A Comparative Study of Retrorectus Mesh Placement Versus Properitoneal Mesh Placement in Open Repairs of Ventral Hernias.

Background Ventral hernias affect millions of patients each year. Surgery is the main line of management and various techniques have been advocated; however, mesh repair has become the norm and different approaches have been described regarding the plane of mesh fixation, but none of them are standardized. Open repair is commonly practiced, and the two most commonly performed methods are retrorectus and properitoneal mesh placement. Objectives To compare the postoperative outcomes between the retrorectus plane and the properitoneal plane of fixation of mesh in open ventral hernia repair. Methods Between September 2018 and August 2020, 56 patients with midline ventral hernia admitted to Ramaiah Hospital, Bengaluru were chosen for this prospective comparative study. Group A had 28 patients who underwent open retrorectus mesh repair and 28 patients in Group B underwent open properitoneal mesh repair. The postoperative outcomes were studied in terms of operating time, postoperative complications, and early recurrence at the end of six months and 24 months post-surgery. Results The operative time for retrorectus mesh placement was significantly lower than properitoneal mesh placement. The latter had a higher complication rate overall with an incidence of 18%, with seroma being the most common complication; however, the difference in complication rates was not statistically significant. Skin necrosis was identical in both groups and 0% of cases in both groups had SSI or mesh infection. Three patients (10.71%) in the retrorectus group and two patients (7.10%) in the properitoneal group developed recurrence at 24 months follow-up. Conclusion Retrorectus mesh repair and properitoneal mesh repair in open ventral abdominal hernias have equally good postoperative outcomes.

Association of Muscle Fibers with Histopathology in Doughnut Specimens Following Stapled Hemorrhoidopexy and Their Impacts on Postoperative Outcomes.

Background Stapled hemorrhoidopexy is widely practiced worldwide since its introduction to the world of proctology and replaced conventional hemorrhoidectomy in treating hemorrhoids. The technique of executing the procedure dictates the outcomes and complications. Here, we attempted to establish the cause of postoperative complications and attributed them to the presence of muscle of fibers in the excised doughnut specimens. Materials and Methods A prospective observational analysis of histopathological specimens obtained from patients who underwent stapled hemorrhoidopexy using procedure for prolapse and hemorrhoids-03 circular staplers in the department of surgery of a tertiary care hospital in southern India was performed, and the correlation between the presence or absence of muscle fibers in the specimens and postoperative complications was evaluated. The patients were followed up for 12 months after the procedure. Results In this study, 155 patients, including 54, 91, and 10 patients with Grade 2, Grade 3, and Grade 4 hemorrhoids, respectively, were included. Group A consisted of 19 patients with muscle fibers on the specimens, whereas Group B consisted of 139 patients without muscle fibers on the specimens. Early complications within 7 days after the procedure were as follows: 21 and 0.7% of the patients in Groups A and B, respectively, presented with postoperative pain with a visual analog scale score of more than 4; 47 and 6% of the patients in Groups A and B, respectively, presented with urinary retention; 26 and 2% of the patients in Groups A and B, respectively, presented with bleeding; and 21 and 2.9% of the patients in Groups A and B, respectively, presented with fecal urgency. A significant association was found between the presence of muscle fibers and early complications ( p < 0.001). Late complications, such as proctalgia and bleeding, accounting for 36.8 and 6.6% in Groups A and B, respectively, were significantly associated with the presence of muscle fibers in histopathology ( p < 0.001). Meanwhile, other late complications, such as incontinence, stenosis, and recurrence, exhibited no association ( p > 0.05). Conclusion The technique in taking purse-string sutures and the depth of the suture bite above the dentate line carry the utmost importance in preventing postoperative complications. Therefore, surgeons should refine their technique of appropriate depth to avoid incorporation of muscle fibers while executing the procedure.

Hernias- Is it a primary defect or a systemic disorder? Role of collagen III in all hernias- A case control study.

INTRODUCTION: The need of this study is to assess the role of collagen III in all hernias which include primary inguinal hernias ventral and recurrent abdominal hernias. Collagen type III represents the mechanically instable, less cross-linked collagen synthesized during the early days of wound healing. Quantitative assessment of collagen III in scar tissue on transversalis fascia as tissue obtained from cases operated for various hernias and compared to that of patients operated for abdominal surgeries for indications other than hernia was compared. MATERIALS AND METHODS: In this study we had a total of 90 patients, of which 45 patients underwent mesh repair for the various hernias and 45 patients who underwent laparotomies for various reasons were included as controls. Size of 1 × 1cm transversalis fascia was taken in both subjects and was sent for quantitative assessment using Immunohistochemistry test. All the above cases were randomized as per age,sex,BMI, co morbidities and materials used for repair. RESULTS: Results were analysed quantitatively and classified into following groups:Based on intensity of staining into Mild, Intermediate and Well stained and based on Quantity of Collagen III into Grade 0---NIL, Grade 1--1-25%, Grade 2-26-50%, Grade 3--51-75%, Grade 4--76-100% (Table 1). In the case group we had 52.4%,35.7% and 11.9% of the cases in Grade 4, Grade 3 and Grade 2 which proved that there was increased presence of Collagen 3, where as 84.4%,4.4% and 11.1% of patients in the control group were classified as Grade 1, Grade 2, Grade 0. For the quantitative study -Chi square test value -81.279 and the p value < 0.001. For the intensity of staining -Chi square test value -57.64 and p value is < 0.001. CONCLUSION: This study signifies that ventral, recurrent and primary inguinal hernias are not just caused because of a primary defect but an acquired disorder with respect to collagen distribution.

How does obesity affect the endocrine system? A narrative review.

Obesity is a chronic, relapsing medical condition that results from an imbalance of energy expenditure and consumption. It is a leading cause of preventable illness, disability and premature death. The causes of obesity are multifactorial and include behavioural, socioeconomic, genetic, environmental and psychosocial factors. Rarely are endocrine diseases, e.g., hypothyroidism or Cushing's syndrome, the cause of obesity. What is less understood is how obesity affects the endocrine system. In this review, we will discuss the impact of obesity on multiple endocrine systems, including the hypothalamic-pituitary axis, changes in vitamin D homeostasis, gender steroids and thyroid hormones. We will also examine the renin angiotensin aldosterone system and insulin pathophysiology associated with obesity. We will provide a general overview of the biochemical changes that can be seen in patients with obesity, review possible aetiologies of these changes and briefly consider current guidelines on their management. This review will not discuss endocrine causes of obesity.

Transanal evisceration of small bowel-a rare surgical emergency.

Transanal evisceration of small bowel is an extremely rare surgical emergency. This is the condition in which the small bowel herniates through breach in the anterior rectal wall and seen eviscerating through the anal canal. It is challenging for a surgeon to deal and manage such a case during emergency, especially if he hasn't dealt with such condition earlier. The present case reported is of 68 year old lady referred to an institution with history of transanal herniation of small bowel for three days duration, following manual reduction of chronic rectal prolapse. The case report illustrates aetiology, management & factors influencing the outcome of this rare emergency have been discussed.

Peculiar case of mucocele of appendiceal tip.

Mucocele of Appendix is a gross or clinical descriptive term for dilatation of the appendiceal lumen by mucus.It is a rare pathology with an overall incidence of 0.2 to 0.3% of all appendectomies. Majority of these cases present with mucocele involved whole length of the appendix. On extensive literature search,exact incidence of mucocele confined only to the tip of appendix is not known, though there are very few case reports. Here we report a peculiar case of large mucocele of appendix confined only to the tip, sparing significant length of proximal appendix and causing diagnostic dilemma pre-operatively in a 43 -years -old lady.