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Preoperative progressive pneumoperitoneum has represented an important advancement in achieving the reintroduction of large herniated volumes into the abdominal cavity. However, this technique is not free of complications. We present a case of a man in his 70s with an accidental peritoneal-cutaneous fistula, secondary to the excessive pressure of the pneumoperitoneum, during the preparation of a large incisional hernia with loss of domain intervention.

The goal of this article was to report the results about the efficacy of treatment of chronic mesh infection (CMI) after abdominal wall hernia repair (AWHR) in one-stage management, with complete mesh explantation of infected prosthesis and simultaneous reinforcement with a biosynthetic poly-4-hydroxybutyrate absorbable (P4HB) mesh. This is a retrospective analysis of all patients that needed mesh removal for CMI between September 2016 and January 2019 at a tertiary center. Epidemiological data, hernia characteristics, surgical, and postoperative variables (Clavien–Dindo classification) of these patients were analyzed. Of the 32 patients who required mesh explantation, 30 received one-stage management of CMI. In 60% of the patients, abdominal wall reconstruction was necessary after the infected mesh removal: 8 cases (26.6%) were treated with Rives–Stoppa repair, 4 (13.3%) with a fascial plication, 1 (3.3%) with anterior component separation, and 1 (3.3%) with transversus abdominis release to repair hernia defects. Three Lichtenstein (10%) and 1 Nyhus repairs (3.3%) were performed in patients with groin hernias. The most frequent postoperative complications were surgical site occurrences: seroma in 5 (20%) patients, hematoma in 2 (6.6%) patients, and wound infection in 1 (3.3%) patient. During the mean follow-up of 34.5 months (range 23–46 months), the overall recurrence rate was 3.3%. Persistent, recurrent, or new CMIs were not observed. In our experience, single-stage management of CMI with complete removal of infected prosthesis and replacement with a P4HB mesh is feasible with acceptable results in terms of mesh reinfection and hernia recurrence.

Resumen Introduccion Las hernias incisionales secundarias al trasplante renal (HITR) se consideran hernias complejas debido a su localizacion lateral a la vaina del musculo recto abdominal. Tambien influyen la presencia del injerto en la fosa iliaca y la proximidad del area inguinal, el margen costal y los huesos iliacos como rebordes de dificil fijacion de la protesis. Ademas, estos pacientes presentan connotaciones especificas, como el tratamiento con inmunosupresores, que podrian alterar la evolucion postoperatoria. El objetivo del estudio fue analizar los resultados obtenidos en la reparacion de las HITR en un hospital terciario, comparando estos datos con la literatura internacional. Metodos Estudio observacional retrospectivo, desde el 1 de enero de 2011 al 31 de enero de 2018, de los pacientes operados de HITR en nuestra unidad. Analisis de factores preoperatorios, intraoperatorios y de complicaciones postoperatorias observados durante el seguimiento. Resultados Se operaron 25 pacientes, encontrando un indice de recidiva herniaria del 4% tras un seguimiento mediano de 27,5 meses (20-39). La tecnica mas utilizada fue la separacion posterior de componentes con liberacion del transverso en un 42%, seguida de la reparacion preperitoneal en un 27% y la reparacion interoblicuos en un 12%. La morbilidad postoperatoria global fue del 23%, siendo las mas frecuentes las relacionadas con el sitio quirurgico (12%). Conclusiones La reparacion de las HITR es un procedimiento seguro en nuestro centro, con un indice de recidiva herniaria aceptable, aunque no exento de complicaciones.

