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Introduction Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix™) over 24 months. Methods A prospective, international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm2, scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months. Results Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery. Conclusion After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations. Trial registration Registered on clinicaltrials.gov (NCT02720042), March 25, 2016.

Francesco Gossetti,1 Nikolaus Zuegel,2 Pasquale Giordano,3 Rupert Pullan,4 Jochen Schuld,5 Paolo Delrio,6 Marco Montorsi,7 Olivier van Kerschaver,8 Jean Lemaitre,9 Ben Griffiths,10 Linda D’Amore1 1Department of Abdominal Wall Surgery, University Hospital (C/O Instituto Clinica Chirugica II), Rome, Italy; 2Visceral Surgery, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg; 3Department of Colorectal Surgery, Whipps Cross University Hospital, Leytonstone, UK; 4Colorectal Surgery, Torbay Hospital, Torquay, UK; 5Clinic for General and Visceral Surgery, Universitätsklinikum des Saarlandes, Homburg, Germany; 6Department of Abdominal Oncology, Istituto Nazionale Tumori, Napoli, Italy; 7General Surgery, Humanitas University and IRCCS Humanitas Research Hospital, Milano, Italy; 8General Surgery, Algemeen Ziekenhuis Sint LUCAS, Gent, Belgium; 9Thoracic Surgery, CHU Ambroise Pare, Mons, Belgium; 10Colorectal Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UKCorrespondence: Francesco GossettiDepartment of Abdominal Wall Surgery, University Hospital (C/O Instituto Clinica Chirurgica II), Policlinico Umberto I, Rome, 00162, ItalyEmail gossetti@tiscali.itPurpose: Despite the advancements in the reinforcement and closure techniques available, complex abdominal wall reconstruction (CAWR) remains a challenging surgical undertaking with considerable risk of postoperative complications. Biological meshes were developed that may help to complement standard closure techniques and offer an alternative to synthetic meshes, which carry significant risks with their use in complex cases.Patients and Methods: A total of 114 patients underwent surgical treatment for CAWR with a Permacol™ (a biologic surgical implant). The study objective was to evaluate the short-term (6 months), mid-term (12– 24 months), and long-term (36 months) clinical outcomes (through 36 months) associated with the use of a biologic surgical implant in these cases.Results: The cumulative hernia recurrence rate was 18.7% (17/91) at 24 months and 22.4% (19/85) at 36 months. Twelve (14.1%) subjects required reoperation for hernia repair within 36 months for repair of recurrent hernias. Between 6- and 36-months post-surgery, patients reported improvement in their Carolina comfort scale (CSS) measures of severity of pain, sensation of mesh, and movement limitations.Conclusion: A biologic surgical implant can provide long-term benefit to complex abdominal wall repairs in patients staged grade III according to the Ventral Hernia Working Group (VHWG).Keywords: Permacol, biologic surgical implant, complex abdominal wall repair

BACKGROUND: Resorbable biomaterials have been developed to reduce the amount of foreign material remaining in the body after hernia repair over the long-term. However, on the short-term, these resorbable materials should render acceptable results with regard to complications, infections, and reoperations to be considered for repair. Additionally, the rate of resorption should not be any faster than collagen deposition and maturation; leading to early hernia recurrence. Therefore, the objective of this study was to collect data on the short-term performance of a new resorbable biosynthetic mesh (Phasix™) in patients requiring Ventral Hernia Working Group (VHWG) Grade 3 midline incisional hernia repair. MATERIALS AND METHODS: A prospective, multi-center, single-arm trial was conducted at surgical departments in 15 hospitals across Europe. Patients aged ≥18, scheduled to undergo elective Ventral Hernia Working Group Grade 3 hernia repair of a hernia larger than 10 cm2 were included. Hernia repair was performed with Phasix™ Mesh in sublay position when achievable. The primary outcome was the rate of surgical site occurrence (SSO), including infections, that required intervention until 3 months after repair. RESULTS: In total, 84 patients were treated with Phasix™ Mesh. Twenty-two patients (26.2%) developed 32 surgical site occurrences. These included 11 surgical site infections, 9 wound dehiscences, 7 seromas, 2 hematomas, 2 skin necroses, and 1 fistula. No significant differences in surgical site occurrence development were found between groups repaired with or without component separation technique, and between clean-contaminated or contaminated wound sites. At three months, there were no hernia recurrences. CONCLUSION: Phasix™ Mesh demonstrated acceptable postoperative surgical site occurrence rates in patients with a Ventral Hernia Working Group Grade 3 hernia. Longer follow-up is needed to evaluate the recurrence rate and the effects on quality of life. This study is ongoing through 24 months of follow-up. ispartof: INTERNATIONAL JOURNAL OF SURGERY vol:83 pages:31-36 ispartof: location:United States status: published

Mesh repair is one of the most popular technique for the treatment of abdominal wall hernias, resulting in lower recurrence rates. However, it is associated with a high risk of mesh-related complications. The aim of the present study is to assess the impact of biomaterials on the intra-abdominal organs, in terms of adhesions and visceral complications, in a series of patients undergoing re-do surgery at our abdominal wall unit. We reviewed the clinical records of 301 patients who undergone laparotomy between June 2008 and May 2018, selecting 67 patients with one or more previous prosthetic abdominal wall repair (AWR). The average number of previous repairs was 1.6 with a mean time interval of 66 months from the last repair. Clinical presentation included hernia recurrence (69%), mesh infection (26%), infection and recurrence (10%), and fistula (1%). Adhesions were intraoperatively observed in all patients, except for eight cases. Mesh was completely removed in 43 patients, partially in four. Postoperative complications were observed in 39% of cases, including wound dehiscence, hematoma, seroma, and mesh infection. Long-term implant results in abdominal wall repair and are not completely known, and literature is still lacking on this topic. Re-do surgery for subsequent pathological events may represent a way to increase our knowledge.

