[Prospective study of laparoscopic treatment of incisional hernia by means of the use of composite mesh: indications, complications, mesh fixation materials and results]. / Studio prospettico sul trattamento laparoscopico del laparocele con mesh composita: indicazioni, complicanze, sistemi di fissaggio e risultati.

The aim of this study was to establish the indications, safety, efficacy, feasibility and reproducibility of laparoscopic techniques in the treatment of abdominal wall defects, even of the larger kind, in order to standardise procedures and confirm the performance of the composite mesh used (Parietex, Sofradim, Trevoux, France). From January 2001 to December 2004, 185 non-selected patients (109 females, 76 males), with a mean age of 56 years (range: 26-77) and a mean BMI of 30 (range: 26-40) were included in the study; 162 patients (87.5%) had incisional hernias and 23 patients (12.5%) primary wall defects. The size of the defects treated ranged from 4 cm to 26 cm (mean: 12.1 cm). All patients underwent laparoscopic repair and all meshes were placed intraperitoneally. Over a mean follow-up period of 29 months (range: 1-48), we observed 11 postoperative complications (6.7%): 7 seromas (4.3%) which were still present after 4 weeks, one of which turned septic after several attempts at percutaneous evacuation and in which the prosthesis had to be removed laparoscopically; 3 (1.8%) experienced persistent neuralgia which disappeared after 2 months' treatment with NSAIDs, and also one case of trocar-induced haematoma. We had 4 recurrences (2.4%), all within 1 to 3 months of surgery; 1 in the size group measuring less than 9 cm and 3 in the larger defect group. Adhesiolysis was performed in 98% of all incisional hernia cases and in 7 cases (4.3%) we had to repair iatrogenic lesions of the small bowel. In 4 patients (2.5%), because of thick adhesions (1 patient) or bowel loop fixation to the previous surgical scar (3 patients), we caused complete bowel perforation repaired by laparoscopic suture. Mean operative time was 65.6 minutes (range: 28-130) and the mean hospital stay was 2.1 days (range: 1-5). We had no conversions and no mortality. We also reviewed the main methods of mesh fixation and believe that the best system at the moment is the EndoAnchor (Ethicon Endo-Surgery, Cincinnati, Ohio) device, although in future the best option is likely to be fixation with non-traumatic biological glue (Tissucol, Baxter, Maurepas), which we have already used in a series of 16 patients with optimal results and no recurrences. The results emerging from this clinical trial confirm the safety and efficacy of laparoscopic repair techniques, of this kind of mesh and of the anchoring devices used as well as the reproducibility of this technique for the intraperitoneal repair of primary and incisional abdominal wall defects, including even those of large size.

[Use of fibrin glue (Tissucol) for mesh fixation in laparoscopic transabdominal hernia repair]. / Utilizzo della colla di fibrina (Tissucol) per il fissaggio protesico nell'ernioalloplastica laparoscopica transaddominale (TAPP): indicazioni, tecnica e risultati iniziali.

The aim of this study was to demonstrate the efficacy and safety and report the results of prosthesis fixation by means of fibrin glue during laparoscopic treatment of inguinal and femoral hernias. From September 2001 to December 2004 we employed fibrin glue (Tissucol, Baxter, Maurepas) as a means of fixation during a transabdominal preperitoneal procedure in 230 patients (225 M, 5 F) with an average age of 45 years (range: 20-75) presenting a total of 320 hernias: 140/230 (60.8%) were monolateral and 90 (39.2%) bilateral; 267/320 hernias (83.6%) were primary and 53 (16.4%) recurrent. We had no perioperative complications. After an average follow-up of 26 months (range: 1-40) the only postoperative complications we encountered were 6 seromas (1.8%) and 1 trocar-site haematoma (0.3%). None of the patients developed scrotal haematomas. None of the patients complained of immediate or subsequent paraesthesia or cruralgia. No recurrences have occurred to date. The mean operative time was 30 minutes for monolateral hernias (range: 15-45) and about 50 minutes for bilateral hernias (range: 30-75). This was true of both primary and recurrent hernias. Patients are usually discharged on day 1 postoperatively. In the absence of pain, working activities are resumed after 5 days and sports can be practiced after 10 days. In our experience, fibrin glue (Tissucol) is the best way of fixing the mesh during a transabdominal preperitoneal procedure. It is better than mechanical devices because, though guaranteeing prosthetic stability, it is completely non-traumatic and presents none of the problems of metal clips.

Laparoscopic stoma creation.

Laparoscopic creation of an intestinal stoma may be preferable to an open operation. We report here our experience with faecal diversions. From April 1992 to April 2003 we performed 55 procedures (23 end colostomies for Miles operations; 21 end colostomies for Hartman procedures; 9 loop colostomies and 3 loop ileostomies). In 45 cases the procedure was completed laparoscopically. Ten (18%) of the cases required conversion due to bulky tumours (6 pts), obesity (2 pts) and adhesions (2 pts). The indications for diversions were rectovaginal fistula (1 pt), anastomosis leakage (1 pt), unresectable rectal cancer (21), rectal cancer resectable by Miles operation (20 pts). The two ileostomies were constructed to protect colo-anal anastomoses. The average duration of surgery was 50 minutes (range: 20-100) and 200 minutes in the case of Miles operations. The average postoperative hospital stay was 3 days (range: 2-5) and 7 days (range: 6-9) after a Miles operation. The demand for analgesics was far lower than with traditional surgery and did not continue after postoperative day two. We had no intraoperative complications. There was no mortality. During the follow-up period all the stomas have functioned well but a prolapse occurred in one case (2.6%). The laparoscopic creation of intestinal stomas is safe, feasible and effective and can be performed with a low morbidity rate. Stoma construction is the simplest of all laparoscopic procedures because it requires little dissection and only minimal mesenteric handling. The length of the procedure is longer in patients who have had prior surgery, but prior surgery is not a contraindication and a laparotomy can be avoided in the majority of patients. Patients who are obstructed or have significant bowel dilation are less prone to damage with laparoscopic procedures. In addition to the benefits of laparoscopic techniques for the patients, a laparoscopic colostomy may be ideal for the surgeon as a basic, initial step in the performance of laparoscopic colorectal procedures.