Salvatore Fazzotta

Laparoscopic repair of boundary incisional hernia in a kidney transplanted patient. A safe tacks-fibrin glue combined mesh fixation technique.

BACKGROUND Incisional hernia in renal transplant patients is a complication that negatively affects the global outcome of transplant and quality of life. The repair of this condition was classically made by open repair with mesh. Increasing evidence suggests that laparoscopic repair could be advocated as the technique of choice in these patients with optimal results. However, the fixation of mesh should be performed by a mixed combination of fibrin sealant (lateral margin of wall defect) and tacks (medial margin). The tacks fixation of the mesh along the lateral margin of the wall defect, close to the graft, is generally difficult for the small size of the remaining aponeurotic plane and dangerous for the underlying presence of the graft. MATERIALS AND METHODS A case of incisional hernia in a kidney transplant recipient was repaired by laparoscopic mesh technique. The polypropylene-polyglycolic acid composite mesh was fastened with a mixed technique of absorbable tacks for medial margin of the defect and fibrin sealant for the lateral side in contiguity with graft surface. RESULTS The patient was discharged after 4 days. The 6-month follow-up did not show mesh displacement or recurrence of hernia. CONCLUSIONS The laparoscopic mesh repair may become the criterion standard for kidney transplant patients affected by incisional hernia. The difficulties of mesh fixation close to the graft can be overcome by the combination of fibrin sealant glue and absorbable tacks at different margins of the wall defect. This technique may offer advantages for this population of patients.

OneShot-M: A New Device for Close Laparoscopy Pneumoperitoneum

Introduction. The induction of pneumoperitoneum is the first and most critical phase of laparoscopy, due to the significant risk of serious vascular and visceral complications. The closed technique for the creation of pneumoperitoneum could lead to several surgical complications. The present study aimed to overcome the complications associated with the insertion of Veress needle, improving its use, and facilitating the rapid creation of pneumoperitoneum. Methods. Thirty large white female pigs were enrolled in our study. A common plunger was modified in order to allow the passage of a 15-cm long Veress needle. This method was applied to 26 laparoscopic procedures (26 pigs) of several specialist branches. Results. OneShot-M close laparoscopy pneumoperitoneum creation device allowed us to obtain pneumoperitoneum quickly in all attempts, without any intraoperative and postoperative complications related to the use of the Veress needle. Conclusion. The use of the proposed device showed an induction time as quick as the standard laparoscopic closed abdominal entry. The patented device is cheap and allows a safe abdominal entry. In addition, abdominal entry is much faster than the classic open technique.

Electrospun PHEA-PLA/PCL Scaffold for Vascular Regeneration: A Preliminary in Vivo Evaluation

BACKGROUND There is increasing interest in the development of vessel substitutes, and many studies are currently focusing on the development of biodegradable scaffolds capable of fostering vascular regeneration. We tested a new biocompatible and biodegradable material with mechanical properties similar to those of blood vessels. METHODS The material used comprises a mixture of α,β-poly(N-2-hydroxyethyl)-d,l-aspartamide (PHEA) and polylactic acid (PLA), combined with polycaprolactone (PCL) by means of electrospinning technique. Low-molecular-weight heparin was also linked to the copolymer. A tubular PHEA-PLA/PCL sample was used to create an arteriovenous fistula in a pig model with the use of the external iliac vessels. The flow was assessed by means of Doppler ultrasound examination weekly, and 1 month after the implantation we removed the scaffold for histopathologic evaluation. RESULTS The implants showed a perfect leak-proof seal and adequate elastic tension to blood pressure. About ∼3 weeks after the implantation, Doppler examination revealed thrombosis of the graft, so we proceeded to its removal. Histologic examination showed chronic inflammation, with the presence of foreign body cells and marked neovascularization. The material had been largely absorbed, leaving some isolated spot residues. CONCLUSIONS The biocompatibility of PHEA-PLA/PCL and its physical properties make it suitable for the replacement of vessels. In the future, the possibility of functionalizing the material with a variety of molecules, to modulate the inflammatory and coagulative responses, will allow obtaining devices suitable for the replacement of native vessels.

Platelet-rich gel for the adjuvant treatment of wound healing of transposed flap for arteriovenous fistula in systemic scleroderma

End-stage renal failure (ESRF) requiring dialysis is a complication of systemic sclerosis. The challenge of performing a distal arteriovenous fistula (AVF) on a scleroderma patient is mainly related to the thickness of the skin. Due to the excessive fibroproliferative response to tissue injury, the closure of the surgical site can lead to compression and clotting of the anastomosis. Skin flap may help the closure but it can be affected by non-healing skin ulcers. These ulcers are often slow healing and unresponsive to traditional treatments; consequently, the patient’s quality of life and prognosis may be severely affected (1). We report the effects of a platelet gel for wound healing in a 58-year-old male with scleroderma and renal failure, following AVF surgery. The skin suture compression caused the failure of the fistula on the day after the intervention (2). During a second look we performed a second anastomosis 3 cm over the previous one. We encountered the same anastomosis compression while we were closing the skin, even though the anastomosis was efficient. While the vessels were suitable for a good anastomosis, the skin thickness caused by sclerodermia was the main issue for a negative outcome. We performed a second skin incision with an angle of about 60 degrees starting from the distal angle of the main incision, creating a skin flap (Fig. 1A). This skin flap was transposed on the skin wound above the anastomosis and sutured with absorbable stitches on the subcutaneous layer and the side above the anastomosis with non-absorbable stitches. The skin wound above the anastomosis was closed with no compression on the fistula, ensuring its good performance. The other side was left open (Fig. 1B). After 5 days from the last operation we checked the wound (Fig. 1C). To heal the wound left by the skin transposition we chose to apply heterologous platelet-rich gel (PRG) (3) (Fig. 1D), whose efficacy has been demonstrated in both in vitro and in vivo models (4). Four-weekly medications were performed with this device. Before applying the PRG, the wound was cleaned each time with saline solution. After the application the gel was covered with Bactigras®. After one week, the first granulation spots appeared (Fig. 2A). After two weeks, the wound cleaning showed that the granulation tissue covered all of the wound (Fig. 2B) and the wound edges appeared narrower. By the fourth week, with the last application of PRG, we obtained a coherent granulation (Fig. 2C). In the fifth week we just cleaned the wound and applied Bactigras® (Fig. 2D). We decided to treat the skin portion left open using heterologous PRG that was already used for the treatment of skin ulcers from systemic sclerosis (1). Satisfying results have been also achieved on uremic and diabetic patients suffering from diabetic ulcers, with ulcer healing and a reduction of disease-associated morbidity and lowering health-care costs (5). Our experience confirmed the utility of PRG on wound healing, particularly on a patient suffering from systemic sclerosis.