Assessment of feasibility and safety of cyanoacrylate glue versus absorbable tacks for inguinal hernia mesh fixation. A prospective comparative study.

Introduction: Mesh fixation is one of the most important steps in laparoscopic inguinal hernia repair. Tacks are often used and provide reliable fixation but they increase the risk of bleeding and chronic pain. To decrease chronic pain, absorbable tacks have been more recently developed. Another method is fixation via glue, which is the most minimally invasive approach, but it may theoretically lead to higher rates of fixation failure. Aim: To analyse the intraoperative mesh fixation success rate and postoperative outcomes between cyanoacrylate and absorbable tacks in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. Material and methods: Adult patients who underwent TAPP hernia repair were included prospectively. Patients were split into two groups: the study group (LB) in which the mesh was fixed with cyanoacrylate glue and the control group (AT) in which absorbable tacks were used. Main outcomes were fixation success rate, early postoperative pain, chronic pain, patient reported outcomes and recurrence rate. Results: The mesh fixation success rate when using LB was 96.70% (n = 88), while in the AT group, the mesh fixation success rate was 100% (n = 120). Patients in the AT group had significantly higher pain scores than patient in the LB group (p < 0.001, 95% CI). There was no significant difference in chronic pain, patient reported outcomes or recurrences between the two groups. Conclusions: Cyanoacrylate glue is a safe option for mesh fixation in transabdominal preperitoneal laparoscopic inguinal hernia repair with improved early postoperative pain and similar chronic pain, patient reported outcomes and recurrence when compared to absorbable tack fixation.

Does CT Reduce the Rate of Negative Laparoscopies for Acute Appendicitis? A Single-Center Retrospective Study.

In surgical practice, surgeons request CT scans to rule out acute appendicitis, even in young patients. We aimed to assess the feasibility of using a CT scan to reduce the rate of negative laparoscopies in patients younger than 40 with equivocal signs of acute appendicitis. Therefore, we conducted a retrospective observational study on the patients admitted with a provisional diagnosis of acute appendicitis. Patients younger than 40 and with the Alvarado score between 3 and 6 were included. These were divided into two groups: those who had or did not have a CT scan. Each group was further subdivided into patients that had a laparoscopy and those that did not. Out of 204 patients included in the study, 16% were included in the CT group, and 84% in the non-CT group. 71.9% of the patients that underwent a CT scan had appendicitis and underwent an appendectomy. Five patients with a normal CT scan had appendectomy due to persistent signs of acute appendicitis. The histopathology of the 23 patients with positive CT was positive, and 3 of the 5 patients with negative CT that underwent appendectomy had positive histology results. The negative appendectomy rate for patients that had preoperative CT is 7.14% compared to 32.4% in patients without preoperative CT. The rate of negative laparoscopy in patients younger than 40 years old that undergo preoperative CT is significantly lower with a p-value of .00667.

Colon biopsies: benefit or burden?

Analyzing colon biopsies is becoming time consuming and a financial burden as colonoscopy is now the main screening and diagnostic procedure of the main gastrointestinal diseases. Colon sampling can provide important information when used accordingly; otherwise it may only load the medical system unnecessarily. Our aim was to retrospectively analyze criteria for colon biopsies and correlate the diagnostic value of randomly sampling colon, especially in patients with diarrhea. This was a retrospective study on 2109 colonoscopies done over one year. Data was collected from the ENDORAD system and included variables such as: age, gender, quality of preparation, procedure, symptoms, biopsies (type, location), and endoscopy and histology findings. Data was analyzed in a descriptive manner. Out of 496 random biopsies, only 7.4% had positive histology findings. The main symptom was diarrhea and 186 cases of patients complaining of diarrhea with normal colonoscopy had random colon sampling. In 5.3% of these cases histology assessment showed changes of microscopic colitis. Fisher's test was significant when correlating the odds of having random biopsies in patients with and without diarrhea and patients younger and older than 60. Random sampling of colon during colonoscopies should be done only in selected patients otherwise it has a low diagnostic value.

Postoperative Outcomes and Patient's Satisfaction after Hybrid TIPP with UHS and TEP Repair for Inguinal Hernias: A Single-Centre Retrospective Comparative Study.

