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Background The two standard methods for inguinal hernioplasty is open and minimal access laparoscopic technique. Most laparoscopic surgeons use a transabdominal preperitoneal approach but totally extraperitoneal (TEP) approach potentially offers several advantages. Objective The aim in this study was to assess the learning curve, cost value, safety, and feasibility of TEP approach. Patients and methods Prospectively collected data on 185 consecutive patients submitted to laparoscopic TEP hernioplasty for inguinal hernia from 2016 to 2018 in Theodor Bilharz Research Institute Hospital. This study involved repair of primary, recurrent inguinal hernia and femoral hernia. The prolene mesh was used for groin hernia repair in all cases with and without fixation. Results All 185 cases started with the laparoscopic TEP technique with only four cases converted to transabdominal preperitoneal technique (2.1%). In 110 (60.7%) cases the mesh was placed without fixation. In 71 cases the mesh was fixed by Tackers or Histoacryl. In unilateral hernia, the mean operating time was 45 min, while in bilateral hernia it was 61 min. Intraoperative complications included three cases of inferior epigastric vessel injury which were managed by metallic clips of 5 mm. The mean pain score was 7.5, while the mean satisfaction score was 5.4. The mean hospital stay was 16.4 h. Regarding postoperative complications, 10 (5.5%) patients developed a postoperative seroma, four (2.1%) patients developed a hematoma, two (1.1%) patients developed a hydrocele, and five (2.7%) patients experienced neuropathic pain. There were three (1.1%) recurrent cases; all these cases were managed by open hernioplasty. Conclusion In this study, the laparoscopic TEP approach is found to be an effective, and safe technique regarding primary, recurrent open inguinal and femoral hernias with good learning curve to laparoscopic surgeon who started with transabdominal preperitoneal technique technique.

Background Patients with decompensated cirrhosis have a high incidence of abdominal wall hernias with a poor outcome after surgical management. Aim The aim was to evaluate the outcome of a new technique in the repair of complicated umbilical hernias in patients with decompensated cirrhosis. Patients and methods In all, 30 consecutive patients with decompensated cirrhosis underwent herniorrhaphy for complicated hernia and were randomized into two groups: group I (n=15) received the new technique: three-transverse-layer technique with regular paracentesis, first, 5–7 interrupted sutures without tie; second, continuous suture starting 3 cm lateral to the angles, third, tie the previous interrupted suture over the continuous tied suture, fourth, the third layer continuous suture to invaginate the previous sutures (using Proline 1/0 at all), fifth, regular paracentesis. Group II (n=15) received two continuous transverse-layer repair, first, suture started 1 cm lateral to the angle and then completed in a continuous manner till 1 cm after the second angle and tied; second, this was then followed by the second layer continuous suture to invaginate the previous sutures. Results Postoperatively, there were complications in 14 (46.67%) patients in the form of wound infection in three (20%) patients in group I and seven (46.67%) patients in group II with no statistical significance between both groups. Wound dehiscence occurred in five (33.33%) patients in group II only with statistical significance between both groups (P Conclusion The new technique of hernia repair in patients with decompensated liver cirrhosis was associated with a significant reduction in wound ascitic leak, wound dehiscence, hospital stay, morbidity, and recurrence.

Objective Liver transplantation is an optimal form of radical therapy for selected patients with hepatocellular carcinoma (HCC). Yet, risk factors determining outcome after living donor liver transplantation (LDLT) are still lacking and need to be well identified to maximize recipient benefit and minimize donor risk. Aim The aim of this study was to retrospectively identify and analyze the factors impacting mortality in HCC patients after LDLT. Patients and methods This is a single-center retrospective analysis of data collected from 205 patients who underwent LDLT in the Department of Surgery, National Liver Institute, Menoufia University, between May 2004 and December 2013. Of these patients, 53 proved to have an HCC in the explanted liver. Preoperative data such as demographic criteria of the patients, liver status, tumor burden, and downstaging or bridging procedures, and all intraoperative and postoperative data were collected and compared against mortality outcome. Mortality was divided into three periods: hospital mortality, which occurred within 30 days after operation; early mortality, which occurred between 2 and 6 months postoperatively; and late mortality, which occurred 6 months after transplantation. Results The mean age of all patients was 48±6.1 years; 50 (94.3%) patients were male. During the follow-up period, 22 (41.5%) patients died. The majority of mortality cases (10; 18.9%) were in the perioperative period; six (11.3%) patients died in the early period and six (11.3%) in the late period. There was a statistically significant relation between mortality rate and cytomegalovirus immunoglobulin (CMV-IgG) negativity and TNM classification (IIIB). Concerning the operative data, there was a significant statistical relation between mortality and actual graft weight, actual graft/recipient weight ratio, and number of blood and plasma transfused units. Postoperatively, there was a significant statistical relation between mortality and the grade of tumor differentiation. In multivariate analysis, CMV-IgG negativity, TNM stage (stage III), actual graft weight, and number of blood transfusion units were independent predictors of mortality. Conclusion Several factors have an independent significant effect on post-liver transplantation mortality. CMV-IgG negativity, advanced tumor stage (IIIB), actual graft weight, volume of intraoperative blood transfusion, poor tumor grade of differentiation, and tumor recurrence have an influence on post-transplantation mortality. Because LDLT can be performed regardless of Child–Pugh classification, model of end-stage liver disease score, and portal hypertension, only tumor factors, graft volume, and technical complications should be considered when selecting HCC patients for LDLT.

