The surgical treatment of Morgagni hernias in adults: a systematic review for the standardization of laparoscopic surgical repair.

A Morgagni hernia is a congenital diaphragmatic hernia that is rarely diagnosed in adults, and the technique for its repair has not yet been standardized. This review will give an overview of the different laparoscopic methods reported by other authors, highlighting the key points indicating a good repair to help standardize the technique. A systematic review of the available articles on PubMed was conducted according to PRISMA 2020 by two authors independently in May 2022. Only articles written in English were included. A total of 180 case reports of laparoscopic Morgagni's hernia repair procedures were found; direct repair was performed in 59 patients, mesh was used in 119 patients, and mesh was not used in 2 patients. The hernia sac was removed in 71 patients, and the defect was closed before mesh placement in 49 patients. Nonabsorbable, dual or biologic mesh was used. The mean operative time was 92.65 min for direct repair and 84.11 min for mesh repair. One recurrence was reported in the direct repair series. The optimal method of repair has not yet been identified. The laparoscopic approach is associated to fewer complications and facilitates a faster recovery than the open approach. Several manoeuvres have been reported to help surgeons, who are not trained in laparoscopic knotting, perform extracorporeal knotting. Mesh should be placed when tension is too high after a direct repair or when primary closure cannot be achieved.

Transanal Hemorrhoidal Dearterialization (THD) Anolift-Prospective Assessment of Safety and Efficacy.

The adjunct of a mucopexy to conventional dearterialization has become a routine part of the transanal hemorrhoidal dearterialization procedure in order to facilitate the management of the prolapsing component and has helped to expand the indications of this technique to more advanced stages of hemorrhoidal disease. A simple technical modification of THD with targeted mucopexy (TM), called Anolift, is described. The aim of the study was to evaluate the safety and effectiveness of this technical variation. The procedure consisted of two parts: one aimed at the dearterialization and the other concentrated on the management of the prolapsing component. Once all the arteries were identified and transfixed an Anolift targeted mucopexy was performed using a continuous barbed suture with a synthetic absorbable monofilament (Polydioxanone) 2/0 Filbloc (Assut Europe) stitch mounted on a 4/8 30 mm needle. Severity of hemorrhoidal symptoms was scored from 0 to 20 using a dedicated questionnaire: the Hemorrhoidal Assessment Severity Score (HASS). From May 2018 to November 2020, 60 patients with hemorrhoidal disease (HD) underwent a THD Anolift procedure. Three patients experienced severe post-operative pain and 10 (23%) suffered with difficulty in evacuation. The median follow-up period was 15.5 months (range 2-32 months). The mean HASS changed from 16.43 pre-operatively to 1.95 post-operatively (p < 0.0001). Pre-operative HASS very strongly correlated with the degree of hemorrhoids (p < 0.001), while there was no correlation between the pre-operative HASS or the degree of hemorrhoids and the post-operative HASS (p = 0.163). There was no significant difference in predicted post-operative HASS according to the pre-operative HD stage. One patient (1.6%) with circumferential IV hemorrhoids had a recurrence and required a further THD. Two patients had excision of skin tags (3%). The Anolift technique is safe and effective for the management of HD even in patients with advanced stages.

Subtotal cholecystectomy for difficult acute cholecystitis: how to finalize safely by laparoscopy-a systematic review.

BACKGROUND: Aim of this study was to clarify the best laparoscopic subtotal cholecystectomy (LSTC) technique for finalizing a difficult cholecystectomy. PATIENTS AND METHODS: A review was performed (1987-2021) searching "difficulty cholecystectomy" AND/OR "subtotal cholecystectomy". The LSTC techniques considered were as follows: type A, leaving posterior wall attached to the liver and the remainder of the gallbladder stump open; type B, like type A but with the stump closed; type C, resection of both the anterior and posterior gallbladder walls and the stump closed; type D, like type C but with the stump open. Morbidity (including mortality) was analysed with Dindo-Clavien classification. RESULTS: Nineteen articles were included. Of the 13,340 patients screened, 678 (8.2%) had cholecystectomy finalized by LSTC: 346 patients (51.0%) had type A LSTC, 134 patients (19.8%) had type B LSTC, 198 patients (29.2%) had type C LSTC, and 198 patients (0%) had type D LSTC. Bile leakage was found in 83 patients (12.2%), and recorded in 58 patients (69.9%) treated by type A. Twenty-three patients (3.4%) developed a subhepatic collection, 19 of whom (82.6%) were treated by type A. Other complications were reported in 72 patients (10.6%). The Dindo-Clavien classification was four for grade I, 27 for grade II, 126 for grade IIIa, 18 for grade IIIb, zero for grade IV and three for grade V. CONCLUSION: In the case of LSTC, closure of the gallbladder stump represents the best method to avoid complications. Careful exploration of the gallbladder stump is mandatory, washing the abdominal cavity and leaving drainage.

