The Effectiveness of Cyanoacrylates versus Sutures for Mesh Fixation after Lichtenstein Repair (SCyMeLi STUDY) A Systematic Review and Meta-Analyze of Randomized Controlled Trials.

Background: Chronic postoperative inguinal pain (CPIP) is still the most frequent complication after open Lichtenstein repair and any strategy to reduce its incidence and implications is a step forward to better outcomes. Between the means of mesh fixation atraumatic glue fixation has been explored as such possibility. A meta-analysis of randomized controlled trials comparing the performance of cyanoacrylate glue versus sutures fixation was conducted. Methods: the meta-analysis was conducted according to the PRISMA guidelines. Randomized controlled trials (RCTs) published between January 2000 and December 2021 were searched for in MEDLINE, PubMed, Web of Science, and Google Scholars. The quality of RCTs and the potential risk of bias were assessed using MINORS criteria and the Cochrane risk of bias tool. Results: of 269 papers the meta-analysis was performed on 19 RCTs including 3578 patients. In the glue fixation group, the operation was shorter (mean pooled difference 6 minutes; SE = 0.47; 95% CI = - 6.77 - - 4.92; t test = -12.36; p 0.0001) and immediate postoperative pain was lower (2.37% vs 13.3%OR - 0.158; 95% CI = 0.064 0.386; p = 0.0001). There was no difference in terms of chronic pain, recurrence rate and wound events. Conclusion: glue fixation of mesh in elective Lichtenstein repair of inguinal hernia seems to be a valid choice for a painful and safe procedure without increasing risk of recurrence.

Early outcomes of open anterior versus posterior components separation with transversus abdominis release for large median incisional hernias: a retrospective stepwise analysis.

BACKGROUND: Complex incisional hernia is still a debatable topic, with increasing incidence and an increased local and systemic postoperative morbidity and mortality. The size of the defect is a risk factor for both difficult closure and 30-day readmission due to complications. The main option for closure such defect is a mesh augmented component separation technique. The goal was to evaluate 30-day wound events and general complications including 90 days mortality. MATERIAL AND METHODS: We present a retrospective study that includes patients from two different university hospitals who underwent open incisional hernia repair with anterior component or posterior component separation between January 2015 and December 2021. Only non-contaminated adult patients (over 18 years old) with postoperative primary or recurrent median abdominal wall defects larger than 6 cm and with complete fascial closure were included. Demographics (age, gender, Body Mass Index-BMI, American Society of Anesthesiologists Classification-ASA score), recurrence rank, and co-morbidities), operative details, patient outcomes complications were collected. A native abdomen/pelvis computerized tomography (CT) scan was performed preoperatively in all patients and the anatomy of the defect and volumetry (abdominal cavity volume, incisional hernia volume and peritoneal volume) were evaluated. One of the component separation technique was performed according to Carbonell's equation. RESULTS: Two hundred and two patients (101 from each group) were included. The patients with posterior component separation were more comorbid and with larger defects. The procedure was longer with 80 min but overall length of hospital stay shorter (p < 0.001) for posterior component separation. Seroma, hematoma and skin necrosis were equally distributed for both group of patients and there was no direct relation to surgery (OR 0.887, 95% CI 0.370-2.125, p = 0.788; OR 1.50, 95% CI 0.677-3.33, p = 0.318 and OR 0.386, 95% CI 0.117-1.276, p = 0.119). Surgical Site Infection rate was increased for anterior component separation (p =0.004). CONCLUSION: Complex incisional hernia repair is a challenge given by a large amount of wound complications. Choosing between anterior and posterior component separation is still a source of significant debate. We were not able to depict significant different rates of complications between the procedures and we couldn't find any specific factor related to complications.

Incisional Hernias with Loss of Abdominal Domain: A New Look to an Older Issue or the Elephant in the Living Room. Literature Review.

Incisional hernia (IH) is a postoperative defect of the abdominal wall through which the contents of the peritoneal cavity are externalized beneath the skin in a peritoneal sac. IH differs in anatomic complexity, but also in its associated comorbidities and surgical history. As IH enlarges, complications occur and these become part of its natural history. The goal of the study is to review the impact of loss of domain upon abdominal wall before and after abdominal wall reconstruction. The absence of anatomical and functional linea alba leads to a combination of muscular disturbances, chronic respiratory and gastrointestinal conditions, and psychosocial issues. The pathophysiological changes are also due to the decrease of the intra-abdominal pressure (IAP). During repair, the sudden reintroduction of the viscera into an unprepared cavity leads to a sudden increase in cavity volume and an increase in IAP with fatal pathophysiological implications. For an optimal repair, preoperatively, the abdominal wall must be augmented by achieving the following objectives: reducing the volume of the sac contents, optimizing compliance, enlargement of the container. At the same time, for the optimal repair, the following must be taken into account: increased knowledge about this condition to manage systemic and local changes, CT scan evaluation, monitoring IAP, plateau pressure (PP), and Positive End Expiratory Pressure (PEEP). In conclusion, the goals can be achieved by systemic optimization with a multidisciplinary team, using Preoperative Progressive Pneumoperitoneum (PPP) and/or Botox (BTX), and abdominal wall reconstruction through a mesh with augmented component separation technique.

Chronic Mesh Infection after Incisional Hernia Repair. Factors Influencing Negative Outcomes of Complete Mesh Removal.

Background: The treatment of incisional hernias has radically changed over the last 50 years due to the introduction of mesh repair, which has been proven to be superior to tissue repairs in terms of recurrence. Severe complications such as bacterial contamination, enteral fistulas and severe visceral adhesions are the bane of mesh repair and lead to great challenges as far as treatment is concerned. Methods: From January 2009 to December 2018, we retrospectively collected operative and outcome data on reoperation following septic complications of incisional hernias (IH) mesh repair in 89 patients. For adjustment, comorbidities, mesh location, prognostic nutritional index (PNI) and operative time were included in an SPSS data analyzer. Results: in the referred interval 89 patients (29 males) met the inclusion criteria. The mean time for the onset of infections 15.04+-0.95 months and the number of previous abdominal interventions varied from 1 to 5. Wound infections were reported to be the primary factor for mesh infection. Following removal only 43% of meshes were found to be positive for bacterial infections; the most common species detected being , MRSA and, . Different techniques of mesh removal and abdominal wall closure were used. After abdominal wall closure, 54% of patients developed post-operative complications with a mortality of 12%. Conclusion: The risk of infection after abdominal wall reconstruction (AWR) appears to be higher than other clean abdominal procedures. Mesh removal is mandatory when the infection prolonged over 3 months. The procedure is associated with a high rate of morbidity and mortality and with low quality of life if the abdomen can't be closed. Prevention is the best treatment option.

Neuronal apoptosis can be prevented by the combined therapy with melatonin and hypothermia in a neonatal rat model of hypoxic-ischemic encephalopathy.

INTRODUCTION: Birth hypoxia is a leading cause of perinatal mortality and neurological morbidity, resulting in central nervous system injury. Cerebral hypoxia and ischemia can produce a severe brain damage following a typical pattern, defined by selective vulnerability of the brain regions. The neonates are most prone to hypoxic-ischemic injuries due to the lack of efficient antioxidant defense. Neonatal hypoxia-ischemia (HI) in a 7-day-old rat HI model can produce cell death by apoptotic or necrotic mechanisms. The degree of apoptotic or necrotic mechanisms responsible for cell death in neonatal hypoxia-ischemia are not very clear as yet. The form of neuronal death may also depend on the severity of ischemic injury. Necrosis predominates in more severe cases, whereas apoptosis occurs in areas with milder ischemic injury. A human study demonstrated apoptotic and necrotic forms of cell death after hypoxic injury, whereas in some brains from stillbirths, only apoptotic figures were observed. The expression of activated caspase-3 reflects the role of apoptosis in neonatal hypoxic ischemic brain injury. OBJECTIVES: The aim of this study was to evaluate the possible neuroprotective effect of melatonin and hypothermia in hypoxic-ischemic encephalopathy in newborn rats. Local damages induced by hypoxia and ischemia were assessed by evaluating the changes in terms of histology and apoptosis. METHODS: The experiment was conducted on 20 newborn Wistar rats premedicated for seven days with melatonin in a dose of 20 mg/kg/day. On the 7th postnatal day (P7), the newborn rats were exposed to ischemia (by clamping the right carotid artery) and hypobaric hypoxia (8% O2 for 90 minutes) and some groups to hypothermia. RESULTS: In this experimental model of neonatal encephalopathy, melatonin, in a dose of 20 mg/kg/day has neuroprotective effect by reducing the number of cells expressing apoptosis in Cornu Ammonis (CA) (Ammon's Horn) CA1, CA2, CA3 and dentate gyrus of the hippocampus when combined with hypothermia. CONCLUSION: The results of this study prove that melatonin is protective in ischemic-hypoxic brain injuries, but the protection is conditioned in most of the brain regions (excepting cerebral cortex) by conjugation with post-injury hypothermia treatment.

Transinguinal Preperitoneal Mesh Plasty - An Alternative or a Dispensable Technique? A Prospective Analyze vs Lichtenstein Repair for Complex Unilateral Groin Hernias.

Background: complex groin hernia is a well describe entity with a high risk of recurrence and postoperative complications. There is no standardized approach and no reports to confirm the efficcacy of a surgical procedure. Our goal was to compare Lichtenstein repair (LR) as "golden standard" for open anterior approach with the transinguinal preperitoneal plasty (TIPP) in the treatment of complex groin hernia repair. Material and methods: the study was a prospective one and includes all patients with complex hernias admitted in the Department of Surgery of the Military Hospital Cluj-Napoca between January 2010 and December 2014. All the patients were randomized in two groups: LR and TIPP. Baseline characteristics, intraoperative findings, pain and complications were recorded. Follow-up was at least 1 year. The main outcome after 1 year were recurrence, chronic pain and its intensity recorded on VAS scale. Results: 205 patients (101 in LR group and 104 in TIPP) were included in the study. There were no differences in baseline characteristics and operative findings. Postoperative pain was lower for TIPP group (p 0.05). Follw-up was 98% at 1 month, 74% after 6 months and 64% after 1 year. Recurrence rate was higher for LR (p=0.027). Pain was increased in LR group. Conclusion: TIPP is equal in terms of chronic pain and recurrence for complex groin inguinal hernias.

The Relationship Between Left Ventricular Fractional Shortening and Intravenous Administration of Stem Cells in Laboratory Rabbits Presenting Chronic Myocardial Infarction.

BACKGROUND AND AIMS: The present study conducted from March 2012 to July 2013 aimed to evaluate from echocardiographic point of view the effects of peripheral intravenous administration of mesenchymal stem cells (MSCs) in laboratory rabbits presenting 30 days old chronic myocardial infarction. MATERIAL AND METHODS: 30 days after the induction of an acute myocardial infarction in 40 laboratory rabbits by direct ligation of the left anterior descending coronary artery at about 10 mm from the apex, we injected 1×106 MSCs in the auricular vein in a group of 30 rabbits, and a group of 10 rabbits were used as controls. 30 days after the injection of stem cells the left ventricular (LV) fractional shortening (FS) was evaluated by echocardiography and compared with the control rabbits. RESULTS: In control rabbits, echocardiography revealed akinesis of apex, interventricular septum kinetics was also impaired, FS being approximately 6%. In 80% (24 rabbits) of the injected rabbits the FS of the LV was significantly greater than in the witness group (26+/-2%, p<0.0001). At 13.3% (4 rabbits) of the injected rabbits the FS of the LV showed no improvement in comparison with the control group (6.5+/-1%). CONCLUSION: An improvement of LV SF 30 days after MSCs were injected(p<0.0001) was noted. We have to further determine if this improvement of the LV function is correlated with any histopathological changes and if it is not lost in time. Also, further studies needs to evaluate if there is any significant change in the overall mortality.

The Surgical Treatment of Inguinal Hernia Using the Laparoscopic Totally Extra-Peritoneal (TEP) Technique.

UNLABELLED: The surgical repair of inguinal hernia represents one of the most frequent procedures used in general surgery. The new surgical techniques are simpler, with a lower morbidity and recurrence of less than 2%. The laparoscopic totally extra-peritoneal (TEP) technique is contraindicated in complicated hernias (occlusion, incarceration) and in voluminous inguino-scrotal hernias. PURPOSE: The evaluation of the TEP technique, of the risk factors and of the postoperative results on the group of patients who have undergone surgery in the Surgical Clinic 2 Cluj Napoca. MATERIAL AND METHOD: The study is prospective, on a group of 40 patients operated with the TEP technique in the Surgical Clinic 2 during the period May 2013 - July 2014. The following have been assessed: the demographic data, the risk factors, the immediate complications, the recurrence of the hernias. RESULTS: The average duration of hospitalization was 6.79 days. The intraoperative incidents were: 7 minimal peritoneal lesions with pneumoperitoneum and a hemorrhagic lesion of the epigastric vessels repaired endoscopically by the clipping of the lesion. There were 2 recurrences, 24 hours and 1 year after surgery, solved by the Lichtenstein technique. After 30 interventions, the average duration of the surgery was of 64 minutes, being longer in the case of bilateral hernias and being influenced by the team's learning curve. CONCLUSIONS: The TEP technique is a safe option followed by a low rate of complications, a low recurrence rate and low intensity postoperative pain.