Learning and implementation of TransREctus sheath PrePeritoneal procedure for inguinal hernia repair.

PURPOSE: The TransREctus sheath PrePeritoneal procedure (TREPP) was introduced as an alternative open and preperitoneal technique for inguinal hernia mesh repair, demonstrating safety and efficacy in retro- and prospective studies. However, little is known about the technique's inherent learning curve. In this study, we aimed to determine TREPP learning curve effects after its implementation in high-volume surgical practice. METHODS: All primary, unilateral TREPP procedures performed in the first three years after implementation (between January 2016 and December 2018) were included out of a large preconstructed regional inguinal hernia database. Data were analyzed on outcome (i.e., surgical complications, hernia recurrences, postoperative pain). Learning curve effects were analyzed by assessing outcome in relation to surgeon experience. RESULTS: In total, 422 primary, unilateral TREPP procedures were performed in 419 patients. In three patients a unilateral TREPP procedure was performed on both sides separated in time. A total of 99 surgical complications were registered in 83 procedures (19.6% of all procedures), most commonly inguinal postoperative pain (8%) and bleeding complications (7%). Hernia recurrences were observed in 17 patients (4%). No statistically significant differences on outcome were found between different surgeon experience (< 40 procedures, 40-80 procedures, > 80 procedures). CONCLUSION: Implementation of TREPP seems not to be associated with a notable increase of adverse events. We were not able to detect a clear learning curve limit, potentially suggesting a relatively short learning curve among already experienced hernia surgeons compared to other guideline techniques.

Innovative biochemisurgical treatment for stabilisation of an end-stage chronic wound in a complex vascular compromized patient.

INTRODUCTION: Treating advanced peripheral arterial occlusive disease (e.g. PAOD IV) poses a significant challenge, as conventional treatments quite often fall short at this stage. However, a range of interventions can be considered to postpone amputation. This study presents an example of advanced stage of Peripheral Artery Occlusive Disease (PAOD) stage IV, encompassing a history of a high thigh amputation on the left side, coupled with pronounced wound healing disorders. PRESENTATION OF CASE: Our patient, 55 years old, smoker and ASA Class III is in a left sided above-the knee-amputation situation. He presented to our outpatient clinic with blistering in the stump area, caused by non-proportinate pressure from the prosthesis. With an emerging septic course and advanced peripheral arterial occlusive disease (PAOD) at Fontaine class IV, revascularization was unfeasible in the left iliac artery axis and groin arteries. Additionally, a stage PAOD IV presents itself with poorly healing wounds on the right side which our patient still uses to support his transfers in and out bed and his wheelchair. Multiple surgical stump revisions and femur shortenings and diverse wound treatments were performed all were unsatisfying for patient and practitioners. We introduced a novel biochemisurgical treatment in our teaching hospital. DISCUSSION: Desiccating-agent-A is an innovative dehydrating agent with potent desiccating characteristics upon application to organic substances. Its formulation involves blending 83% methane sulfonic acid with proton acceptors and dimethyl sulfoxide, as outlined in patent application. The case description results in an illustrated follow up period of 16 months and is presented in line with the recommendations of the consensus-based surgical case reporting guideline development. CONCLUSION: The goal of achieving a secondary healing trend is to establish stability within the wound area or achieve complete healing. This endeavor becomes particularly intricate when severe blood circulation compromise exists. Nonetheless, progress in wound treatment measures has made it feasible to achieve this aim by fostering the formation of dry and clean necrotic tissue. This dry and clean wound is now manageable in a patient's home situation, allowing for effective care and a better chance at preventing further severe complications.

Case report: Incarcerated obturator hernia, initially presenting as right hip pain!

