Surgery Research and Practice The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Vacuum-Assisted Abdominal Closure Is Safe and Effective: A Cohort Study in 74 Consecutive Patients Mon, 11 Sep 2017 10:30:02 +0000 Background. Vacuum-assisted closure (VAC) has, in many instances, become the treatment of choice in patients with abdominal catastrophes. This study describes the use and outcome of ABThera KCI® VAC in the Region Southern Denmark covering a population of approximately 1.202 mill inhabitants. Method. A prospective multicenter study including all patients treated with VAC during an eleven-month period. Results. A total of 74 consecutive patients were included. Median age was 64.4 (9–89) years, 64% were men, and median body mass index was 25 (17–42). Duration of VAC treatment was median 4.5 (0–39) days with median 1 (0–16) dressing changes. Seventy per cent of the patients attended the intensive care unit. The 90-day mortality was 15%. A secondary closure of the fascia was obtained in 84% of the surviving patients. Only one patient developed an enteroatmospheric fistula. Patients with secondary closure were less likely to develop large hernias and had better self-evaluated physical health score (p < 0,05). No difference in mental health was found. Conclusion. The abdominal VAC treatment in patients with abdominal catastrophes is safe and with a relative low complication rate. Whether it might be superior to conventional treatment with primary closure when possible has yet to be proven in a randomized study. R. O. Jensen, T. Buchbjerg, R. M. Simonsen, R. Eckardt, and N. Qvist Copyright © 2017 R. O. Jensen et al. All rights reserved. Improved Biochemical Parameters in Patients Who Undergo Early Resection in Isolated Ileocaecal Crohn’s Disease Mon, 10 Jul 2017 08:49:55 +0000 Introduction. The aim of this study is to evaluate the outcome of introduction of early surgery in the course of isolated ileocecal Crohn’s disease, where there is no absolute indication of surgery. Methods. Observational study involving patients with isolated ileocecal Crohn’s disease who underwent early surgical resection (within one year of the presentation of the hospital). A complete blood count, ESR, and CRP were done and compared between the preoperative value, 1st postoperative visit (3-4 weeks), and last follow-up visit. Statistical analysis was done using Analysis of Variance (ANOVA) to compare the different figures. Results. There was a statistically significant increase in the hemoglobin levels between preoperative, postoperative, and long-term follow-up and a significant decrease in leukocyte count between the pre- and postoperative values (, and , , resp.). Similarly, the ESR and CRP values were decreased significantly at long-term follow-up (, and , , resp.). Conclusion. Early surgical resection in isolated ileocaecal Crohn’s disease achieved significant biochemical improvements. These successful results in this small number of patients indicate that early surgical intervention may provide better outcomes. These initial results encourage larger and comparative studies of long-term results versus long-term use of biological agents. Mirzafaraz Saeed, Hari Hullur, Amro Salem, Abbas Ali, Yousif Sahib, and Mobeen Ashfaq Copyright © 2017 Mirzafaraz Saeed et al. All rights reserved. Diagnosis and Management of Intraoperative Colorectal Anastomotic Leaks: A Global Retrospective Patient Chart Review Study Wed, 14 Jun 2017 00:00:00 +0000 Background. This targeted chart review study reports the first ever detailed global account of clinical approaches adopted to detect and manage anastomotic leaks identified during surgery in routine clinical practice. Method. 156 surgeons from eight countries retrospectively extracted data from surgical records of 458 patients who underwent colorectal surgery with an identified intraoperative leak at the circular anastomosis. Demographic details, procedures, and outcomes were analyzed descriptively, by country. Results. Most surgeries were performed laparoscopically (57.6%), followed by open surgeries (35.8%). The burden of intraoperative leaks on the healthcare system is driven in large part by the additional interventions such as using a sealant, recreating the anastomosis, and diverting the anastomosis to a colostomy bag, undertaken to manage the leak. The mean duration of hospitalization was 19.9 days. Postoperative anastomotic leaks occurred in 62 patients (13.5%), most frequently 4 to 7 days after surgery. Overall, country-specific differences were observed in patient characteristics, surgical procedures, method of diagnosis of intraoperative leak, interventions, and length of hospital stay. Conclusion. The potential cost of time and material needed to repair intraoperative leaks during surgery is substantial and often hidden to the healthcare system, potentially leading to an underestimation of the impact of this complication. A. Schiff, S. Roy, M. Pignot, S. K. Ghosh, and E. J. Fegelman Copyright © 2017 A. Schiff et al. All rights reserved. Laparoscopic Cholecystectomy in the Elderly: An Experience at a Tertiary Care Hospital in Western Nepal Wed, 10 May 2017 06:29:55 +0000 Background. The incidence of gallstone increases with increasing age. No studies have been reported in the elderly population with laparoscopic cholecystectomy from developing nations. The aim of this study was to compare perioperative outcomes of laparoscopic cholecystectomy between the elderly (≥60 years old) and the young (<60 years old). Methods. From July 2015 to June 