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Resumen La situacion actual de la pandemia por SARS-CoV-2 tiene paralizada la cirugia no urgente y/u oncologica en muchos hospitales de nuestro pais con lo que esto conlleva para la salud de los ciudadanos que estan pendientes de una intervencion quirurgica. La cirugia mayor ambulatoria puede abarcar en su cartera de servicios mas del 85% de los procedimientos quirurgicos que se realizan en un servicio de cirugia y se presenta como una alternativa factible y segura en el momento actual ya que no requiere camas de ingreso y disminuye claramente el riesgo de infeccion. Ademas, es la herramienta que deberia generalizarse para solucionar la acumulacion de pacientes en lista de espera que la pandemia esta generando, por lo que parece oportuno que desde la seccion de Cirugia Mayor Ambulatoria de la Asociacion Espanola de Cirujanos se presente una serie de recomendaciones para la implementacion de la misma en estas circunstancias excepcionales que nos toca vivir.

When Rectocele is part of a complex pelvic organ prolapse, a full repair is recommended. The aim of this study was to evaluate the clinical and radiological results after laparoscopic surgery in patients with symptomatic rectocele and III/IV stage vaginal vault prolapse METHODS: This is a prospective cohort study of women with symptomatic rectoceles and middle compartment prolapse operated on between 2013 and 2015, who underwent a laparoscopic sacrocolpoperineopexy with synthetic Y mesh attached to puborectalis muscles, the anterior and posterior vagina wall and the sacrum. The clinical outcomes measured were symptoms of prolapse, obstructive defecation syndrome and quality of life. Radiological outcomes were distance of the vaginal vault below pubococcigeal line and depth of rectovaginal wall protrusion in dynamic pelvic resonance.33 patients were included. 32 of them remained asymptomatic after a three years follow-up. Significant differences were shown in the obstructed defecation score and quality of life after 6, 12 and 36 months compared to preoperatively. No differences were identified when the postoperative results were compared. Significant differences were shown in preoperative vaginal vault prolapse (3.2 cms ± 0.8 SD below the pubococcigeal Line) and rectocele size, compared with 1 and 3 years after surgery. There were no significant differences in vaginal vault prolapse when compared after 1 and 3 years. When rectocele size after 1 and 3 years was compared, significant differences were shown, but only one clinical recurrence (3%) was identified after a mean follow-up of 47 months.Laparoscopic sacrocolpoperineopexy in patients with symptomatic rectocele and III/IV vaginal vault prolapse solves the constipation and obstructed defecation with an excellent quality of life and low clinical recurrences. Radiological deterioration, especially in rectocele size, was identified in the mid-term follow-up without clinical significance.

Chronic metal exposure, e.g. from metal mining, may cause accumulation of metals in soft and hard tissues, and in developing biomineralizations in the human body. Gallstones are biomineralizations formed in the gallbladder which are able to trap trace elements from the bile. Laser Ablation-Inductively Coupled Plasma-Mass Spectrometry (LA-ICP-MS) was used to analyze gallstone cross-sections to trace the elemental abundances and correlate them with the principal phases constituting gallstones, namely cholesterol, Ca bilirubinate salts, Ca carbonate, and Ca phosphate. Five different types of gallstones (pure, mixed, and composite cholesterol stones, pigment stone, and carbonate stone) were chosen according to a previous classification based on phase characterization by different spectroscopic and microscopic techniques. These data were combined with bulk solution ICP-MS/OES analyses for total elemental concentrations. The results indicated that cholesterol has a zero capacity to retain elements except for Ca. Hence, pure cholesterol stones contained the lowest bulk metal concentrations, and the metals were found in the scarce carbonate and phosphate phases in these calculi. Calcium and trace element concentrations increased in other types of gallstones along with increasing amount of bilirubinate, carbonates and phosphates; pigment stones being the most enriched in metals. Phosphates were the principal carriers of Ca, P, Na, Mg, Mn, Fe, Pb, and Cd, whereas carbonate phases were enriched in Ca, Mg, Na, and Mn in order of decreasing abundance. Bilirubinate on the other hand was enriched in Ca, Cu, Ag, and Ni. The higher trace metal affinities of bilirubinate and phosphate explain the elevated metal concentrations observed in the pigment stones. These results give new insight to the trace metal behavior in the gallstone formation and the metal accumulation in the human body, validating the possible use of these biomineralizations as a proxy for exposure to metal pollution.

Introduction the identification of a 10 cm bezoar in a hiatal hernia is unusual. Hiatal hernias are usually asymptomatic. When signs of strangulation are present the prognosis is unlucky if urgent surgical intervention is not performed. Although sometimes the prognosis is bad because of the advanced state of gastric ischemia. Case report a 67-year-old female patient undergoing Nissen fundoplication with recurrence of hiatal hernia, volvulated and strangulated with giant bezoar inside the hhital hernia sac. Discussion despite of poor results, surgical treatment in these cases must be urgent.