INTRODUCTION: An incarcerated Obturator herniation is a rare external abdominal hernia. Abdominal CT-scanning is the first choice for the diagnosis of such an incarcerated Obturator hernia. Since intestinal incarceration leads to acute necrosis. Therefore emergency surgical treatment is required. However, due to the lack of specificity of the clinical manifestations of incarcerated Obturator hernia, a delay in adequate diagnostics may be higher than expected. PRESENTATION OF CASE: An 82 year woman was admitted to the hospital because of right hip joint pain. She was initially evaluated and admitted by orthopedics team for suspected arthritis. A CT-scan with contrast was ordered, which showed an intestinal ischemic obstruction in a right sided obturator hernia, an acute laparotomy was carried out. DISCUSSION: This case is important and differs from the well-known similar cases through the emergency admission at the orthopedic department because of the clear right hip pain and clinical history from the patient. An Obturator herniation (OH) is a rare external abdominal hernia accounting for only 0.07 %-1 % of all hernia cases. Because the female pelvis is wider which can lead to herniation of abdominal contents. The Howship-Romberg sign should be checked during physical examination. CONCLUSION: Obturator hernia is very rare and difficult to diagnose. Moreover when elderly women suffer from long-term chronic diseases, a very thin body, or a history of multiple deliveries. Howship-Romberg sign should be checked in these situations during physical examination. Early diagnosis and treatment significantly reduces the occurrence of intestinal perforation, necrosis, sepsis and/or other severe adverse events, thereby, a significant prognostic improvement of patients.

Benefit of sequential bilateral cochlear implantation in children between 5 to 18 years old: A prospective cohort study.

OBJECTIVE: To determine the benefit of sequential cochlear implantation after a long inter-implantation interval in children with bilateral deafness receiving their second implant between 5 and 18 years of age. STUDY DESIGN: Prospective cohort-study. SETTING: Tertiary multicenter. PATIENTS: 85 children with bilateral deafness and unilateral implantation receiving a contralateral cochlear implant at the age of 5 to 18 years. METHOD: The primary outcomes were speech recognition in quiet and noise (CVC) scores. The secondary outcomes were language outcomes and subjective hearing abilities, all measured before and 12 months after sequential bilateral cochlear implantation. Medians of the paired data were compared using the Wilcoxon signed-rank test. Univariable linear regression analyses was used to analyze associations between variables and performance outcomes. RESULTS: A significant benefit was found for speech recognition in quiet (96% [89-98] vs 91% [85-96]; p < 0.01) and noise (65% [57-75] vs 54% [47-71]; p = 0.01) in the bilateral CI condition compared to unilateral (n = 75, excluded 10 non-users). No benefit was seen for language outcomes. The subjective sound quality score was statistically significant higher in bilateral compared to the unilateral CI condition. Pre-operative residual hearing level in the ear of the second implant, the inter-implant interval and age at time of second implantation was not significantly associated with performance scores. CONCLUSION: After 12 months of use, sequential bilateral cochlear implantation showed improved speech perception in quiet and noise and improved subjective sound quality outcomes in children despite a great inter-implantation interval (median of 8 years [range 1-16 years]).

Plexus anesthesia versus general anesthesia for carotid endarterectomy: A systematic review with meta-analyses.

INTRODUCTION: Traditional carotid endarterectomy is considered to be the standard technique for prevention of a new stroke in patients with a symptomatic carotid stenosis. Use of plexus anesthesia or general anesthesia in traditional carotid endarterectomy is, to date, not unequivocally proven to be superior to one other. A systematic review was needed for evaluation of benefits and harms to determine which technique, plexus anesthesia or general anesthesia is more effective for traditional carotid endarterectomy in patients with symptomatic carotid stenosis. METHODS: The review was conducted according to our protocol following the recommendations of Cochrane and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches were updated on the October 1, 2020. We did not find any randomized clinical trial comparing plexus anesthesia and general anesthesia in carotid endarterectomy with patch angioplasty matching our protocol criteria in patients with a symptomatic and significant (≥50%) carotid stenosis. CONCLUSIONS: Based on the current, high risk of bias evidence, we concluded there is a need for new randomized clinical trials with overall low risk of bias comparing plexus anesthesia with general anesthesia in carotid endarterectomy with patch closure of the arterial wall in patients with a symptomatic and significant (≥50%) stenosis of the internal carotid artery.Protocol unique identification number (UIN): CRD42019139913, (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139913).

Transrectus sheath pre-peritoneal (TREPP) procedure versus totally extraperitoneal (TEP) procedure and Lichtenstein technique: a propensity-score-matched analysis in Dutch high-volume regional hospitals.

