Beneficial effects of fibrin glue (Quixil) versus Lichtenstein conventional technique in inguinal hernia repair: a randomized clinical trial.

INTRODUCTION: In inguinal hernia repair, many complications are due to mesh fixation technique. Therefore, new types of atraumatic methods of fixation have been proposed. In this article, we present the results of a prospective multicentric parallel randomized controlled trial aiming to compare two mesh fixation techniques: fibrin sealant (QUIXIL(®), Omrix Biopharmaceuticals S.A., Belgium) and Lichtenstein technique. METHOD: Adult patients with primary uncomplicated inguinal hernia were randomized in two groups: fibrin sealant group (FSG) and Lichtenstein group (LTG). The two groups underwent a follow-up of 15 months. Operative time is the primary outcome. Intraoperative and postoperative outcomes were analyzed. Moreover, a differential cost analysis was performed. Patients and evaluators (with exception of the surgeon who treated the patient) were blinded. RESULTS: A total of 102 patients, 50 in FSG and 52 in LTG, were enrolled from January 2009 to June 2010, and two patients were lost to follow-up at the twelfth month. No significant differences in baseline and clinical characteristics were observed in the two groups. Operative time was longer in LTG (median/ interquartile range: 35 min/30-42.5 min vs. 31 min/28-35 min; effect size: 0.65/95% CI 0.50-0.91; p < 0.05). No differences in intraoperative complications were observed. No significant differences were observed in early complication rate (RR = 0.62; p > 0.05). Numbness rate was lower in the FSG at 1 week (RR = 0.43; p < 0.01) and at 1 month (RR = 0.17; p < 0.05). No significant differences were observed after 6 months. Postoperative pain was lower in the FSG at 1 week (0/0-1 vs. 1/0-2; p < 0.05) and at 1 month (0/0-0 vs. 0/0-1; p < 0.05). Pain disappeared in all patients after 6 months. Analgesic assumption rate was lower in the FSG (RR = 0.42; p < 0.05). Twenty per cent of FSG and 9.62% of LTG patients were discharged within 12 h; 78% of FSG and 90.38% of LTG patients were discharged within 24 h. The only one recurrence we observed was in FSG group. About costs, although fibrin sealant needed for one mesh fixation is about 10 times more costly than the needed sutures, the total costs of the two procedures did not change significantly. This was mainly due to reduction in operative time. CONCLUSIONS: The use of fibrin sealant determined a significant reduction in short-term numbness rate and postoperative pain. There was no relevant difference in total costs per patient between the two procedures.

[Videolaparoscopic oncologic surgery of the right colon: our experience]. / Chirurgia oncologica videolaparoscopica del colon destro: nostra esperienza.

The authors present their experience in videolaparoscopic surgery for right colon cancer after two years of videolaparoscopic surgery for approach to colorectal cancer. In the period between March 2002 and March 2003 they have practiced 11 right emicolectomy by videolaparoscopic technique for neoplasms: 7 were males and 4 were females with age of about 70 years old. These case included: 7 right colon's cancers, 2 cecal cancers and two hepatic flexure cancers. One postoperative complications has been observed (9%) for bowel's occlusion for early adhesion syndrome. On the base of their experience the authors perform usually videolaparoscopic surgery (M.I.S.) for the approach to right colon cancer.

[Videolaparoscopic oncologic surgery of the left and right colon: our experience]. / Chirurgia oncologica videolaparoscopica del colon sinistro e del retto: nostra esperienza.

The authors present their experience in videolaparoscopic surgery for colorectal cancer. In the period between November 2000 and march 2003 they have treated 31 patients by videolaparoscopic surgery for colorectal cancer: 17 were males and 14 were females with age included between 41 and 93 y.o. These case included: 15 rectal cancers, 12 sigmoid cancer, 3 cases of lineal flexura's cancers and I case of transverse cancer. Postoperative complications has been observed in three cases (9.6%) in the first 14 operations practiced, then confirming the learning curve. The authors perform usually mini-invasive surgery (MIS) for the approach to colorectal cancer surgery.

[Laparoscopic or open appendectomy. Critical review of the literature and personal experience]. / Appendicectomia laparoscopica o a cielo aperto. Revisione critica della letteratura ed esperienza personale.