Traumatic limb wounds management: Efficacy of silver and hyaluronic acid-containing dressings.

Traumatic limb wound management represents a common and challenging health problem. Conservative treatment can be a good option when surgery fails or surgical reconstruction is planned. Wound healing is a complex process that involves several factors and can be delayed if wound details are not noticed. So, expert healthcare professionals should take care of these delicate patients to obtain satisfactory outcomes in terms of cosmesis and functionality of the residual scar. Thanks to the description of three patients with traumatic limb injuries, this article emphasizes the importance of respecting what we call the three golden rules of wound management: correct cleaning of the wound, its accurate inspection and choose the appropriate dressing according to the wound aspect.

Learning curve for laparoscopic cholecystectomy has not been defined: A systematic review.

BACKGROUND: Laparoscopic cholecystectomy is one of the most performed surgeries worldwide but its learning curve is still unclear. METHODS: A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the learning curve of laparoscopic cholecystectomy were included. The Newcastle-Ottawa scale for cohort studies and the GRADE scale were used for the quality assessment of the selected articles. RESULTS: Nine cohort studies published between 1991 and 2020 were included. All studies showed a great heterogeneity among the considered variables. Seven articles (77.7%) assessed intraoperative variables only, without considering patient's characteristics, operator's experience, and grade of gallbladder inflammation. Only five articles (55%) provided a precise cut-off value to see proficiency in the learning curve, ranging from 13 to 200 laparoscopic cholecystectomies. CONCLUSIONS: The lack of clear guidelines when evaluating the learning curve in surgery, probably contributed to the divergent data and heterogeneous results among the studies. The development of guidelines for the investigation and reporting of a surgical learning curve would be helpful to obtain more objective and reliable data especially for common operation such as laparoscopic cholecystectomy.

Forty years after the first totally implantable venous access device (TIVAD) implant: the pure surgical cut-down technique only avoids immediate complications that can be fatal.

AIM: Even though TIVADs have been implanted for a long time, immediate complications are still occurring. The aim of this work was to review different techniques of placing TIVAD implants to evaluate the aetiology of immediate complications. METHODS: A systematic literature review was performed using the PubMed, Cochrane and Google Scholar databases in accordance with the PRISMA guidelines. The patient numbers, number of implanted devices, specialists involved, implant techniques, implant sites and immediate complication onsets were studied. RESULTS: Of the 1256 manuscripts reviewed, 36 were eligible for inclusion in the study, for a total of 17,388 patients with equivalent TIVAD implantation. A total of 2745 patients (15.8%) were treated with a surgical technique and 14,643 patients (84.2%) were treated with a percutaneous technique. Of the 2745 devices (15.8%) implanted by a surgical technique, 1721 devices (62.7%) were placed in the cephalic vein (CFV). Of the 14,643 implants (84.2%) placed with a percutaneous technique, 5784 devices (39.5%) were placed in the internal jugular vein (IJV), and 5321 devices (36.3%) were placed in the subclavian vein (SCV). The number of immediate complications in patients undergoing surgical techniques was 32 (1.2%) HMMs. In patients treated with a percutaneous technique, the number of total complications were 333 (2.8%): 71 PNX (0.5%), 2 HMT (0.01%), 175 accidental artery punctures AAP (1.2%) and 85 HMM (0.6%). No mortality was reported with either technique. CONCLUSION: The percutaneous approach is currently the most commonly used technique to implant a TIVAD, but despite specialist's best efforts, immediate complications are still occurring. Surgical cut-down, 40 years after the first implant, is still the only technique that can avoid all of the immediate complications that can be fatal.

Quantifying the scientific interest in surgical training and education: numerical evidence of a PubMed analysis.

The scientific interest (SI) for a given field can be ascertained by quantifying the volume of published research. We quantified the SI in surgical education to clarify the extent of worldwide efforts on this crucial factor required to improve health-care systems. A set of Medical Subject Headings (MeSH) was defined for the PubMed search. The number of Pubmed Indexed Papers (nPIP) relevant to the SI was extracted from database conception to December 2016 and their distribution and evolution by country were analyzed at 10-year intervals. Population Adjusted Index (PAI) and Medical School Adjusted Index (MSAI) analyses were performed for countries with the nPIP > 30. We identified 51,713 articles written in 33 different languages related to surgical education; 87.6% of these were written in English. General surgery was the leading surgical specialty. The overall nPIP doubled every 10 years from 1987 (from 6009 to 13,501, to 26,272) but stabilized at 3707, 3800 and 3433 in the past 3 years, respectively. The PAI and MSAI analyses showed that the USA, United Kingdom, New Zealand, Canada, Australia and Ireland are top producers of published research in surgical education, constituting a combined 62.88% of the nPIP. Our quantification of the change in SI in surgical education and training gives a clear picture of evolution, efforts and leadership worldwide over time. This picture mirrors an international academic society that should encourage all those involved in surgical education to improve efforts in educational research.

Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases.

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

Is the sublay self-gripping mesh effective for incisional ventral hernia repair? Our experience and a systematic review of the literature.

Sublay mesh repair seems to be the most effective method for treating incisional hernias (IHs). The aim of this study was to report our experience with retromuscular repair and self-gripping mesh for the treatment of midline IHs. In addition, we provided a systematic review of the literature regarding the use of this novel combination. All patients undergoing elective IH repair from June 2016 to November 2018 were included. The self-gripping mesh was placed in the sublay position. Demographic data, defect sizes, postoperative complications and follow-up durations were collected. A systematic review of the available literature was conducted in January 2020 using main databases. A total of 37 patients (20/17M/F) were included in this study, and the mean age and body mass index (BMI) were 58 years and 27 kg/m2, respectively. Minor complications occurred in six patients. Long-term follow-up demonstrated recurrence in three patients. Regarding the review, five publications were considered relevant. The highest complication rate was 28.6%, and the recurrence rate varied from 0 to 5.1%. This is the first review of the literature regarding sublay IH repair using a self-gripping mesh. The low rates of postoperative complications and recurrence in our experience and those reported by most of the reviewed articles demonstrate that this is a safe and effective method for repairing IHs.

Single segment of spleen autotransplantation, after splenectomy for trauma, can restore splenic functions.

BACKGROUND: Splenectomy is sometimes necessary after abdominal trauma, but splenectomized patients are at risk of sepsis due to impaired immunological functions. To overcome this risk, autotransplantation of the spleen by using a new technique has been proposed, but so far, a demonstration of functionality of the transplanted tissue is lacking. METHODS: We therefore evaluated 5 patients who underwent a splenic autotransplant in comparison with 5 splenectomized patients without splenic autotransplant and 7 normal subjects. RESULTS: We confirmed that the patients not undergoing autotransplantation, when compared to normal subjects, had a higher platelet count, higher percentage of micronucleated reticulocytes (p = 0.002), increased levels of naive B lymphocytes (p = 0.01), a defect of class-switched memory (p = 0.001) and class-unswitched memory B cells (p = 0.002), and increased levels of PD1 on T lymphocytes CD8+ (p = 0.08). In contrast, no significant differences for any of the abovementioned parameters were recorded between patients who underwent spleen autotransplantation and normal subjects. CONCLUSION: These findings suggest that splenic autotransplantation is able to restore an adequate hemocatheretic activity as well as recover the immunological deficit after splenectomy.

