Laparoscopic ventral hernia repair is safe and cost effective

Background: Ventral hernia repair is increasingly performed by laparoscopic means since the introduction of dual-layer meshes. This study aimed to compare the early complications and cost effectiveness of open hernia repair with those associated with laparoscopic repair. Methods: Open ventral hernia repair was performed for 92 consecutive patients using a Vypro mesh, followed by laparoscopic repair for 49 consecutive patients using a Parietene composite mesh. Results: The rate of surgical-site infections was significantly higher with open ventral hernia repair (13 vs 1; p = 0.03). The median length of hospital stay was significantly shorter with laparoscopic surgery (7 vs 6 days; p = 0.02). For laparoscopic repair, the direct operative costs were higher (2,314 vs 2,853 euros; p = 0.03), and the overall hospital costs were lower (9,787 vs 7,654 euros; p = 0.02). Conclusions: Laparoscopic ventral hernia repair leads to fewer surgical-site infections and a shorter hospital stay than open repair. Despite increased operative costs, overall hospital costs are lowered by laparoscopic ventral hernia repai

The Role of Surgical Expertise and Surgical Access in Retroperitoneal Sarcoma Resection - A Retrospective Study.

Background Retroperitoneal sarcoma (RPS) is a rare disease often requiring multi-visceral and wide margin resections for which a resection in a sarcoma center is advised. Midline incision seems to be the access of choice. However, up to now there is no evidence for the best surgical access. This study aimed to analyze the oncological outcome according to the surgical expertise and also the incision used for the resection. Methods All patients treated for RPS between 2007 and 2018 at the Department of Visceral Surgery and Medicine of the University Hospital Bern and receiving a RPS resection in curative intent were included. Patient- and treatment specific factors as well as local recurrence-free, disease-free and overall survival were analyzed in correlation to the hospital type where the resection occurred. Results Thirty-five patients were treated for RPS at our center. The majority received their primary RPS resection at a sarcoma center (SC = 23) the rest of the resection were performed in a non-sarcoma center (non-SC = 12). Median tumor size was 24 cm. Resections were performed via a midline laparotomy (ML = 31) or flank incision (FI = 4). All patients with a primary FI (n = 4) were operated in a non-SC (p = 0.003). No patient operated at a non-SC received a multivisceral resection (p = 0.004). Incomplete resection (R2) was observed more often when resection was done in a non-SC (p = 0.013). Resection at a non-SC was significantly associated with worse recurrence-free survival and disease-free survival after R0/1 resection (2 vs 17 months; Log Rank p-value = 0.02 respectively 2 vs 15 months; Log Rank p-value < 0.001). Conclusions Resection at a non-SC is associated with more incomplete resection and worse outcome in RPS surgery. Inadequate access, such as FI, may prevent complete resection and multivisceral resection if indicated and demonstrates the importance of surgical expertise in the outcome of RPS resection

Die Behandlungspraxis bei Patienten mit isolierter stumpfer Milzverletzung: Eine Befragung der Schweizer Traumatologen

Zusammenfassung: Hintergrund: Das nicht-operative Management (NOM) des stumpfen Milztraumas hat sich in den vergangenen Jahren als Therapiekonzept etabliert. Es bestehen jedoch zahlreiche Kontroversen bezüglich der Überwachung und Nachsorge dieser Patienten. Ziel dieser Studie war es, mittels einer Umfrage bei Mitgliedern der Schweizerischen Gesellschaft für Allgemeine und Unfallchirurgie (SGAUC) die aktuelle Praxis bezüglich NOM beim isolierten Milztrauma zu erfassen und mögliche Diskrepanzen zur aktuellen Literatur zu eruieren. Studiendesign und Untersuchungsmethode: Sämtliche praktizierende Mitglieder der SGAUC wurden mittels schriftlichem Umfragebogen adressiert. Dieser enthielt Fragen zu Person und Klinik des Chirurgen, Fragen zu Diagnostik und Management während der Hospitalisation sowie zu radiologischen Verlaufskontrollen und zur stufenweisen Wiederaufnahme von Alltagsaktivitäten. Ergebnisse: An der Umfrage nahmen 52 von 165 (31,5%) praktizierenden Mitgliedern der SGAUC teil. Diese deckten 62,8% aller Schweizer Traumazentren ab. Vierzehn Befragte (26,9%) verfügen an ihrer Klinik über ein Protokoll zur Behandlung des Milztraumas. Als initiale Bildgebung beim hämodynamisch stabilen Patienten mit stumpfem Abdomaninaltrauma gaben 82,7% der Befragten die Sonographie an. Bei sonographischem Verdacht auf Milztrauma verzichteten allerdings 19,2% der Befragten auf eine weitergehende Diagnostik. Die Hälfte der Chirurgen gab außerdem an, bei sichtbarem Kontrastmittelextravasat aus der Milz keine weiteren therapeutischen Maßnahmen einzuleiten. 86,5% der Befragten würden Patienten mit niedriggradigem Milztrauma für durchschnittlich 1,6 (0-4Tage) in einem kontinuierlich-monitorisierten Bett überwachen. Keine Unterschiede wurden hinsichtlich der Aktivitätsrestriktion zwischen mittel- und hochgradigen Milztraumata gemacht. Schlussfolgerung: Aufgrund eines Mangels an evidenzbasierten Richtlinien zum NOM des Milztraumas gibt es eine beträchtliche Variabilität in der klinischen Praxis selbst unter erfahrenen Chirurgen. Die größten Diskrepanzen zu den Empfehlungen in der aktuellen Literatur waren zum einen der Verzicht auf eine Computertomographie bei Verdacht auf Milztrauma, zum anderen das konservative Vorgehen trotz nachgewiesenem Kontrastmittelaustrit