To clarify the factors related to recurrence after component separation technique (CST). A retrospective study was conducted of 381 patients who underwent CST between May 2006 and May 2017 at a tertiary center. All patients had a transverse hernia defect grade W3 in EHS classification. Recurrence rate was determined by clinical examination plus confirmation by abdominal CT scan. At a median of 61.6 months of postoperative follow-up, we reported 34 cases of hernia recurrence (8.9%). On multivariate analysis, BMI > 30 (OR 2.20; CI 1.10–3.91, p = 0.031), immunosuppressive drug use (OR 1.06 CI 1.48–2.75, p = 0.003) and development of surgical site infection (OR 2.7; CI 1.53–4.01, p = 0.002) were factors of recurrence after CST. There was no difference in recurrence rate among repairs of primary and recurrent hernias, urgent repair, operative time, type of prosthesis, or concomitant procedures, even planned or unplanned enterotomies. Obesity (BMI > 30), immunosuppressive drug use, and postoperative wound infections were predictors of recurrence after CST.

OBJECTIVE A randomized controlled trial (RCT) was undertaken to evaluate whether the prophylactic application of a specific single-use negative pressure (sNPWT) dressing on closed surgical incisions after incisional hernia (IH) repair decreases the risk of surgical site occurrences (SSOs) and the length of stay. BACKGROUND The sNPWT dressings have been associated to several advantages like cost savings and prevention of SSOs like seroma, hematoma, dehiscence, or wound infection (SSI) in closed surgical incisions. But this beneficious effect has not been previously studied in cases of close wounds after abdominal wall hernia repairs. METHODS An RCT was undertaken between May 2017 and January 2020 (ClinicalTrials.gov registration number NCT03576222). Participating patients, with IH type W2 or W3 according to European Hernia Society classification, were randomly assigned to receive intraoperatively either the sNPWT (PICO)(72 patients) or a conventional dressing at the end of the hernia repair (74 patients). The primary endpoint was the development of SSOs during the first 30 days after hernia repair. The secondary endpoint included length of hospital stay. Statistical analysis was performed using IBM SPSS Statistics Version 23.0. RESULTS At 30 days postoperatively, there was significatively higher incidence of SSOs in the control group compared to the treatment group (29.8% vs 16.6%, P < 0.042). There was no SSI in the treatment group and 6 cases in the control group (0% vs 8%, P < 0.002). No significant differences regarding seroma, hematoma, wound dehiscence, and length of stay were observed between the groups. CONCLUSION The use of prophylactic sNPWT PICO dressing for closed surgical incisions following IH repair reduces significatively the overall incidence of SSOs and the SSI at 30 days postoperatively.

Background An increasing number of patients have large or complex abdominal wall defects. Component separation technique (CST) is a very effective method for reconstructing complex midline abdominal wall defects in a manner that restores innervated muscle function without excessive tension. Our goal is to show our results by a modified CST for treating large ventral hernias. Materials and methods A total of 351 patients with complex ventral hernias have been treated over a 10-year period. Pre-and postoperative CT scans were performed in all patients. All ventral hernias were W3, according to the EHS classification 1. We analyzed demographic variables, co-morbidities, hernia characteristics, operative, and post-operative variables. Results One hundred and seventy patients (48.4%) were men; the average age of the study population was 51.6 +/- 23.2 years with an average BMI of 32.3 +/- 1.3. The hernia was located in the midline in 321 cases (91.5%) versus the flank in 30 (8.5%). In 45 patients, preoperative botulinum toxin (BT) and progressive pneumoperitoneum (PPP) were needed due to giant hernia defects when the VIH/VAC ratio was > 20%. Postoperative complications related to the surgical site were seroma (35.1%), hematoma (9.1%), infection (7.2%), and wound necrosis (8.8%). Complications related to the repair were evisceration in 3 patients (1.1%), small bowel fistula in 4 patients (1.5%), 11 cases of mesh infection (2.9%), and abdominal compartment syndrome (ACS) in 2 patients. There were 29 hernia recurrences (8.2%) with a mean follow-up of 31.6 +/- 8.1 months. Conclusion The modified CST is an effective strategy for managing complex ventral hernias that enables primary fascial closure with low rates of morbidity and hernia recurrence.