Background: Transabdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) inguinal hernia repairs are largely acclaimed for their lower risk of chronic postoperative pain and acceptable recurrence rates. However, hybrid/combined open procedures are still a reliable option among surgeons. Our aim is to compare the outcomes and patients satisfaction of hybrid TIPP (hTIPP) procedure using the Ultrapro Hernia System with laparoscopic pre-peritoneal mesh repair approaches (TEP) to assess its safety and effectiveness. Patients and Methods: The study design is a single center, retrospective comparative study on 90 patients who had hTIPP and TEP inguinal hernia repair in the NAAS General Hospital, over a four-year period (2013-2017). Results: Unplanned postoperative hospital admission was comparable both groups, the figures were 3 patients for hTIPP and 3 patients for TEP. There was no statistically significant difference in the immediate, early and late postoperative pain and complications in both groups. The recurrence rate was nil in hTIPP group compared to one recurrent case in TEP. There is no statistical difference in the five outcomes of the PROM questionnaire and satisfaction rate between hTIPP and TEP. Conclusions: There is no significant difference between hTIPP and TEP in terms of postoperative outcomes and patient satisfaction. hTIPP approach is a safe and feasible alternative to TEP.

Evaluation of the effectiveness and patients' contentment with transanal haemorrhoidal artery dearterialisation and mucopexy (THD) for treatment of haemorrhoidal disease: a 6-year study.

INTRODUCTION: With high incidence of haemorrhoidal disease and significant complication rates of traditional haemorrhoidectomy procedures, transanal haemorrhoidal artery ligation and mucopexy (THD) emerges as a minimally invasive procedure with superior results. However, it is crucial that effectiveness of results and patient satisfaction be gauged based on post-operative experience, symptomology and recurrence. AIM: Our aim is to provide a long-term analysis of efficacy and patient's satisfaction for the procedure, for the largest patient population, in correlation to presenting symptoms and degree of haemorrhoids. METHOD: A prospective study was conducted for all the patients (324) that underwent THD between 2011 and 2016 in Naas General Hospital. The assessment was done for postoperative complications, symptoms pre- and postoperatively and patients' satisfaction rating. Clinical follow-up was done after 6 weeks and long-term follow-up by standardized questionnaire filled by telephonic clinic. RESULTS: Of the 324 patients who underwent surgery, 256 (79.0%) participated in the study. There were 119 (46.5%) males and 137 (53.5%) females. The average age of patients was 48.40 years (17-82). Two hundred and fifteen (84.0%) patients had no recurrence. Forty-one (16.0%) had recurrence requiring further treatment. There was statistically significant higher recurrence in patients with grade 3 and 4 haemorrhoids and per-rectal bleeding (p < 0.05) while there was no statistically significant recurrence for age, gender, sedentary lifestyle and constipation/pruritus. Two hundred and twenty-four (87.5%) patients were completely satisfied from the procedure and highly recommend the procedure. CONCLUSION: THD is a comparably pain-free procedure with improved results that prides in higher long-term satisfaction, minimal recurrence and fewer complications, in comparison to other surgical modalities.

Laparoscopic surgery for rectal cancer: a single-centre experience of 120 cases.

INTRODUCTION: For colorectal surgeons, laparoscopic rectal cancer surgery poses a new challenge. The defence of the questionable oncological safety tempered by the impracticality of the long learning curve is rapidly fading. As a unit specialising in minimally invasive surgery, we have routinely undertaken rectal cancer surgery laparoscopically since 2005. METHODS: Patients undergoing surgery for rectal cancer between June 2005 and February 2010 were retrospectively reviewed from a prospectively maintained colorectal cancer database. RESULTS: One hundred and thirty patients underwent surgery for rectal cancer during the study period. One hundred and twenty patients had a laparoscopic resection, six were converted to open (conversion rate 5%) and 10 had a planned primary open procedure. Fifty four were low rectal tumours and 76 were upper rectal tumours. One hundred and thirteen patients had an anterior resection (87%), 17 patients an abdomino-perineal resection (13%) and 62 of the 130 patients (47.6%) had neoadjuvant radiotherapy. The median lymph node retrieval rate was 12 (9-14), five patients (3.8%) had a positive circumferential margin and the clinical anastomotic leak rate was 3.8% (n = 5 patients). There was no significant difference in the stated parameters for neoadjuvant versus non-neoadjuvant patients and for upper versus lower rectal tumours. Ninety three percent of mesorectal excision specimens were complete on pathological assessment. CONCLUSIONS: During the study period, 92% of rectal cancers underwent a laparoscopic resection with low rates of morbidity and acceptable short-term oncological outcomes. This data supports the view that laparoscopic surgery for rectal cancer can be safely delivered in mid-volume centres by surgeons who have completed the learning curve for laparoscopic colorectal surgery.