[Background]: Adhesion formation is a major problem when a mesh is exposed to intraabodminal viscera, with potential severe complications (bowel occlusion, fistulas or abscesses). New methods for preventing adhesions from a polypropylene mesh placed intra-abdominally or to solve difficult situations, such as when the peritoneum cannot be closed during a TAPP repair for an inguinal hernia, are still being seeked. This study mimics in an animal model a situation that can be found in clinical practice during laparoscopic inguinal hernioplasty. A polypropylene mesh could be exposed to the intra-abdominal cavity even when the peritoneum is closed due to different circumstances, with no options to guarantee the prosthetic material of being exposed to the intrabdominal viscera. Different options have been suggested to solve these situations, being proposed in this study to cover the visceral surface of the mesh with an absorbable sponge containing thrombin, fibrinogen, and clotting factors (Tachosil®, Nycomed, Takeda, Osaka, Japan), to assess its use as a barrier to prevent postoperative adhesion formation., [Material and methods]: Thirty Wistar white rats (300–450 mg) were included in this study as experimental animals, being randomized into three groups (A, B, and C). We performed a bilateral prosthetic repair with conventional polypropylene mesh (2 × 2 cm, 82 kD). Prosthesis fixation was performed as follows. Group A: absorbable suture; group B: metal staples; group C: metal tackers. A piece of insulating absorbable sponge (Tachosil® 5 × 5 cm) was placed to cover the visceral surface of mesh placed at the right side of each animal. After 10 days, we performed a gross examination (by laparoscopy and laparotomy), measuring the quantity and the quality of the adhesions. Samples were taken for histopathological analysis. [Results]: Tachosil®-treated prostheses showed a statistically significant decrease in the quality of the adhesion found (p, [Conclusions]: The use of Tachosil® as a barrier material led to the absence of strong adhesions as it prevented direct contact between the mesh and the internal organs, preventing major problems associated with strong adhesions.

Laparoscopic ventral or incisional hernia repair requires intraperitoneal mesh placement. This is associated with an increase in adhesions, bowel obstruction and enterocutaneous fistula. Intraabdominal meshes are laparoscopically fixed using traumatic fixation methods that increase acute, chronic pain and adhesions to bowel loops. The aim was to check the safety and effectiveness of the laparoscopic approach in ventral or incisional hernia, using a self-adhesive mesh in the preperitoneal space without tacks or transfascial sutures, and to objectively assess its benefits and complications. Patients aged between 18 and 67 years old with medial, lateral ventral and incisional hernias between 3 and 8 cm in size were included in this study. Fifty patients were included in the study, which was conducted between January 2013 and March 2015. The average length of surgery was 57.3 ± 18 min. The average hospital stay was 1.1 ± 0.3 days. The average time taken to return to work was 9.2 ± 2.4 days. The most common post-operative complication was seroma, which was observed in 13 patients (26 %). The average follow-up was 15.4 ± 5.5 months. Three patients were lost to follow-up during this period. There was no hernia recurrence during examination nor on CT scan during the follow-up period. The average score on the visual analogue scale before surgery was 4 ± 1. After surgery, the score was as follows: 3 ± 0.8 on the first day after surgery, 0.9 ± 0.5 after the first week, 0.4 ± 0.4 after the first month and 0 after 90 days. No patient showed chronic pain. Overall satisfaction (VAS for surgery) was 8.3 ± 0.6. The use of self-adhesive meshes during the laparoscopic transabdominal preperitoneal approach in small- and medium-sized ventral or incisional hernias is safe and effective, with low post-operative pain, quick functional recovery and high overall satisfaction after surgery with no increase in recurrence in the short term.

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This study aims to explore the impact of chronic metal exposure derived from persistent pollution from mining activity using human gallstones as proxies. The samples were obtained from patients residing in geologically and environmentally contrasting areas in the Province of Huelva, SW Spain, allowing for the evaluation of the regional effect of metal pollution. The study group resides in the Iberian Pyrite Belt characterized by natural and anthropogenic metal pollution from mining activities, whereas the control group resides in the Ossa Morena Zone famous for its natural parks. A total of 68 gallstones were first classified based on their phase composition and structure and subsequently their chemical composition was studied using solution Inductively Coupled Plasma-Mass Spectrometry. The metal concentrations increased in the cholesterol-rich gallstones from pure, to mixed and composite cholesterol stones along with the increasing amount of minor phases, such as bilirubinate, carbonate, and phosphate. These cholesterol stones did not show an evident enrichment tendency. On the contrary, pigment stones, composed of bilirubinate, carbonate, and phosphate phases, were rich in a variety of elements and the regional comparison showed that the pigment stones from the study area were enriched in sulfide-associated metal(loid)s, Mn, Fe, Cu, Zn, Sr, As, Ag, Sb, and Pb with respect to the control group. Inhalation of polluted airborne particulate matter is considered as one of the main exposure routes among the residents of the study area. Additionally, consumption of local water and locally produced food products such as fruit and vegetables and dermal contact may be possible sources of exposure, but no direct connection was observed.