2016, a retrospective review of medical records of 78 elderly patients (≥60 years old) and 164 young patients (<60 years old) who underwent laparoscopic cholecystectomy was done. The patients’ demographics and perioperative outcomes were analyzed. Results. Median ages were 65 years (range: 60–80) and 45 years (range: 21–59) for the elderly group and the young group. The majority of patients were female (62.8 and 72%). There were no significant differences in the conversion rate (9 and 7.9%, ), postoperative complications (17.9 and 14.6%, ), and length of stay in the hospital (4 days for both groups, ) between the two groups. There was no mortality in either of the groups. Conclusion. Our results of laparoscopic cholecystectomy in elderly patients are comparable with those in young patients. Therefore, laparoscopic cholecystectomy is safe even in the elderly population. Tika Ram Bhandari, Sudha Shahi, Rajeev Bhandari, and Rajesh Poudel Copyright © 2017 Tika Ram Bhandari et al. All rights reserved. Intraoperative Injection of Technetium-99m Sulfur Colloid for Sentinel Lymph Node Biopsy in Breast Cancer Patients: A Single Institution Experience Thu, 13 Apr 2017 00:00:00 +0000 Background. Most institutions require a patient undergoing sentinel lymph node biopsy to go through nuclear medicine prior to surgery to be injected with radioisotope. This study describes the long-term results using intraoperative injection of radioisotope. Methods. Since late 2002, all patients undergoing a sentinel lymph node biopsy at the Yale-New Haven Breast Center underwent intraoperative injection of technetium-99m sulfur colloid. Endpoints included number of sentinel and nonsentinel lymph nodes obtained and number of positive sentinel and nonsentinel lymph nodes. Results. At least one sentinel lymph node was obtained in 2,333 out of 2,338 cases of sentinel node biopsy for an identification rate of 99.8%. The median number of sentinel nodes found was 2 and the mean was 2.33 (range: 1–15). There were 512 cases (21.9%) in which a sentinel node was positive for metastatic carcinoma. Of the patients with a positive sentinel lymph node who underwent axillary dissection, there were 242 cases (54.2%) with no additional positive nonsentinel lymph nodes. Advantages of intraoperative injection included increased comfort for the patient and simplification of scheduling. There were no radiation related complications. Conclusion. Intraoperative injection of technetium-99m sulfur colloid is convenient, effective, safe, and comfortable for the patient. Julian Berrocal, Lawrence Saperstein, Baiba Grube, Nina R. Horowitz, Anees B. Chagpar, Brigid K. Killelea, and Donald R. Lannin Copyright © 2017 Julian Berrocal et al. All rights reserved. Viability of Airborne Tumor Cells during Excision by Ultrasonic Device Sun, 09 Apr 2017 00:00:00 +0000 Background. Laparoscopic surgery has become more widely used, but peritoneal dissemination and port-site metastasis have been reported to occur in these surgeries. One reason for these problems is the ultrasonically activated scalpel (UAS) used for laparoscopic surgery. This study aimed to investigate the viability of airborne cells released during cancer dissection using a UAS. Methods. Flank tumors measuring about 2 cm were induced in male NOD-Cg-RagIL2r mice by subcutaneous injection of 1 × 106 HepG2 cells. Dissection was performed with UAS (in high or low power modes) and PowerStar bipolar scissors. The mist of released tissue was collected in cell culture medium. The viability of the cellular material was assessed with trypan blue exclusion cell counting, counting after immunofluorescence staining, and flow cytometric analysis. Results. Large quantities of cellular debris were trapped in the tissue dispersed by both devices. In all experiments, there were significantly more viable cells produced by the UAS in high power mode. By using suction at the excision site, the number of viable cancer cells was reduced. Conclusions. This study demonstrates that viable cancer cells can be released into the nearby environment during tumor ablation with a UAS. Masakazu Hashimoto, Tsuyoshi Kobayashi, Hirotaka Tashiro, Shintaro Kuroda, Yoshihiro Mikuriya, Tomoyuki Abe, Yuka Tanaka, and Hideki Ohdan Copyright © 2017 Masakazu Hashimoto et al. All rights reserved. Clinical Study on the Etiology of Postthyroidectomy Skin Sinus Formation Sun, 12 Mar 2017 00:00:00 +0000 Background. Thyroidectomy is one of the most frequently performed surgical procedures worldwide. Despite technical advances and high experience of thyroidectomy of specialized centers, it is still burdened by a significant rate of postoperative complications. Among them, the skin sinus formation is an extremely rare postthyroidectomy complication. Here, we first report the incidence of the skin sinus formation after thyroidectomy to identify the causes for skin sinus formation after thyroidectomy and to discuss its prevention and treatment options. Methods. A retrospective analysis was carried out of patients who underwent excision operation of fistula for postthyroidectomy skin sinus formation. Data were retrieved from medical records department of the Affiliated Hospital of Inner Mongolia Medical University. Results. Of the 5,686 patients who underwent thyroid surgery, only 5 patients (0.088%) had developed skin sinus formation. All 5 patients successfully underwent complete excision of fistula. Conclusion. Infection, foreign body, thyroid surgery procedure, combined disease, and iatrogenic factors may be related