Valter Martino

Transabdominal pre-peritoneal mesh in inguinal hernia repair in elderly: end point of our experience

BackgroundAim of this study is to present our standardized laparoscopic transabdominal preperitoneal hernia repair (TAPP) technique, and to study our experience in the elderly as far as concerns preoperative and postoperative variables.MethodsWe described our standardized TAPP technique according with Stuttgart technique [1], and we evalutated our teams experience in TAPP inguinal hernia repair in elderly (> 65 yrs) and in young patients (< 65 yrs).ResultsWe retrospectively reviewed our Surgery Divisions experience about TAPP; we included in our study 185 patients. The sample was subdivided in two groups: TAPP Group (< 65 years patients) and TAPPe Group (> 65 years patients). TAPP Group was composed by 154 patients and TAPPe Group of 31 patients. According with literature, in this subgroup recurrence rate (3,2%), early and delayed complications and mean operative time (86 min). There were no major vascular or intestinal complications. At the moment follow-up is 31 months. There were no incisional hernias on umbilical trocar. Mean satisfaction rate was excellent also in elderly patients.ConclusionsAccording with literature, in our experience TAPP technique is a safe and feasible procedure, even in elderly patients.

Wound defects in the elderly: our experience

Patients and methods To assess the safety and efficacy of laparoscopic [1-5] primary inguinal and incisional repair we reviewed the records of our patients of over 70 years old, who underwent such a procedure from June 2007 to September 2010: hernia defect size, recurrence, operative time, and procedure-related complications [6] were evaluated and a laparoscopic approach was attempted in all patients who required a mesh repair. We scheduled 42 patients (32 M 10 F, with 53 wound defects totally) for laparoscopic incisional [7] and primary inguinal hernia repair and we performed 17 surgical repair for incisional hernia and 36 for primary hernia. Of those, 13 were done for incisional hernias with a single defect (24.5% recurrence hernias), 4 with multiple defects (7.54% recurrence hernias), 12 were performed for unilateral inguinal hernias (22.56 % recurrence hernias), 16 for bilateral inguinal hernias (30.08 % recurrence hernias), 4 for umbilical hernias (1 recurrence hernias), 2 for epigastric and linea alba’s hernias, and 2 for rectum diastasis. The majority of the patients were normal weight with a mean BMI of 25 kg/m2 (45%), 38% 25 > BMI > 30 (overweight), 17% BMI > 30 (obesity). There was no conversion to an open procedure. The mean operative time was 128 minutes (range: 50 – 325). In all the patients only mesh was used (37.5% polypropylene not reabsorbable, 42.5% tridimensional polyestercollagen composite mesh, 20% lightweight multifilament mesh partly reabsorbable) [8]. The meshes were fixed in 82.5 % with absorbable fixation device, in 5% with a non-absorbable device and in 12.5 % with fibrin glue [9]. In contrast to other authors [10-13], major complications were 14.24% (6/42: 2 chronic inguinal pain, 4 recurrences). Minor complications were 5/42 (11.90%) and included only asymptomatic seromas that were aspirated. The mean hospital stay was 4.7 days (range: 1-18 days).

Elective and emergency laparoscopic cholecystectomy in the elderly: early or delayed approach

Materials and methods From January 2005 to December 2009 114 laparoscopic cholecystectomy in the elderly were performed in our surgical division: 67 for gallbladder stones and 47 for acute cholecystitis. The diagnosis of cholecystitis and gallbladder stones was based on general condition, physical examination, laboratory, radiological findings and sepsis score. For the study we’ve also considered: total hospital stay, timing after and before the operation, kind and duration of operation, conversion to the open procedure, drain and final pathological results. From this study 29 patients were excluded (17 for choledocolytiasis associated and 12 for hospitalisation > 20 days). We hadn’t excluded patients ASA III and ASA IV: in these patients (27.4 %, 17 ASA III and 4 ASA IV) abdominal pressure not superior of 10 mmHg was used [1]. Elderly patients included in the study were 85 (49 M, 36 F). Ordinary Cholecystectomy were peformed in 45 cases and Emergency Cholecystectomy in 40 cases. This last group was further divided into two groups [2-4]: DEA Early, E-DLC, (31 patients operated on within 72 hours from onset of symptoms) and DEA Delayed, DDLC, (9 patients operated on after 72 hours to 9 days from onset of symptoms). We’ve also considered the operating team (Table 1) that performed the operation because the first operator’s experience was considered as an important factor in order to evaluate our results [5-11].