Resumen El neumoperitoneo progresivo preoperatorio y la toxina botulinica tipo A son herramientas utiles en la preparacion de los pacientes con hernias gigantes que han perdido el domicilio. Ambos procedimientos son armas complementarias del procedimiento quirurgico, especialmente con el uso de tecnicas protesicas sin tension, que permiten el manejo integral de estos pacientes. Este articulo tiene por objeto actualizar conceptos relacionados con ambos procedimientos, incidiendo en las ventajas que aportan en el manejo preoperatorio de las hernias gigantes que han perdido el domicilio.

Objectives: Preoperative botulinum toxin type A (BT) and progressive pneumoperitoneum (PPP) are useful tools in the preparation of patients with loss of domain hernias (LODH). The purpose of our retrospective study is to report our experience in the treatment of 100 consecutive patients with LODH, with the combined use of these techniques. Methods: Of the 753 patients operated on for ventral incisional hernia between June 2010 and December 2018 in our hospital, 100 patients with LODH were analyzed retrospectively. Diameters of abdominal cavity and hernia sac, and volumes of incisional hernia (VIH) and abdominal cavity (VAC) were calculated from CT scan, based on the index of Tanaka. Results: The median insufflated volume of air for PPP was 8,600 +/- 4,200 cc (4,500-15,250). BT administration time was 38.2 days (33-48). A significant average reduction of 15% of the VIH/VAC ratio was observed on CT scan after the combination of PPP and BT (p = 0.001). Anterior component separation (CST) and transversus abdominis release (TAR) were the most frequent repair techniques. Complete fascial closure was possible in 97%, and mesh bridging was needed in three cases. In postoperative follow-up of 34.5 months (11-62), we reported eight cases of hernia recurrence (8%). Conclusion: PPP and BT are useful tools in the treatment of LODH. These techniques significantly reduce the VIH/VAC ratio, allowing the reduction of the hernia content into the abdominal cavity, which represents a key factor in the management of these hernias.

Introduction Incisional hernias secondary to renal transplantation (IHRT) are considered complex hernias because they are lateral to the sheath of the rectus abdominis muscle. The presence of the graft in the iliac fossa and the proximity to the inguinal area, costal margin and iliac bones, as zones with difficult fixation for prostheses, increases repair complexity. In addition, these patients have specific characteristics, such as treatment with immunosuppressive medication, that could alter postoperative evolution. The objective of this study was to analyze the results obtained in IHRT repair at a tertiary hospital, and to compare these data with the international literature. Methods Retrospective observational study of patients treated surgically for IHRT in our unit from January 1, 2011 to January 31, 2018. Preoperative conditions, intraoperative factors and postoperative complications during follow-up were analyzed. Results Twenty-five patients underwent hernia repair, finding a 4% hernia recurrence rate during a median follow-up of 27.5 months (20–39). The most frequently used technique was the posterior transversus abdominis release component separation technique in 42%, followed by preperitoneal repair in 27% and interoblique repair in 12%. The overall postoperative morbidity was 23%, which was frequently related to the surgical site (12%). Conclusions IHRT repair is a safe procedure at our medical center, with an acceptable rate of hernia recurrence, but it is not without complications.

Background The main objective was to identify predictive factors associated with prosthesis infection and mesh explantation after abdominal wall hernia repair (AWHR). Methods This is a retrospective review of all patients who underwent AWHR from January 2004 to May 2014 at a tertiary center. Multivariate analysis identified predictors of mesh infection and explantation after AWHR. Results From 3,470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. Steroid or immunosuppressive drugs use (odds ratio [OR] 2.22; confidence interval [CI] 1.16 to 3.95), urgent repair (OR 5.06; CI 2.21 to 8.60), and postoperative surgical site infection (OR 2.9; CI 1.55 to 4.10) were predictive of mesh infection. Predictors of mesh explantation were type of mesh (OR 3.13; CI 1.71 to 5.21), onlay position (OR 3.51; CI 1.23 to 6.12), and associated enterotomy in the same procedure (OR 5.17; CI 2.05 to 7.12). Conclusions Immunosuppressive drugs use, urgent repair, and postoperative surgical site infection are predictive of mesh infection. Risk factors of prosthesis explantation are polytetrafluoroethylene mesh, onlay mesh position, and associated enterotomy in the same procedure.