Highlights • Mesh related unusual complication. • Intraluminal mesh migration. • Mesh erosion., Introduction Meshes are commonly employed in abdominal hernia repair to reduce recurrence rates. Prosthetic repair, however, increases the risk of mesh related complications, including migration into adjacent viscera and erosion which can occur as uncommon and can be difficult to be diagnose. Presentation of case This is a case of transmural migration of composite mesh into the bowel, presenting as chronic abdominal pain and anemia 14 years after incisional hernia repair. Discussion Mesh implantation in hernia repair has increased the incidence of complications, such as seroma, hematoma and infection. Migration into adjacent viscera and erosion may present as complications related to the use of meshes. Their precise frequency after abdominal wall hernia repair is not well known and their late occurrence can make the diagnosis difficult. Conclusion Transmural migration of composite mesh is an uncommon complication of incisional hernia repair. Its pathogenesis is still not completely clear but it has been reported many years after implant surgery. It should be considered in a typical presentation of patients with history of previous prosthetic ventral hernia repair.

A currently unsolved problem of open inguinal hernia repair (IHR) is chronic postoperative inguinal pain (CPIP), which affects 10–12% of patients after IHR. In the present paper, we explored the results of a newly designed partially absorbable mesh made of polypropylene and polylactic acid (HybridMesh®) for open hernia repair and its impact on postoperative safety, efficacy, comfort and pain. A prospective multicentric pilot trial was conducted in third-referral centers across Italy (n = 5). Inclusion criteria were unilateral primary inguinal hernia in patients of both genders and BMI

The increasing number of abdominal wall repairs (AWR) for primary and incisional hernias performed yearly worldwide, the complication and recurrence rate of this surgery, with the attention focusing on high risk patient, the new reconstructive procedures, and the introduction on the market of numerous meshes and devices make inevitable that surgeons specialize in abdominal wall surgery. This is particularly true in case of complex AWR (cAWR), where surgeon’s volume experience has been demonstrated to play a significant role in the outcome. In addition, the management of these patients may result in high financial losses no more sustainable by the institutions. Therefore, it is necessary to implement more cost-efficient strategies to correct the balance. This objective can be more easily achieved in facilities specifically dedicated to the treatment of hernias.

Incisional hernia is a common complication of abdominal wall surgery, including laparotomy, stoma creation, and laparoscopic approach, that causes a negative impact on the patient’s quality of life and body image and may be responsible for potential serious complications. Its repair, moreover, is at high risk of recurrence thus leading to a vicious circle, each subsequent repair being at higher risk of relapse. Direct and indirect costs for these patients are very high with overall financial losses, particularly when the cost of readmissions is added. The magnitude of costs related to incisional hernia strongly suggests the need of effective prevention solutions. Patients’ reported outcome and adequate follow-up have to be better assessed, possibly by large controlled multicenter randomized trials to assess the best cost-effective indications. The European Hernia Society Guidelines Development Group already moved in this direction by publishing, in 2015, evidence-based guidelines on the closure of abdominal wall incisions and, in 2018, those on prevention and treatment of parastomal hernia. Different levels of recommendation are made with regard to the main topics, based on the evaluation of available high-quality studies and meta-analysis. Works are still in progress, as there are still many unsolved questions needing more careful observations and longer, comparable follow-up.

Background The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. Methods The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. Results The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. Conclusion The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.

BACKGROUND: Incisional heia is a frequent complication of midline laparotomy. The use of mesh in hernia repair has been reported to lead to fewer recurrences compared to primary repair. However, in Ventral Hernia Working Group (VHWG) Grade 3 hernia patients, whose hernia is potentially contaminated, synthetic mesh is prone to infection. There is a strong preference for resorbable biological mesh in contaminated fields, since it is more able to resist infection, and because it is fully resorbed, the chance of a foreign body reaction is reduced. However, when not crosslinked, biological resorbable mesh products tend to degrade too quickly to facilitate native cellular ingrowth. Phasix™ Mesh is a biosynthetic mesh with both the biocompatibility and resorbability of a biological mesh and the mechanical strength of a synthetic mesh. This multi-center single-arm study aims to collect data on safety and performance of Phasix™ Mesh in Grade 3 hernia patients. METHODS: A total of 85 VHWG Grade 3 hernia patients will be treated with Phasix™ Mesh in 15 sites across Europe. The primary outcome is Surgical Site Occurrence (SSO) including hematoma, seroma, infection, dehiscence and fistula formation (requiring intervention) through 3 months. Secondary outcomes include recurrence, infection and quality of life related outcomes after 24 months. Follow-up visits will be at drain removal (if drains were not placed, then on discharge or staple removal instead) and in the 1st, 3rd, 6th, 12th, 18th and 24th month after surgery. CONCLUSION: Based on evidence from this clinical study Depending on the results this clinical study will yield, Phasix™ Mesh may become a preferred treatment option in VHWG Grade 3 patients. TRIAL REGISTRATION: The trial was registered on March 25, 2016 on clinicaltrials.gov: NCT02720042 . ispartof: BMC SURGERY vol:18 issue:1 ispartof: location:England status: published

Training hernia surgery has become more and more challenging today. The increasingly high number of inguinal and ventral/incisional repairs, new surgical approaches, innovative techniques, both open and laparoscopic, and a huge number of prosthetic materials and medical devices available to the market, together with the complexity of patient population, require in fact a specialized surgeon with a deep knowledge in hernia surgery. According to these concerns, the Italian School of Hernia and Abdominal Wall Surgery was created in 2008, first in Europe, to train surgery residents and surgeons interested to develop a special knowledge in hernia surgery.