with skin sinus formation after thyroidectomy. To reduce the recurrence of postoperative infections and sinus formation, intra- and postoperative compliance with aseptic processing, intraoperative use absorbable surgical suture/ligature, repeated irrigation and drainage, and postoperative administration of anti-inflammatory treatment are to be followed. Shan Jin, Wuyuntu Bao, Oyungerel Borkhuu, and Yun-Tian Yang Copyright © 2017 Shan Jin et al. All rights reserved. Diagnosis, Symptoms, and Outcomes of Hirschsprung’s Disease from the Perspective of Gender Tue, 07 Mar 2017 08:51:11 +0000 Background/Aim. Hirschsprung’s disease (HD) has a skewed gender distribution, with a female to male ratio of 1 : 4. This study aims to examine differences between boys and girls with HD regarding preoperative features and postoperative treatment and outcome. Method. The first part of the study was conducted as a retrospective review of all HD patients who underwent transanal endorectal pull-through (TERPT). Pre-, peri-, immediate post-, and first-year postoperative data were collected. The second part was conducted as an observational cross-sectional study by comparing bowel function scores (BFS) determined by structured interviews of patients 4 years old and older. Results. Included were 39 boys and 12 girls. Of these, 25 boys and 9 girls were older than 4 years and participated in the BFS interview. Boys had a higher frequency of hospitalizations during the first postoperative year compared to girls ( and , ). At long-term follow-up, more boys reported abnormal frequency of defecation, 16 compared to 2 (). There was no difference between genders in terms of preoperative symptoms and overall bowel function later. Conclusion. Boys with HD had more hospitalizations and a higher rate of abnormal frequency of defecation than girls with HD. Christina Granéli, Eero Dahlin, Anna Börjesson, Einar Arnbjörnsson, and Pernilla Stenström Copyright © 2017 Christina Granéli et al. All rights reserved. Mesh Inguinal Hernia Repair and Appendectomy in the Treatment of Amyand’s Hernia with Non-Inflamed Appendices Tue, 17 Jan 2017 08:11:38 +0000 Amyand’s hernia is defined as protrusion of the vermiform appendix in an inguinal hernia sac. It is a rare entity with variable clinical presentation from normal vermiform appendix to abscess formation due to perforation of acute appendicitis. Although surgical treatment includes appendectomy and hernia repair, appendectomy in the absence of an inflamed appendix and use of a mesh in cases of appendectomy remain to be controversial. The aim of this study was to review the experience of mesh inguinal hernia repair plus appendectomy performed for Amyand’s hernia with noninflamed appendices. There were five male patients with a mean age of 42.4 ± 16.1 years in this retrospective study in which Amyand’s hernia was treated with mesh inguinal hernia repair plus appendectomy for noninflamed appendices. Patients with acute appendicitis and perforated vermiform appendix were excluded. There were four right sided and one bilateral inguinal hernia. Postoperative courses were uneventful. During the follow-up period (14.0 ± 7.7 months), there was no inguinal hernia recurrence. Mesh inguinal hernia repair with appendectomy can be performed for Amyand’s hernia in the absence of acute appendicitis. However, presence of fibrous connections between the vermiform appendix and the surrounding hernia sac may be regarded as a parameter to perform appendectomy. Emin Kose, Abdullah Sisik, and Mustafa Hasbahceci Copyright © 2017 Emin Kose et al. All rights reserved. Incidence and Etiology of Surgical Site Infections among Emergency Postoperative Patients in Mbarara Regional Referral Hospital, South Western Uganda Thu, 12 Jan 2017 10:32:57 +0000 Background. This prospective hospital based study was conducted to determine the incidence, risk factors, and causative agents of surgical site infection their susceptibility to among 114 emergency postoperative patients at the Mbarara Regional Referral Hospital between September 2014 and January 2015. Methods. Consented patients were consecutively enrolled and their preoperative, intraoperative, and postoperative data were collected. Follow-ups were done in the surgical outpatient clinics. Wound specimens were collected and processed as per Sops; susceptibility testing was done using the Kirby-Bauer disc diffusion technique. Data was analyzed using STATA 11.0. Results. Overall SSI incidence was 16.4%: 5.9% superficial and 47.1% deep and organ space SSIs each. Klebsiella pneumoniae was the most predominant organism (50%) followed by Staphylococcus aureus (27.8%). E. coli and P. aeruginosa both accounted for 11.1%. Wound class (), anaemia (), low serum albumin (), and property of suture material used () were significantly associated with SSIs. All organisms had 100% resistance to ampicillin, tetracycline, septrin, and erythromycin. Ciprofloxacin and ceftriaxone are highly sensitive to all organisms. Conclusion. The incidence of SSI in this hospital is very high. Klebsiella pneumoniae is the predominant cause. Ciprofloxacin are very potent antibiotics against organisms that cause SSI. Abubaker Lubega, Bazira Joel, and Najjuka Justina Lucy Copyright © 2017 Abubaker Lubega et al. All rights reserved. Laparoscopic Treatment of Adrenal Tumors: A Single-Center Experience with 58 Patients Wed, 16 Nov 2016 05:54:20 +0000 Background. The aim of this study is to discuss the laparoscopic approach and assess the immunohistochemical expression profiles of