ResumenLa hernia de Amyand se define como la presencia del apéndice cecal en el interior del saco de una hernia inguinal. Se trata de una patología infrecuente de difícil diagnóstico preoperatorio, y resulta en la mayoría de las ocasiones un hallazgo intraoperatorio.Presentamos tres casos evaluados y tratados en nuestro centro. Dos de ellos fueron intervenidos de forma programada, mientras que el tercero necesitó cirugía urgente.Dada la rareza del cuadro y la escasa bibliografía médica existente, resulta complicado unificar criterios sobre el manejo óptimo de esta patología. A pesar de esto, consideramos que la mejor opción es la reducción del apéndice al interior de la cavidad abdominal sin exéresis de este en los casos en los que no exista cuadro de apendicitis concomitante, junto con una reparación del defecto herniario según las técnicas habituales.AbstractAmyand's hernia is defined as the presence of the appendix in an inguinal hernial sac.It is a rare pathology that represents a diagnostic challenge. In the majority of cases diagnosisis not reached until surgical exploration of the inguinal canal is performed.We present three cases treated in our center, two of them underwent programmed surgery and a third case was intervened as an urgent procedure.Due to the exceptional presentation of this kind of hernia and the scarce bibliographic reference it is difficult to decide what is the ideal management of this pathology. We consider that the best treatment approach is to reduce the appendix into the abdominal cavity, if there are no signs of inflammatory process, and perform a standard hernial repair.

Resumen Introduccion La coledocolitiasis es la causa mas comun de ictericia obstructiva y ocurre en un 5-10% de los pacientes que presentan colelitiasis. Objetivos Elaboracion un modelo predictivo preoperatorio de coledocolitiasis. Material y metodos Estudio prospectivo de 556 pacientes ingresados en nuestros servicios por patologia biliar. Analisis comparativo de variables preoperatorias clinicas, analiticas y ecograficas de los pacientes sin coledocolitiasis frente a las de los 65 pacientes con dicho hallazgo. Analisis multivariante de regresion logistica para obtener un modelo predictivo de coledocolitiasis, determinando sensibilidad, especificidad, valores predictivos positivo (VPP) y negativo (VPN). Resultados Los factores predictivos de coledocolitiasis fueron la existencia de historia biliar previa (antecedentes de colicos biliares, colecistitis, coledocolitiasis o pancreatitis aguda biliar) (p = 0,021; OR = 2.225; IC 95%: 1.130-4.381), las cifras de BT al ingreso superior a 4 mg/dl (p = 0,046; OR = 2.403; IC 95%: 1.106-5.685), el valor de la FA al ingreso superior a 150 mg/dl (p = 0.022; OR = 2.631; IC 95%: 1.386-6.231), cifras de la GGT superiores a 100 (p = 0,035; OR = 2,10; IC 95%: 1.345-5.850), y el hallazgo ecografico de dilatacion de la via biliar (p = 0,034; OR = 3.063; IC 95%: 1.086-8.649). Un score superior a 5 conlleva una especificidad y VPP de 100% para detectar coledocolitiasis, y un score inferior a 3, una sensibilidad y un VPN del 100% para descartarla. Conclusiones El score obtenido descarta o confirma preoperatoriamente la existencia de coledocolitiasis, y permite al paciente beneficiarse directamente de la colecistectomia laparoscopica (CL) o de la realizacion previa de colangiopancreatografia retrograda endoscopica (CPRE).