Central Mesh Failure (CMF) after abdominal wall repair (AWR) is uncommon but should be considered in case of recurrence. The mechanism is unclear and different theories are actually proposed, as the action of opposite forces acting in the abdominal wall on the prosthesis, and the characteristics of the device to be implanted. The use of lightweight meshes in some cases could be inadequate to withstand the bursting strenght of the abdominal wall. Three cases of incisional hernia recurrence due to central mesh failure are here reported. KEY WORDS: Abdominal wall repair (AWR), Central mesh failure (CMF), Hernia recurrence, Lightweight mesh.La rottura della protesi usata per la riparazione dei difetti della parete addominale è un evento poco comune che andrebbe, tuttavia, considerato tra le cause di recidiva. I meccanismi alla base di tale evento, che si verifica solitamente nella parte centrale della protesi, sono ancora poco chiari. Sono state proposte diverse teorie che considerano le forze antitetiche che agiscono sulla protesi impiantata nella parete addominale e le caratteristiche strutturali dei materiali impiantati. Protesi “leggere”, potrebbero essere insufficienti, in alcuni casi, a resistere alla tensione che si sviluppa a livello della parete addominale. In questo lavoro vengono presentati tre casi di ernia incisionale recidiva causata da una rottura centrale di protesi.

Besides the Lichtenstein technique, the mesh plug repair (MPR) has demonstrated excellent results over the years, with recurrence, chronic pain, and quality of life rates comparable to Lichtenstein’s in most of the reported outcomes. MPR is a deep repair with the device laying in the pre-peritoneal space. The technique was originally proposed in the late 1980s by Gilbert and Trabucco and finally standardized by Rutkow, who introduced the first preformed plug (PerFix™). Since then, many 3D devices have been offered on the market, made with new materials and new profiles, to meet the current requirements of the hernia surgery and overcome criticisms addressed to this technique, such as the excessive use of foreign material and the risk of plug migration. In fact, choosing the proper plug besides paying attention to technical details can reduce migration that seems anyway very rare. Originally proposed for all groin hernias, MPR today should be indicated for the treatment of lateral, recurrent “internal,” and femoral hernias, according to a tailored management of inguinal hernia. MPR offers the fastest learning curve, the shortest operative time, and the lowest perceived difficulty among all the procedures for groin hernia repair. It should remain in the toolbox of all general surgeons.

In ventral hernia repair, when prosthetic material is placed intraperitoneally, it may lead to an inflammatory reaction resulting in adhesions between the mesh and abdominal viscera. Several meshes have been developed to minimize this process. In this experimental study, the ability of different combined meshes to attenuate the adhesion formation was examined.Three commercially available lightweight porous combined meshes were placed intraperitoneally to repair an abdominal wall defect in rats: DynaMesh-IPOM (PVDF + PP), TiMesh (titanium-coated filament PP) and C-QUR/FX (omega-3 fatty acid-coated filament PP). The DynaMesh-CICAT (PVDF) was implanted in the control group. Adhesion formation was macroscopically evaluated and scored after 7 and 21 days.All animals except two presented intra-abdominal adhesions. None of the meshes examined in the study demonstrated to prevent adhesions. C-QUR/FX reduced adhesion formation at 7 days' follow-up compared with all other meshes but by 21 days this effect was diminished. Between 7 and 21 days adhesion extension significantly decreased for TiMesh. TAS did not show significant modifications between 7 and 21 days' follow-up for each mesh.The combined porous meshes tested in the present study demonstrated to reduce but not to prevent the adhesion formation, even if with some differences. Combined porous meshes could be chosen instead of simple meshes for retro-rectus preperitoneal prosthetic ventral hernia repair.

Highlights • Laparoscopy is useful in approaching a complex abdominal cavity. • Multidisciplinary approach and well-planned surgery improved the EAF treatment. • Different forms of tube drainage inside or around the fistula are proposed., Introduction Entero-atmospheric fistula (EAF) is an uncommon complication. Its timing and surgical management could be extremely challenging because extensive adhesions may heavily affect the approach to the abdominal cavity. Presentation of case We hereby report a case of EAF in a 70 year-old man. In order to control the fistula output and the surrounding tissue damage from enteric content, the patient was managed conservatively using different technical solutions. Finally, the patient underwent surgery that started with a laparoscopic approach in order to avoid the hostile abdomen. Discussion Due to the lack of guidelines, treatment of EAF requires a multidisciplinary approach and different technical options based on the experience and inventiveness of the surgeon. Among others, the vacuum assisted wound management proved to be a useful support andlaparoscopy demonstrated to be valuable in approaching the abdominal cavity. Conclusion According to our experience the success of the treatment of EAF may be improved adopting a multidisciplinary approach and well-planned surgery in referral centers.

