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Aim The eTEP approach for ventral hernia is becoming a promising treatment option for obese patients as a scheduled procedure, in specialized high volumen centers. Is it feasible also in emergency surgey? M&M We present a case of a 73 year old female patient with an incarcerated ventral hernia, presenting itself as a bowel obstruction on the early postoperative period after a prosthetic knee surgery. The patient had a previous midline laparotomy (Cesarian), two onlay ventral hernia repairs, and body mass index of 32. The CT imaging findings revealed a bowel obstruction close to incarcerated ventral hernia. We performed an endoscopic retromuscular sac exploration, reduced the incarcerated hernia, ruled out bowel damage, completed intraperitoneal adhesiolysis and followed through with an eTEP procedure, closing anterior and posterior rectus sheat running sutures. We began closing supraumbilical abdominal wall using inferior trocars and finished closing infraumbilical part using superior trocars. Then we introduced and deployed a polypropylene 26×15 cm mesh. No mesh fixation or drains were used. Results Bowel obstruction was solved after surgery. Oral liquids intake started on the second postoperative day. Despite of knee pain, sedentary lifestyle, depressive disorder and obesity, the patient started walking, assisted by physiotherapist also on second postoperative day. Intravenous naproxen and acetaminophen were used as painkillers. Discharged on postoperative day 10 because of knee wound celulitis. Conclusions eTEP approach seams feasible also in emergency surgeries in specialized centers.

This is a case presentation of a preperitoneal repair of a bilateral Spigelian hernia and a recurrent left inguinal hernia. A 71 year old male patient was admitted in the Emergency department after a 3 hour right quadrant acute pain. On his medical record he had an anterior left inguinal repair (Lichtenstein) 6 months before. The physical examination revealed a bulge on the right lower quadrant. The Spigelian hernia was incarcerated but easily reduced. The CT scan findings include a bilateral Spigelian hernia (bowel content), a small umbilical and a left inguinal omental hernia. The patient did not suffer any other incarceration episodes before the surgery, programmed 10 days later. We present the video of the surgical TEP repair, a preperitoneal access, triple hernia reduction, double 15×20cm polypropilene tailored mesh placement. The patient was discharged on the second postoperative day, and had an uneventful recovery with no recurrence after 3 months followup.

Aim Laparoscopic total extraperitoneal approach (TEP) is a widely recognised treatment for hernia repair. As a reference group in minimally invasive hernia repair, with more than 1200 TEP cases performed in the last 5 years, and with more than 25 years of experience, we want to share our TEP systematisation in 10 steps, as we teach in our international courses. Material and Methods We describe the technique in 10 simple steps, attaching small video-clips to illustrate each one. Results Demostration of the 10 TEP steps: Conclusions Together with proctoring, this systematic way of teaching TEP technique allows a safer and shorter learning curve, by providing a series of simple steps to follow and repeat.

Aim Laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia can be technically challenging. The learning curve is long, unless you have supervision and systematisation of the procedure. After learning curve of TEP is achieved, it is time to broaden horizons, and repair ventral hernias using the extended totally extraperitoneal laparoscopic technique (ETEP). The purpose of this paper is to describe the key points and pitfalls in the ETEP learning curve, coming from the expertise of TEP hernia repair. Material and Methods After overcoming the learning curve of laparoscopic TEP inguinal hernia repair, with more than 110 consecutives procedures performed in an experienced centre, and having reduced operative times and maintaining a minimal complication rate, I start my learning curve of ETEP with supervision and systematisation of the technique. We will move from the key points already known from the TEP learning curve, identifying similarities to the more complex points of ETEP learning curve. Results and conclusions The extrapolable key points from TEP are: The critical points, which need enhanced surveillance, are: It is important to emphasise that this technique requires patience and proctoring.

We present the clinical case of a 58 year old patient with a left subcostal incisional hernia, years after an emergent aortic thrombectomy and aortobifemoral bypass. The physical examination revealed a lateral subcostal bulge near the anterior axillary line. CT findings showed a left lateral 5 cm defect without significant muscular atrophy. An endoscopic ipsilateral transversus abdominal release (TAR) and preperitoneal mesh repair was successfully performed. 1: Port placement. We used one 10 mm port and two 5 mm ports in a left near-midline position. 2: Retrorectal and Bogros space dissection. Locating the arcuate line and opening the posterior rectus sheath we then proceeded with the left transversus abdominal release (in a down to up direction). 3: Hernia dissection. After the hernial sac is identified we opened it to explore the peritoneal cavity and release the possible adhesions if encountered. 4: Full space dissection. Once the defect dissection is finished, we fully completed the TAR in order to achieve a satisfactory space for the mesh placement. 5: Defect closure. We performed a two-plane resorbable continuous barbed suture. 6: Mesh placement. We measured the surgical space in order to insert a tailored mesh and lay it without fixation or drain. Clinical outcome: The patient is discharged on postoperative day 1 and took acetaminophen 3 times daily for 48 hours, due to good pain control. On the first postoperative followup (10 days) the patient had resumed usual activities, driving and was already back to work. He was advised to avoid heavy efforts.