Three-dimensional vision enhances task performance independently of the surgical method

Background: Within the next few years, the medical industry will launch increasingly affordable three-dimensional (3D) vision systems for the operating room (OR). This study aimed to evaluate the effect of two-dimensional (2D) and 3D visualization on surgical skills and task performance. Methods: In this study, 34 individuals with varying laparoscopic experience (18 inexperienced individuals) performed three tasks to test spatial relationships, grasping and positioning, dexterity, precision, and hand-eye and hand-hand coordination. Each task was performed in 3D using binocular vision for open performance, the Viking 3Di Vision System for laparoscopic performance, and the DaVinci robotic system. The same tasks were repeated in 2D using an eye patch for monocular vision, conventional laparoscopy, and the DaVinci robotic system. Results: Loss of 3D vision significantly increased the perceived difficulty of a task and the time required to perform it, independently of the approach (P<0.0001-0.02). Simple tasks took 25% to 30% longer to complete and more complex tasks took 75% longer with 2D than with 3D vision. Only the difficult task was performed faster with the robot than with laparoscopy (P=0.005). In every case, 3D robotic performance was superior to conventional laparoscopy (2D) (P<0.001-0.015). Conclusions: The more complex the task, the more 3D vision accelerates task completion compared with 2D vision. The gain in task performance is independent of the surgical metho

Prospective randomized trial comparing sutured with sutureless mesh fixation for Lichtenstein hernia repair: long-term results

Background: Following Lichtenstein hernia repair, up to 25% of patients experience prolonged postoperative and chronic pain as well as discomfort in the groin. One of the underlying causes of these complaints are the compression or irritation of nerves by the sutures used to fixate the mesh. We compared the level and rate of chronic pain in patients operated with the classical Lichtenstein technique fixated by sutures to patients with sutureless mesh fixation technique. Methods: A two-armed randomized trial with 264 male patients was performed. After consent, patients were randomized preoperatively. For the fixation of the mesh we used either sutures with slow-absorbing material (PDS 2.0) (group I, n=133) or tissue glue (Histoacryl) (group II, n=131). Follow-up examinations were performed after 3, 12months and after 5years. Results: Patient characteristics in the two groups were similar. No cross-over between groups was observed. After 5years, long-term follow-up could be completed for 59% of subjects. After 5years, 10/85 (11.7%) patients in group I and 3/70 (4.2%) in group II suffered from chronic pain in the groin region (P=0.108). The operation time was significantly shorter in group II (79min vs 73min, P=0.01). One early recurrence occurred in group II (3months). The recurrence rate was 0 and 0% after 12months and 5.9% (5/85) and 10% (7/70) after 5years in group I and group II, respectively (P=0.379). Conclusion: After 5years, the two techniques of mesh fixation resulted in similar rates of chronic pain. Whereas recurrence rates were comparable, fixation of the mesh with tissue glue decreased operating room time significantly. Hence, suture less mesh fixation with Histoacryl is a sensible alternative to suture fixation and should be especially considered for patients prone to pai

Roux-en-Y Drainage of the Pancreatic Stump Decreases Pancreatic Fistula After Distal Pancreatic Resection

