Comparative analysis of innovative minimally invasive reconstructive techniques of abdominal-wall hernias: ventral TAPP versus laparoscopic IPOM

Die laparoskopische Reparation von Bauchwandbrüchen ist seit Jahren Bestandteil der Hernienchirurgie. Als Standardtechnik gilt das lap. IPOM Verfahren, welches sich aufgrund seiner vergleichsweise einfachen und standardisierten Operationstechnik sowie der guten Langzeitergebnisse bezüglich eines Rezidivs etabliert hat. Diese Methode wird jedoch aufgrund von nicht unerheblichen postoperativen Schmerzen und der Tatsache, dass die Netzeinlage intraabdominell erfolgt und somit direkten Kontakt zu den viszeralen Organen hat, in der aktuellen Literatur zunehmend kontrovers diskutiert. In der Chirurgischen Klinik Charité Campus Mitte / Campus Virchow-Klinikum wird seit 2014 neben der etablierten lap. IPOM Methode die ventral TAPP für ventrale Hernien kleiner bis mittlerer Größe durchgeführt. Dieses ebenfalls minimalinvasive Verfahren erlaubt eine präperitoneale Netzplatzierung. Gegenstand dieser Arbeit ist es, die lap. IPOM Methode mit der innovativen ventral TAPP Technik im Anwendungsgebiet von ventralen Hernien kleiner bis mittlerer Größe zu vergleichen. Diesbezüglich wurden sämtliche Fälle, die zwischen 2014 und 2020 am Campus Mitte / Campus Virchow-Klinikum mit den beiden Operationstechniken behandelt wurden, aus der prospektiv geführten Datenbank extrahiert und retrospektiv aufgearbeitet. Dies ergab nach Anwendung der Exklusionskriterien 180 Fälle. Patienten mit einer Herniengröße von mehr als 5 cm wurden ausgeschlossen, da die ventral TAPP hier nicht zur Anwendung kam. Anschließend wurde eine Propensity-Score-Analyse durchgeführt. Hieraus ergaben sich Kohorten von jeweils 27 Patienten, welche in Bezug auf ihre perioperativen Daten, postoperativen Ergebnisse und Kosteneffektivität analysiert wurden. Die statistische Auswertung der erhobenen Daten zeigte signifikant erhöhte Werte in Bezug auf die postoperative Einnahme von Opiaten in der lap. IPOM Gruppe im Vergleich zu den ventral TAPP Patienten (p=0,001). Weiterhin war die objektivierte postoperative Schmerzempfindung anhand des VAS nach einer lap. IPOM Hernienreparation sowohl in ihrem maximalen Ausmaß (p=0,004) als auch bei Bewegung (p=0,008) und in Ruhe (p=0,023) signifikant höher. Hernienrezidive wurden über einen Nachbeobachtungszeitraum von 31.96 ± 27.57 (lap. IPOM) sowie 14.70 ± 15.76 (ventral TAPP) Monaten in keiner der beiden Gruppen festgestellt. Bezüglich der Materialkosten ist die ventral TAPP (34,37 ± 0,47 €) deutlich günstiger als die lap. IPOM Methode (742,57 ± 128,44 €; p=0,001). Auch war die Dauer des stationären Aufenthaltes bei der lap. IPOM Kohorte signifikant länger (2.81 ± 0.88 versus 2.37 ± 0.69 Tage; p=0,043). Insgesamt zeigte der Vergleich der beiden Methoden, dass die ventral TAPP eine alternative Technik zur etablierten lap. IPOM Hernienreparation bietet. Die Ergebnisse zeigen, dass die postoperativen Schmerzen, die Materialkosten und der stationäre Krankenhausaufenthalt der ventral TAPP Kohorte im Vergleich zur lap. IPOM signifikant niedriger waren.Laparoscopic repair of abdominal wall hernias has been an essential part of hernia surgery for many years. The lap. IPOM has established itself due to its comparatively simple and standardized surgical technique as well as good long-term results with regard to recurrence. However, this method is controversially discussed in the current literature due to considerable postoperative pain and the fact that the mesh is placed intraabdominally and thus has direct contact to the visceral organs. In addition to the established lap. IPOM method, the innovative ventral TAPP for ventral hernias of small to medium size has been performed at the Department of Surgery Charité Campus Mitte / Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin since 2014. This procedure, also minimally invasive, allows for preperitoneal mesh placement. The purpose of this study is to compare the lap. IPOM method with this innovative technique (ventral TAPP) for treatment of ventral hernias of small to medium size. In this regard, all cases between 2014 and 2020 at Charité Campus Mitte / Campus Virchow-Klinikum treated with either one of these surgical techniques were extracted from the prospectively maintained database and retrospectively analyzed. 180 cases were identified after application of the exclusion criteria. Subsequently, patients with hernia size greater than 5 cm were excluded because the ventral TAPP method is not suitable for larger hernias. A propensity-score matching was performed. This resulted in cohorts of 27 patients each, which were analyzed in terms of their perioperative data, surgical outcomes, and cost-effectiveness. Statistical analysis of the collected data showed significant higher values in terms of postoperative opiate use in the lap. IPOM group compared to the ventral TAPP patients (p=0.001). Furthermore, objectified postoperative pain perception using the VAS was significantly elevated after lap. IPOM hernia repair. Data was showed higher values during maximum extent (p=0.004) and during movement (p=0.008) as well as at rest (p=0.023). Hernia recurrences were not observed in either group over a follow-up period of 31.96 ± 27.57 months (lap. IPOM) and 14.70 ± 15.76 months (ventral TAPP). Regarding material costs, the ventral TAPP (34,37 ± 0,47 €) is significantly cheaper than the lap. IPOM method (742.57 ± 128.44 €; p=0.001). Also, the length of inpatient stay was significantly longer in the lap. IPOM cohort (2.81 ± 0.88 versus 2.37 ± 0.69 days; p=0,043). Overall, the comparison of the two methods showed that the ventral TAPP method is an alternative technique to the established lap. IPOM hernia repair. In particular the results show that postoperative pain, material costs and inpatient hospital stay were significantly lower in the ventral TAPP cohort compared with lap. IPOM cohort