synaptophysin, Ki-67, and inhibin and patient outcomes in adrenal masses through a series of cases treated at our institution. Method. The study was conducted on 58 patients who were diagnosed with adrenal masses. All cases were operated on laparoscopically for adrenal masses. Results. Both inhibin and synaptophysin were found positive in 45 patients (77,6%). Ki-67 was negative in 11 patients, whereas it was found positive in 42 with a rate of 1%. The size of the masses ranged from 1 up to 9 cm (mean 4,3 ± 1,5). Urine hormone excretion was measured within normal ranges in 47 out of 58 patients (81%). Most of the diagnosed patients were harboring Cortical Adenoma (: 38; 65,5%). All of the masses were successfully resected without complication except 3 patients. Because of complications of bleeding, the operation was converted to open surgery for 2 patients. Conclusion. Morbidity, mortality, and healing were comparable, regardless of tumor size, yet involvement in both laparoscopic and adrenal surgery was required. Our results suggested that laparoscopic adrenalectomy should replace open surgery as the standard treatment for most adrenal masses. Aziz Ari, Kenan Buyukasik, Cihad Tatar, Ozgur Segmen, Feyzullah Ersoz, Soykan Arikan, Feray Gunver, and Serkan Sari Copyright © 2016 Aziz Ari et al. All rights reserved. Physiotherapy Practice Patterns for Management of Patients Undergoing Thoracic Surgeries in India: A Survey Mon, 31 Oct 2016 13:36:07 +0000 Aim. The aim of the current study is to determine the practice patterns of physiotherapists for patients undergoing thoracic surgeries in India. Materials and Methodology. A cross-sectional survey was conducted across India in which 600 questionnaires were sent in emails to physiotherapists. The questionnaire addressed assessment and treatment techniques of thoracic surgery. Results. A total of 234 completed questionnaires were returned with a response rate of 39%, with the majority of responses received from Telangana, Karnataka, and Andhra Pradesh. More than 90% of the responders practiced physical examination, chest expansion, chest X-ray, ABG analysis, pulmonary function test, and SpO2 (oxygen saturation) as the assessment measures in both the pre- and the postoperative phase. Breathing exercises, incentive spirometry, thoracic expansion exercises, coughing and huffing, positioning, and modified postural drainage are found to be commonly used physiotherapy interventions, both pre- and postoperatively, with a response rate of more than 90%. A response rate of more than 84.6% indicated that patients are made to dangle their lower limbs over the edge of the bed on the 1st postoperative day. Mobilization, such as walking up to a chair, sit to stand exercises, and perambulation within the patient’s room, was started on the 2nd postoperative day, as stated by more than 65% of the physiotherapists. Staircase climbing was started on the 5th postoperative day. The most commonly used functional evaluation prior to discharge was 6-minute walk test. This was, in fact, practiced by 77.4% of the physiotherapists in their clinical settings. Conclusion. The most predominantly employed assessment measures included were physical examination, chest expansion, ABG analysis, pulmonary function test, chest X-ray, SpO2 (oxygen saturation), peripheral muscle strength, and cardiopulmonary exercise. The physiotherapy interventions most commonly used were breathing exercises, thoracic expansion exercises, incentive spirometry, and coughing and huffing techniques, in both the pre- and the postoperative phase. Sagarika Sultanpuram, Gopala Krishna Alaparthi, Shyam Krishnan Krishnakumar, and Zulfeequer C. P. Ottayil Copyright © 2016 Sagarika Sultanpuram et al. All rights reserved. Laparoscopic versus Open Surgery in Complicated Appendicitis in Children Less Than 5 Years Old: A Six-Year Single-Centre Experience Sun, 25 Sep 2016 09:39:17 +0000 Introduction. Acute appendicitis is the most common surgical emergency in the pediatric population. The peak incidence occurs in the first decade of life, while it is uncommon to face appendicitis in children younger than 5 years of age. Laparoscopy is now demonstrated to be the optimal approach also to treat complicated appendicitis, but in very young children this standardized operation is not always easy to perform. Material and Methods. From January 2009 to December 2015 we operated on 525 acute appendicitis, with 120 patients less than 5 years of age. Results. 90 children had a complicated appendicitis (localized or diffuse peritonitis): 43 (48%) were operated on by open approach and 47 (52%) by laparoscopy. The overall incidence of postoperative complications was greater in the open appendectomy group (63% versus 26%) and all severe complications requiring reintervention (6% of cases: 3 postoperative abscesses resolved with ultrasound guided percutaneous abscess drainage; 1 tubal surgery for salpingitis; 1 adhesion-related ileus requiring relaparotomy) were mostly associated with open surgery. Conclusions. Laparoscopic surgery resulted as the best approach for treating complicated appendicitis also in younger children, with minor and less severe postoperative complications compared to open surgery. R. Guanà, L. Lonati, S. Garofalo, N. Tommasoni, L. Ferrero, A. Cerrina, R. Lemini, C. Dallan, and J. Schleef Copyright © 2016 R. Guanà et al. All rights reserved. Laparoscopic versus Open Omental Patch Repair for Early Presentation of Perforated Peptic Ulcer: Matched Retrospective Cohort Study Mon, 19 Sep 2016 09:24:36 +0000 Introduction. The aim of this study was to compare the outcomes between laparoscopic and open omental patch repair (LOPR versus OR) in patients with similar presentation of perforated peptic ulcer (PPU). The secondary aim was to evaluate the outcomes according to the severity of peritonitis. Methods. All patients who underwent omental patch repair at two university-affiliated institutes between January 2010 and December 2014 were reviewed. Matched cohort between LOPR and OR groups was achieved by only including patients that had ulcer perforation <2 cm in size and symptoms occurring <48 hours. Outcome measures were defined in accordance with length of stay (LOS), postoperative complications, and mortality. Results. 