This study explores the environmental impact of metal exposure on humans through detailed phase and structural characterization of gallstones from two environmentally contrasting populations in Huelva Province (SW Spain). A total of 42 gallstone samples, obtained after surgical intervention at the Riotinto Hospital, were studied by powder X-ray diffraction (XRD), Fourier Transformed Infra-Red spectroscopy (FTIR), FTIR-μ-ATR (Attenuated Total Reflection) coupled with an optical microscope, and by Environmental Scanning Electron Microscope with Energy Dispersive X-ray Spectroscopy (ESEM-EDS), and subsequently classified according to their phase composition and structure. Additionally, the patients were enquired for their living habits in order to analyze the source of possible exposure to metal contamination. The gallstones were classified into pure, mixed and composite cholesterol stones, black and brown pigment stones, and carbonate stones. The patients from the study group residing in a region with acknowledged metal contamination of both natural and anthropogenic origin have a higher risk of metal exposure through contaminated soil, particle matter in the air, and consumption of local water and food products. According to our findings, the metal exposure is related to a higher tendency of forming black pigment stones in the study group in comparison to the control group residing in a natural park with nearly pristine environmental conditions. Moreover, the gallstones from the study group showed to contain more abundant metal components, such as Cu, Fe, Ni, and Zn, than those from the control group. To our knowledge this is the first study to examine the regional environmental impact of metal exposure on human gallstones.

Resumen Introduccion Dado que estudios actuales han mostrado la validez de la fijacion atraumatica con cola de fibrina (Tissucol ® ) frente a las suturas convencionales con malla de polipropileno, en este trabajo se quiere estudiar el comportamiento en las mallas reabsorbibles. Material y metodos Se utilizaron 20 ratas blancas Wistar. Se realizaron 2 defectos herniarios en la pared abdominal, que se repararon de forma preperitoneal con malla reabsorbible de acido poliglicolico y carbonato trimetileno, en el lado de la derecha la malla se fijo con Tissucol ® y en el lado de la izquierda se fijo con sutura convencional fijada a la fascia muscular. Se sacrificaron 10 ratas a los 14 dias (serie A) y el resto a los 28 dias (serie B). Se emplearon para comprobar la contingencia de la pared abdominal 2 test; el test de presion: neumoperitoneo mayor de 40 mmHg mantenido durante 1 min, y el test de traccion: dinamometria de la zona afectada mayor de 300 g de traccion por cm 2 . Se analizo la pared abdominal para determinar la integracion de la malla de nueva generacion. Resultados La fijacion de la malla tras los test de presion y de traccion no evidencio alteraciones estadisticamente significativas en los 2 grupos. La integracion de la malla fue mayor en los casos de fijacion con cola de fibrina, donde se observo un aumento del numero de neovasos. Conclusiones La fijacion con colas biologicas de fibrina equiparo a la convencional. La malla reabsorbible se integro adecuadamente y se comprobo que tanto la neoformacion vascular como la propia integracion de la malla es mas notable al aplicar el sellante de fibrina que con la sutura convencional.

Introduction Current studies have shown the validity of the atraumatic fixation with fibrin glue (Tissucol ® ) compared to conventional sutures in polypropylene mesh fixation. We propose to study the behaviour of absorbable mesh. Material and methods We used 20 Wistar white rats. Two hernia defects were made in the abdominal wall, which were repaired using absorbable PGA-TMC preperitoneal mesh. The right side of the mesh was fixed with Tissucol ® and left side with conventional suture attached to the muscle fascia. One group of 10 rats were sacrificed at day 14 (series A) and the other 10 rats at 28 days (series B). We used 2 tests to assess the contingency of the abdominal wall; pressure test: pneumoperitoneum more than 40 mm Hg maintained for 1 min, traction test: dynamometry of the affected area more than 300 mg per cm 2 of traction. Abdominal wall was analysed to determine the integration of the new generation mesh. Results The fixation of the mesh after the pressure and traction tests showed no statistically significant changes in either group. The integration of the mesh and vessel neoformation was higher in the cases of fixation with fibrin glue. Conclusions Biological fixation with fibrin glue is similar to the conventional. Absorbable mesh was suitably integrated and vascular neoformation and integration of the mesh was also found to be better than conventional sutures when fibrin sealant was applied.

The aim of this study was to investigate the effects of fibrin glue on the prevention of postoperative peritoneal adhesion to prosthetic materials used in ventral hernia repair.Ten pigs were included in this study. The abdomens of the animals were opened by means of a median subumbilical laparotomy to place four prostheses that were cut into square pieces of 4 x 4 cm. The two prostheses in the most cephalic position were polypropylene meshes, and the other two prostheses in a more caudal position were expanded polytetrafluoroethylene prostheses (Dualmesh Plus Corduroy). The prostheses on the right side of each animal were previously impregnated with fibrin glue. After 5 weeks, the animals were reoperated on to assess the quantity and quality (consistency) of the adhesions.There were fewer intraperitoneal adhesions and they were more labile in the case of prostheses impregnated with fibrin glue. Moreover, we also observed that in many of the animals the polypropylene mesh did not show any adhesions, although polypropylene has been considered to be a typical adhesion producing material.Fibrin glue reduces both the quantity and consistency of adhesions, even in the case of polypropylene meshes.

