Costantino Campisi

Prosthetic repair of a perforated Amyand’s hernia: hazardous or feasible?

Dear Sir, We read with interest the article published in your journal by Sharma H et al. [1]. The authors present results from a large group with Amyand’s hernia. They conclude that the inXammatory status of the appendix determines the surgical approach and the type of hernia repair, with or without the use of an alloplastic mesh. As reported in literature [2, 3], use of a synthetic mesh should be avoided because of the high risk of infection. We report a case successfully treated by simultaneous appendectomy and mesh repair. A man of 62 was referred with diagnosis of incarcerated right inguinal hernia. We decided on a surgical open approach. The groin was explored through anterior access. After opening of the external oblique aponeurosis we found an important abscess rising from the internal ring. We drained the purulent material accurately and isolated a sliding hernia. The sac contained the caecum and the perforated gangrenous appendix, both incarcerated in the deep ring. We continued with the appendectomy and irrigation of the peritoneum and the inguinal area with antibiotics. The caecum was freed from adhesion to the sac and reduced into the abdominal cavity. We then resected the previously ligated sac. We decided to repair the inguinal defect, given the presence of intense inXammation and tissutal edema, positioning the PAD complex, a polypropylene Xat mesh that we routinely use to repair primitive inguinal hernias in our department, over the transversalis fascia [4]. Two Redon drainages were left below the aponeurosis, one in direction of the deep ring and the other along the spermatic cord in direction of scrotum; these were removed on seventh postoperative day. We administered postoperative intravenous metronidazole, 500 mg three times a day for 4 days, and piperacillin/tazobactam, 4.5 g three times a day, for 8 days, to the patient. On eighth postoperative day the patient was discharged asymptomatic. One-month and sixmonth follow-ups revealed no problem. In cases of perforated appendicitis in the hernial sac it may seem very hazardous deciding for a mesh repair after appendicectomy [5, 6]. The recommended direct suture using Shouldice’s or Bassini’s procedures could be technically very diYcult in an inXamed and edematous area, however, and could increase the risk of recurrence. We believe use of a synthetic mesh is feasible and safe enough if the inguinal area has previously been accurately irrigated with antibiotics, a drain is placed under the aponeurosis, and the patient is treated postoperatively with intravenous antibiotics. Use of inert materials, for example polypropylene, is, moreover, important, in our opinion, to minimize the risk of infections, as well as plain type protheses are useful to avoid the creation of empty spaces and porousness of the protheses that could make it easy to drain the infection. In our opinion, the presence of pus or perforation of the appendix is not an absolute contraindication to positioning of a mesh for hernia repair, which remains a valid alternative when a direct hernia repair seems diYcult to perform. G. Torino (&) Pediatric Surgery Unit, Policlinico Umberto I, University “La Sapienza”, Viale Del Policlinico 155, 00161 Rome, Italy e-mail: giovannitorino@interfree.it

Intraoperative sentinel node detection by an innovative imaging probe.

Intraoperative tumor detection has been used in many applications, and today the sentinel node technique is a widely employed surgical procedure in breast cancer. Different detector systems are employed but several problems have been reported in clinical practice, in particular the difficulty to accurately detect the sentinel node within the axillary soft tissue. The problem is even greater for abdominal and thoracic tumors. We propose an innovative Imaging Probe (IP) able to visualize on a monitor the primary tumor and secondary lesions, if appropriately radiolabeled. The IP can be optimally applied for minimally invasive surgery in breast cancer treatment, and a preliminary experience related to 15 patients and 20 sentinel nodes is reported here. We compared the results obtained with the IP to those obtained with an Anger camera and a traditional scintillation detector, and found them to be very promising. In particular the surgeons work is greatly facilitated by direct visual guidance instead of a generic acoustic signal.

Directional probe for radio‐guided surgery: A pilot study

PURPOSE The sentinel lymph node (SLN) biopsy technique has highly evolved during the last 20 yr. Consequently, the intraoperative use of Gamma Probes (GPs) for SLN mapping is increased. This preliminary study evaluates a novel directional GP prototype. This proof-of-concept prototype is designed to identify the direction of radiopharmaceuticals uptakes, by combining the information from multiple detectors. The purpose of this work is to develop a tool able to effectively guide the surgeon reducing the surgery time. METHODS The proposed prototype consists of three CsI(Tl) scintillation crystals, each coupled with an S10931 silicon photomultiplier (Hamamatsu Photonics K.K., Hamamatsu, JP). The three detectors lie on the same plane with an angle of 30° between them. The central detector is placed as in a common GP, so it can be used to pinpoint the target tissue. Meanwhile, the lateral sensors provide a broader view of the surgical field. A dedicated data acquisition system digitizes and processes the signals from the front-end electronics. Finally, an embedded system, based on ARM processor, calculates and displays the acquired count rates. In order to assess the prototype behavior, the isosensitivity curves for the three detectors were measured. Meanwhile, for the central one, the main quality criteria measurements were also performed (i.e., sensitivity, radial sensitivity, and spatial resolution). RESULTS For the central detector, the measured sensitivity at the tip of the probe is better than 5 cps/kBq. The full width at half maximum (FWHM) of the radial sensitivity is less than 30° and the FWHM of the lateral sensitivity (spatial resolution) is about 7.2 mm. The central detector measured isosensitivity distribution shows a narrow profile in agreement with the spatial resolution measured. On the contrary, the two lateral detectors exhibit widespread isosensitivity distributions that mean a larger field of view. The system had shown satisfactory performance and reliability, meeting the minimal requirements of gamma probe systems. CONCLUSIONS The prototype presented in this paper allows a rapid localization by the use of the whole system, while the sole central detector can be used to pinpoint the target source. This device, unlike common GPs, allows localizing simultaneously different areas of radiopharmaceuticals uptake, thus precisely guiding the surgeon to the region of interest. These preliminary results encourage to develop a further prototype for intraoperative validation.