148 patients met the predefined inclusion criteria with LOPR performed in 40 patients. Outcome measures consistently support laparoscopic approach but only length of hospital stay (LOS) achieved statistical significance (LOPR 4 days versus OR 5 days, ). In a subgroup analysis of patients with MPI score >21, LOPR is also shown to benefit, particularly resulting in significant shorter LOS (4 days versus 11 days, ). Conclusion. LOPR offers improved short-term outcomes in patients who present within 48 hours and with perforation size <2 cm. LOPR also proved to be more beneficial in high MPI cases. Daniel Jin Keat Lee, MaDong Ye, Keith Haozhe Sun, Vishalkumar G. Shelat, and Aaryan Koura Copyright © 2016 Daniel Jin Keat Lee et al. All rights reserved. A Prospective Observational Cohort Study on Orthopaedic and Anaesthetic Registrars Performing Femoral Nerve Block on Patients with an Acute Hip Fracture Thu, 15 Sep 2016 16:08:53 +0000 We investigated if a femoral nerve block (FNB) for patients with a proximal femoral fracture (PFF) and administered by an orthopaedic registrar (OR) instead of an anaesthesiology registrar (AR) lowers the lead time to block and reduces the total amount of rescue analgesics during the preoperative phase. 205 patients were included in a prospective observational cohort study. The main outcome variable was rescue analgesics as total intravenous morphine prior to surgery. All results were adjusted for confounding using age, sex, cognitive dysfunction, and ASA classification. The OR group () was over 2 hours faster in performing the block compared to the AR group () but was nonetheless correlated with an increased amount of rescue analgesics during the study, 2.4 mg morphine (95% CI 0.0–4.9) more compared to the AR group. We found no difference between the groups in the risk of adverse events. We conclude that, for patients with an acute PFF and with morphine consumption as end point, how soon from arrival to hospital the patients receive a FNB is of lesser importance than who is administering it. Based on our results we recommend that emergency hospitals should have routines for anaesthesiologists performing FNB on this frail patient group. Åsa Thelaus, Tobias Pettersson, Max Gordon, Ferid Krupic, and Olof Sköldenberg Copyright © 2016 Åsa Thelaus et al. All rights reserved. Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter Thu, 25 Aug 2016 06:21:14 +0000 Benefits of ERAS protocol have been well documented; however, it is unclear whether the improvement stems from the protocol or shifts in expectations. Interdisciplinary educational seminars were conducted for all health professionals. However, one test surgeon adopted the protocol. 394 patients undergoing elective abdominal surgery from June 2013 to April 2015 with a median age of 63 years were included. The implementation of ERAS protocol resulted in a decrease in the length of stay (LOS) and mortality, whereas the difference in cost was found to be insignificant. For the test surgeon, ERAS was associated with decreased LOS, cost, and mortality. For the control providers, the LOS, cost, mortality, readmission rates, and complications remained similar both before and after the implementation of ERAS. An ERAS protocol on the single high-volume surgical unit decreased the cost, LOS, and mortality. Timothy L. Fitzgerald, Catalina Mosquera, Nicholas J. Koutlas, Nasreen A. Vohra, Kimberly V. Edwards, and Emmanuel E. Zervos Copyright © 2016 Timothy L. Fitzgerald et al. All rights reserved. Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies Wed, 24 Aug 2016 13:06:45 +0000 Introduction. Epidural analgesia has been a cornerstone of any ERAS program for open colorectal surgery. With the improvements in anesthetic and analgesic techniques as well as the introduction of the laparoscopy for colorectal resection, the role of epidural analgesia has been questioned. The aim of the review was to assess through a meta-analysis the impact of epidural analgesia compared to other analgesic techniques for colorectal laparoscopic surgery within an ERAS program. Methods. Literature research was performed on PubMed, Embase, and the Cochrane Library. All randomised clinical trials that reported data on hospital stay, postoperative complications, and readmissions rates within an ERAS program with and without an epidural analgesia after a colorectal laparoscopic resection were included. Results. Five randomised clinical trials were selected and a total of 168 patients submitted to epidural analgesia were compared to 163 patients treated by an alternative analgesic technique. Pooled data show a longer hospital stay in the epidural group with a mean difference of 1.07 (95% CI 0.06–2.08) without any significant differences in postoperative complications and readmissions rates. Conclusion. Epidural analgesia does not seem to offer any additional clinical benefits to patients undergoing laparoscopic colorectal surgery within an ERAS program. Giuseppe Borzellino, Nader Kamal Francis, Olivier Chapuis, Evguenia Krastinova, Valérie Dyevre, and Michele Genna Copyright © 2016 Giuseppe Borzellino et al. All rights reserved. Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair Using Memory-Ring Mesh: A Pilot Study Thu, 18 Aug 2016 07:50:50 +0000 Purpose. To evaluate the feasibility, safety, and effectiveness of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair using a memory-ring patch (Polysoft™ mesh). Patients and Methods. Between April 2010 and March 2013, a total of 76 inguinal hernias underwent TAPP repair using Polysoft mesh in 67 adults under general anesthesia. Three different senior resident surgeons performed TAPP repair under the instruction of a specialist surgeon. Nine patients had bilateral hernias. The 76 hernias included 37 indirect inguinal hernias, 29 direct hernias, 1 femoral hernia, 1 pantaloon hernia (combined direct/indirect inguinal hernia), and 8 recurrent hernias after open anterior hernia repair. The immediate postoperative outcomes as well as the short-term outcomes (mainly recurrence and incidence of chronic pain) were studied. Results. There was no conversion from TAPP repair to anterior open repair. The mean operation time was 109 minutes (range, 40–132) for unilateral hernia repair. Scrotal seroma was diagnosed at the operation site in 5 patients. No patient had operation-related orchitis, testicle edema, trocar site infection, or chronic pain during follow-up. Conclusions. The use of Polysoft mesh for TAPP inguinal hernia repair does not seem to adversely affect the quality of repair. The use of this mesh is therefore feasible and safe and may reduce postoperative pain. Takeshi Matsutani, Tsutomu Nomura, Nobutoshi Hagiwara, Akihisa Matsuda, Yoshimune Takao, and Eiji Uchida Copyright © 2016 Takeshi Matsutani et al. All rights reserved. Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach Mon, 18 Jul 2016 09:27:59 +0000 ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of “multimodal” and “multidisciplinary” approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of “outcome” may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards “protective” techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery. Dario Bugada, Valentina Bellini, Andrea Fanelli, Maurizio Marchesini, Christian Compagnone, Marco Baciarello, Massimo Allegri, and Guido Fanelli Copyright © 2016 Dario Bugada et al. All rights reserved. Comment on “Surgically Resected Gall Bladder: Is Histopathology Needed for All?” Sun, 17 Jul 2016 12:37:02 +0000 Savio George Barreto Copyright © 2016 Savio George Barreto. All rights reserved. Improving Surgical Access in Rural Africa through a Surgical Camp Model Thu, 16 Jun 2016 07:55:04 +0000 Introduction. Surgical camps are preplanned activities where volunteer surgical teams congregate at specified place(s) and perform a wide range of mostly elective procedures for a limited period of time. This is usually at no cost to the patients, who belong to vulnerable (poor and hard to reach) communities. We describe a surgical camp model and its challenges as a means of improving access to surgical services. Methods. A cross-sectional descriptive study. Data from a recent Association of Surgeons of Uganda surgical camp were collected and analyzed for demographics, costs, procedure types, and rates and, in addition, challenges encountered and solutions. Personnel that participated in this exercise included specialist surgeons, surgical residents, medical officers, clinical officers, anesthetists, and theater nurses (a total of 121 staff). Results. In total, 551 procedures were performed during a four-day-long camp. Mean age was 35 years (SD 23), M : F ratio was 2 : 1. Herniorrhaphy, skin lump excision, hydrocelectomy, and thyroidectomy formed 81% of all the procedures. Average cost per procedure was $73 USD. Conclusion. Surgical camps offer increased access to surgical services to vulnerable populations. Hernias and goiters were most common. Surgical camps should become an integral part of the Health Service delivery in low-resourced environments. M. Galukande, O. Kituuka, E. Elobu, J. Jombwe, J. Sekabira, Elissa Butler, and J. Faulal Copyright © 2016 M. Galukande et al. All rights reserved. The Onstep Method for Inguinal Hernia Repair: Operative Technique and Technical Tips Thu, 09 Jun 2016 13:51:01 +0000 Inguinal hernia repair is one of the most common surgical procedures and several different surgical techniques are available. The Onstep method is a new promising technique. The technique is simple with a number of straightforward steps. This paper provides a full description of the technique together with tips and tricks to make it easy and without complications. Jacob Rosenberg and Kristoffer Andresen Copyright © 2016 Jacob Rosenberg and Kristoffer Andresen. All rights reserved. Through Thick and Thin: Identifying Barriers to Bariatric Surgery, Weight Loss Maintenance, and Tailoring Obesity Treatment for the Future Mon, 23 May 2016 13:17:28 +0000 More than one-third of the adults in the United States are obese. This complex metabolic disorder is associated with multiple comorbidities and increased all-cause mortality. Bariatric surgery has been shown to be more effective than medical therapy and has been associated with weight loss maintenance and decreased mortality. In spite of these well-established benefits, less