The Role of Macrophage Migration Inhibitory Factor (MIF) and D-Dopachrome Tautomerase (D-DT/MIF-2) in Infections: A Clinical Perspective

Macrophage migration inhibitory factor (MIF) and its homolog, D-dopachrome tautomerase (D-DT), are cytokines that play critical roles in the immune response to various infectious diseases. This review provides an overview of the complex involvement of MIF and D-DT in bacterial, viral, fungal, and parasitic infections. The role of MIF in different types of infections is controversial, as it has either a protective function or a host damage-enhancing function depending on the pathogen. Depending on the specific role of MIF, different therapeutic options for MIF-targeting drugs arise. Human MIF-neutralizing antibodies, anti-parasite MIF antibodies, small molecule MIF inhibitors or MIF-blocking peptides, as well as the administration of exogenous MIF or MIF activity-augmenting small molecules have potential therapeutic applications and need to be further explored in the future. In addition, MIF has been shown to be a potential biomarker and therapeutic target in sepsis. Further research is needed to unravel the complexity of MIF and D-DT in infectious diseases and to develop personalized therapeutic approaches targeting these cytokines. Overall, a comprehensive understanding of the role of MIF and D-DT in infections could lead to new strategies for the diagnosis, treatment, and management of infectious diseases

The History of Carbon Monoxide Intoxication

Intoxication with carbon monoxide in organisms needing oxygen has probably existed on Earth as long as fire and its smoke. What was observed in antiquity and the Middle Ages, and usually ended fatally, was first successfully treated in the last century. Since then, diagnostics and treatments have undergone exciting developments, in particular specific treatments such as hyperbaric oxygen therapy. In this review, different historic aspects of the etiology, diagnosis and treatment of carbon monoxide intoxication are described and discussed

Necrotizing Fasciitis after Panniculectomy Caused by Finegoldia magna

Summary:. Necrotizing fasciitis is a rare yet severe complication after body contouring surgery. We present a case of a 54-year-old woman with a complex medical history who developed necrotizing fasciitis 9 days after panniculectomy and epigastric hernia repair. Microbiological examination revealed Finegoldia magna as the causative agent, a rare pathogen in necrotizing fasciitis. Patients undergoing body contouring may be at increased risk of developing necrotizing fasciitis; therefore, increased attention should be paid to this differential diagnosis in case of postoperative signs of infection. This case report highlights the pivotal importance of early recognition, prompt surgical intervention, and comprehensive medical treatment to improve patient outcomes in necrotizing fasciitis

Integrative Medicine and Plastic Surgery: A Synergy-Not an Antonym

BACKGROUND Integrative medicine focuses on the human being as a whole-on the body, mind, and spirit-to achieve optimal health and healing. As a synthesis of conventional and complementary treatment options, integrative medicine combines the pathological with the salutogenetic approach of therapy. The aim is to create a holistic system of medicine for the individual. So far, little is known about its role in plastic surgery. HYPOTHESIS We hypothesize that integrative medicine based on a conventional therapy with additional anthroposophic therapies is very potent and beneficial for plastic surgery patients. Evaluation and consequence of the hypothesis: Additional anthroposophic pharmacological and non-pharmacological treatments are promising for all areas of plastic surgery. We are convinced that our specific approach will induce further clinical trials to underline its therapeutic potential

Incidence, Diagnosis and Repair of a Diaphragmatic Hernia Following Hepatic Surgery: A Single Center Analysis of 3107 Consecutive Liver Resections