Preoperative progressive pneumoperitoneum and botulinum toxin type A are useful tools in the preparation of patients with loss of domain hernias. Both procedures are complementary in the surgical repair, especially with the use of prosthetic techniques without tension, that allow a integral management of these patients. The aim of this paper is to update concepts related to both procedures, emphasizing the advantages that take place in the preoperative management of loss of domain hernias.

Background: To compare the results with complete mesh removal (CMR) versus partial mesh removal (PMR) in the treatment of mesh infection after abdominal wall hernia repair (AWHR). Methods: Retrospective review of all patients who underwent surgery for mesh infection between January 2004 and May 2014 at a tertiary center. Results: Of 3470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. CMR was achieved on 38 occasions, while PMR was undertaken ten times. We observed more postoperative complications in CMR than PMR group (p = 0.04). Three patients with intestinal fistula were reoperated in postoperative period after a difficult mesh removal; one of them died due to multiple organ failure. The overall recurrence rate after explantation was 47.9%: recurrence was more frequent in CMR group (p = 0.001), although persistent or new mesh infection was observed more frequently with PMR (p = 0.001). Conclusions: Although PMR has less postoperative morbidity, shorter duration of hospitalization and lower rate of recurrence than CMR, prosthetic infection persists in up to 50% of cases. (C) 2016 Elsevier Inc. All rights reserved.

For the last two decades, general and digestive surgeons have attempted to improve the postoperative course of surgical patients. Classical perioperative treatment can be described as a period of preoperative dehydration caused by fasting and intensive colon preparation followed by fluid overload generally due to excessively prolonged serum therapy. There is also perioperative surgical stress, the trauma of surgery itself, and a long period of drainage and nasogastric tubes. The patient is thus literally confined to bed and mobilization is, at the very least, difficult. Moreover, the use of opiates delays intestinal peristalsis and consequently oral nutrition. All together, these factors prolong the length of hospital stay and hamper recovery. All these perioperative treatment modalities have been questioned by Kehlet, resulting in a set of new, more realistic and evidence-based modalities, currently known as the fast-track program. The aim of this program is to decrease perioperative stress, reduce organ involvement produced by surgical trauma and hasten the patient's general recovery. Major advantages of this program consist not only of shorter length of hospital stay but also of a concurrent improvement in patients' quality of life and a reduction in mortality. The present review article analyzes all these modalities, with special emphasis on laparoscopic colorectal surgery. This approach is presented as one of the elements of the fast-track program.

Background: Hibernoma or lipoma of brown fat is a rare benign tumor, representing 1.6% of the neoplasms of this tissue. Because of its histological characteristics can be wrongly classified as liposarcoma, therefore a correct differential diagnosis is necessary to provide appropriate treatment.Case presentation: The patient on which this case study is based is a 44-year-old male with a painless soft mass in his axilla located by his 4th and 5th ribs. The resected specimen did not have the classic macroscopic features of lipoma or fibrolipoma. Microscopically, the report described a proliferation of unilocular adipocytes with eccentric nucleus and, in less frequency, multilocular adipocytes with central nucleus. He had no recurrence after excision.Conclusions: Despite radiology studies and other technologies such as magnetic resonance imaging, computerized axial tomography (CAT), etc., the clinical diagnosis of hibernoma could be difficult. Lipoma-like hibernoma only have a few multilocular cells and can be wrongly classified as liposarcoma. Well-differentiated liposarcoma resembles it on low-power examination. Due to this it is especially important to perform a differential diagnosis with lipoma, fibroma, and even with liposarcoma. In this study we describe the histological features, the molecular markers and cytogenetic aspects that contribute to differentiate hibernoma from others tumors.

Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis.To design a preoperative predictive score for choledocholithiasis.A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p=0.021, OR=2.225, 95% CI: 1.130-4.381), total bilirubin values4mg/dl (p=0.046, OR=2.403, 95% CI: 1.106-5.685), alkaline phosphatase values150mg/dl (p=0.022 income, OR=2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values100mg/dl (p=0.035, OR=2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct8mm (p=0.034, OR=3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis.The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP).