Proper training in laparoscopic hernia repair is necessary to minimize the rising recurrence rate in Japan.

INTRODUCTION: The Japan Society for Endoscopic Surgery reported that the recurrence rate for inguinal hernia repair in Japan was less than 1% in 2010. However, its 2012 survey found that the recurrence rate had increased to 4% for the transabdominal preperitoneal procedure and 5% for the totally extraperitoneal procedure. We held 14 hernia repair training courses from 2011 to 2016 with help from Covidien. This study aimed to determine the effect of this training on the recurrence rate. METHODS: Training was composed of a theoretical revision of inguinal anatomy, dry laboratory suturing, a video lecture, and practice on an animal model. We made inquiries about the length of each surgeon's career, post-training changes in surgical methods, and recurrence rates before and after training. RESULTS: We received responses from 159 of 300 trainees (53%). The mean career length was 12.7 ± 8.2 years. The annual number of transabdominal preperitoneal procedures performed increased from 20.9 ± 29.9 to 32.4 ± 56.1 after training (P < 0.001), and the number of totally extraperitoneal procedures increased from 9.5 ± 13.9 to 13.9 ± 16.9 (P = 0.0218). The annual number of procedures performed via the anterior approach decreased from 153.1 ± 28.4 to 28.4 ± 52.2 after training (P < 0.001). The pre-training transabdominal preperitoneal procedure recurrence rate was 0.9%, and this decreased to 0.4% after training. There was no pre-training recurrence rate for the totally extraperitoneal procedure, but this was 0.4% after training. CONCLUSION: The high recurrence rate after inguinal hernia repair in Japan was mainly due to inadequate training in the laparoscopic method. Our laparoscopic hernia repair training course achieved low recurrence rates.

A Prospective, Single-Arm, Single-Center, Case Series to Determine the Feasibility of Safe Skill Transfer for Transabdominal Preperitoneal (TAPP) Repair Utilizing a Hands-On Mentorship Model.

OBJECTIVES: It is difficult to introduce laparoscopic surgery in institutions with a small number of patients, and surgical training relies heavily on mentors to produce well-trained surgeons. The aim of this study was to determine whether implementation of a hands-on mentorship model could provide safe skill transfer for transabdominal preperitoneal (TAPP) repair. METHODS: A trainee who had no experience with TAPP repair underwent operative tutorials until the mentor judged that the trainee could carry out the operation independently. Ten patients who underwent an elective TAPP repair were prospectively enrolled in this study. RESULTS: No cases had over 5 mL of bleeding, intraoperative/postoperative complications, or recurrence. There were significant differences in operation times between the first 4 cases and the later 5 cases, except for a bilateral inguinal hernia case. CONCLUSION: A prospective, single-arm, single-center, case series showed the feasibility of safe skill transfer for TAPP repair using a hands-on mentorship model.

New suture: tail clinch knot for transabdominal preperitoneal hernia repair.

INTRODUCTION: There is some controversy regarding the proper surgical method for inguinal hernia repair and whether transabdominal preperitoneal or totally extraperitoneal repair should be used. The greatest difference between these procedures is the need for absorbable sutures to close the peritoneal incision. MATERIALS AND SURGICAL TECHNIQUE: The clinch knot is a kind of slip knot that is used for securing a fishing lure, hook, or swivel to a fishing line. This knot is used by fishermen and has historically proven to be secure. DISCUSSION: When a clinch knot is placed at the tail end of a suture thread, a running suture can be started without knot tying.

Risk factors for loss to follow-up during active surveillance of patients with Stage I seminoma.

OBJECTIVE: To elucidate the patterns and risk factors for loss to follow-up during active surveillance for Stage I seminoma. METHODS: A total of 425 cases with Stage I seminoma underwent radical orchiectomy from 1985 to 2006 at 25 Japanese institutions, including 22 community hospitals and 3 university hospitals. The post-orchiectomy management selected was active surveillance for 186 patients, adjuvant radiotherapy for 182 patients and chemotherapy for 57 patients. The Kaplan-Meier method was used to estimate the recurrence-free survival and loss to follow-up rate. The risk factors for loss to follow-up were examined using Cox's proportional hazards model with multiple variables. RESULTS: The 2-, 5- and 10-year loss to follow-up rates in the active surveillance group were 14.2, 37.8 and 71.3%, respectively, which were not significantly different in comparison with those in the active surveillance and adjuvant radiotherapy or chemotherapy groups. With regard to the active surveillance group, the multivariate analysis demonstrated that patients younger than 36 years at diagnosis, patients diagnosed since 2000 and patients treated at hospitals that enrolled more than 10 cases had a significant risk for loss to follow-up. No significant correlation between the loss to follow-up rate and pathological risk factors such as tumor size (≤4 versus >4 cm) and rete testis invasion (presence versus absence) was shown. CONCLUSIONS: The loss to follow-up rates beyond 5 years were unsatisfactorily high during active surveillance. Further approaches to improve the quality of active surveillance are needed, especially for high-risk patients such as those of younger age.

Greatly impaired migration of implanted aquaporin-4-deficient astroglial cells in mouse brain toward a site of injury.

We reported previously that astroglia cultured from aquaporin-4-deficient (AQP4-/-) mice migrate more slowly in vitro than those from wild-type (AQP4+/+) mice (J. Cell Sci. 2005;118, 5691-5698). Here, we investigate the migration of fluorescently labeled AQP4+/+ and AQP4-/- astroglia after implantation into mouse brains in which directional movement was stimulated by a planar stab wound 3 mm away from the axis of the injection needle. Two days after cell injection we determined the location, elongation ratio, and orientation of labeled cells. Migration of AQP4+/+ but not AQP4-/- cells toward the stab was greater than away from the stab. AQP4+/+ astroglia moved on average 1.5 mm toward the stab compared with 0.6 mm for AQP4-/- cells. More than 25% of the migrating AQP4+/+ cells but <3% of AQP4-/- cells appeared elongated (axial ratio>2.5). In transwell assays, AQP4+/+ astroglia migrated faster than AQP4-/- cells in a manner dependent on pore size. At 8 h, approximately 50% of AQP4+/+ cells migrated through 8-microm diameter pores, whereas equivalent migration of AQP4-/- cells was found for 12-microm diameter pores. These results provide in vivo evidence for AQP4-dependent astroglial migration and suggest that modulation of AQP4 expression or function might alter glial scarring.