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Cord lipomas are frequent findings in laparoscopic inguinal hernia surgeries in male patients. The symptoms of lipoma and the potential benefits of removing them are often overlooked because the focus is on the primary pathology of the hernia itself. Current recommendations are to reduce this fatty content, when present. When inguinal cord lipomas are left untreated in inguinal hernia surgery they can potentially cause symptoms and be detected in follow-up imaging exams. The objective of this study was to study incidence of cord lipomas in a cohort operated on by a single group specializing in abdominal wall surgery, as well as to analyze the possible relationship of this finding with the patient's symptoms, the characteristics of the operated hernia and postoperative outcome. This is a prospective study of male patients operated on for inguinal hernia laparoscopically or robotically in a single reference center. Of the total of 141 hernias, the distribution according to European Hernia Society classification showed that 45.4% were lateral, 19.1% medial and 35.5% mixed, highlighting a variety in the presentation of hernias. Analysis of the size of the hernias revealed that the majority (35.5%) were ≤ 1.5 cm. Inguinal cord lipoma was present in 64.5% of the samples, with no statistically significant association between the presence of the lipoma and an indirect hernia sac or obesity. The incidence of surgical site occurrences (SSO) was 9,2%, with seroma and hematoma. No recurrences were observed during follow-up, indicating a successful approach. There were no statistically significant relationships between SSO, the presence of lipoma and indirect hernial sac., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: to consolidate a Trauma Register (TR) trough REDCap data acquisition platform and to validate, in this context, local Quality Indicators (QI) as improvement opportunities in trauma management., Methods: continuous data acquisition of all patients admitted in Irmandade da Santa Casa de Misericórdia de São Paulo adult Trauma bay and it's validation in REDCap platform; 6 months retrospective cohort of QI impact in length of hospitalar stay, complications and mortality. Fisher, Chi-squared, Wilcoxon and Kruskal-Wallis tests were used to correlate QIs fails with the endpoints, considering p<0.05 and CI <95% as statically significant., Results: 465 were admitted in Trauma bay, with 137 patients hospitalized (29.5%); the number of QIs compromised were related with more complications (p=0.075) and increased length of stay (p=0.028), especially the delay in open fracture's surgical management, which increased the severe complications' incidence (p=0.005)., Conclusion: the REDCap data acquisition platform is useful as a tool for multi center TR implementation, from ethical and logistical point of view; nevertheless, the proposed QIs are validated as attention points in trauma management, allowing improvements in traumatized patients treatment.

Purpose: Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application., Method: A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated., Results: Imaging post-BTA revealed hernia width reduction of 1.9 cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1 cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH 2 O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%., Conclusion: BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Surgical repair of large hernia defects requires detailed pre-operative planning, particularly in cases with loss of domain. This situation often hampers mid-line reconstruction, even after component separation, when the size of the hernia is disproportional to the volume of the abdominal area. In this case, other strategies may be needed to place the viscera back into the abdominal cavity after reducing the hernia sac. The administration of botulinum toxin prior to the surgical procedure has been indicated as an adjunct for more complex cases. This results in stretching of the lateral musculature of the abdomen, allowing midline approximation. In addition, the application of botulinum toxin alone has been investigated as a means of downstaging in the management of ventral hernias, thereby precluding component separation and enabling primary closure of the midline by placement of mesh within the retromuscular space using the Rives Stoppa technique., Methods: Systematic review of the literature for observational studies involving patients undergoing pre-operative application of botulinum toxin for ventral hernia repair was conducted according to the PRISMA guidelines., Results: Advance of the lateral musculature of the abdomen by an average of 4.11 cm with low heterogeneity, as well as low rates of surgical site infection (SSI), surgical site occurrences (SSO) and recurrence, was shown., Conclusion: Pre-operative application of botulinum toxin for ventral hernia repair promoted an increase in the length of the lateral musculature of the abdomen which can help improve the outcomes of morbidity and recurrence., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

The ideal ventral hernia surgical repair is still in discussion1. The defect closure with a mesh-based repair is the base of surgical repair, in open or minimally invasive techniques2. The open methods lead to a higher surgical site infections incidence, meanwhile, the laparoscopic IPOM (intraperitoneal onlay mesh) increases the risk of intestinal lesions, adhesions, and bowel obstruction, in addition to requiring double mesh and fixation products which increase its costs and could worsen the post-operative pain3-5. The eTEP (extended/enhanced view totally intraperitoneal) technique has also arisen as a good option for this hernia repair. To avoid the disadvantages found in classic open and laparoscopic techniques, the MILOS (Endoscopically Assisted Mini or Less Open Sublay Repair) concept, created by W. Reinpold et al. in 2009, 3 years after eTEP conceptualization, allows the usage of bigger meshes through a small skin incision and laparoscopic retro-rectus space dissection, as the 2016 modification, avoiding an intraperitoneal mesh placement6,7. This new technique has been called E-MILOS (Endoscopic Mini or Less Open Sublay Repair)8. The aim of this paper is to report the E-MILOS techniques primary experience Brazil, in Santa Casa de Misericórdia de São Paulo.