UNLABELLED: In the era of video-laparoscopic surgery there are a lot of surgeons that still continue to perform open appendectomy. This choice is the consequence of the good results of open appendectomy (clinical, cosmetic, hospital stays and hospital costs). Published trials on laparoscopic appendectomy don't show that it is superior to the open approach. The aim of this study is to critically review the literature on laparoscopic and traditional appendectomies and to report a clinical experience on 86 consecutive patients that underwent open appendectomy. PATIENTS AND METHODS: From September 2000 to March 2001, in the Department of Emergency Surgery of Villa Scassi Hospital in Genoa, 86 patients underwent open appendectomy (32 men; mean age 29.8 years; range 15-54 years/54 women; mean age 22.4 years; range 13-80 years). All the patients underwent blood examinations, abdomino-pelvic ultrasonographys and the women gynecological evaluation. The Authors used, almost always, the Stropeni way of access (cutaneous Mac Burney and right para-rectal incision of the muscles). Discharge has been done as soon as possible. Removed appendices were submitted to histological examination and were classified as normal or pathologic according to the severity of the lesion. Review of articles has been done on Medline. RESULTS: Suspected appendicitis have been confirmed by histological examination that documented 1 normal appendix, 7 chronic appendicitis, 45 acute catharralis, 22 acute suppurative and 11 gangrenous or perforated appendicitis. The specificity of open appendectomy has been 97.6% (100% for men). Post-operative complications were: 2 wound infections and 1 recurrence of an abscess (2.58%). Open appendectomy did carry an hospital bill of 2,500,000 IT liras (1,200 USA dollars) for non complicated appendicitis and 2,000 USA dollars for perforated appendicitis. The early discharge allowed us to spend 119 millions IT liras less in 7 months (99,600 USA dollars in a year). DISCUSSION: The role of laparoscopic appendectomy isn't still established. After a critical review of the literature we can suggest that: 1) laparoscopic appendectomy increase operative time (63 vs 43 minutes: p < 0.0001); 2) laparoscopic approach can reduce the length of post-operative stay in hospital; 3) hospital bill is strongly reduced by open appendectomy (4,274 vs 7,923 USA dollars). On our experience the cost of the hospital for uncomplicated appendicitis is 2,500,000 IT liras (1,200 USA dollars). Otherwise it has been suggested that laparoscopic appendectomy has a better diagnostic accuracy respect to open appendectomy. Some Authors report a percentage of "negative" appendices of 16-50%. In Authors experience the percentage of "negative" appendices is 1.3% and so the diagnostic accuracy is 96% in women and 100% in men, probably because we systematically performed a preoperative abdomino-pelvic ultrasonography and, for the women, a gynecological evaluation. In conclusion, laparoscopic appendectomy should be done in case of suspected appendicitis in women. In the other cases, when there is a strong clinical suspect of appendicitis and, in particular, in case of suppurative appendicitis, the Authors recommend to perform an open appendectomy using the Stropeni approach. In case of perforated appendicitis with abdominal abscess they recommend to perform an open appendectomy using the right para-rectal approach or the median umbilical-pubis approach.

Mini-laparoscopic cholecystectomy.

BACKGROUND/AIMS: The authors describe their experience in performing cholecystectomy using mini-laparoscopy in selected cases of uncomplicated cholelithiasis. This involved making one 10 mm, one 5 mm and two 2 mm incisions. METHODOLOGY: From July 1996 to August 1997, 60 cholecystectomies were performed using mini-laparoscopy, out of a total of 203 video-laparocholecystectomies performed during the same period. RESULTS: Average length of the operations was 36 minutes from insertion of the first trocar to extraction of the gallbladder. All patients were discharged in the second day after surgery. No short-term intra- or post- operative complications occurred. CONCLUSIONS: The benefits of mini-cholecystectomy are potential advantages in improved appearance, reduced pain, better respiratory function, fewer wall complications. Therefore, the authors believe that mini-laparoscopy should not be assessed in terms of percentage of use or success, but rather considered as a part of the laparoscopic method to be used in selected cases.

[Laparoscopic cholecystectomy in patients who previously underwent major laparotomy]. / Colecistectomia laparoscopica in pazienti con pregresse laparotomie maggiori.

This paper describes the experience gained and the techniques used by the authors in the laparoscopic treatment of biliary calculosis in patients who previously underwent abdominal surgery, excluding cases with incisions below the horizontal line passing through the umbilicus (in these cases there are usually no adhesions to hinder operative laparoscopy of the gallbladder). Between October 1991 and July 1995,776 laparoscopies were performed on bile ducts (715 for calculosis of the gallbladder and 61 for cholecysto-choledochal calculosis). In 18 cases there was scarring of the abdominal wall due to previous major surgery (12 gastric resections, 3 resections of the colon, 1 splenectomy, 1 case of fundoplication for hiatal hernia, 1 resection of the ileum). In all cases access was by open laparoscopy to the lower right or periumbilical abdominal quadrant. When necessary, local viscerolysis was performed using various techniques with variations depending on the adhesions encountered. In all cases surgery was performed laparoscopically. In 2 cases a calculosis of the common bile duct was treated at the same time. The average duration of surgery was 70 min for cholelithiasis and 145 min for cholecysto-choledochal calculosis. On average patients were released from hospital 4 and 7 days after surgery respectively. No major or minor complications were encountered.

[The laparoscopic treatment of common bile duct lithiasis]. / Trattamento laparoscopico della litiasi della via biliare principale.

Recently the indications to video laparoscopic approach in abdominal surgery are considerably increased thanks to the very good results of the video laparocholecystectomy technique. The improvement of this methodology and of the instruments employed has permitted to extend the indications also to the treatment of cholecysto-choledochal lithiasis. After considering the actual possibilities of treating this kind of pathology, authors report their experience of 28 cases of choledocholithotomies carried out laparoscopically "at the same time" from October 1991 to October 1993, out of 431 operations on biliary tract performed for benign disease, 350 of which (81.2%) treated with a laparoscopic approach. In 26 cases the treatment has been completed. In one case (3.5%) it was necessary to perform a laparotomy due to an empyema with a wedged choledochal stone, in another case it was necessary to performed a laparoscopic-endoscopic treatment for removing wedged choledochal stone, but because of the failure of this treatment, a laparotomy followed. The only complication worth mentioning out of 27 choledocholithotomies performed is an external biliary fistula (3.7%) treated with a following laparotomy operation. The 25 patients only laparoscopically treated were discharged on the postoperative day 5. Even if a long-term follow-up lacks, authors consider the laparoscopic choledocholithotomy an efficacious cure for the treatment of cholecysto-choledochal lithiasis as it is a mini-invasive technique, which clears up the disease in one time, avoids not necessary papillotomy and reduces the risk of mortality and morbidity to their lowest terms.