The aim of this study was to investigate the effects of hyaluronidase gel on the prevention of post-operative peritoneal adhesions to prosthetic materials used in laparosopic ventral hernia repair.Ten pigs were included in this study. The animals were anesthetized using Na-penthotal for induction and isofluorane for maintenance. The abdomen was opened and, using helical fasteners, four implantations were performed (squares of 4 x 4 cm). Two of the implants, placed in an upper location, were in polypropylene mesh, and two of the implants, placed in a lower area, were in polytetrafluoroethylene (PTFE-e, Dualmesh Plus Corduroy). The implants located in the right side of animals were painted with hyaluronidase gel. Two helical fasteners, painted and unpainted, were implanted in a medial location. After a five-week period the pigs were operated on again, intraperitoneal adhesion ratios and grades were determined, and the pigs later sacrificed. Specimens having abdominal wall implants were taken for histological studies.Intraperitoneal adhesions decreased in implants painted with hyaluronidase gel in a comparative study with implants located in the left side of animals (not painted). On the other hand the polypropylene mesh, said typically to produce intraperitoneal adhesions, produced almost no adhesion in many animals.Hyaluronidase gel reduces post-operative peritoneal adhesions ratio and grades including in the presence of polypropylene mesh.

Resumen Introduccion En nuestra practica diaria quirurgica nos enfrentamos a infecciones del propio sitio quirurgico con frecuencia. Uno de los grandes retos para el cirujano hoy en dia es la prevencion y el tratamiento de las infecciones, y en especial las infecciones de material protesico. En la actualidad disponemos de una nueva sutura (Vicryl Plus) que ha demostrado in vitro y en modelo experimental su capacidad para inhibir el crecimiento bacteriano y por lo tanto prevenir la tan temida infeccion posquirurgica. Objetivos Nos proponemos en nuestro estudio experimental realizar una comparacion entre una infeccion provocada en una protesis para tratar la enfermedad herniaria fijada con sutura reabsorbible convencional y la nueva sutura motivo del estudio, sutura reabsorbible con impregnacion antiseptica. Material y metodo Utilizamos como modelo animal ratas Wistar blancas (20), a las cuales les practicamos dos hernioplastias. Una fijada con Vicryl Plus y otra con Vicryl normal. Posteriormente se infecta cada malla de polipropileno con Staphylococcus aureus, y permanece en su jaula individual una semana. A la semana procedemos al sacrificio de las ratas y la extraccion de las mallas para su estudio macroscopico, microscopico y mibrobiologico. Resultados Comprobamos que la mayoria de las mallas fijadas con la nueva sutura (Vicryl Plus) presentaban macroscopicamente menos indicios de infeccion, sin abscesos ni dehiscencia de la hernioplastia, en contra de lo observado en aquellas fijadas con sutura convencional. En el estudio microbiologico cuantitativo bacteriano el numero de bacterias cuantificadas por gramo de muestra es menor tambien en las protesis fijadas con Vicryl Plus. En la anatomia patologica de la muestra observamos menor colonizacion de la malla y menor respuesta inflamatoria con la fijacion con Vicryl Plus que con Vicryl normal. En el estudio estadistico se comprueba la menor tasa de infeccion al comparar las medianas de ambos grupos y los rangos intercuartilicos de la cuantificacion microbiana. Conclusiones Es posible disminuir el indice de infeccion del sitio quirurgico tras la colocacion de material protesico realizando su fijacion con este nuevo tipo de sutura antimicrobiana (Vicryl Plus). Pensamos que es un nuevo aliado en la lucha contra la infeccion postoperatoria, y es de especial interes su uso en cirugia con hernioplastia, cirugia de urgencia y cirugia sucia o potencialmente contaminada.

Resumen Introduccion El objetivo de este estudio es investigar el efecto de la cola de fibrina y del gel de hialuronidasa en la prevencion de adherencias peritoneales a las protesis intraperitoneales. Material y metodo En este estudio hemos utilizado 20 cerdos, divididos en 2 grupos: en todos los animales se procedio a colocar implantes de 4 × 4 cm: 2 de malla de polipropileno en una posicion mas cefalica, y otros dos de politetrafluoroetileno (Dualmesh® Plus Corduroy) en una posicion mas caudal. Los implantes situados en el lado derecho del animal se impregnaron de inhibidores de la produccion de adherencias (en 10 animales se utilizo cola de fibrina, serie A, y en otros 10 se utilizo gel de hialuronidasa, serie B). Despues de 5 semanas, se procedio al sacrificio de los animales y se evaluaron los resultados (cantidad y calidad de las adherencias formadas, asi como datos histologicos de integracion de las protesis, como mesotelizacion infiltracion por fibroblastos, vasos neoformados, etc.). Resultados Al cabo de 5 semanas se apreciaba que los implantes impregnados de sustancias inhibidoras de la produccion de adherencias presentaban menos adherencias, estas (cuando existian) eran mas laxas, e incluso en muchos casos los implantes estaban perfectamente peritonizados. La integracion de las protesis no estaba afectada por la presencia de los inhibidores. Conclusiones La formacion de adherencias puede disminuirse tras la cirugia abdominal. La disminucion conseguida es mayor en la cantidad que en la consistencia de adherencias. Los resultados son algo mejores en la serie en la que se utilizo hialuronidasa que en la que se utilizo cola de fibrina. La hialuronidasa tiene la ventaja de tener un menor coste.