Umbilical hernia rupture with evisceration of omentum from massive ascites: a case report.

INTRODUCTION: The incidence of hernias is increased in patients with alcoholic liver disease with ascites. To the best of our knowledge, this is the first report of an acute rise in intra-abdominal pressure from straining for stool as the cause of a ruptured umbilical hernia. CASE PRESENTATION: An 81-year-old Caucasian man with a history of alcoholic liver disease presented to our emergency department with an erythematous umbilical hernia and clear, yellow discharge from the umbilicus. On straining for stool, after initial clinical assessment, our patient noted a gush of fluid and evisceration of omentum from the umbilical hernia. An urgent laparotomy was performed with excision of the umbilicus and devitalized omentum. CONCLUSION: We report the case of a patient with a history of alcoholic liver disease with ascites. Ascites causes a chronic increase in intra-abdominal pressure. A sudden increase in intra-abdominal pressure, such as coughing, vomiting, gastroscopy or, as in this case, straining for stool can cause rupture of an umbilical hernia. The presence of discoloration, ulceration or a rapid increase in size of the umbilical hernia signals impending rupture and should prompt the physician to reduce the intra-abdominal pressure.

Laparoscopic resection for low rectal cancer: evaluation of oncological efficacy.

INTRODUCTION: Laparoscopic resection of low rectal cancer poses significant technical difficulties for the surgeon. There is a lack of published follow-up data in relation to the surgical, oncological and survival outcomes in these patients. AIM: The aim of this study is to evaluate the surgical, oncological and survival outcomes in all patients undergoing laparoscopic resection for low rectal cancer. METHODS: Consecutive patients undergoing laparoscopic resection for low rectal cancers were included in the study. Clinical, pathological and follow-up data were recorded over a 4-year period. The mean follow-up was 25 months RESULTS: A total of 53 patients were included in the study, 30 of whom were males. The mean age was 64.14 years (range, 34-86 years). The mean hospital stay was 8.2 days (range, 4-42 days). Fifty were completed laparoscopically and three were converted to an open procedure. Thirty-eight were anterior resections and 15 were abdominoperineal resections. Twenty-four patients received neoadjuvant chemoradiotherapy. The total mesorectal excision was optimal in 51 (98%) cases. There were no anastomotic sequelae and no surgical mortality. There was no local recurrence detected. The overall survival (mean follow-up, 25 months) was 93.5%. CONCLUSION: Laparoscopic resection for low rectal cancers permits optimum oncological control. In our series, this technical approach is associated with excellent 4-year survival and clinical outcomes.

Complex rectal polyps: other treatment modalities required when offering a transanal endoscopic microsurgery service.

PURPOSE: Complex rectal polyps may present a clinical challenge. The study aim was to assess different treatment modalities required in the management of patients referred for transanal endoscopic microsurgery. METHODS: Patients referred with complex rectal polyps from 1998 to 2008 were entered prospectively to a colorectal database. These data was analyzed for referral pattern, histology, surgical procedures performed, and subsequent outcome. RESULTS: Of the 209 patients referred (101 female, 108 male, median age of 65 years, range of 24-89), 132 (63%) were deemed suitable for transanal endoscopic microsurgery. Seventeen patients required a second staged procedure; three patients required an anterior resection at time of index surgery. Seventeen patients referred for transanal endoscopic microsurgery went direct to anterior resection, 37 underwent snare polypectomy (SP), and 17 patients underwent transanal excision. Six patients had no surgery (three unfit for anesthesia and three had no residual lesions). Thus, 37% of the patients referred for transanal endoscopic microsurgery required a different treatment modality. CONCLUSIONS: Majority of patients referred to our unit with complex rectal polyps were suitable for transanal endoscopic microsurgery. However, this study highlights that in offering a transanal microsurgery service, one should be prepared for a diversity of pathology necessitating a range of management options.

Short-term outcomes following laparoscopic resection for colon cancer.