A retrospective, Italian multicenter study of complex abdominal wall defect repair with a Permacol biological mesh.

Complex abdominal wall defects (CAWDs) can be difficult to repair and using a conventional synthetic mesh is often unsuitable. A biological mesh might offer a solution for CAWD repair, but the clinical outcomes are unclear. Here, we evaluated the efficacy of a cross-linked, acellular porcine dermal collagen matrix implant (Permacol) for CAWD repair in a cohort of 60 patients. Here, 58.3% patients presented with a grade 3 hernia (according to the Ventral Hernia Working Group grading system) and a contaminated surgical field. Permacol was implanted as a bridge in 46.7%, as an underlay (intraperitoneal position) in 38.3% and as a sublay (retromuscolar position) in 15% of patients. Fascia closure was achieved in 53.3% of patients. The surgical site occurrence rate was 35% and the defect size significantly influenced the probability of post-operative complications. The long-term (2 year) hernia recurrence rate was 36.2%. This study represents the first large multi-centre Italian case series on Permacol implants in patients with a CAWD. Our data suggest that Permacol is a feasible strategy to repair a CAWD, with acceptable early complications and long-term (2 year) recurrence rates.

Biological Mesh Combined With Topical Negative Pressure Therapy in Complex Abdominal Wounds: A Short Series and a Review of the Literature.

INTRODUCTION: Complex abdominal wounds (CAWs) are an increasing clinical problem in abdominal surgery and pose a challenge for the surgeon. OBJECTIVE: This review analyzes the results of treating CAWs with a porcine biological mesh and topical negative pressure (TNP) to address the feasibility, effectiveness, level of risk, and overall results. MATERIALS AND METHODS: A series of 4 consecutive cases treated with the biologic mesh and TNP at the General Surgery Unit of the Cannizzaro Hospital (Catania, Italy) is reported and analyzed. In addition, a review of the literature published in all languages from 2000 to 2015 in the MEDLINE/PubMed database was performed to identify cases of CAWs treated with the association of biologic mesh and TNP. RESULTS: Taking into account the authors' experience and review of literature, a total of 12 patients (4 treated in the authors' department) were treated with the aforementioned combination. The main indications for using this association were a large abdominal wall defect, laparotomy, or wound dehiscence and wound infection. In almost all cases, this combination demonstrated a successful outcome with a clear improvement in wound healing and no adverse effects. CONCLUSIONS: From these cases and the review of the literature, the authors believe TNP can be applied on a biological mesh with effectiveness in improving the treatment of the CAWs without relevant risk to the patient or biological mesh.

Peritoneal lavage: a simple tool to prevent bleeding during and after laparoscopic cholecystectomy.

Bleeding remains one of the most serious complications of laparoscopic cholecystectomy and can increase mortality. Even if several patient-related and intraoperative factors increase the risk of bleeding, complete hemostasis should be achieved at the end of each surgical procedure. Although irrigation is a standard step, its importance is often underestimated. This commentary highlights the efficacy of peritoneal lavage in identifying bleeding sources and the effect of saline temperature.

Intestinal obstruction due to congenital bands in adults who have never had abdominal surgery Two case reports and a review of the literature.

Congenital abdominal bands are a very rare entity and are often silent for a person's entire life. In a very few circumstances, however, they can manifest with clinical symptoms. Diagnosis of these bands is very challenging as the patient has never submitted for abdominal surgery and imaging, laboratory tests and clinical examination can be silent or unspecific. Two patients were admitted to and operated on in our hospital between June 2017 and July 2018. All patients had a bowel obstruction at the time of presentation, presenting no emission of faeces or gas. Conservative therapy was tried in one case, and surgical intervention was required. At surgery, both patients were found to have congenital bands causing the occlusion. The postoperative courses were uneventful. Small bowel obstruction (SBO) by congenital bands remains a challenging disease for surgeons. Diagnosis of SBO has to be suspected even if radiology does not indicate any relevant features. Laparoscopy should be the preferred approach, but if not feasible, then open surgery can resolve the case. KEY WORDS: Adhesions, Congenital bands, Intestinal occlusion, Laparoscopy.