Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines

BACKGROUND: The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues. METHODS: The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group. RESULTS AND CONCLUSIONS: The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.(AU)

Outcomes and survival after laparoscopic gastrectomy for adenocarcinoma. Analysis on 65 patients operated on by conventional or robot-assisted minimal access procedures.

AIMS: Despite laparoscopic surgery for gastric cancer has gained worldwide acceptance, long term results and survival are seldom reported. This study was designed to assess long term outcomes after laparoscopic gastrectomy with D2 dissection. The short term results of conventional and robot-assisted minimally invasive procedures were also examined. PATIENTS AND METHODS: The charts of 65 patients who underwent laparoscopic surgery for non-metastatic adenocarcinoma were reviewed retrospectively. This series included 35 patients with early gastric cancer (EGC) and 30 with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for distal cancers. Laparoscopic total gastrectomy (LTG) with modified D1 lymphadenectomy was performed for mid-proximal EGC. RESULTS: Sixty gastrectomies were carried out laparoscopically, 56 LSG and 4 LTG. Conversion to laparotomy was required in 5 patients with distal cancer. No intraoperative complication was registered. Morbidity included 2 duodenal leaks that healed conservatively. Two postoperative deaths were registered. An average number 31.3+/-8.8 lymph nodes were collected. The mean hospital stay was 10 days (range 7-24). The mean follow up was 30 months (range 2-86) and the cumulative overall 5 year survival rate was 78%. Survival at 5 years for EGC was 94% and survival at 4 years for AGC was 53% (57% for non-converted patients). CONCLUSIONS: Laparoscopic gastrectomy for cancer represents a valid alternative to open surgery with minimal morbidity and acceptable long term survival. Considering the risk of preoperative under diagnoses a D2 lymphadenectomy is suggested also for EGC. This study validated the effectiveness of minimally invasive technique in the management of gastric cancer.

Laparoscopic resection for rectal adenocarcinoma.

AIMS: Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival. PATIENTS AND METHODS: Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up. RESULTS: Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%. CONCLUSION: Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.

Laparoscopic management of incisional hernias > or = 15 cm in diameter.

BACKGROUND: Despite good results in terms of safety and minimal recurrence ensured by laparoscopy in the management of incisional hernias, the use of minimally invasive techniques for large incisional wall defects is still controversial. METHODS: Between 2002 and 2008 as many as 36 patients with abdominal wall defects > or = 15 cm were managed laparoscopically in our institution. The wall defects were > or = 20 cm in eight cases. The diameter of parietal defects was measured from within the peritoneal cavity. None had loss of domain. Body mass index (BMI) for 18 patients was > or = 30 kg/m(2). RESULTS: The mean duration of operations was 195 +/- 28 min (range 75-540). One patient needed conversion for ileal injury and massive adhesions. Post-operative complications occurred in nine patients; there were six surgical complications. Morbidity in obese and non-obese patients was not statistically different (p > 0.05). There was no postoperative death. Mean hospital stay was 4.97 +/- 3.4 days (range 2-18). Mean follow up was 28 months (range 2-68) and only one hernia recurrence was observed. CONCLUSIONS: Minimum-access procedures can provide good results in the repair of giant incisional hernia. Obesity is not a contraindication to laparoscopic repair. Further studies are expected to confirm our promising results.

Robot-assisted laparoscopic gastrectomy with D2 dissection for adenocarcinoma: initial experience with 17 patients.

Robot-assisted gastrectomy has been practised so far in very few centres in the world. The aims of this study were to assess the feasibility of robot-assisted gastrectomy for adenocarcinoma with D2 lymph nodal dissection and to analyze our preliminary results. Between January 2006 and August 2008, as many as 17 patients (11 females, 6 males) underwent laparoscopic robot-assisted surgery for non-metastatic adenocarcinoma of the stomach by a 3-armed da Vinci(®) Robotic Surgical System. The mean age of patients was 65.9 years. This series included eight patients with early gastric cancer (EGC) and nine with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for 16 distal cancers. Laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy was performed for one AGC of the middle third of the stomach. No intraoperative complication was registered. Conversion to laparotomy was required in two patients with distal cancer. The mean operating time (excluding converted patients) was 352 min (348 for LSG). Morbidity consisted in one pancreatic leak that healed conservatively. One death occurred postoperatively for haemorragic stroke. On average, 25.5 ± 4 lymph nodes were collected (range 10-40). The resection margin was 6.4 ± 0.6 cm (range 4.2-8), and the margin was tumour free in all the specimens. The mean hospital stay of totally laparoscopic subtotal gastrectomy was 10 ± 1.2 days (range 8-13). The mean follow-up was 14 months (range 1-29) and three patients with AGC showed recurrence after LSG and died of disease. Robotics in gastrectomy for cancer is a feasible and safe procedure, yielding adequate D2 nodal clearance with respect of oncologic principles. Robotic techniques can represent a remarkable tool to improve laparoscopic surgeon's ability and precision in small surgical fields, i.e. during D2 dissection. This study demonstrated the feasibility of robot-assisted gastrectomy for cancer although further studies are required to validate our preliminary results, especially as far as patients' benefits are concerned.