Objective: to assess the role of autopsy in the diagnosis of missed injuries (MI) and definition of trauma quality program goals., Method: Retrospective analysis of autopsy reports and patient's charts. Injuries present in the autopsy, but not in the chart, were defined as "missed". MI were characterized using Goldman's criteria: Class I, if the diagnosis would have modified the management and outcome; Class II, if it would have modified the management, but not the outcome; Class III, if it would not have modified neither the management nor the outcome. We used Mann-Whitney's U and Pearson's chi square for statistical analysis, considering p<0.05 as significant., Results: We included 192 patients, with mean age of 56.8 years. Blunt trauma accounted for 181 cases, and 28.6% were due to falls from the same level. MI were diagnosed in 39 patients (20.3%). Using Goldman's criteria, MI were categorized as Class I in 3 (1.6%) and Class II in 11 (5.6%). MI were more often diagnosed in the thoracic segment (25 patients, 64.1% of the MI). The variables significantly associated (p<0.05) to MI were: time of hospitalization < 48 h, severe trauma mechanism, and not undergoing surgery or computed tomography. At autopsy, the values of ISS and NISS were higher in patients with MI., Conclusion: the review of the autopsy report allowed diagnosis of MIs, which did not influence outcome in their majority. Many opportunities of improvement in quality of care were identified.

Objective: to review the clinical assessment of head injuries in motorcyclists involved in traffic accidents., Method: prospective observational study, including adult motorcyclists involved in traffic accidents in a period of 12 months. Patients sustaining signs of intoxication were excluded. A modification of the Canadian Head CT Rules was used to indicate computed tomography (CT). Patients not undergoing CT were followed by phone calls for three months. Collected variables were compared between the group sustaining head injuries and the others. We used chi-square, Fisher, and Student's t for statistical analysis, considering p<0.05 as significant., Results: we included 208 patients, 99.0% were wearing helmets. Seventeen sustained signs of intoxication and were excluded. Ninety (47.1%) underwent CT and 12 (6.3%) sustained head injuries. Head injuries were significantly associated with Glasgow Coma Scale<15 (52.3% vs. 2.8% - p<0,001) and a positive physical exam (17.1% vs. zero - p<0,05). Four (2.1%) patients with intracranial mass lesions needed surgical interventions. None helmet-wearing patients admitted with GCS=15 and normal physical examination sustained head injuries., Conclusion: Head CT is not necessary for helmet-wearing motorcyclists admitted with GCS=15 and normal physical examination.

Objective: to describe the use of the robotic platform in inguinal hernia recurrence after a previous laparoscopic repair., Methods: patients with recurrent inguinal hernias following a laparoscopic repair who have undergone robotic transabdominal preperitoneal between December 2015 through September 2020 were identified in a prospectively maintained database. Outcomes of interest included demographics, hernia characteristics, operative details and rates of 30-day surgical site occurrence, surgical site occurrences requiring procedural interventions, surgical site infection and hernia recurrence were abstracted., Results: nineteen patients (95% male, mean age 55 years, mean body mass index 28) had 27 hernias repaired (N=8 bilateral). Average operative time was 168.9 ± 49.3min (range 90-240). There were two intraoperative complications all of them were bleeding from the inferior epigastric vessel injuries. Three SSOs occurred (N=2 seromas and N=1 hematoma. After a median 35.7 months follow-up (IQR 13-49), no recurrence has been diagnosed. One patient developed chronic postoperative inguinal pain., Conclusions: on a small number of selected patients and experienced hands, we found that the use of the robotic platform for repair of recurrent hernias after prior laparoscopic repair appears to be feasible, safe and effective despite being technically demanding. Further studies in larger cohorts are necessary to determine if this technique provides any benefits in recurrent inguinal hernia scenario.