A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

The history of groin hernia surgery is as long as the history of surgery. For many centuries doctors, anatomists and surgeons have been devoted to this pathology, afflicting the mankind throughout its evolution. Since ancient times the Italian contribution has been very important with many representative personalities. Authors, investigators and pioneers are really well represented. Every period (the classic period, the Middle Age, the Renaissance and the post-Renaissance) opened new perspectives for a better understanding. During the 18th century, more information about groin anatomy, mainly due to Antonio Scarpa, prepared the Bassini revolution. Edoardo Bassini developed the first modern anatomically based hernia repair. This procedure spread worldwide becoming the most performed surgical technique. After World War II synthetic meshes were introduced and a new era has begun for hernia repair, once again with the support of Italian surgeons, first of all Ermanno Trabucco. But Italian contribution extends also to educational, with the first national school for abdominal wall surgery starting in Rome, and to Italian participation and support in international scientific societies. Authors hereby wish to resume this long history highlighting the "made in Italy" for groin hernia surgery.Bassini, Groin hernia, History, Prosthetic repair.La storia della chirurgia erniaria è lunga quanto la storia della chirurgia. Per secoli medici, anatomisti e chirurghi si sono dedicati a questa patologia, che ha afflitto il genere umano durante tutto il corso della sue evoluzione. Fin dall’antichità il ruolo della chirurgia italiana è stato significativo, con numerosi illustri personaggi che hanno lasciato una traccia indelebile. Sono numerosi gli autori, i ricercatori ed i pionieri che hanno offerto il loro contributo in ogni periodo, dall’epoca classica attraverso il Medio Evo ed il Rinascimento, fino al ‘700. Nel 18o secolo, le nuove acquisizioni nel campo dell’anatomia umana, ad opera principalmente di Antonio Scarpa, hanno preparato la strada al rivoluzionario metodo di Bassini, che può a ragione essere definito come la prima procedura moderna di riparazione dell’ernia inguinale su base anatomica. La tecnica di Bassini ha avuto una grandissima diffusione, fino a diventare l’intervento più eseguito nel mondo. Dopo la II Guerra Mondiale, con l’introduzione delle protesi sintetiche è iniziata una nuova era che ha visto ancora una volta i chirurghi italiani pronti ad offrire un sostanziale contributo, primo fra tutti Ermanno Trabucco. Ma il ruolo italiano nella chirurgia dell’ernia inguinale va ben oltre la chirurgia estendendosi all’educazione, con la creazione a Roma della prima scuola di chirurgia della parete addominale, ed alla partecipazione di numerosi chirurghi alle società scientifiche internazionali, in ruoli di prestigio. Il presente lavoro ha voluto riassumere questa lunga storia ed evidenziare il “made in Italy” nella chirurgia dell’ernia inguinale.

The authors read the article "The importance of registries in the postmarketing surveillance of surgical meshes" by Kockerling et al, and they completely agree on the role of a clinical follow-up of surgical meshes even if they suggest that a surveillance longer than one year is advisable, particularly in IPOM repair, to collect not only late complications but also more serious adverse events. This seems be the only way to properly assess the safety of the mesh.

Although Mesh Plug Repair (MPR) represents an effective method for the treatment of groin hernia, some criticisms still concern adverse effects related to the plug (shrinkage, chronic pain, migration and erosion). Different mesh and plug devices have been proposed in the past mostly to prevent migration but none of these achieved the same popularity as the cone or flower-shaped plug. Authors hereby present a pilot study with a new tridimensional device, denominated NeT Plug and Patch, that avoids any risk of migration. Results after 12 months follow-up have demonstrated low incidence of postoperative and chronic pain, with both patients and surgeons greatly satisfied. NeT Plug and Patch has proven to achieve a simple and effective repair for primary inguinal hernias.Mesh-plug, Plug migration, Trabucco repair.Sebbene la tecnica Mesh Plug rappresenti una procedura di indubbia efficacia nel trattamento dell’ernia inguinale, tuttora permangono dubbi in relazione alla storia naturale del plug. In particolare, il plug può andare incontro a coartazione (shrinkage) con formazione di un “meshoma” responsabile di una sintomatologia dolorosa cronica. Più raramente, il plug può migrare e provocare erosione delle strutture anatomiche circostanti. Nel passato sono stati proposti alcuni devices per cercare di risolvere il problema della migrazione; nessuno di questi, tuttavia, ha raggiunto la popolarità dei plug conici o a forma di fiore. Il presente lavoro riporta i risultati di uno studio pilota condotto con l’impiego di un nuovo device tridimensionale, il NeT PlugPatch. I risultati dopo 12 mesi di follow-up, hanno dimostrato una ridotta incidenza di dolore postoperatorio e cronico, senza rischio di migrazione. Inoltre è stata registrata una compliance soddisfacente sia dei pazienti che degli operatori. La protesi NeT PlugPatch ha dimostrato di poter realizzare un’ernioplastica semplice ed efficace per la riparazione dell’ernia inguinale.