Total and subtotal laparoscopic gastrectomy for adenocarcinoma.

BACKGROUND: Laparoscopic gastrectomies are currently performed in many centers, but compliance with oncologic requirements still represents a subject open to debate. The aim of this work was to compare the short-term and oncologic outcomes after laparoscopic and open surgery in gastric adenocarcinoma. METHODS: From June 2000 through June 2005, 147 patients in our institution underwent gastrectomy by open or mininvasive approach for adenocarcinoma. The laparoscopy group included 48 patients, 29 with early gastric cancer (EGC) and 19 with antral advanced gastric cancer (AGC). The short-term results and oncologic data were compared to those obtained in 99 patients who underwent open surgery. Survival in the laparoscopy group was analyzed. RESULTS: In the laparoscopy group no intraoperative complications were observed, and conversion was needed in only one patient with a large advanced tumor. Overall, 32 lymph nodes were collected by D2 dissection, 30 for EGC, 34 for advanced cancers. The resection margin was 6.7 cm (range: 4-8 cm). The mean operating time was 240 min (range: 150-360 min), with a blood loss of 150 ml on average (range: 70-250 ml). Morbidity included two duodenal leaks that healed without reoperation; after enclosing or reinforcing the staple line, no further leaking was noted. There was one death from massive bleeding in a cirrhotic patient. Ambulation and oral feeding started significantly earlier than in open surgery. The mean hospital stay was 10 days (range: 7-24 days), significantly shorter than the stay of 18 days after open surgery (p < 0.05). All patients treated laparoscopically were alive without recurrence at the end of this study. CONCLUSIONS: Short-term results with laparoscopic gastrectomy were better than with open surgery in this study. Oncologic radicality was a major concern, but in the authors' experience the extent of lymphadenectomy was the same as in open surgery. This study suggests that laparoscopic gastrectomy in malignancies is a reliable tool and oncologic requirements can be warranted.

Outcomes of laparoscopic Miles' operation in very low rectal adenocarcinoma. Analysis of 32 cases.

AIMS: Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers. METHODS: The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival. RESULTS: A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50. CONCLUSIONS: The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.

Laparoscopic splenectomy: A retrospective review of 75 cases.

Laparoscopic splenectomy (LS) is considered a safe procedure for spleens of normal size as well as for larger spleens. Seventy-five consecutive patients underwent LS. Splenomegaly was defined by diameter >15 cm and by weight >400 g. Thirty patients had splenomegaly. The outcomes with spleens <15 cm and spleens >15 cm were compared. LS was successfully completed in 73 cases (97.4%). Spleens >15 cm required longer operating time and were associated with greater blood loss (P < 0.001), longer hospital stay, and more complications. Two patients needed blood transfusion. No overwhelming postsplenectomy infection was registered, and operative mortality was zero.

[Criteria for training in laparoscopic gastric surgery: guidelines and experience of 30 cases]. / Criteri di apprendimento nella chirurgia laparoscopia delle lesioni gastriche. Proposta di linee guida es esperienzxa di 30 casi.