Appendiceal tumors are found in about 1% of appendectomies performed and 0.5% of intestinal neoplasias. Appendiceal carcinoids are the predominant histology in this group and are usually casual after appendectomy for other reasons. The prognosis is excellent and survival is 95% at 5 years after surgery.Retrospective analysis of all patients with appendiceal carcinoid surgery in our hospital for 20 years (1990-2010) and survival at 5 years. We also discuss the need for additional treatment and testing for follow-up visits.42 patients underwent surgery for appendiceal carcinoid tumor. 38 of them were operated on urgently, mostly for suspected acute appendicitis, without having reached the carcinoid tumor diagnosed preoperatively in any of them. The predominant symptomatology at admission was abdominal pain. Surgical treatment was appendectomy in 34 patients (12 laparoscopic), 7 patients required colon resections over intraoperatively by colonic involvement; only one patient required reoperation to complete right hemicolectomy. 2 patients had disseminated disease at diagnosis (liver metastases). The 5-year survival is over 95%, with no recurrence.The appendiceal carcinoid tumor is difficult to diagnose preoperatively. Appendectomy surgical treatment is usually sufficient, although colonic resections may be needed for dissemination. The 5-year survival is over 95%.Antecedentes: los tumores apendiculares se encuentran en cerca de 1% de las apendicectomías y representan 0.5% de las neoplasias intestinales. El tipo de tumor más frecuente es el carcinoide apendicular, que casi siempre es un hallazgo durante la apendicectomía por otro motivo. Su pronóstico es excelente y la supervivencia es mayor de 95% a cinco años de la intervención. Objetivo: reportar una serie de casos y analizar la supervivencia media a cinco años posteriores a la identificación el tumor. Material y métodos: análisis retrospectivo (1990-2010) de pacientes con tumor carcinoide apendicular intervenidos en el servicio de Cirugía General y del Aparato Digestivo del Hospital Universitario Virgen del Rocío, Sevilla, España. Se analizaron: la supervivencia a cinco años, la necesidad de tratamiento complementario y las pruebas para seguimiento en la consulta. Resultados: se encontraron 42 pacientes intervenidos por tener un tumor carcinoide apendicular. En 38 pacientes la operación fue de urgencia, la mayoría por sospecha de apendicitis aguda, sin que en ninguno se hubiera establecido el diagnóstico de tumor carcinoide antes de la operación. El síntoma predominante al ingreso fue el dolor abdominal. El tratamiento quirúrgico fue: apendicectomía en 34 pacientes (12 por laparoscopia), en el intraoperatorio siete pacientes requirieron resecciones colónicas mayores debido a la afectación del colon; sólo uno requirió la reintervención para completar la hemicolectomía derecha. Al momento del diagnóstico dos pacientes tenían enfermedad diseminada (metástasis hepáticas). La supervivencia a cinco años fue superior a 95%, sin recidivas o tratamiento posterior de la enfermedad. Conclusiones: el tumor carcinoide apendicular difícilmente se diagnostica antes del procedimiento quirúrgico. La apendicectomía suele ser suficiente aunque en algunos pacientes las resecciones colónicas son necesarias por diseminación. La supervivencia a 5 años es superior a 95%.

Ventral hernias are a common problem in a general surgery and hernioplasty is an integral part of a general surgeon's practice. The use of prosthetic material has drastically reduced the risk of recurrence, but has introduced additional potential complications such as surgical wound infections, adhesion formation, graft rejection, etc. The development of a wound infection in a hernia that is repaired with a prosthetic material is a grave complication, often requiring removal of the prosthesis. This experimental study examined efficacy of completely absorbable, hydrophilic, PGA-TMC (polyglycolic acid-trimethylene carbonate) prosthesis impregnated with antibiotic for reduction of infectious complications.Antibiotic-impregnated PGA-TMC prostheses were placed intraperitoneally in 90 Wistar white rats that were randomized and distributed into four groups. Group 0 (23 rats): there were placed PGA-TMC prosthesis without antibiotic impregnation (control group). Group 1 (25 rats): meshes were placed and infected later with 1 × 10(8) UFC of S. aureus/1 ml/2 cm(2) (Staphylococcus aureus ATCC 6538 American Type Culture Collection, Rockville, MD). Group 2 (21 rats): cefazolin-impregnated prostheses were placed (1 g × 100 ml, at the rate of 1 ml/cm(2) of prosthesis) and were subsequently infected with the same bacterial inoculate. Group 3 (21 rats): cefazolin-impregnated prostheses with double quantity of cefazolin and infected. A week later these animals were killed and specimens were extracted for bacterial quantification and histological studies.Evident decrease of bacterial colonization was observed in series 2 and 3 [the ones impregnated with cefazolin, in comparison with the group 1 (infected without previous antibiotic impregnation)] with statistically significant results (p 0.00). Results were really positive when the antibiotic solution had been applied to the mesh. There have been formed adherences to the prosthesis when placing it in contact with intraabdominal viscera. However, cefazolin impregnation of the mesh has reduced an adhesion formation, mostly when the infection reached a minimum, inhibiting the inflammatory answer to the infection in a prosthetic material.Impregnation of the absorbable hydrophilic prosthesis PGA-TMC with cefazolin prevents the infection of the prosthesis placed in infected localization. Therefore, we think this option should be considered as a new and useful alternative in case of contaminated and dirty surgical fields or when a replacement of the prosthesis is required.

Advances in laparoscopy of the abdominal wall hernia / , Advances in laparoscopy of the abdominal wall hernia / , کتابخانه دیجیتال جندی شاپور اهواز

Mesh fixation in laparoscopic ventral hernia benefits from a wide range of devices and materials that can be used, according to the location and characteristics of both the hernia and mesh. At our disposal are sutures (metal, traumatic, plastic, absorbable) and adhesives. The advantages of fibrin have been incorporated into traditional metal sutures (tackers), offering potential improvements in terms of integration and the decrease of possible complications (seroma, hematoma, etc.).