Diaphragmatic hernia (DH) after a liver resection (LR) is an uncommon but potentially severe complication. In this retrospective study, we aim to share our experience with DH in our hepatic surgery center. We retrospectively analyzed 3107 patients who underwent a liver resection between January 2012 and September 2019. The diagnosis of DH was based on clinical examination and radiological imaging and confirmed by intraoperative findings during surgical repair. Five out of 3107 (0.16%) patients after LR developed DH. Especially, all five DH patients had a major right-sided LR before (n = 716, 0.7%). The mean time interval between initial LR and occurrence of DH was 30 months (range 15 to 44 months). DH exclusively occurred after a right or extended right hepatectomy. Two patients underwent emergency surgery, three were asymptomatic, and DH was diagnosed in follow-up imaging. Three of these five treated patients (60%) developed DH recurrence: two of three (67%) patients after suture repair alone and the only patient after suture repair in combination with an absorbable mesh. The patient who was treated with a composite mesh implant did not show any signs of DH recurrence after 52 months of follow-up. In patients who develop DH after liver surgery, a mesh augmentation with nonresorbable material is generally recommended. In order to diagnose these patients in an early state, we recommend that special attention be paid and a prompt and targeted diagnostic examination of patients with abdominal complaints after right-sided liver resections take place

Hydroceles of the Canal of Nuck in Adults—Diagnostic, Treatment and Results of a Rare Condition in Females

Nuck's hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck's canal from September 2016 to January 2020 at the Department of Surgery of Charite Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck's hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck's hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck ' s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon's skills. If inguinal channel has been widened by the presence of a Nuck's hydrocele, a mesh plasty, as performed in hernia surgery, should be considered

Macrophage Migration Inhibitory Factor-An Innovative Indicator for Free Flap Ischemia after Microsurgical Reconstruction

(1) Background: Nowadays, the use of microsurgical free flaps is a standard operative procedure in reconstructive surgery. Still, thrombosis of the microanastomosis is one of the most fatal postoperative complications. Clinical evaluation, different technical devices and laboratory markers are used to monitor critical flap perfusion. Macrophage migration inhibitory factor (MIF), a structurally unique cytokine with chemokine-like characteristics, could play a role in predicting vascular problems and the failure of flap perfusion. (2) Methods: In this prospective observational study, 26 subjects that underwent microsurgical reconstruction were observed. Besides clinical data, the number of blood leukocytes, CRP and MIF were monitored. (3) Results: Blood levels of MIF, C-reactive protein (CRP) and leukocytes increased directly after surgery. Subjects that needed surgical revision due to thrombosis of the microanastomosis showed significantly higher blood levels of MIF than subjects without revision. (4) Conclusion: We conclude that MIF is a potential and innovative indicator for thrombosis of the microanastomosis after free flap surgery. Since it is easy to obtain diagnostically, MIF could be an additional tool to monitor flap perfusion besides clinical and technical assessments

Microsurgical Reconstruction of Foot Defects: A Case Series with Long-Term Follow-Up

(1) Background: Microsurgical reconstruction of foot defects with free flaps is rare as it is a challenging task for a surgeon. For extensive defects, advanced surgical procedures, such as free flap transfer with microsurgical anastomosis, may be the last chance to avoid major amputation. The aim of the study was to examine the opportunities and risks posed by free flap reconstruction of foot defects and to illustrate in which situations reconstruction is useful on the basis of case characteristics. (2) Methods: In this study, we retrospectively analyzed data of cases with free flap reconstruction of the foot from 2007 to 2022. Therefore, demographic data, comorbidities, information about the defect situation, data on the operational procedure, and complications were evaluated. (3) Results: A total of 27 cases with free flap coverage of foot defects could be included. In 24 of these cases (89%), defect coverage was successful. In 18 patients, some form of complication occurred in the postoperative stage. The most frequently used flap was the latissimus dorsi flap, with 13 procedures. (4) Conclusions: Foot reconstruction using free flaps is a proven procedure for the treatment of larger foot defects and can offer a predominantly good functional outcome. The lengthy process and possible complications should be thoroughly discussed in advance so as to provide criteria, suitably adjusted to the individual prerequisites of the patients, for deciding whether limb salvage using advanced surgical procedures should be attempted

Macrophage migration inhibitory factor — an innovative indicator for free flap ischemia after microsurgical reconstruction

(1) Background: Nowadays, the use of microsurgical free flaps is a standard operative procedure in reconstructive surgery. Still, thrombosis of the microanastomosis is one of the most fatal postoperative complications. Clinical evaluation, different technical devices and laboratory markers are used to monitor critical flap perfusion. Macrophage migration inhibitory factor (MIF), a structurally unique cytokine with chemokine-like characteristics, could play a role in predicting vascular problems and the failure of flap perfusion. (2) Methods: In this prospective observational study, 26 subjects that underwent microsurgical reconstruction were observed. Besides clinical data, the number of blood leukocytes, CRP and MIF were monitored. (3) Results: Blood levels of MIF, C-reactive protein (CRP) and leukocytes increased directly after surgery. Subjects that needed surgical revision due to thrombosis of the microanastomosis showed significantly higher blood levels of MIF than subjects without revision. (4) Conclusion: We conclude that MIF is a potential and innovative indicator for thrombosis of the microanastomosis after free flap surgery. Since it is easy to obtain diagnostically, MIF could be an additional tool to monitor flap perfusion besides clinical and technical assessments