AIM: Although many studies on laparoscopic surgery of the stomach have been conducted so far, yet they have not provided surgeons with criteria for gradual and safe training with this technique. The results of gastric surgery with 30 patients operated on by laparoscopic approach are hereby described. The aim of this issue is to provide surgeons with guide lines for progressive training, respectful to patients, complying with oncologic criteria and useful to reduce conversion rate or drawbacks at the start of the experience. METHODS: The Authors made a retrospective analysis on 30 patients affected by gastric lesions, 5 benign chronic ulcers and 25 neoplasms of the stomach. Our guide lines suggest that the training begin with the treatment of benign lesions, followed by early gastric cancer (EGC) and by advanced gastric cancer (AGC) of the antrum. Our experience started with 4 laparoscopic subtotal distal gastrectomies (LSGs) for benign ulcer; independent of the guidelines hereby proposed 1 laparoscopic total gastrectomy (LTG) was done after the intraoperative finding of a benign ulcer of the lesser curve penetrating into the left hepatic lobe. The beginning of training included also 1 LSG for distal stromal tumor (GIST). Subsequently 13 early gastric cancers (EGC) were operated on: echoendoscopy could demonstrate 12 T1 m and 1 T1 sm and no evidence of nodal involvement. The diameter of EGCs was 1,3 cm on average ( range 0,7-4 cm), all were marked by Indian ink to allow performance of 10 LSGs and 3 LTGs. Moreover, 8 LSGs for advanced gastric carcinoma (AGC) of the antrum were carried out. The training in malignancies progressed with LTG for 2 non-Hodgkin gastric lymphomas; 1 lymphoma required conversion to laparotomy due to infiltration of the diaphragmatic crus. A D2 lymphadenectomy was associated to gastrectomy in adenocarcinomas. RESULTS: The feasibility of laparoscopic gastric surgery was confirmed by this study, with operating time of 240 minutes (range 150-360), intraoperative blood loss was 180 ml (range 100-250), and only 1 patient required blood transfusion for postoperative bleeding. The specific morbidity rate was 10% owing to duodenal leakage in 3 cases in the early phase of this study (3/30): 1 required laparotomy. The mortality rate was 3% due to 1 serious postoperative bleeding and acute hepatic failure in a patient with post-alcoholic cirrhosis. The conversion rate was 3% (1/30). The nasogastric tube was removed on the 4(th) postoperative day, and the oral intake started on the 6(th) postoperative day after a barium follow-through examination. The mean postoperative hospital stay was 16 days (range 10-25). The number of nodes retrieved was 18 on average and it improved with the experience: from the minimum of 9 nodes in benign ulcers, it grew to 20 in EGCs and to 25 in AGCs, so that this data confirmed the guide lines proposed in this issue . The histologic examination of EGC confirmed the data of echoendoscopy about nodal status. CONCLUSIONS: Laparoscopic surgery is a safe and feasible procedure both for benign and for malignant lesions of the stomach. The results analysed hereby suggest that at the start of training be treated patients affected by benign lesions, followed by patients with EGC and then by patients with AGC. For gastric cancers, the average number of 18 nodes harvested from each patient was adequate, complying with the requirements suggested by the latest TNM classification. This choice of progressive selection of patients for training represents a good means to get an optimal performance level, especially in view of the oncologic requirements, and can prevent surgeons from elevated conversion rates and disappointing outcomes at the beginning of experience.

[Penetrating injuries of the neck: review of 16 operated cases]. / Lesioni penetranti del collo: revisione di 16 casi operati.

BACKGROUND: Cervical lesions from penetrating trauma in the neck are increasing together with other types of trauma especially in big towns. Nevertheless in Italy a Register of Trauma is still lacking and no guidelines are available. Conservative management is also advocated and is still under discussion. Comparison of diagnostic tools and evaluation of different treatments in case of vascular damage is also expected. PATIENTS AND METHODS: A series of 16 penetrating lesions of the neck including various degrees of severity were treated over a span of 5 year. The penetrating trauma was due to stab wound or similar causes in 11 cases; to gunshot wound in 3 and to traffic accidents in 2 cases. All of them received surgical treatment. In 56% of cases (9/16) of cases vascular structures were involved, in 4 cases the aerodigestive tract was involved (25%), and in 1 the spinal cord was injured (6%) resulting in a Brown-Sequard syndrome. Other patients presented with superficial lesions, and reconstruction of muscles by simple suture or ligature of veins could obtain complete healing. RESULTS: The penetrating trauma brought about death in 2 cases (1 stab wound, 1 gunshot wound), while 1 lesion of carotid artery and 4 lesions of jugular vein were successfully repaired. In 1 case of lesion in zone 3 a serious bleeding from damage to lingual artery was cured in spite of the minimal width of the external injury. Hypopharyngeal lesions could be treated in 2 cases. One was associated with lethal vascular damage. In 1 case of tracheal lesion with cervical hematoma and dyspnea, patency of the airways became the main concern and and a cannula was placed in the trachea. The Brown-Séquard syndrome could improve with rehabilitation therapy in 3 years. All of the minimal cervical lesions healed with uneventful course. CONCLUSIONS: The penetrating trauma in the neck may show various degrees of severity: nevertheless, no cervical penetrating trauma should be underestimated in spite of the minimal width of the lesion. Surgical exploration was invariably the preferred treatment in our experience.