We read with great interest the article by Abdelfatah et al. titled ‘‘Long-term outcomes ([5 year follow-up) with porcine acellular dermal matrix (Permacol) in incisional hernia at risk for infection’’ [1]. This retrospective study included 65 consecutive patients, who underwent abdominal wall reconstruction (AWR) with porcine acellular dermal matrix (PADM) for repair of incisional hernias at high risk for surgical site infection (SSI). The surgical wound was clean in 49 %, clean-contaminated or contaminated in 45 % and infected in 6 % of cases. At the end of the study, authors concluded the use of Permacol PADM is far from ideal to unsatisfactory in the overall picture. Only in selected patients its use might prove to be useful. In fact, results from Abdelfatah et al. are discouraging and PADM as bioprosthesis for ventral hernia appears unreliable as definitive repair at this time. In Abdelfatah series, SSI occurred in 20 % within 30 postoperative days and in 37 % after this period (with 25 % of PADM infection). Infection required subtotal or total removal of PADM in 15 cases. Fifty-nine patients with a follow-up C5 years displayed overall recurrence in 66 %, documented at physical examination or objective findings (CT scan or reoperation). Why these bad results? authors have full knowledge of some limitations of their study, including the heterogeneous differing types of repair, onlay, inlays and sublays with bridging (patches) or reinforcement by the PADM. We absolutely agree with them and we believe that the explanation of such discouraging results actually must be sought in the surgical technique. Abdelfatah et al. report that a bridging patch repair was performed in 31/65 patients, an onlay or intraperitoneal reinforcement of an autogenous suture repair in 28/65 and an inlay repair in 6/65. PADM was never placed as a sublay in the retromuscular space, as described by Rives and Stoppa [2, 3]. Results from our experience are different. Between July 2005 and December 2013, 45 consecutive patients underwent abdominal wall reconstruction (AWR) with PADM (32 with Permacol, Covidien and 13 with CollaMend, Bard, Davol) for incisional hernias. Four patients needed more than one implant, due to concomitant hernias in other sites (parastomal or perineal), for a total number of 50 implants. All patients were at risk of infection, 87 % of them displaying grade III, according to mod.WVHG (Table 1) [4]. In 86 % of implants, PADM was used as augmentation repair while in 14 % of them sublay bridging repair was performed (Table 2). Sixty-eight percent of defects were treated with primary suture of the midline and retromuscular PADM reinforcement (Rives–Stoppa technique). When ventral rectus sheaths could not be reapproximated, techniques of posterior components separation were performed [5, 6]. All patients were collected in a database and examined every year. The presence or absence of recurrent hernias was documented by cross-sectional imaging (CT scan or MRI) with Valsalva manoeuvre. Our short-term SSI rate was quite similar to Abdelfatah et al. (26 vs. 20 %), despite the higher risk of infection in our patients (87 vs. 50 %). In our series, one patient died due to sepsis on 30th postoperative day. Long-term SSI was demonstrated in 2 cases (4 %), both belonging to the This comment refers to the article available at doi:10.1007/s10029013-1165-9.

Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC). In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B). In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups. The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

Hepatocellular carcinoma (HCC) is considered an optimal indication for liver transplantation (LT) because it may eliminate both the tumor and the underlying liver disease. The present study sought to compare cumulative survival, rate of HCC recurrence, and causes of death among patients with cirrhosis and HCC before and after the adoption of more restrictive criteria (Milan selection criteria) at the time of patient listing. Among 226 adult patients who received an elective liver transplantation between 1999 and 2005, 58 (27%) had a diagnosis of HCC at the time. The 38 patients who underwent transplantation for HCC in the period 1989 to 1998 were considered the "historical group." After LT (mean follow-up, 34 + 28 months), the cumulative survival rate was better among HCC versus non-HCC recipients (93% vs 71% at 1 year and 81% vs 67% at 3 years, respectively; P.046), although the difference tended to attenuate after 5 years (66% vs 67%, respectively). Tumor recurrence (evaluated in patients surviving at least 3 months after LT) was observed in 10/31 in the historical group versus 4/53 among those who underwent transplantation after 1999. Among the causes of death, recurrence represented 50% in the old series and 23% in patients who underwent transplantation after 1999. Cumulative survival significantly improved among HCC patients who underwent transplantation after 1999 (93% vs 66% at 1 year and 81% vs 50% at 3 years; P.00001). The 58 patients who underwent transplantation with a diagnosis of cirrhosis and concomitant HCC after 1999 showed even better survival than patients who underwent transplantation for end-stage liver disease without malignancy.

Background The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. Methods Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. Results Median follow-up time was 649 days (max: 2857), median age 57 years (range 23–91), and BMI 32 kg/m 2 (range 17.6–77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives–Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan–Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. Conclusions Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. Clinical trial registration number NCT01214252 (http://www.clinicaltrials.gov).

We read with great interest the report by Symeonidis et al. on long-term results of a pilot study on plug and patch hernia repair using a fully absorbable mesh (polyglycolic acid/trimethylene carbonate—Gore BIO-A) [1], previously described [2]. At the 3-year follow-up, clinical examination revealed recurrence in three out of the eight patients (37.5 %). We agree with the authors when affirming that this result represents a crucial finding requiring appropriate critical interpretation. In 2009, we started a prospective multicentre study on the use of BIO-A plug and patch in groin hernia repair, as announced in a previous note [3]. In our study, the rationale for the use of BIO-A was the reduction of the potential risk of injury when a polypropylene (PP) mesh is placed in contact with the bare vas deferens, as in the case of plug and patch hernia repair; the goal was the evaluation of any higher long-term recurrence rate. On a pilot basis, we enrolled 15 young adults (\45 years), including only primary lateral (L-lateral according to EHS’s classification) hernias. At surgery, the hernia was classified as L1, L2 and L3 in 5, 8 and 2 cases, respectively. All patients underwent clinical examination 18 months after the procedure (medium term results). None of them presented any complication and all patients were totally satisfied. After 30 months (long-term follow-up), patients were contacted again. Two of them moved to a new address and for this reason were invited to a telephone interview. All the remaining patients were submitted to clinical examination. A recurrence was clinically diagnosed in two cases (2 patients aged 45, with L3 hernia), both revealing a medial (M) hernia at reoperation. No patient without recurrence complained foreign body sensation or pain, including the patients undergoing telephone inquiry. The recurrence rate in our study has proved to be three times lower than in Symeonidis et al.’s study (13 vs. 37.5 %). We believe that this might be due to two reasons. The first concerns the patients’ selection (different study design). In fact, Symeonidis et al. enrolled patients irrespective of the hernia type, lateral or medial, and of the age. Conversely in our study, we selected only patients aged\45, with lateral hernias. The second reason is related to the surgical technique. Symeonidis et al. finally restored the anatomy of the inguinal canal by closing the external oblique aponeurosis superficially to the spermatic cord. In our procedure, the external oblique aponeurosis was placed dorsally to the cord, as we routinely perform in all inguinal hernia repair. The adoption of these parameters by Symeonidis et al. could have probably reduced their recurrence rate to our values. Despite this, the incidence of 13 %, we have registered, appears unacceptable and requires a critical update. Based on the results of our pilot study, it seems that the polyglycolic acid/trimethylene carbonate absorbable mesh (Gore BIO-A Tissue Reinforcement ) patch cannot guarantee a solid reinforcement of the posterior wall of the inguinal canal, or prevent a medial hernia. Current data This comment refers to the article available at doi: 10.1007/s10029-012-1016-0.