BACKGROUND: Laparoscopic resection for colon cancer has been proven to have a similar oncological efficacy compared to open resection. Despite this, it is performed by a minority of colorectal surgeons. The aim of our study was to evaluate the short-term clinical, oncological and survival outcomes in all patients undergoing laparoscopic resection for colon cancer. METHODS: From July 2005 to December 2008, 202 consecutive patients underwent laparoscopic resection for colon cancer. Surgery was analysed on an intention to treat basis. The mean follow-up was 24.3 months. RESULTS: Two hundred twenty-two patients underwent resection for colon cancer. Two hundred two underwent laparoscopic resection (91%). One hundred sixteen were male patients. Mean age was 65.9 years (range = 24-91). The median length of stay was 6.6 days (mean = 7.1 days). One hundred eighty-eight of 202 (93.1%) were completed laparoscopically. Fourteen (6.9%) were converted. The overall morbidity rate was 15.8%. There were three clinically apparent anastomotic leaks. The 30-day mortality was 1 (0.5%). The mean nodal yield was 13.4 (range = 8-37) nodes. There were no positive margins detected. Overall survival in laparoscopically treated colon cancer was 88.1%. In those patients with non-metastatic disease, the overall survival was 90.7% (165/182). CONCLUSION: Laparoscopic resection for colon cancer is achievable in 85% (188/222) of patients. This facilitates adequate oncological clearance. It is associated with a low morbidity rate and favourable short-term survival outcomes. This data reflects the potential outcomes dedicated MIS colorectal units will have to offer colon cancer patients once laparoscopic colorectal surgery becomes the de facto surgical approach.

Electromyographic biofeedback can improve subjective and objective measures of fecal incontinence in the short term.

Electromyographic biofeedback therapy has demonstrated subjective improvement in patients with fecal incontinence that is comparable to surgery. We assessed the efficacy of biofeedback therapy in a consecutive heterogeneous group of patients using both subjective and objective assessment criteria. These 28 patients with fecal incontinence were studied retrospectively. Patients were assessed using a quality-of-life questionnaire (QOL), the Vaizey and Wexner incontinence scoring systems, and anorectal manometry for efficacy of treatment, before and after biofeedback therapy. Eighty-six percent of patients completed the study. Median follow-up was 18 months. Eighty percent of patients demonstrated significant improvements in their Vaizey and Wexner scores (P<0.001 and P<0.001, respectively). The mean QOL score improved from 62 to 77 (P<0.01). Significant improvements were also demonstrated in the mean resting pressure (P<0.01), peak amplitude of squeeze (P<0.01), and the duration of squeeze pressure (P<0.05). The deferred 15-minute evacuation time also significantly increased (P<0.001). This study reported significant short-term improvement in fecal incontinence with electromyographic biofeedback therapy using validated subjective and objective scoring systems. Similarly, this treatment also significantly improved anorectal manometric findings. Our data confirm the role of biofeedback therapy in the multimodality approach to patients with fecal incontinence.

Dynamic magnetic resonance imaging of the pelvic floor in patients with idiopathic combined fecal and urinary incontinence.

The etiologies of combined fecal and urinary incontinence may be interrelated but remain poorly understood. A potential variable in this process is global pelvic floor dysfunction. The aim of this study was to prospectively assess the use of phased-array, body coil dynamic MRI in identifying pelvic floor abnormalities in patients with combined incontinence symptoms. Symptomatic patients were compared to asymptomatic control subjects and were selected from those referred to the pelvic physiology laboratory with complaints of combined urinary and fecal incontinence. All patients underwent standard urodynamic studies and anorectal physiologic assessment. Colonoscopy and endoanal ultrasonography were also performed. A standardized protocol was used for dynamic MRI, and the parameters were measured using workstation software (callipers, compass, and densitometer). In the incontinent group there was a significant difference, when compared to control subjects, in the angle of the levator ani muscle arch of the levator plate complex (3.0+/-5 degrees vs. 14+/-10 degrees; P=0.004), the width of the levator hiatus (58.3+/-8 mm vs. 46.5+/-8 mm; P=0.001), the area and tissue density of the levator ani muscle (19.5+/-1 mm(2) vs. 26.9+/-1 mm(2); P=0.001, and 157.3+/-47 pixels vs. 126.1+/-23 pixels; P=0.025, respectively), and in the length of the external anal sphincter (20.0+/-5 mm vs. 26.6+/-13 mm; P=0.03). Body coil dynamic MRI is a noninvasive and well-tolerated imaging modality. Our data show that it can identify changes in pelvic muscle morphology in patients with disorders of incontinence, and this may help in planning better management strategies.