than 1% of candidates undergo surgery due to multiple factors, such as patient and physician perceptions and attitudes, patient-physician interaction, lack of resources, and cost burden. Furthermore, even in patients who do undergo bariatric surgery and/or alternate weight loss interventions, long-term weight control is associated with high-risk failure and weight regain. In this review, we highlight some of the current barriers to bariatric surgery and long-term weight loss maintenance and underscore the importance of an individualized multidisciplinary longitudinal strategy for the treatment of obesity. Donevan Westerveld and Dennis Yang Copyright © 2016 Donevan Westerveld and Dennis Yang. All rights reserved. The Comparison of Lichtenstein Procedure with and without Mesh-Fixation for Inguinal Hernia Repair Thu, 21 Apr 2016 07:51:49 +0000 Aim. Although inguinal hernia repair is the most frequently performed surgical procedure in the world, the best repair method has not gained acceptance yet. The ideal repair must be safe, simple, and easy to perform and require minimal dissection which provides enough exploration, maintain patient’s comfort in the early stage, and also be cost-effective, reducing operation costs, labor loss, hospital stay, and recurrence. Materials and Methods. There were eighty-five patients between the ages of 18 and 75, diagnosed with inguinal hernia in our clinic. Lichtenstein procedure for hernia repair was performed under spinal anesthesia in all patients. Forty-two patients had the standard procedure and, in 43 patients, the polypropylene mesh was used without fixation. All patients were examined and questioned on the 7th day of the operation in terms of pain, scrotal edema, and the presence of seroma and later on in the 6th postoperative month in terms of paresthesia, neuropraxia, and recurrence by a single physician. Results. Operative time and pain scores in the nonfixation group were significantly lower, without any increase in rates of recurrence. Conclusion. Based on these findings, in Lichtenstein hernia repair method, nonfixation technique can be used safely with better results. Feyzullah Ersoz, Serdar Culcu, Yigit Duzkoylu, Hasan Bektas, Serkan Sari, Soykan Arikan, and Mehmet Mehdi Deniz Copyright © 2016 Feyzullah Ersoz et al. All rights reserved. Evaluation of Spontaneous Pneumothorax Surgeries: A 16-Year Experience in Japan Wed, 13 Apr 2016 09:31:37 +0000 Background. Video-assisted thoracoscopic surgery is the surgical procedure of choice for spontaneous pneumothorax due to its noninvasiveness and convenience. A higher recurrence rate with thoracoscopic bullectomy (TB) than that after traditional thoracotomy (TT) led us to adopt thoracoscopic double-loop ligation (TLL) as our standard procedure in 1998. This study compares the effectiveness and safety of these 3 operative procedures. Methods. Patients who underwent their first surgery for spontaneous pneumothorax at our hospital between January 1994 and December 2010 were included. Patients with a history of surgery for spontaneous pneumothorax, those with special clinical conditions such as lymphangioleiomyomatosis, or those with catamenial, traumatic, or iatrogenic pneumothorax were excluded. Results. A total of 777 males (14–91 years old; 814 pneumothorax sides), and 96 females (16–78 years old; 99 pneumothorax sides) were included in the study. TT was performed in 137 patients (143 sides), TB in 106 patients (112 sides), and TLL in 630 patients (658 sides). The postoperative recurrence rates were 3.5%, 16.1%, and 5.3% in the TT, TB, and TLL groups, respectively (). Mean blood loss and operating time were lowest for TLL. Conclusions. The results suggest that TLL should be the surgical procedure of choice for spontaneous pneumothorax. Ryo Takahashi Copyright © 2016 Ryo Takahashi. All rights reserved. Difficulties and Problematic Steps in Teaching the Onstep Technique for Inguinal Hernia Repair, Results from a Focus Group Interview Sun, 10 Apr 2016 09:20:54 +0000 Background. When a new surgical technique is brought into a department, it is often experienced surgeons that learn it first and then pass it on to younger surgeons in training. This study seeks to clarify the problems and positive experiences when teaching and training surgeons in the Onstep technique for inguinal hernia repair, seen from the instructor’s point of view. Methods. We designed a qualitative study using a focus group to allow participants to elaborate freely and facilitate a discussion. Participants were surgeons with extensive experience in performing the Onstep technique from Germany, UK, France, Belgium, Italy, Greece, and Sweden. Results. Four main themes were found, with one theme covering three subthemes: instruction of others (experience, patient selection, and tailored teaching), comfort, concerns/fear, and anatomy. Conclusion. Surgeons receiving a one-day training course should preferably have experience with other types of hernia repairs. If trainees are inexperienced, the training setup should be a traditional step-by-step programme. A training setup should consist of an explanation of the technique with emphasis on anatomy and difficult parts of the procedure and then a training day should follow. Surgeons teaching surgery can use these findings to improve their everyday practice. Kristoffer Andresen, Jannie Laursen, and Jacob Rosenberg Copyright © 2016 Kristoffer Andresen et al. All rights reserved. Effects of Lornoxicam on Anastomotic Healing: A Randomized, Blinded, Placebo-Control