Background: A wide variety of meshes are available for surgical treatment of abdominal wall defects. These meshes are constructed with different materials with different biological properties. Methods: A prospective database was instituted (January 2009-December 2010) to register biological prostheses (BPs) implanted in Italy. Results: A total of 193 cases were registered. The mean age of the patients was 53.1 years (SD ±7.4). The ratio of males to females was 1.3 to 1. The mean body mass index was 28.2 (SD ±4.1). The breakdown of American Society of Anesthesiologists (ASA) scores was as follows: ASA I, 35.7%; ASA II, 27.5%; ASA III, 31.6%, and ASA IV, 5.2%. For ventral-incisional hernias, the mean duration of surgery was 101.1 min (SD ±25.3), while for inguinal-femoral hernias it was 49.2 min (SD ±19.1). The rate of urgent procedures was 36.7%. The surgical field was clean in 57.4% of cases, clean-contaminated in 21.3%, contaminated in 12.3% and dirty in 9%. Techniques used for inguinal-femoral hernias were as follows: Lichtenstein in 66.7%, plug and mesh in 3.8%, transabdominal-preperitoneal in 25.7% and intraperitoneal onlay mesh in 3.8%. The following prostheses were used: swine intestinal submucosa in 54.9%, porcine dermal collagen in 39.9% and bovine pericardium in 5.2%. In 45.1% of cases the prostheses were cross-linked. Techniques used for ventral-incisional hernias were as follows: onlay in 3.6%, inlay in 5.5%, sublay in 62.7% and underlay via laparoscopy in 28.2%. The mean overlap was 4.1 cm (SD ±1.2). No intestinal anastomosis was necessary in 65.3% of cases; however, small/large bowel resection and anastomoses were necessary in 22.3 and 12.4% of cases, respectively. Intraoperative blood transfusion was necessary in 10.4% of procedures. The skin was completely closed in 84% of procedures. At the 1-month follow-up, there were no complications in 54.4% of cases. Among the cases with complications, 10 patients (5.8%) experienced recurrence, and the postoperative readmission rate was 12.9%. The average visual analog scale (VAS) score for pain was 2.9 (SD ±1.2) at rest. At the 1-year follow-up, there were no complications in 96.4% of cases. Two patients experienced recurrence, and the postoperative readmission rate was 3.6%. The average VAS score for pain was 1.8 (SD ±0.8) at rest. Conclusions: This register shows that BPs are highly versatile and can be used in either open or laparoscopic surgery in all kinds of patients and in contaminated surgical fields. However, due to the very good outcomes of synthetic meshes and the high costs of BPs, the latter should only be used in selected cases.

Plug repair actually represents one of most recommended procedures in open groin hernia repair. It is generally recognized that Lichtenstein in 1968 first introduced the plug technique for femoral and recurrent inguinal hernia. The present paper backdates more than 50 years the first application of a plug due to an ingenious Italian surgeon named Davide Fieschi.

Introduction Indications for repair of abdominal hernia are well established and widely diffused. Controversies still exist about the indication in using the different prosthetic materials and principally about the biological ones. Material and methods In February 2012, the Italian Biological Prosthesis Work-Group (IBPWG), counting a background of 264 biologic implants, met in Bergamo (Italy) for 1-day meeting with the aim to elaborate a decisional model on biological prosthesis use in abdominal surgery. Results A diagram to simplify the decisional process in using biologics has been elaborated. Conclusion The present score represents a first attempt to combine scientific knowledge and clinical expertise in order to offer precise indications about the kind of biological mesh to use.

We read with great interest the report by Efthimiou et al. [1] on plug and patch hernia repair using a polyglycolic acid-trimethylene carbonate mesh. The purpose of this pilot study (ten patients with direct and indirect inguinal hernia with a mean age of 65.6 years) was to evaluate the efficacy of using a totally absorbable device (Gore BIO-A Tissue Reinforcement patch and Gore BIO-A plug), looking primarily at recurrence and chronic pain assessed 1 year after the operation. The authors stress, and we agree with, that an ideal mesh for inguinal hernia repair should cause the minimum foreign body reaction. Moreover, the excessive local inflammatory reaction that occurs when a polypropylene (PP) mesh, especially heavyweight PP, is implanted, may cause prosthetic shrinkage and chronic pain. For these reasons, surgeons would consider the use of PP with different characteristics (low-weight large porous PP, PP/polyglactine composite, PP with polytetrafluorethylene surface) or other materials as polyvinyliden fluoride (PVDF). Gore BIO-A mesh is made of a biocompatible synthetic polymer. Its design structure (with open highly interconnected pores) creates a scaffold that facilitates tissue generation, mimicking native collagen fibres. This material is fully absorbed in approximately 6 months. At 1 year follow-up, none of the patients from Efthimiou’s study had clinical signs of recurrence. Only one patient experienced intermittent pain without the need for any medication. On the other hand, the authors do not highlight any protective role on the vas deferens that could possibly be played by Gore BIO-A plug and patch repair, probably because all patients in their study were elderly. Many experimental studies in animals have shown that PP mesh can adversely affect spermatic cord structure and/ or function [2–5]. On the contrary, little clinical information is available regarding the long-term effects of PP mesh on the vas deferens. One possible reason is that most men undergoing hernia repair tend to be elderly, and thus not so concerned about maintaining their reproductive potential. However, a multiinstitutional experiment and some casereports [6–8] have confirmed the potential risk of injury when a PP mesh is placed in contact with the bare vas deferens, as in the case of plug and patch repair. PP herniorraphy is being offered to young adults whose fertility status will be an issue in the future. At present, we are unable to determine whether PP mesh will result in an higher incidence of inguinal vasal obstruction and infertility. In 2009, we began a prospective multicentre study on the use of BIO-A prosthesis in young adults (maximum age 45 years) to try to answer these questions, and to offer a safer repair to patients. Only primary indirect (L, lateral, according to EHS’s classification) hernias were included in the study. All patients underwent open plug and patch repair. C-reactive protein (CRP) samples were collected to estimate the inflammatory response. Pain was evaluated using VAS score, and quality of life status by the SF-36 system. Mid-term results (at 2 years) will be published soon. In the meantime, we wish to point out that, at 18-month follow-up, none of the 15 patients enrolled by our Centre had any complications and all patients were totally satisfied. We can also assume that no adverse events affected the cord structure. P. Negro (&) F. Gossetti M. R. Dassatti J. Andreuccetti L. D’Amore Department of General Surgery ‘‘P. Stefanini’’, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy e-mail: pal.negro@libero.it