PURPOSE: Results of the most commonly used inguinal hernia repair techniques often originate from expert centers or from randomized controlled studies. In this study, we portray daily-practice results of a high-volume, regional surgical group in the Netherlands, comparing TREPP (open (posterior) transrectus sheath pre-peritoneal) with Lichtenstein (open anterior) and TEP (endoscopic (posterior) totally extraperitoneal). We hypothesize that the TREPP shows more favorable outcome compared to the current gold standard procedures: TEP and Lichtenstein. METHODS: Between January 2016 and December 2018, 3285 consecutive patients underwent surgical treatment and were included for analysis. The outcome measures were postoperative pain, recurrence rate and other surgical complications. Propensity-score matching was used to address potential selection bias. RESULTS: After propensity-score matching, there was no statistically significant difference in postoperative pain in the TREPP group compared to the Lichtenstein group (TREPP 7.3% versus Lichtenstein 6.3%; p = 0.67) nor in TREPP compared to TEP (TREPP 7.4% versus TEP 4.1%; p = 0.064). There was no statistically significant difference in recurrences in the TREPP group compared to Lichtenstein (3.8% vs 2.5%; p = 0.42), nor in the TREPP versus TEP comparison (3.9% vs 2.8%; p = 0.55) CONCLUSION: This study compares TREPP with Lichtenstein and TEP in the presence of postoperative pain, recurrences and other adverse outcomes. After propensity-score matching, no statistically significant difference in postoperative pain or recurrences remained between either TREPP compared to Lichtenstein, or TREPP compared to TEP. Based on these results, TREPP, Lichtenstein and TEP showed comparable results in postoperative pain, recurrences and other surgical site complications.

Emergency TREPP for Strangulated Inguinal Hernia Repair: A Consecutive Case Series.

Background Patients with strangulated inguinal hernia (SIH) require emergency surgical treatment. International guidelines do not specify the surgical technique of preference. Frequently, an open anterior approach such as the Lichtenstein technique is used. The TransREctus sheath Pre-Peritoneal (TREPP) technique is an alternative, open posterior approach, which has shown promising results in the elective treatment of inguinal hernias. This study aims to evaluate the feasibility and safety of the TREPP technique in the emergency setting of SIHs. Materials and Methods After medical ethical approval was warranted, all consecutive patients, who underwent emergency TREPP (e-TREPP) at a high-volume hernia institute, were retrospectively included from 2006 up to and including 2016. Data retrieved from the electronic patient files were combined with the findings during a long-term outcome physical investigation at an outpatient department visit. e-TREPP was, prior to the start of the study, defined as TREPP performed immediately at the operation room. Results Thirty-three patients underwent e-TREPP for SIH. Ten patients were clinically evaluated, ten patients were deceased, nine patients could not be contacted, and four patients did not or could not consent. Of the ten deceased patients, one patient died perioperatively due to massive aspiration followed by cardiac arrest. Nine patients died due to other causes. Two patients developed a recurrence after (after 13 days and 16 months respectively). Two patients were surgically treated for a wound infection (mesh removal in one). No patient reported chronic postoperative inguinal pain. Conclusion e-TREPP in experienced hands seems feasible and safe (Level of Evidence 4) for the treatment of patients with strangulated inguinal hernia, with percentages of postoperative complications comparable to other techniques.

Plexus anesthesia versus general anesthesia in patients for carotid endarterectomy with patch angioplasty: Protocol for a systematic review with meta-analyses and Trial Sequential Analysis of randomized clinical trials.