The current relentless advances of surgery continuously bring forth new techniques, new devices, and new materials. Currently, the single-port ventral hernia surgery is in practice and is being increasingly used. Robotic surgery has started tackling hernias, though at great cost, permitting procedures performed by a single surgeon. Other techniques are gaining importance: laparoscopic surgery of diastasis recti, especially in women after childbirth; transabdominal repair with preperitoneal mesh placement; and closure of the defect before placement of the mesh, which seems to favor the recovery and dynamics of the abdominal wall muscles.

One of the most controversial situations in laparoscopic abdominal wall hernia surgery is an incarcerated or strangulated hernia. Currently, there are few groups that perform laparoscopic surgery for these complicated hernias with a high probability of conversion to laparotomy. We describe in this chapter the concepts of hernia incarceration and hernia strangulation and the surgical techniques and resources that can be used in this emergency situation.

Two laparoscopic techniques for laparoscopic inguinal hernia repair are used currently: a totally extraperitoneal technique (TEP) and a transabdominal preperitoneal technique (TAPP). In TAPP, the peritoneum is incised to gain access to the preperitoneal space, and similar surgical steps are performed in both techniques: hernia content reduction, treatment of hernial sac, and placement of preperitoneal mesh. Nowadays, it is accepted that TEP is preferred over TAPP because the TEP technique has a lower rate of trocar-site hernias and intra-abdominal injuries. However, TEP is a more demanding and complex technique, with a higher learning curve. For laparoscopic inguinal hernia repair, the TAPP intervention should be learned as a first step. TEP has a steeper learning curve, and after mastering TEP, performing TAPP will come easily.

Laparoscopic surgery is the gold standard in multiple surgical fields. In abdominal wall surgery, it is becoming more frequently used, changing rapidly as one generation of surgeons who performed laparotomy incisions is replaced by another that tends towards the laparoscopic approach. One of the key steps is becoming more familiar with the laparoscopic technique, its instruments, and the basic principles of this procedure. Skills are very important as is knowledge about sectorization, triangulation, ergonomics, and the equipment needed to perform this type of surgery (optical, grasper, trocars, etc.).

Current development of meshes has made possible the introduction and widespread use of laparoscopic techniques. Currently, we have multiple material combinations of meshes. It is important to make the correct choice of materials depending upon the type of hernia. We describe the classification of biomaterials of Amid with the latest variations by Bellon and Coda. The type of material and the pore diameter are subjects of intense study. Complications such as seroma and infection decrease with the correct selection of mesh for each surgery.

Aim To evaluate the effectiveness of human fibrinogen-thrombin collagen patch (TachoSil®) in the reinforcement of high-risk colon anastomoses. Methods A quasi-experimental study was conducted in Wistar rats (n = 56) that all underwent high-risk anastomoses (anastomosis with only two sutures) after colectomies. The rats were divided into two randomized groups: Control group (24 rats) and treatment group (24 rats). In the treatment group, high-risk anastomosis was reinforced with TachoSil® (a piece of TachoSil® was applied over this high-risk anastomosis, covering the gap). Leak incidence, overall survival, intra-abdominal adhesions, and histologic healing of anastomoses were analyzed. Survivors were divided into two subgroups and euthanized at 15 and 30 d after intervention in order to analyze the adhesions and histologic changes. Results Overall survival was 71.4% and 57.14% in the TachoSil® group and control group, respectively (P = 0.29); four rats died from other causes and six rats in the treatment group and 10 in the control group experienced colonic leakage (P > 0.05). The intra-abdominal adhesion score was similar in both groups, with no differences between subgroups. We found non-significant differences in the healing process according to the histologic score used in both groups (P = 0.066). Conclusion In our study, the use of TachoSil® was associated with a non-statistically significant reduction in the rate of leakage in high-risk anastomoses. TachoSil® has been shown to be a safe product because it does not affect the histologic healing process or increase intra-abdominal adhesions.

Surgical site infections are frequent in daily surgical practice. One of the main challenges currently facing surgeons is the prevention and treatment of infections, especially those involving prosthetic material. A new suture (Vicryl Plus) has become available. In vitro studies and experimental models have demonstrated the ability of this suture to inhibit bacterial growth and consequently prevent postsurgical infection.To compare infections provoked in prosthetic implants fixed with reabsorbable conventional sutures with those in meshes fixed with reabsorbable sutures with antiseptic impregnation.Twenty white Wistar rats were used. In each rat, two hernioplasties were performed: one fixed with Vicryl Plus and the other with normal Vicryl. Subsequently, each polypropylene mesh was infected with S. aureus, and the rats remained in individual cages for a week. After 1 week, the rats were sacrificed and the meshes were extracted for macroscopic, microscopic and microbiologic study.Most of the meshes fixed with the new suture (Vicryl Plus) showed macroscopically fewer infections than those fixed with conventional suture, without abscesses and without dehiscence of the hernioplasty. In the microbiological quantitative bacterial study, the number of bacteria quantified per gram of sample was also lower in prostheses fixed with Vicryl Plus. Pathological analysis showed lesser colonization of the mesh and lower inflammatory response with Vicryl Plus than with normal Vicryl. In the statistical analysis, comparison of the medians of both groups and the interquartile ranges of microbial quantification revealed a lower infection rate in the Vicryl Plus group.The infection rate in the surgical site can be reduced by mesh fixation using the new antimicrobial suture (Vicryl Plus). We believe that this type of suture constitutes a new weapon in the fight against postoperative infection, especially in hernioplasty, emergency surgery, and dirty or potentially contaminated surgery.

Introducción: diversos factores influyen en la cicatrización correcta de las suturas intestinales tras la práctica de una resección intestinal. Uno de los factores más implicados es el estado nutricional del paciente. Objetivos: evaluar la influencia de la desnutrición inducida sobre la viabilidad de una anastomosis intestinal primaria mediante el análisis del procolágeno (PINP) como marcador de la síntesis de colágeno I, y del telopéptido carboxiterminal del colágeno I (ICTP) como marcador de la destrucción del mismo. Métodos: 40 ratas Wistar y material de radioinmunoensayo. Métodos: diseñamos 2 grupos de ratas, 20 animales por cada grupo: grupo control (A) y grupo "desnutrición" (B). Se analiza PINP e ICTP mediante RIA sobre tejido colónico homogeneizado, preanastomótico y anastomótico. Resultados: existen unos niveles menores de PINP en el colon de las ratas del grupo B comparado con el colon del grupo A (0,3620 y 0,4340 µg/g respectivamente) (p = 0,032). Hay un mayor nivel de ICTP analizado en el colon del grupo B (0,9545 en contraposición a 0,8460 µg/g en el grupo A) (p = 0,875). En las anastomosis del grupo B existe una menor síntesis de PINP en comparación con el grupo A (0,376 y 0,468 µg/g respectivamente, p = 0,002). Conclusiones: la anastomosis colónica incrementa los niveles de PINP e ICTP en el tejido cicatricial (p = 0,000); la malnutrición reduce la colagenización de las anastomosis (p = 0,000).

Se trata de un paciente varon de 58 anos; entre susantecedentes destacan amigdalectomia y tonsilectomia alos 8 anos, apendicetomia a los 19 anos, pancreatitis alos 29 anos que se trato de forma conservadora, sin se-cuelas posteriores, y politraumatismo por accidente detrafico a los 42 anos con fractura de 17 costillas, hemo-neumotorax bilateral, hemopericardio, ulceras de Cus-hing por estres, arrancamiento acromio-clavicular dere-cho, rotura del ligamento lateral interno de la rodilladerecha, con un ingreso en UCI de 40 dias con ventila-cion asistida por traqueotomia. Se le dio el alta a los 145dias, y en la actualidad su estado general esta conserva-do, aunque con algunas secuelas no relevantes paraeste proceso patologico que comunicamos.El paciente presentaba una tumoracion del tamano deuna lenteja, que no producia dolor alguno, aunque un in-tenso prurito nocturno, desde hacia 2 anos aproximada-mente. La tumoracion fue aumentando de tamano, perose mantuvo asintomatica durante 2 anos. El paciente de-sestimo la intervencion en varias ocasiones.En el ultimo mes aparecio dolor en la zona de la tumo-racion, en forma de calambre con irradiacion hacia la ro-dilla, sin ocasionarle limitacion en su vida diaria. A la ex-ploracion se trataba de una tumoracion dura, no decaracter petreo, redondeada, no adherida a planos pro-fundos, que adquiria un color violaceo, facilmente accesi-ble por cirugia ambulatoria (fig. 1).Se realizo intervencion quirurgica de forma programadacon anestesia local, en la cual identificamos una masaabigarrada no capsulada, con forma de morula o de raci-mo, muy vascularizada y sangrante durante la exeresis;no adherida a planos profundos, y se pudo extirpar ma-croscopicamente en su totalidad (fig. 2). Aunque impresio-naba de lipoma, no parecia coincidir con las caracteristi-cas propias de las tumoraciones derivadas del tejidograso. Se reseco la piel sobrante y se realizo sutura sim-ple.La pieza quirurgica se envio para estudio anatomopa-tologico que informo, en la descripcion macroscopica, defragmento irregular de tejido fibroadiposo de 35 mm queal corte mostro areas firmes y amarillentas. El diagnosti-co final fue de glomangioma.