Endoscopic submucosal dissection (ESD) has gained worldwide acceptance as a treatment for early gastrointestinal cancers (EGICs). However, the management of these tumors in the Western world is still mainly surgical. Our aim was to evaluate the safety and feasibility of ESD at a European center. Based on the knowledge transferred by one of the most experienced Japanese institutions, we conducted a pilot study on 25 consecutive patients with EGICs located in the esophagus (n = 3), stomach (n = 7), duodenum (n = 1), and colon (n = 14) at our tertiary center over a 2-year-period. The main outcome measurements were complete (R0) resection, as well as en-bloc resection and the management of complications. The R0 and en-bloc resection rates were 100% and 84%, respectively. There were three cases of bleeding and five cases of perforation. With a median follow up of 18 months, two recurrences were observed. We conclude that ESD for early esophageal and gastric cancers is feasible and effective, while colonic ESD requires more expertise.

Plug and patch hernioplasty is a technique showing very good results. Actually some criticisms mainly concern the amount of prosthetic material and the shrinkage of the plug resulting in recurrence of hernia, groin pain, and/or migration. The new tridimensional mesh Parietene PP allows to achieve a plug and patch hernioplasty, without any risk of plug migration. The Parietene PP hernia repair in simple and easy to learn. Preliminary results are very satisfactory and comparable with the best outcome from mesh plug repair, without any risk of plug migration.

Vascular lesions may complicate the course of acute pancreatitis. The activated pancreatic enzymes, particularly elastase, might cause lysis of the elastic component of the arterial wall thus leading to aneurysmal changes. This report is on a case of aneurysm of the infrarenal aorta following complicated acute pancreatitis and treated by endovascular technique.

Most surgeons performing abdominal-wall surgery consider the Rives-Stoppa technique to be the gold standard procedure in the open treatment of midline ventral hernias, particularly incisional hernias. As is well-known, this procedure involves: (1) anatomic plasty of the posterior lamina of the rectus sheath, from the xyphoid apophysis to the linear arcuata (of Douglas) and from there, depending on the wall defect, dissection of the pre-peritoneal space to the pubic symphysis and the Bogros space; (2) implantation of the mesh in the newly formed retromuscular space above and/or below the umbilicus (sub-lay repair). Plasty of the linea alba concludes the layered reconstruction of the abdominal wall and separates the mesh from the subcutaneous tissue.

The development of acute large bowel obstruction secondary to colorectal cancer is very common and, while right hemicolectomy with a primary anastomosis is the accepted procedure for right-sided obstructing tumors, the different strategies performed for left-sided tumors, including staged procedures, Hartmann's procedure, and resection with anastomosis, remain a subject of controversy. We present herein the case reports of three patients who developed two synchronous occlusive tumors of the large bowel. Complete exploration of the entire colon is highly recommended to assess the most feasible therapeutic option in such cases, as the second occlusive tumor, often hidden within the bowel segments, can cause failure of limited resection or intestinal decompression.

Although the technique of plugging the inguinal canal to prevent the emergence of herniated tissue is almost two centuries years-old (1), it is only twenty- five years that the plug is part of the equipment of modern hernia surgery. Since 1974, when Lichtenstein and Shore have proposed the use of a “rolled cylindrical as cigarette mesh plug” in the surgical treatment of both femoral and recurrent inguinal hernias (2), this technique has extended its clinical indications and progressively spread, recording a significant increase over the last decade that has put it as an option to the onlay patch hernioplasty (3).

We read with great interest the article by Yilmaz et al. [1], presenting a case-report of mechanic bowel obstruction in a patient previously submitted to left inguinal hernia repair with mesh plug technique. During surgery, it was found that the plug was migrated into the sigmoid mesentery, thus occluding the sigmoid colon. Mesh plug repair (MPR) is a worldwide largely used technique mostly for the treatment of lateral groin hernia. The main criticism to MPR is that the plug can migrate and/or erode the surrounding structures. The 3-D rigid structure and the profile of the plug may be responsible for this complication even if it may occasionally complicate flat mesh preperitoneal hernia repair (such as Stoppa’s, Prolene Hernia System or laparoscopic repair). Since 1997, our literature database has collected 2 coecum [2, 3] and 5 left colonic involvement after plug repair [4–8]. The case-report by Yilmaz and a personal case (a 70 year-old patient with plug erosion into the sigmoid colon 9 years later a MPR, requiring sigmoidectomy) should be added to these. It is important to underline that 5 of 7 patients (mean age, 71) suffered from diverticular disease. This fact can suggest that diverticular inflammation might cause attraction of the plug with consequent erosion into the colon. Probably other cases of plug migration did not come to publication for medico-legal implications, indifference of authors or lack of recognition and the rate therefore could be underestimated. Can we avoid this risk? Some authors believe that lack of fixation of mesh plug predisposes to its migration [9], but other technical details could also contribute to reduce this complication, such as to avoid the excision of the sac, identify and repair any hole in the peritoneal sac, use preshaped devices, choose the proper size and light material. When dealing with aged patients suffering from left inguinal hernia and colonic diverticular disease, we suggest to consider avoiding plug repair and preferring the Lichtenstein procedure.