Experimental Study Thu, 07 Apr 2016 13:36:19 +0000 Introduction and Aim. With the implementation of multimodal analgesia regimens, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are often administered for optimal pain control and reduction of opioid use. The aim of the study was to examine the effects of lornoxicam, a NSAID, on anastomotic healing employing an animal model. Materials and Methods. A total of 28 Wistar rats were randomly assigned in two groups. All animals underwent ascending colonic transection followed by an end-to-end hand sewn anastomosis. Group 1 received intraperitoneally lornoxicam before and daily after surgery. Group 2 received intraperitoneally an equal volume of placebo. Half of the animals in each group were euthanized on the 3rd pod and the remaining on the 7th pod. Macro- and microscopic indicators of anastomotic healing were compared using a two-tailed Fisher exact test. Results. The lornoxicam group significantly decreased fibroblast in growth and reepithelization of the mucosa at the anastomotic site on the 3rd pod and significantly increased occurrence of deep reaching defects, necrosis, and microabscess on the 7th pod. Conclusion. Lornoxicam administration during the perioperative period adversely affects histologic parameters of intestinal anastomotic healing. These effects of lornoxicam administration were not found to induce significant increase of anastomotic dehiscence in the rat model. Stamatoula Drakopoulou, Elissaios Kontis, Eirini Pantiora, Antonios Vezakis, Despoina Karandrea, Eftychia Aravidou, Agathi Konti-Paphiti, Erifili Argyra, Dionisios Voros, Andreas A. Polydorou, and Georgios P. Fragulidis Copyright © 2016 Stamatoula Drakopoulou et al. All rights reserved. Surgically Resected Gall Bladder: Is Histopathology Needed for All? Wed, 30 Mar 2016 11:38:37 +0000 Background. Laparoscopic cholecystectomy is considered to be gold standard for symptomatic gall stones. As a routine every specimen is sent for histopathological examination postoperatively. Incidentally finding gall bladder cancers in those specimens is around 0.5–1.1%. The aim of this study is to identify those preoperative and intraoperative factors in patients with incidental gall bladder cancer to reduce unnecessary work load on pathologist and cost of investigation particularly in a developing world. Methods. Retrospective records were analyzed from January 2005 to February 2015 in a surgical unit. Demographic data, preoperative imaging, peroperative findings, macroscopic appearance, and histopathological findings were noted. Gall bladder wall was considered to be thickened if ≥3 mm on preoperative imaging or surgeons comment (on operative findings) and histopathology report. AJCC TNM system was used to stage gall bladder cancer. Results. 973 patients underwent cholecystectomy for symptomatic gallstone disease. Gallbladder carcinoma was incidentally found in 11 cases. Macroscopic abnormalities of the gallbladder were found in all those 11 patients. In patients with a macroscopically normal gallbladder, there were no cases of gallbladder carcinoma. Conclusion. Preoperative and operative findings play a pivotal role in determining incidental chances of gall bladder malignancy. Vikash Talreja, Aun Ali, Rabel Khawaja, Kiran Rani, Sunil Sadruddin Samnani, and Farah Naz Farid Copyright © 2016 Vikash Talreja et al. All rights reserved. Haemostasis in Thyroid Surgery: Collagen-Fibrinogen-Thrombin Patch versus Cellulose Gauze—Our Experience Thu, 25 Feb 2016 11:12:50 +0000 Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, “near total,” or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery. Nicola Tartaglia, Alessandra Di Lascia, Vincenzo Lizzi, Pasquale Cianci, Alberto Fersini, Antonio Ambrosi, and Vincenzo Neri Copyright © 2016 Nicola Tartaglia et al. All rights reserved. High-Volume Transanal Surgery with CPH34 HV for the Treatment of III-IV Degree Haemorrhoids: Final Short-Term Results of an Italian Multicenter Clinical Study Sun, 21 Feb 2016 15:38:20 +0000 The clinical chart of 621 patients with III-IV haemorrhoids undergoing Stapled Hemorrhoidopexy (SH) with CPH34 HV in 2012–2014 was consecutively reviewed to assess its safety and efficacy after at least 12 months of follow-up. Mean volume of prolapsectomy was significantly higher (13.0 mL; SD, 1.4) in larger prolapse (9.3 mL; SD, 1.2) (). Residual or recurrent haemorrhoids occurred in 11 of 621 patients (1.8%) and in 12 of 581 patients (1.9%), respectively. Relapse was correlated with higher preoperative Constipation Scoring System (CSS) (), Pescatori’s degree (), Goligher’s grade (), prolapse exceeding half of the length of the Circular Anal Dilator (CAD) (), and higher volume of prolapsectomy (). At regression analysis, only the preoperative CSS, Pescatori’s degree, Goligher’s grade, and volume of resection were significantly predictive of relapse. A high level of satisfaction (VAS = 8.6; SD, 1.0) coupled with a reduction of 12-month CSS (Δ preoperative CSS/12 mo CSS = 3.4, SD, 2.0; ) was observed. The wider prolapsectomy achievable with CPH34 HV determined an overall 3.7% relapse rate in patients with high prevalence of large internal rectal prolapse, coupled with high satisfaction index, significant reduction of CSS, and very low complication rates. Giuliano Reboa, Marco Gipponi, Maurizio Gallo, Giovanni Ciotta, Marco Tarantello, Angelo Caviglia, Antonio Pagliazzo, Luigi Masoni, Giuseppe Caldarelli, Fabio Gaj, Bruno Masci, and Andrea Verdi Copyright © 2016 Giuliano Reboa et al. All rights reserved.