Bone anchor as fixation method for abdominal wall reconstruction. A case report about a ten times recurred inguinal hernia.

INTRODUCTION: While the use of bone anchor fixation for abdominal wall reconstruction for supra-pubic incisional hernia is well described (Yee et al., 2008 [1]), we show in this case report, written in line with the SCARE criteria (Agha et al., 2020 [2]), a novel use of this tool as an adjunct in the repair of a ten time recurrent inguinal hernia. CASE REPORT: A 65 years old multiparous, diabetic non-obese female, with previous abdominoplasty was submitted for left inguinal hernia for ten times, between multiples complications between infection, more than one mesh excision by anterior approach and laparoscopic approach. The wide range of procedures culminated in a destruction of the abdominal wall, making it impossible for a usual fixation of mesh in the region. Therefore, a multidisciplinary approach was planned for the patient with a bone anchor as a mesh fixation method. With a year follow up we did not observe a local hernia recurrence. CLINICAL DISCUSSION: Hernia itself is a multifactorial disease. As a anatomical defect, surgery is the only effective treatment. Our report brings a novel approach to a challenging case with many previous unsuccessful applications of conventional surgeries. Hence, we stimulate the multidisciplinary discussion for enhancing post operatory outcomes and a better point of care for the patient.

A novel approach for the treatment of Morgagni hernias: robotic transabdominal preperitoneal diaphragmatic hernia repair.

PURPOSE: We introduce a novel approach to the surgical repair of Morgagni hernias (MHs) utilizing the robotic transabdominal preperitoneal repair (rTAPP) approach. Borrowed from our previous and robust experience with rTAPP repairs for hernias of the anterior abdominal wall, this technique boasts the benefits of hernia sac reduction, the use of an uncoated mesh in an extraperitoneal plane, and minimal fixation leading to lower postoperative pain relative to other approaches. METHODS: To evaluate the effectiveness of this novel approach, five consecutive symptomatic Morgagni hernias (MHs) were repaired with the rTAPP approach. The size of the defect, mesh size, length of stay, follow-up imaging, and follow-up complications were documented for comparison. RESULTS: The size of the MH defects ranged from 4 × 6 cm to 5 × 10 cm. LOS was an average of 1.2 days. Two out of the five patients underwent concomitant repair of a lower abdominal hernias (one Spigelian hernia, and one indirect inguinal hernia). Outpatient follow-up from surgery ranged anywhere from 6 months to 4 years, with most patients receiving follow-up after 1 year. Four out of the five patients received follow-up CT scans to confirm the absence of hernia recurrence. One patient experienced an incisional hernia from the midline 12-mm port site which was repaired 1 year after. CONCLUSION: We propose a new technique for a minimally invasive strategy to treat these complex hernias utilizing an rTAPP technique resulting in minimal length of stay and a durable result in long-term follow-up. The benefits of repair, which include minimal postoperative pain, minimal length of stay, and cost-effective prosthetic mesh hidden from the visceral contents, are consistent with the author's experience for rTAPP repairs for hernias of the anterior abdominal wall.

Critical view of robotic-assisted transverse abdominal release (r-TAR).

INTRODUCTION: Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures. DESCRIPTION OF THE TECHNIQUE: We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains. DISCUSSION: Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Robotic transabdominal retromuscular umbilical prosthetic hernia repair (TARUP): observational study on the operative time during the learning curve.

PURPOSE: The use of extraperitoneal mesh in place of intra-peritoneal mesh is gaining popularity in laparoscopic ventral hernia repair. We have adopted a robotic assisted laparoscopic technique using a lateral single-dock robotic access with retromuscular mesh placement after opening the ipsilateral posterior rectus fascia. In this study, we wanted to evaluate the changes in operative times during the initial experience with this novel technique. METHODS: The initial consecutive patients undergoing robotic assisted transabdominal retromuscular umbilical prosthetic repair (r-TARUP) using a 15 × 15 cm self-fixating mesh were prospectively entered in the study and the operative times during the separate steps of the surgical procedure were recorded. Complications were reported up to 4 week post operatively and quality of life was assessed using the EuraHS-QoL score. RESULTS: Over a 5 month inclusion period, 41 patients with either a primary (n = 34) or a trocar site hernia (n = 7) at the umbilicus were identified. All hernias had a mean diameter of less than 4 cm. The total OR time decreased significantly during the learning curve (tertile 1: 126 min versus tertile 3: 102 min; p = 0.002) due to a decrease in the skin-to-skin operating time (tertile 1: 81 min versus tertile 3:61 min; p = 0.002). The decrease in the retromuscular dissection time was the most significant of all the steps that comprised the console time (p = 0.004). The non-surgical time did not decrease (p = 0.15). The operation was performed on an outpatient basis in 68% of patients and with a one-night-stay in 29%. No complications related to the introduction of the robotic technique for this approach were observed and the early outcome is promising, with favorable quality-of-life evaluation at 4 weeks. CONCLUSIONS: The decrease in operative time during the adoption of r-TARUP was mainly related to the improved efficiency in the dissection phase of the procedure. The technique is reproducible and safe and the operative time compares favorably to published operative times for laparoscopic and open retromuscular umbilical hernia repair.

High-throughput SNP detection by using DNA pooling and denaturing high performance liquid chromatography (DHPLC).

One of the critical steps in the positional cloning of a complex disease gene involves association analysis between a phenotype and a set of densely spaced diallelic markers, typically single nucleotide repeats (SNPs), covering the region of interest. However, the effort and cost of detecting sufficient numbers of SNPs across relatively large physical distances represents a significant rate-limiting step. We have explored DNA pooling, in conjunction with denaturing high performance liquid chromatography (DHPLC), as a possible strategy for augmenting the efficiency, economy, and throughput of SNP detection. DHPLC is traditionally used to detect variants in polymerase chain reaction products containing both allelic forms of a polymorphism (e.g., heterozygotes or a 1:1 mix of both alleles) via heteroduplex separation and thereby requires separate analyses of multiple individual test samples. We have adapted this technology to identify variants in pooled DNA. To evaluate the utility and sensitivity of this approach, we constructed DNA pools comprised of 20 previously genotyped individuals with a frequency representation of 0%-50% for the variant allele. Mutation detection was performed by using temperature-modulated heteroduplex formation/DHPLC and dye-terminator sequencing. Using DHPLC, we could consistently detect SNPs at lower than 5% frequency, corresponding to the detection of one variant allele in a pool of 20 alleles. In contrast, fluorescent sequencing detected variants in the same pools only if the frequency of the less common allele was at least 10%. We conclude that DNA pooling of samples for DHPLC analysis is an effective way to increase throughput efficiency of SNP detection.

Expression of the genes encoding myelin basic protein and proteolipid protein in human malignant gliomas.

Pathological differentiation of oligodendroglioma and mixed oligoastrocytoma from astrocytoma is difficult, relying on morphological characteristics due to the lack of reliable immunohistochemical stains. Oligodendrocytes, the presumed cell of origin of oligodendrogliomas, highly express the genes encoding myelin basic protein (MBP) and proteolipid protein (PLP). We analyzed the expression of these genes to determine whether they might be useful molecular markers of oligodendrocytic tumors. MBP and PLP were highly expressed in all oligodendrogliomas and minimally expressed in glioblastomas multiforme. MBP was highly expressed in mixed oligoastrocytomas, whereas PLP expression was minimal. The association between tumor classification and expression of the MBP and PLP genes was statistically significant. Expression of these genes may serve as a useful molecular marker for some subtypes of human gliomas.