Laparoscopic appendectomy in the elderly: our experience

BackgroundLaparoscopic appendectomy for acute appendicitis is one of the most common surgical procedures performed in the world. We aimed to compare laparoscopic and open appendectomy in the elderly in our experience.MethodsWe performed a retrospective review of elderly patients who underwent appendectomy for acute appendicitis from 1st of January 2006 to the 31st of July 2012. We analyzed 39 appendectomies in elderly patients: 20 procedures were performed using open technique (Group O) and 19 using laparoscopic technique (Group L).ResultsIn the analysis of intraoperative variables there was no statistically significant difference. In this study there was no statistically significant difference also in peri-operative variables.ConclusionLaparoscopic appendectomy is a safe and feasible technique in acute appendicitis also in the elderly.

Informed consent in robotic surgery: quality of information and patient perception

Abstract Introduction Obtaining a valid informed consent in the medical and surgical field is a long debated issue in the literature. In robotic surgery we believe in the necessity to follow three arrangements to make the informed consent more complete. Material and methods This study presents correlations and descriptions based on forensic medicine concepts research, literature review, and the proposal of an integration in the classic concept of informed consent. Conclusion In robotic surgery we believe in the necessity to follow three arrangements to make the IC more complete. Integrate the information already present in the informed consent with data on the surgeon’s experience in RS, the number of procedures of the department and the regional map of expertises by procedure.

Laparoscopic repair of wound defects in the elderly: our experience of 5 years

BackgroundLaparoscopic approach for wound defects is a procedure that aims to reduce surgical aggressiveness against the abdominal wall by using minimal incisions and dedicated instruments.MethodsWe report our experience about clinical outcome of elderly patients undergoing laparoscopic repair for incisional hernias (Group I) and primary inguinal hernias (Group II) from June 2007 to September 2012.We analyzed preoperative and postoperative data for the laparoscopic approach in the elderly.Results and discussionIn our experience there was no significant difference in laparoscopic procedure between normalweight and overweight patients.ConclusionsLaparoscopic repair for primary inguinal hernias and incisional ventral hernias with transabdominal placement of composite mesh in the elderly achieves excellent results with lower morbidity in comparison with open surgical approaches.

Meso-pancreatectomy for pancreatic neuroendocrine tumor.

We report a case of a meso-pancreatectomy performed on a pancreatic glucagonoma in a 58 years-old woman. MP is a conservative surgical treatment consisting in a resection of the body of the pancreas with the aim of reducing postoperative hormone insufficiency. This approach is curative in benign or low-malignant neoplasm of the central part of the pancreas.

Fibrin glue versus stapler fixation in laparoscopic transabdominal inguinal hernia repair: a single center 5-year experience and analysis of the results in the elderly.

INTRODUCTION Inguinal hernia surgery is one of the most common surgical procedures performed worldwide. Some studies demonstrated clear advantages of laparoscopic approach in terms of chronic pain, recurrence rate and daily life activities Aim of this study was to compare short and long-terms outcome of tacks and fibrin glue used during laparoscopic transabdominal hernioplasty (TAPP). METHODS This is a retrospective study conducted by our division of General Surgery. From May 2008 to May 2013 we performed 116 hernioplasty with TAPP technique. We compared two groups of patients: a group of 59 patients treated with fibrin glue and a group of 57 patients treated with conventional tacks and the two subgroups of patients over 65 years old. We evaluated: perioperative outcomes, early and late complications. RESULTS There were no significative difference about length of postoperative stay, time to return to work, recurrence rate and complications. DISCUSSION This study demonstrates that fibrin glue are same tolerated than tacks by patients and that the glues lead to the same good results during initial follow-up and in long term data also in the elderly. Meticulous preparation of the groin with preservation of spermatic sheet is in our opinion necessary to provide effective pain reduction and a good result in every TAPP procedure.

Malfunctions of robotic system in surgery: role and responsibility of surgeon in legal point of view

Abstract Robotic surgery (RS) technology has undergone rapid growth in the surgical field since its approval. In clinical practice, failure of robotic procedures mainly results from a surgeon’s inability or to a device malfunction. We reviewed the literature to estimate the impact of this second circumstance in RS and its consequent legal implications. According to data from the literature, device malfunction is rare. We believe it is necessary to complement surgical training with a technical understanding of RS devices.

Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: A randomized prospective clinical trial in young and elderly patients

Abstract Laparoscopic transabdominal preperitoneal inguinal hernia repair is a safe and effective technique. In this study we tested the hypothesis that self-gripping mesh used with the laparoscopic approach is comparable to polypropylene mesh in terms of perioperative complications, against a lower overall cost of the procedure. We carried out a prospective randomized trial comparing a group of 30 patients who underwent laparoscopic inguinal hernia repair with self-gripping mesh versus a group of 30 patients who received polypropylene mesh with fibrin glue fixation. There were no statistically significant differences between the two groups with regard to intraoperative variables, early or late intraoperative complications, chronic pain or recurrence. Self-gripping mesh in transabdominal hernia repair was found to be a valid alternative to polypropylene mesh in terms of complications, recurrence and postoperative pain. The cost analysis and comparability of outcomes support the preferential use of self-gripping mesh.