INTRODUCTION: Traditional carotid endarterectomy is considered to be the standard technique for prevention of a new stroke in patients with a symptomatic carotid stenosis. Use of plexus anesthesia or general anesthesia in traditional carotid endarterectomy is, to date, not unequivocally proven to be superior to one other. A systematic review is needed for evaluation of benefits and harms to determine which technique, plexus anesthesia or general anesthesia is more effective for traditional carotid endarterectomy in patients with symptomatic carotid stenosis. METHODS AND OUTCOMES: The review will be conducted according to this protocol following the recommendations of the 'Cochrane Handbook for Systematic Reviews' and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomized Clinical Trials comparing plexus anesthesia versus general anesthesia in traditional carotid endarterectomy will be included. Primary outcomes will be postoperative death and/ or stroke (<30 days) and serious adverse events. Secondary outcomes will be non-serious adverse events.We will primarily base our conclusions on meta-analyses of trials with overall low risk of bias. We will use Trial Sequential Analysis to assist the evaluation of imprecision in Grading of Recommendations Assessment, Development and Evaluation. However, if pooled point-estimates of all trials are similar to pooled point-estimates of trials with overall low risk of bias and there is lack of a statistical significant interaction between estimates from trials with overall high risk of bias and trials with overall low risk of bias we will consider the Trial Sequential Analysis adjusted confidence interval precision of the estimate achieved in all trials as the result of our meta-analyses. ETHICS AND DISSEMINATION: The proposed systematic review will collect and analyze secondary data from already performed studies therefore ethical approval is not required. The results of the systematic review will be disseminated by publication in a peer-review journal and submitted for presentation at relevant conferences.

Long-term results from a randomized comparison of open transinguinal preperitoneal hernia repair and the Lichtenstein method (TULIP trial).

BACKGROUND: The short-term results of the TULIP trial comparing transinguinal preperitoneal (TIPP) inguinal hernia repair with the Lichtenstein method have been reported with follow-up of 1 year. After TIPP repair, fewer patients had chronic postoperative inguinal pain (CPIP); they had better health status and lower costs. The present study reports the long-term outcomes of this trial. METHODS: All surviving patients initially randomized in the TULIP trial were contacted. Patients were interviewed by telephone and sent a questionnaire. Those reporting any complaints were invited for outpatient review. Chronic pain, hernia recurrence and reoperation were documented, along with any sensory change or disturbance of sexual activity. RESULTS: Of 302 patients initially randomized, 251 (83·1 per cent) were included in the analysis (119 TIPP, 132 Lichtenstein), with a median follow-up of 85 (range 74-117) months. Of 25 patients with chronic postoperative inguinal pain after 1 year, only one, who underwent Lichtenstein repair, still had groin pain at long-term follow-up. The overall hernia recurrence rate was 2·8 per cent (7 patients), with no difference between the groups. CONCLUSION: Both TIPP and Lichtenstein hernia repairs are durable. Patients with chronic postoperative inguinal pain after 1 year can be reassured that the groin pain tends to fade over time.

Case series of recurrent inguinal hernia after primary TREPP repair: re-TREPP seems feasible and safe.

INTRODUCTION: The Trans REctussheath PrePeritoneal (TREPP) mesh repair was introduced in 2006 to decrease the risk of postoperative inguinal pain in hernia surgery. For the repair of a recurrent inguinal hernia after a primary TREPP an alternative open anterior route (Lichtenstein) may seem the most logical option, but coincides with an increased risk of chronic postoperative inguinal pain. Therefore, this study aimed to evaluate the feasibility of a second TREPP procedure to repair a recurrent inguinal hernia after an initial TREPP repair. METHODS: Consecutive patients with a recurrent inguinal hernia after a primary TREPP, repaired by a re-TREPP were retrospectively included in the study. Data, retrieved from the electronic patient files, were combined with the clinical findings at the outpatient department where the patients were physically investigated according to a priorly written and registered protocol. RESULTS: Overall about 1800 TREPPs were performed between 2006 and 2013. Since the introduction of TREPP in 2006, 40 patients presented with a recurrence in our center. From this group 19 patients were re-operated with the TREPP technique. No intraoperative complications occurred. There was one conversion from re-TREPP to Lichtenstein and no re-recurrences occurred to date. Ten out of 19 patients could be clinically evaluated with a mean follow-up period of 37 months (range 11-95). None of these patients (n=10) complained of chronic postoperative inguinal pain. Two patients reported discomfort. One patient died non procedure related, three weeks after re-TREPP of sudden cardiac death. CONCLUSION: These first experiences with re-TREPP for secondary inguinal hernia repair are encouraging for the aspects of feasibility and safety, particularly in experienced surgical hands.