Los angiosarcomas de bazo son neoplasias de baja frecuencia caracterizadas por su mal pronostico. Presentamos el caso de una mujer de 35 anos de edad que ingresa de forma urgente en nuestro servicio, sin antecedentes personales de interes. Se encuentra en seguimiento por neurocirugia y cirugia plastica tras intervencion quirurgica hacia 45 dias de una tumoracion localizada en la region sacra y glutea izquierda, cuyo estudio histopatologico fue informado como hemangioendotelioma retiforme sacro con afectacion del hueso y partes blandas adyacentes, que muestra proliferacion de canales vasculares con areas de patron de crecimiento solido y otras de papilas intraluminales con celulas en “tachuela”, con moderado pleomorfismo e indice de mitosis bajo (sin encontrarse estructuras neoplasicas en la medula osea). La lesion glutea fue informada como angiosarcoma que afecta a piel y tejido celular subcutaneo, no encapsulado, con elevado indice mitotico, notable atipia celular y estar marginado por una proliferacion vascular de bajo grado de la que parece desarrollarse. El estudio inmunohistoquimico de esta lesion mostro CD34 positivo para celulas neoplasicas, actina de musculo liso con positividad para celulas neoplasicas, citoqueratinas negativas y Ki-67 con positividad menor del 30% (indice proliferativo bajo). La paciente acude a urgencias presentando deterioro brusco del nivel de conciencia y mal estado general acompanado de aumento del perimetro abdominal y dolor localizado en el epigastrio y el hipocondrio izquierdo junto con hipotension y taquicardia. Se practica una ecografia abdominal que informa de abdomen con liquido libre peritoneal compatible con hemoperitoneo. En la tomografia computarizada (TC) abdominal posterior se aprecia una imagen indicativa de infarto esplenico con liquido libre intraperitoneal (fig. 1). Con estos datos clinico-radiologicos se indica la realizacion de una laparotomia media exploradora de forma urgente, en la que se encuentran 2 l de sangre libre en el abdomen, y tras su aspirado se comprobo un bazo con varias lesiones sangrantes en su superficie que rompian su capsula; por tanto, se realizo una esplenectomia y colocacion de drenaje en el lecho quirurgico. El informe anatomopatologico microscopico del bazo describia: presencia de dos nodulos bien delimitados de aspecto hemorragico. En el analisis microscopico se informaban como angiosarcomas y metaplasia mieloide. Hemoperitoneo espontaneo por hemangiosarcoma de bazo

La fistula yeyunocolica es infrecuente, con solo 6 casos comunicados en la literatura cientifica internacional. Los principales tipos de fistulas son las colovesicales (65%), fundamentalmente en varones, y las fistulas colovaginales (25%), seguidas por coloentericas y fistulas colouterinas1. Si bien la diverticulitis aguda es la causa principal de las fistulas entericas (entre un 5 y un 33% de las diverticulitis), la segunda causa es la neoplasia de colon complicada2. Entre otras causas destaca la enfermedad inflamatoria intestinal, sobre todo la enfermedad de Crohn. Desde que Haldane publico el primer caso de una fistula gastrointestinal de origen maligno, en 1862, ha aumentado la notificacion de fistulas malignas asociadas a adenocarcinoma localmente avanzado3. La indicacion sera la cirugia, con extirpacion del segmento de colon neoplasico y del segmento yeyunal implicado, siempre que sea posible, con intencion de realizar cirugia radical y definitiva. Presentamos el caso de un paciente varon de 70 anos que ingresa de forma programada con historia desde hacia 2 anos de estrenimiento, y con empeoramiento de su estado general, asi como una perdida objetivada de unos 20 kg de peso, en los ultimos meses. Sin alteraciones analiticas, solo antigeno CEA de 10,6. Se practico tanto un transito gastroduodenal baritado como una endoscopia oral alta, donde se observo una fistula yeyunocolica probablemente secundaria a carcinoma de colon. Una colonoscopia informo de imagenes indicativas de tumoracion en esa zona, sin poder constatarlo ni tomar biopsias. En el estudio de extension se realizo tomografia computarizada de abdomen, que identifico una fistula yeyunocolica. Se decidio la intervencion quirurgica con la sospecha diagnostica de fistula yeyunocolica por probable cancer de colon. En la intervencion se comprobo esta comunicacion y un engrosamiento del mesocolon, junto con adenopatias. Se realizo exeresis oncologica de la lesion y anastomosis terminoterminal de colon y de yeyuno, respectivamente (fig. 1). La anatomia patologica mostro adenocarcinoma bien diferenciado, de probable origen colonico, que fistuliza a intestino delgado y metastasis de adenocarcinoma en 1 de 5 ganglios linfaticos aislados. El tumor se catalogo en estadio C3 de Astler-Coller. El paciente evoluciono favorablemente tras la intervencion quirurgica, y es tributario de tratamiento oncologico (quimioterapia). El tratamiento de este tipo de fistulas siempre comprende la indicacion quirurgica, con exeresis del trayecto fistuloso y extirpacion de los segmentos afectados1-4.

Objective: we want to present our experience about surgical pathology of Meckel’s diverticulum by means of a retrospective study. Material and methods: we report a group of patients of our Department of General and Abdominal Surgery and Paediatric Surgery of our Hospital with Meckel’s diverticulum since January 1997 to January 2010. We report the clinical presentation, complementary test, interventions, and the postoperative follow up. Results: 45 patients were operated in total, 33 of them in emergency surgery under the clinical form of acute abdominal pain; and the others 12 in programmed surgery, these cases came up more frequently like a clinical manifestations of latent abdominal pain, rectal bleeding and anaemia. The complementary tests were so varied; abdominal ultrasounds were used in 63% of emergency cases and the 40% of programmed cases, in these patients, gammagraphy with Tc 99 was the second test in frequency. Laparoscopy was used in 10 cases (22%). The main surgery technique used was diverticulectomy (82%). Conclusions: the presence of Meckel’s diverticulum has to be clinically suspected in all patients with abdominal pain of unknown aetiology. Access to the abdominal cavity using routine laparoscopy provides essential information on the diagnosis and for the treatment.