First of all, we wish to thank Tripoloni and Schierano [1] for the attention they paid to our trial comparing fibrin glue versus suture for open tension-free Lichtenstein hernia repair [2]. We appreciate their interest in the details. We agree that the two groups may have included subgroups that could cause bias, but we have to remember that this was a prospective observational multicenter study. The study was not randomized or blinded and, for this reason, no formal power calculations were undertaken. This is what happens with observational studies (cohort studies) which, for this reason, reach the level of evidence 2B with grade of recommendation B. Nonetheless, they can provide interesting results or suggestions for clinical practice. In our study, fewer patients in the fibrin glue group reported pain, numbness, and discomfort compared with patients in the sutures group at 1 month, and this occurred until the third month, when all differences disappeared, with the exception of numbness, which continued to be more prevalent in the sutures group. Tripoloni and Schierano [1] noted that the difference in pain intensity in favor of fibrin glue is not clinically meaningful. We agree with this, but the fact remains statistically meaningful. Anyway, in the literature, comparisons among different techniques for hernia repair, i.e., open versus laparoscopic repair, are often based on little variation in terms of mild or mild moderate pain. In our study, the mean operating time was reduced by 9% in the fibrin glue group compared to the sutures group. Although this value is statistically meaningful, Tripoloni and Schierano [1] believe that 6 min for each procedure is of little practical importance. We wish to underline that our study included 16 centers with extensive experience in hernia surgery. In less expert hands, i.e., residents and young surgeons, this saving of time is probably greater, with economic advantages. Of greater importance seems to be the remark on the risk of recurrence and that fibrin glue should expose to higher recurrence risk if compared to the sutures group. Actually, the two recurrences in our study occurred in the first group and in patients with direct hernias (type M) (more numerous in the fibrin glue group for the lack of stratification). We revised the files of both patients that were re-operated for recurrence. In both cases, a mesh of inadequate size was used. Both hernias recurred distally to the mesh, close to the pubic tubercle, type M1. The letter by Tripoloni and Schierano [1] provides us the opportunity to stress the importance of using a mesh of sufficient size to overlap the pubic tubercle, as requested also when a tension-free suture Lichtenstein repair for direct hernia is performed. With this solution, the difference in the recurrence rate between the two techniques nullifies. We, together with all the co-workers in our study, continue to believe that, in the future, the use of fibrin or synthetic glue for mesh fixation or self-gripping meshes will probably replace sutures in groin hernia repair.

collected 5 years after hernioplasty by an expert in locating people. Of 839 patients, 764 (91%) were contacted by a physician and answered a telephone questionnaire. Only 75 patients were lost at follow-up because of change of address. Among the more important questions were: Do you feel any painful sensation? Do you feel anything abnormal in the groin? Do you have any recurrence or any other symptom? All patients (119 of 764) complaining of any sign consistent with discomfort or painful sensation throughout the groin attended a physical examination by an independent surgeon, with experience in hernia surgery. As in the study of Berndsen, the importance of pain was graduated as mild (occasional discomfort or pain that does not interfere with daily activity), moderate (discomfort or pain that occasionally interferes with daily activity) and severe (discomfort or pain that interferes with daily activity). Results are shown in Table 1. At physical examination, 19 of 24 patients turned from moderate to mild. Overall discomfort after 5 years was 6.5%, with only 0.9% of patients complaining of moderate (0.6%) or severe (0.3%) pain. We found no relationship between late discomfort and early postoperative pain. On the contrary, a correlation with preoperative pain was evidenced, but it was not statistically signiWcant. Our results from this large series, with high follow-up percentage (91%) and supplemental physical examination after 5 years, have demonstrated that the incidence of late discomfort after plug and patch hernioplasty is as low as it is for the TAPP procedure in Berndsen’s study. Our present purpose is not to compare late results of plug and patch repair with that technique but to stress that the true incidence of long-term discomfort after prosthetic hernioplasty could not be as high for all well-standardised techniques as believed.

Since its introduction in 1987 laparoscopic cholecystectomy (LC) has gained rapid acceptance as the preferred management of symptomatic cholelithiasis. In our department, during the past 3 years, the number of open cholecystectomies (OCs) has dramatically decreased. The impact of the introduction of LC as a part of the overall surgical procedures performed by residents is analyzed. To date junior-level residents have already more experience in LC than in OC. Indeed in our teaching unit junior-level residents performed only 5% of biliary surgical procedures in open surgery. Residents participated in the "surgeon's" position in 47.9% of the LCs and as either surgeon or first assistant in 100%. We analyzed both the cases where residents acted as surgeons and where they did not. It appeared that there was no difference in the complication and conversion rates. More intraoperative cholangiographies (IOCs) were performed by residents. This was probably due to the anxiety of making a mistake because of their lack of experience. This report suggests that the decrease in the number of OCs is not a drawback and that it is possible to acquire an adequate knowledge of biliary anatomy and surgery from LC training, if strict proctoring criteria are respected.