Introduction: The presence of Atrial Fibrillation (AF) with herniation of abdominal content through the esophageal hiatus can be explained by the compression of the cardiac tissue by the viscera and, consequently, of its electrical transmission network, compromising the correct propagation of stimuli. Due to the causal relationship, hernia correction is almost always able to reverse the arrhythmic picture., Presentation of the Case: A 75-year-old male with atrial fibrillation with a large hiatal hernia causing clinical decompensation was successfully treated after a laparocopic correction- primary closure of the defect was made with barbed surgical thread plus and placing a biological mesh (porcine small intestine submucosa, non-cross-linked), fixed with cyanoacrylate; after the procedure, he was discharged asymptomatic and with sinus heart rhythm., Discussion: It is noticed that for cases in which the patient presents with a type IV hiatal hernia associated with atrial fibrillation, the laparoscopic correction of hernia using a mesh for the correction of the defect has good results in the literature. In the present case, it is noted that despite the severity of the condition denoted by hemodynamic instability and the need for electrical cardioversion, the surgical correction of the hiatal hernia was able to reverse the arrhythmic picture definitively., Conclusion: the concomitance of AF and hiatal hernia can explain the difficulty to control the arrhythmic picture and is necessary to consider, as soon as possible, the surgical correction of the defect as part of the treatment., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: There has been a great advance in the treatment of inguinal hernias with a significant reduction in recurrences with the use of polypropylene mesh. Local complications such as infections, rejection, and chronic pain are widely studied and reported in the literature. The Autoimmune [Auto-inflammatory] Syndrome Induced by Adjuvants (ASIA) is little known and can be triggered by using polypropylene mesh., Presentation of the Case: 33-year-old female patient, married, and an administrative manager. History of smoking, previous breast surgery with silicone prosthesis, appendectomy. One year and four months ago, she underwent bilateral inguinal hernioplasty by laparoscopy. Shortly after the inguinal hernia surgery, systemic, urinary symptoms, and chronic local pain appeared. She reported low back pain, fatigue, memory loss, and mood swings associated with limiting pelvic pain, dysuria, and dyspareunia. We performed a robotic surgical procedure to remove the meshes bilaterally. Three days after surgery, the patient was discharged with adequate pain control, without the need for opioids. During outpatient follow-up, there was a significant improvement in symptoms, both local and systemic., Discussion: Local complications with the use of polypropylene mesh to repair inguinal hernias are well described in the literature, highlighting chronic postoperative pain that can affect 10-20% of patients. Recently, polypropylene prostheses have been found to act as adjuvants and may be the trigger for an exacerbated immune response adaptive to an autoantigen. Thus, being capable of causing an autoimmune disease variant of the Autoimmune [Auto-inflammatory] Syndrome Induced by Adjuvants (ASIA), described by Shoenfeld and Agmon-Levin in 2011., Conclusion: In addition to local complications, systemic symptoms related to the use of polypropylene mesh can also occur. In the Autoimmune [Auto-inflammatory] Syndrome Induced by Adjuvants (ASIA), systemic symptoms, for being nonspecific, make diagnosis difficult and are often not attributed to the use of mesh., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Blunt trauma is still the leading mechanism of trauma found in patients admitted to trauma centres worldwide. In these patients, the gastric injury is a very rare lesion, occurring in less than 2% of all blunt traumas. Besides the low incidence, gastric rupture mortality is high, which makes the diagnosis an essential step. Thus, this study aims to report two blunt gastric injuries, with different clinical features, prompting the discussion about the main features of clinical suspicion and diagnosis, besides the main therapeutic approaches. Therefore, this study can alert the medical community to the quick diagnosis and assertive therapy, saving patients of unwelcome endpoints., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: to analyze the relation between Trauma Quality Indicators (QI) and death, as well as clinical adverse events in severe trauma patients., Methods: analysis of data collected in the Trauma Register between 2014-2015, including patients with Injury Severity Score (ISS) > 16, reviewing the QI: (F1) Acute subdural hematoma drainage > 4 hours with Glasgow Coma Scale (GCS) <9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours; (F4) Admission-laparotomy time greater than 60 min in hemodynamically instable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time > 6 hours; (F10) Surgery > 24 hours. T the chi-squared and Fisher tests were used to calculate statistical relevance, considering p<0.05 as relevant., Results: 127 patients were included, whose ISS ranged from 17 to 75 (28.8 + 11.5). There were adverse events in 80 cases (63%) and 29 died (22.8%). Twenty-six patients had some QI compromised (20.6%). From the 101 patients with no QI, 22% died, and 7 of 26 patients with compromised QI (26.9%) (p=0.595). From the patients with no compromised QI, 62% presented some adverse event. From the patients with any compromised QI, 18 (65.4%) had some adverse event on clinical evolution (p=0.751)., Conclusion: the QI should not be used as death or adverse events predictors in severe trauma patients.

Purpose: to trauma quality indicators as a tool to identify opportunities of improvement in elderly trauma patient's' treatment., Methods: prospective analysis of data collected between 2014-2015, and stored in the iTreg software (by Ecossistemas). Trauma victims, aged older than 60 years and trauma quality indicators were assessed, based on those supported by SBAIT in 2013: (F1) Acute subdural hematoma drainage after 4 hours from admission, in patients with GCS<9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours from extubation; (F4) Admission-laparotomy time greater than 60 min. in hemodynamically uinstable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours from admission; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time greater than 6 hours; (F10) Surgery after 24 from admission. The indicators, treatments, adverse effects and deaths were analyzed, using the SPSS software, and the chi-squared and Fisher tests were used to calculate the statistical relevance., Results: from the 92 cases, 36 (39,1%) had complications and 15 (16,3%) died. The adequate use of quality indicator's were substantially different among those who survived (was of 12%) compared to those who died (55,6%). The incidence of complications was of 77,8% (7/9) in patients with compromised indicators and 34,9% (28/83) in those without (p=0.017)., Conclusions: trauma quality indicators are directly related with the occurrence of complications and deaths, in elderly trauma patients.