTH. Indication for surgical treatment is unresponsive medical therapy. CONCLUSIONS: There are no large prospective studies that comparing the medical and surgical treatment. The choice is not unique and we have to consider the singolar case and the clinical condition of the patient.

Comparison Between Rapid Intraoperative and Central Laboratory Parathormone Dosage in 12 Kidney Transplant Candidates.

BACKGROUND: The rapid intraoperative parathormone (PTH) and at central laboratory PTH dosage gives similar results. The central laboratory provides results in longer times and higher costs. Intraoperative measurement can reduce time and costs during parathyroidectomy. METHODS: Twelve patients undergoing parathyroidectomy for hyperparathyroidism renal transplant candidates were included. Diagnosis was made by laboratory tests (serum calcium, PTH) and imaging techniques (ultrasonography and scintigraphy). All patients presented PTH levels of >400 pg/mL (the limit value to be maintained in list for kidney transplantation) and resistant to medical therapy. For each patient, 2 blood samples were collected before surgery at anesthesia induction for PTH testing intraoperative (rapid assay) and central laboratory, and 10 minutes after the removal of each gland. The times from collection-processing to communication to the surgeon of the results were compared for both the methods. It was considered successful the abatement of PTH of ≥70% at rapid intraoperative testing and consequently surgical intervention stopped before communication of central laboratory PTH testing. RESULTS: The average time of reporting the test results of the central laboratory was 41.5 minutes (SD ± 9), whereas with the rapid intraoperative PTH (ioPTH) testing the average time was 9.9 minutes (SD ± 2.02). An average of 33.6 minutes of the duration per intervention (SD ± 10.27) were virtually saved with the use of ioPTH testing. The 2 values of the Pearson correlation (ρ) of 0.99 obtained (for baseline) and 0.975 (for the 10-minute) lead us to conclude that there is an excellent correlation between the series of data. CONCLUSIONS: Rapid ioPTH testing, owing to its accuracy, permits a dramatic reduction of operating time for patients with secondary hyperparathyroidism that need to be treated before inclusion on the waiting list.

Renal Allograft Compartment Syndrome: Is It Possible to Prevent?

Renal allograft compartment syndrome (RACS) is a complication characterized by increased pressure over 15 to 20 mm Hg of the iliac fossa site of transplanted kidney that can lead to a reduction of the blood supply to the graft, resulting in organ ischemia. This study aims to evaluate, through a review of the literature, the incidence, detection, treatment, and possible prevention of RACS. The incidence of this complication, which appears generally in the immediate post-transplantation period, is currently approximately 1% to 2% and is underestimated because of poor nosography for the presence of symptoms common to other post-transplantation complications. Doppler ultrasound is indispensable to evaluate the graft function in the immediate postoperative period and in the following days. The onset of RACS involves a surgical decompression of the graft and the subsequent closure of the abdominal wall with tension-free technique. Several authors agree that only the immediate surgical decompression following an early diagnosis can ensure a recovery of the graft. Early detection of the RACS is the key to preventing the loss of the graft. It is desirable to prevent this syndrome by reducing the discrepancy in weight between donor and recipient by 17%. However the shortage of organs makes such a selection not easy; therefore, in cases at risk for RACS, a close instrumental and clinical monitoring of the patient during post-transplantation recovery is recommended, so a prompt surgical decompression can be performed if RACS is suspected.

Human fibrin glue sealing versus suture polypropylene fixation in Lichtenstein inguinal herniorrhaphy: a prospective observational study.

BACKGROUND: Patients who underwent primary inguinal hernia repair still report a high rate of postoperative pain after operation due to the effect of mesh fixation by suture.An alternative is the use of human fibrin glue. We compared the two techniques. METHODS: 468 patients randomly underwent primary inguinal hernia Lichtenstein repair fixing the mesh by suture or by human fibrin glue (HFG); in both cases the mesh was fixed to the posterior wall of the inguinal canal and to the inguinal ligament. RESULTS: No significant differences were recorded between the two groups in terms of complications, while the sutureless technique reduces the operative time and the postoperative pain. CONCLUSIONS: A widespread technique for the treatment of inguinal hernia is the application of a mesh using Lichtenstein procedure. The prosthesis can be fixed by traditional suture or using a new method of sutureless fixation with adhesive materials that shows an excellent local tolerability and lack of adverse effects and contraindications.

A simple technique to improve residual skin plasticity for scrotal reconstruction in Fournier's Gangrene.

A 50 years-old man developed 24 hours after hemorrhoidectomy a severe Fournier's gangrene of the scrotum necessitating surgical exeresis of more than 2/3 of scrotal skin followed by hyperbaric oxygen therapy. After the resolution of the septic phase, scrotum reconstruction was obtained by tissue expansion to avoid more invasive advanced reconstructive techniques. The procedure consisted of an enzymatic and mechanical debridement and progressive skin expansion by package of gauzes of increasing volume covered with a collagenasecloramphenicol ointment (Iruxol®- Smith and Nephew, Italy), then closing the wound edges by temporary stitches to put under tension the skin. The reestablishment of the natural elasticity of the scrotal skin was obtained in ten days and at the final closure of the wound edges an acceptable optimal aesthetic result was achieved.