Aim The purpose of the study is to analyze whether a previous medical history of lower abdominal surgery (or pelvic radiotherapy) involves a different postoperative outcome in TEP inguinal repairs. Material & Methods We performed a retrospective analysis of 1252 TEP procedures included from 2015 to 2019 at our institution. We compared the short-term intraoperative difficulties and the postoperative outcome in patients with and without previous lower abdominal surgeries. The postoperative data collected included variables such as comorbidities, hernia classification, intraoperative complications, rate of conversion to open surgery, admission status, postoperative follow-up, chronic pain, and hernia recurrence. We defined a “surgical success” dichotomous variable only for patients in an outpatient setting. It included cases with no complications during surgery, no need for conversión, and no chronic pain, no readmission or recurrence during followup. Results Out of the 1252 TEP procedures, 250 (19%) had previous lower abdominal surgery (or pelvic radiotherapy). At the time of applying the “surgical success” variable we found a statistically significant difference in the conversion to open surgery rate between both groups (0.7% versus 5.6% p value 0.005). No differences were found in complications, readmissions, chronic pain, functional recovery or recurrence rates. Conclusions TEP procedure in patients with previous lower abdominal surgery showed a higher rate of conversion to open surgery compared to previously non operated patientes. The fact of having previous surgery did not imply however a worse postoperative outcome after a TEP procedure.

Colorectal liver metastases (CLM) have significant molecular heterogeneity, which contributes to the risk of recurrence following surgery. Most of the traditional scores intended to predict recurrence is based on clinicopathological variables and it is unclear whether incorporating molecular biomarkers might improve our assessment of the risk of recurrence. Our aim was to determine if molecular biomarkers might be associated with the risk of recurrence after surgery of CLM. A total of 121 patients diagnosed with colorectal cancer (CRC) with resected liver metastases were included. The role of several clinicopathological variables to predict patient’s outcome after resection of liver metastases was analyzed. Eighteen genes related to CRC pathogenesis were also included in the analyses. Univariate and multivariate stepwise Cox regression analyses were performed to identify factors associated with recurrence and the risk of death. Eight prognostic factors for progression-free survival and nine factors for overall survival were identified in the univariate analyses. After adjusting for other risk factors, only the expression of two molecular factors was associated with the risk of recurrence: TS (HR 0.631, 95 % CI 0.422–0.944) and SMAD4 (HR 1.680, 95 % CI 1.047–2.695). None of the variables was significantly associated with the risk of death in the multivariate analyses. The prognostic significance of most traditional clinicopathological variables might be insufficient to define patients at risk for recurrence after liver metastases resection. Molecular biomarkers might improve the identification of patients with higher risk of recurrence.

The use of fibrin glues for the closure of wounds in mesh repair of abdominal wall incisional hernias has been found to reduce the morbidity rate. However, the substances of this type derived from blood have the potential risk of virus transmission. The application of a nonbiologic adhesive would eliminate this risk, while offering the same advantages. We have performed a prospective study with the aim of analyzing results of the application of enbucrylate (Histoacryl ®, B. Braun Melsungen AG, Germany) between the muscle layers and subcutaneous tissue after incisional hernia repair with associated dermolipectomy, assessing local morbidity, mean hospital stay and need of wound care. The study included 42 patients divided into two groups, with and without enbucrylate, and results were compared between the groups. The two groups of patients were homogeneous with respect to their clinical data. The incisional hernia was at the midline in all cases, and was repaired using retromuscular prefascial polypropylene mesh in combination with dermolipectomy. Patients in the Histoacryl ® group developed less local morbidity (seromas, hematomas or abscesses) (p < 0.05), had a shorter mean hospital stay (p < o.o1) and required less wound care. We found that this approach improved the results of surgery for large eventrations when repaired by mesh placement and dermolipectomy and decreased global cost because morbidity and hospital stay were reduced.

Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI. We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS. The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo’s grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1–6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h. Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.