Accuracy and reproducibility of fast fractional flow reserve computation from invasive coronary angiography.

Fractional flow reserve (FFR) guided percutaneous coronary intervention (PCI) is associated with favourable outcome compared with revascularization based on angiographic stenosis severity alone. The feasibility of the new image-based quantitative flow ratio (QFR) assessed from 3D quantitative coronary angiography (QCA) and thrombolysis in myocardial infarction (TIMI) frame count using three different flow models has been reported recently. The aim of the current study was to assess the accuracy, and in particular, the reproducibility of these three QFR techniques when compared with invasive FFR. QFR was derived (1) from adenosine induced hyperaemic coronary angiography images (adenosine-flow QFR [aQFR]), (2) from non-hyperemic images (contrast-flow QFR [cQFR]) and (3) using a fixed empiric hyperaemic flow [fixed-flow QFR (fQFR)]. The three QFR values were calculated in 17 patients who prospectively underwent invasive FFR measurement in 20 vessels. Two independent observers performed the QFR analyses. Mean difference, standard deviation and 95% limits of agreement (LOA) between invasive FFR and aQFR, cQFR and fQFR for observer 1 were: 0.01 ± 0.04 (95% LOA: -0.07; 0.10), 0.01 ± 0.05 (95% LOA: -0.08; 0.10), 0.01 ± 0.04 (95% LOA: -0.06; 0.08) and for observer 2: 0.00 ± 0.03 (95% LOA: -0.06; 0.07), -0.01 ± 0.03 (95% LOA: -0.07; 0.05), 0.00 ± 0.03 (95% LOA: -0.06; 0.05). Values between the 2 observers were (to assess reproducibility) for aQFR: 0.01 ± 0.04 (95% LOA: -0.07; 0.09), for cQFR: 0.02 ± 0.04 (95% LOA: -0.06; 0.09) and for fQFR: 0.01 ± 0.05 (95% LOA: -0.07; 0.10). In a small number of patients we showed good accuracy of three QFR techniques (aQFR, cQFR and fQFR) to predict invasive FFR. Furthermore, good inter-observer agreement of the QFR values was observed between two independent observers.

Prevotella intermedia infection causing acute and complicated aortitis-A case report.

INTRODUCTION: Aortitis is a general term that refers to all conditions involving an inflammation of the aortic wall. This case report describes the surgical approach of a patient with infectious and symptomatic aortitis caused by the rare vector Prevotella intermedia. PRESENTATION OF CASE: A 44-year old male patient was admitted with fever and general discomfort after a period of sore throat in a non-teaching hospital. After two weeks he developed acute abdominal and back pain accompanied by sweating and elevated infection parameters. Computed tomography angiography revealed atherosclerotic changes of the infrarenal aorta with a locally contained rupture of the aorta alongside peri-aortal signs of inflammation (and aortitis aspects). An urgent aortic reconstruction was performed according to Nevelsteen. The blood cultures turned out positive for Prevotella intermedia. Postoperatively the patient received antibiotics for six weeks. The patient recovered uneventful from this infection and surgical procedure. DISCUSSION: A complicated and acute aortitis is a rare but potentially life-threatening disease. The aetiology can be ordered into two main groups; inflammatory and infectious. Diagnosis is based upon symptoms, biochemical values, microbiological results and imaging modalities. Treatment depends on aetiology and should be discussed in an experienced multidisciplinary setting. Infectious aortitis should be treated with antibiotics for at least six weeks with close monitoring of the patient's clinic and biochemical values, even after surgery. CONCLUSION: Prevotella intermedia is a rare causative agent for aortitis. Acute aortitis is a challenging clinical entity which should be managed in an equipped medical center by an experienced multidisciplinary team.

The TREPP as alternative technique for recurrent inguinal hernia after Lichtenstein's repair: A consecutive case series.