Clinically relevant fistula after distal pancreatic resection occurs in 5-30% of patients, prolonging recovery and considerably increasing in-hospital stay and costs. We tested whether routine drainage of the pancreatic stump into a Roux-en-Y limb after distal pancreatic resection decreased the incidence of fistula. From October 2001, data of all patients undergoing pancreatic distal resection were entered in a prospective database. From June 2003 after resection, the main pancreatic duct and the pancreatic stump were oversewn, and in addition, anastomosed into a jejunal Roux-en-Y limb by a single-layer suture (n = 23). A drain was placed near the anastomosis, and all patients received octreotide for 5-7days postoperatively. The volume of the drained fluid was registered daily, and concentration of amylase was measured and recorded every other day. Patient demographics, hospital stay, pancreatic fistula incidence (≥30ml amylase-rich fluid/day on/after postoperative day 10), perioperative morbidity, and follow-up after discharge were compared with our initial series of patients (treated October 2001-May 2003) who underwent oversewing only (n = 20). Indications, patient demographics, blood loss, and tolerance of an oral diet were similar. There were four (20%) pancreatic fistulas in the "oversewn” group and none in the anastomosis group (p < 0.05). Nonsurgical morbidity, in-hospital stay, and follow-up were comparable in both group

Quality of life after hepatic resection

Background: Long-term quality of life (QoL) after liver resection is becoming increasingly important, as improvements in operative methods and perioperative care have decreased morbidity and mortality rates. In this study, postoperative QoL after resection of benign or malignant liver tumours was evaluated. Methods: In this single-centre study, QoL was evaluated prospectively using the European Organisation for Research and Treatment of Cancer QLQ-C30 and the liver-specific QLQ-LMC21 module before, and 1, 3, 6 and 12months after open or laparoscopic liver surgery. Results: Between June 2007 and January 2013, 188 patients (130 with malignant and 58 with benign tumours) requiringmajor liver resection were included. Global health status was no different between the two groups before and 1month after liver resection. All patients showed an improvement in global health status at 3, 6 and 12months after surgery. Patients with benign tumours had better global health status than those with malignant tumours at these time points (P<0⋅001, P=0⋅002 and P=0⋅006 respectively). Patients with benign disease had better physical function scores (P=0⋅011, P=0⋅025 and P=0⋅041) and lower fatigue scores (P=0⋅001, P=0⋅002 and P=0⋅002) at 3, 6 and 12months than those with malignant disease. Conclusion: This study confirmed overall good QoL in patients undergoing liver resection for benign or malignant tumours, which improved after surgery. Benign diseases were associated with better shortand long-term QoL scores

No signs of check-list fatigue - introducing the StOP? intra-operative briefing enhances the quality of an established pre-operative briefing in a pre-post intervention study.

The team timeout (TTO) is a safety checklist to be performed by the surgical team prior to incision. Exchange of critical information is, however, important not only before but also during an operation and members of surgical teams frequently feel insufficiently informed by the operating surgeon about the ongoing procedure. To improve the exchange of critical information during surgery, the StOP?-protocol was developed: At appropriate moments during the procedure, the leading surgeon briefly interrupts the operation and informs the team about the current Status (St) and next steps/objectives (O) of the operation, as well as possible Problems (P), and encourages questions of other team members (?). The StOP?-protocol draws attention to the team. Anticipating the occurrence of StOP?-protocols may support awareness of team processes and quality issues from the beginning and thus support other interventions such as the TTO; however, it also may signal an additional demand and contribute to a phenomenon akin to "checklist fatigue." We investigated if, and how, the introduction of the StOP?-protocol influenced TTO quality. This was a prospective intervention study employing a pre-post design. In the visceral surgical departments of two university hospitals and one urban hospital the quality of 356 timeouts (out of 371 included operation) was assessed by external observers before (154) and after (202) the introduction of the StOP?-briefing. Timeout quality was rated in terms of timeout completeness (number of checklist items mentioned) and timeout quality (engagement, pace, social atmosphere, noise). As compared to the baseline, after the implementation of the StOP?-protocol, observed timeouts had higher completeness ratings (F = 8.69, p = 0.003) and were rated by observers as higher in engagement (F = 13.48, p &lt; 0.001), less rushed (F = 14.85, p &lt; 0.001), in a better social atmosphere (F = 5.83, p &lt; 0.016) and less noisy (F = 5.35, p &lt; 0.022). Aspects of TTO are affected by the anticipation of StOP?-protocols. However, rather than harming the timeout goals by inducing "checklist fatigue," it increases completeness and quality of the team timeout

Prospective randomized trial comparing sutured with sutureless mesh fixation for Lichtenstein hernia repair: long-term results

Following Lichtenstein hernia repair, up to 25% of patients experience prolonged postoperative and chronic pain as well as discomfort in the groin. One of the underlying causes of these complaints are the compression or irritation of nerves by the sutures used to fixate the mesh. We compared the level and rate of chronic pain in patients operated with the classical Lichtenstein technique fixated by sutures to patients with sutureless mesh fixation technique