Background Biliary complications (BCs) of living liver donors are of serious concern as they threaten the donor’s health and life. Technical problems are the main cause of these complications. Aim We conducted a retrospective analysis of the incidence, types, and management polices of BCs in our cohort of donors of living donor liver transplantation, with special emphasis on the impact of technical refinement of bile duct stump closure. Patients and methods Data were reviewed from a prospectively maintained database of all donors who underwent hepatectomy. The incidence and types of and management options for BCs in living liver donors were compared in two successive phases of our program of living donor liver transplantation. The first period included 140 donors in a procedure in which the bile duct stump was closed using continuous sutures or interrupted sutures, whereas the second period comprised 100 donors in a procedure in which the bile duct stump was closed using a newly designed technique by combining suturing and reinforcement with a metallic clip just below the suture line. Before abdominal closure, the intraoperative cholangiogram was repeated. Results The overall incidence of BCs among donors was 14.2%. On comparison of BCs in the two studied phases we found significant differences in the rate of BCs: 20% in the first phase and 6% in the second phase. Further, a significant difference was documented in the two periods with respect to age less than 30 years, male donors, BMI more than 25%, left lobe or left lateral graft, and one duct (P Conclusion Our newly adopted technique of bile duct stump closure as well as the performance of two intraoperative cholangiographies before cutting and after closure of the stump resulted in significant improvement in and reduction of BCs. This new technique is safe, simple, and reproducible and does not prolong the surgery.

Background: Iatrogenic bile duct injuries (IBDIs) remain an important problem in gastrointestinal surgery and represent a big challenge for surgeons. Aim: To review the management of IBDI and describe short- and long-term postoperative complications of surgical repair at our tertiary referral institute. Patients and Methods: This was a retrospective review of the medical record of all patients referred for the management of IBDIs between January 2005 and January 2015. One hundred patients formed the study cohort. Preoperative data including patient demographics, mechanism of injury, operative details, and postoperative outcomes were extracted. Research Ethics Board approval was obtained. Results: There were 36 men and 64 women, with a mean age 45.4 ΁ 11.5 years. Open cholecystectomy was the most common procedure in 61 patients, whereas laparoscopic surgery was the primary treatment in 39 patients. Twenty-nine patients treated by nonsurgical management in the form of endoscopic retrograde cholangiopancreatography (ERCP) and stenting and percutaneous abdominal drainage. Seventy patients underwent operative surgery in the form of Roux-en-Y H.J, and T-tube insertion in the common bile duct in two cases. Short-term complications encountered in 15 (20.8%) cases, with a significant correlation with a previous ERCP intervention (P = 0.047). Long-term complications encountered in 12 (16.6%) patients, with a significant relation with the intermediate timing (within 2 weeks) of repair (P = 0.037). Conclusions: Prompt diagnosis of the type and grade of injury is mandatory before deciding management. Intermediate time for surgical intervention was significantly related to stricture complications. ERCP should be done only in cases that can benefit from conservative management (Strasberg from A-D) as the incidence of postoperative complication is high after surgical repair.

Background Several large centers have reported outstanding outcomes of living donor liver transplantation in decreasing mortality on the liver transplant waiting list. Nevertheless, living donor liver transplantation is not without risk to the volunteer donors. The rate of complications differs widely among transplant centers. Yet, there is no consensus on how to define and stratify complications by severity. Participants and methods This retrospective study to identify and analyze the surgical outcomes of 204 consecutive living donor hepatectomies was carried out between April 2003 and October 2013 by using the modified Clavien classification system, according to which grade I=minor complications, grade II=any deviation from the normal postoperative course requiring pharmacologic treatment, grade III=complications requiring invasive treatment, grade IV=complications causing organ dysfunction requiring ICU management, and grade V=complications resulting in death. Results The present study included 129 (63.2%) males and 75 (36.8%) females, with the donor’s mean age being 27.72±6.4 years (range: 19–45 years). There were 64 (31.4%) donors who developed postoperative complications, with a total of 74 complications. Ten (4.9%) donors had more than one complication. Twenty-nine (39.2%) donors had Clavien’s grade I complications, 38 (51.3%) donors had Clavien’s grade IIIa, six (8.1%) donors had Clavien’s grade IIIb complications, and there was one (0.5%) case of mortality (Clavien’s grade V). Conclusion Donor hepatectomy is a relatively safe procedure when performed by a dedicated and well-trained team. A prompt diagnosis and meticulous intervention is considered the first priority whenever a donor complication is expected. Furthermore, a continuous standardized reporting and a comprehensive database are crucial to precisely define true donor morbidity.

Background: Most major hepatocellular carcinoma (HCC) staging systems recommend hepatic resection only for patients with early-stage of HCC. Still there is controversial about resection of patients with large HCC (defined as >5 cm). The aim of this retrospective study is to investigate the clinicopathological features that impacted the long-term outcomes of 1 year after hepatectomy of large HCC >5 cm in cirrhotic patients. Materials and Methods: From February 2012 to December 2015, a total of 92 patients with resection of large HCC on liver cirrhosis were reviewed retrospectively and considered for clinicopathological features that impacted the long-term outcomes. Time to recurrence (recurrence-free survival) and overall survival (OS) were determined by Kaplan-Meier analysis. Results: Twenty-nine (31.5%) patients developed tumor recurrence. The mean time until tumor recurrence was 12.4 ± 6.6 months. The cumulative 1-, 2-, and 3-year disease-free survival rates were 73%, 28%, and 18%, respectively. On multivariate analysis, male gender, α-fetoprotein >400, bilobed tumors, patients with portal hypertension, plasma transfusion, and absence of tumor capsule remained independent predictors for recurrence of HCC. The OS rates at 1, 2, and 3 years were 73%, 31%, and 16%, respectively. On multivariate analysis, α-fetoprotein >400 and plasma transfusion remained independent predictors for death. Conclusions: Liver resection is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. Identification of risk factors and close postresection follow-up with early detection are mandatory measures for prompt treatment of tumor recurrence which is reflected by a beneficial survival rate for this group of patients.