BACKGROUND: Recurrent inguinal hernias after initial repair with mesh are preferably treated via an alternative route (e.g. posterior after anterior). For recurrent inguinal hernias after an anterior repair such as Lichtenstein's, an endoscopic approach such as the total extraperitoneal or transabdominal preperitoneal technique (TEP or TAPP) is recommended if expertise is present. The TransREctus sheath PrePeritoneal (TREPP) technique is a promising open posterior technique and could be an alternative to endoscopic methods. This study aims to evaluate the results of the TREPP technique for recurrent inguinal hernia. MATERIALS AND METHODS: Consecutive patients who underwent a TREPP repair for recurrent hernia after initial operation according to Lichtenstein were included in a retrospective manner. A minimum of one year follow-up after the TREPP repair was maintained. Data retrieved from the patient files were combined with the findings at an outpatient department visit. RESULTS: Between January 2006 and December 2013 fifty-two patients were eligible for inclusion of which 38 patients were clinically evaluated. The mean follow-up of these thirty-eight patients was 65 months (range 17-108 months) in which 2 patients had developed a re-recurrence. One patient reported chronic postoperative inguinal pain (CPIP) since the TREPP and four patients experienced CPIP since the primary inguinal hernia repair. Peri-operative and <30 day complications were rare and no severe adverse events occurred. CONCLUSION: TREPP seems to be a feasible alternative for recurrent inguinal hernia repair after an initial operation according to Lichtenstein. It may yield extra advantages compared to endoscopic repairs, such as a short learning curve, spinal anesthesia and lower costs.

Teaching the transrectus sheath preperiotneal mesh repair: TREPP in 9 steps.

BACKGROUND: The preperitoneal mesh position seems preferable to reduce the number of patients with postoperative chronic pain after inguinal hernia surgery. The transrectus sheath preperitoneal mesh repair (TREPP) is gaining popularity. Teaching a new technique requires a standardized approach to achieve an optimal learning curve. The aim of this paper was to provide a step-by-step teaching module for hernia surgeons learning the TREPP. METHODS: Literature was critically reviewed and the forthcoming nine surgical steps of the new TREPP technique and its rationale are described in this article. The TREPP hernia repair technique is illustrated with an online education video and three photos of the anatomical landmarks and the proposed mesh position of TREPP. RESULTS: The nine steps of TREPP are described extensively and the critical steps are presented in a standardized way for surgical educational purposes. Also the rationale and technical considerations of inguinal hernia experts are presented. DISCUSSION: TREPP may be a promising technique for groin hernia surgery. To date there have been no major complications with the TREPP repair which is currently the subject of a RCT. The learning curve of TREPP is being investigated and teaching of this technique requires standardization for trainee surgeons. CONCLUSION: TREPP potentially merges the advantages of a preperitoneal positioned mesh with an open technique. Initial results are promising and TREPP seems to be applicable in different hospitals in the Netherlands. Since the start of an active teaching program, TREPP has been introduced and accepted well by dedicated hernia surgeons in other hospitals in the Netherlands and Europe.

Membrane organization determines barrier properties of endothelial cells and short-chain sphingolipid-facilitated doxorubicin influx.

The endothelial lining and its outer lipid membrane are the first major barriers drug molecules encounter upon intravenous administration. Our previous work identified lipid analogs that counteract plasma membrane barrier function for a series of amphiphilic drugs. For example, short-chain sphingolipids (SCS), like N-octanoyl-glucosylceramide, effectively elevated doxorubicin accumulation in tumor cells, both in vitro and in vivo, and in endothelial cells, whereas other (normal) cells remained unaffected. We hypothesize here that local membrane lipid composition and the degree of lipid ordering define SCS efficacy in individual cells. To this end, we study the differential effect of SCS on bovine aortic endothelial cells (BAEC) in its confluent versus proliferative state, as a model system. While their (plasma membrane) lipidome stays remarkably unaltered when BAECs reach confluency, their lipids segregate to form apical and basolateral domains. Using probe NR12S, we reveal that lipids in the apical membrane are more condensed/liquid-ordered. SCS preferentially attenuate the barrier posed by these condensed membranes and facilitate doxorubicin influx in these particular membrane regions. We confirm these findings in MDCK cells and artificial membranes. In conclusion, SCS-facilitated drug traversal acts on condensed membrane domains, elicited by confluency in resting endothelium.