Open Repair Research Articles

Safety and validity of selective cerebrospinal fluid drainage in open and endovascular aortic repair.

Although cerebrospinal fluid drainage has been shown to reduce the risk of ischemic spinal cord injury, serious complications have also been reported. We have been using it selectively in a pressure- and volume-regulated method and aimed to evaluate its safety, and its validity in elective thoracic endovascular aortic repair in a propensity-matched cohort. Among the 450 patients who underwent open surgery (n = 169) or thoracic endovascular aortic repair (n = 281) on the descending or thoracoabdominal aorta, 147 underwent cerebrospinal fluid drainage, which was prophylactic in 135 and therapeutic in 12. Prophylactic drainage was performed in elective open surgery under distal aortic perfusion (n = 67) or in selected patients undergoing thoracic endovascular aortic repair (n = 68). Drainage-related complications were observed in 13 (9.6%), one of which was graded severe (0.74%). In patients undergoing prophylactic drainage, spinal cord injury was detected in 2/135 (1.5%). In patients without prophylactic drainage, 15/315 (4.8%) developed spinal cord injury. Therapeutic drainage was performed in 12 of these 15 patients, 10 of whom remained paralytic in varying degree. In the inverse probability weighted analysis of the patients undergoing elective thoracic endovascular aortic repair, the incidence of spinal cord injury was lower with prophylactic drainage (p = 0.028). Pressure- and volume-regulated spinal drainage rarely causes serious complications. Its prophylactic use seems beneficial in selected patients, including those undergoing thoracic endovascular aortic repair with high risk for spinal cord injury.

Ultrasound-guided transversus abdominis plane block is an effective opioid-sparing alternative to epidural anesthesia in open abdominal aortic aneurysm repair

ObjectiveThis study evaluated the effectiveness of ultrasound-guided transversus abdominis plane (TAP) blocks compared with epidural (EPI) and general anesthesia (GA) in managing postoperative pain following open abdominal aortic aneurysm (AAA) repair. MethodsA retrospective review was conducted on 61 elective open AAA repairs performed between January 2016 and December 2021. Patients were categorized into three groups: GA, GA plus EPI, and GA plus TAP block. The primary outcome measured was opioid requirements, reported as morphine milligram equivalents (MME) at 48, 72, and 120 hours postoperatively. The additional opioid requirements between 48 and 72 hours (ΔMME₁) and between 72 and 120 hours (ΔMME₂) were also evaluated. Secondary outcomes included vasopressor requirements, extubation in the operating room, and length of stay in the intensive care unit and hospital. ResultsThe mean MMEs at 48, 72, and 120 hours were statistically significant across all groups. The mean MME at 48 hours was 51.1 ± 71.9 in the TAP group compared with 140.5 ± 121.7 in the GA group. Pairwise comparisons showed a significant difference between the GA and TAP groups at 48 hours (P = .002), whereas the difference between EPI and TAP at 48 hours was not significant (P = .098). Additional opioid requirements between 48 and 72 hours after surgery (ΔMME₁) showed a significant difference between EPI and TAP (P = .045). All groups had significantly different MMEs at 72 hours, with no significant differences observed at 120 hours. Secondary outcomes were not significantly different across the groups. ConclusionsTAP blocks provide effective postoperative pain control with decreased opioid requirements similar to EPI anesthesia during the first 48 hours postoperatively. This factor makes TAP blocks a viable alternative to EPI anesthesia in open AAA repairs. Further multicenter studies are recommended to validate these findings.

The Safety and Outcomes of Elective Endovascular Aneurysm Repair in the Elderly: A Systemic Review and Meta-Analysis.

Prevalence of abdominal aortic aneurysms (AAAs) increases with age. Previous trials confirm that elective endovascular aneurysm repair (EVAR) is an effective intervention for AAA. However, few elderly patients were recruited into randomized trials, whereas in contemporary clinical practice, elective repair is commonly performed on octogenarians. We evaluated the safety and outcome of elective EVAR in elderly patients to inform clinical practice and vascular service provision. A systematic review and meta-analysis of studies reporting risk of complications and death in patients undergoing elective EVAR was performed (PROSPERO CRD: 42022308423). Observational studies and interventional arms of randomized trials were included if the outcome rates or raw data were provided. Primary outcome was 30-day mortality. Secondary outcomes were longer-term mortality, 30-day major adverse events, and aneurysm-related mortality. Primary and secondary outcomes were compared between octogenarians and non-octogenarians. Exclusion criteria were emergency procedures, non-infrarenal aneurysms, and lack of octogenarian data. A total of 41 studies were eligible from 10 099 citations, including 10 national and 5 international registries, 26 retrospective studies, and our own prospective cohort. The analysis included 208 997 non-octogenarians (mean age=70.19 [SD=0.62]) and 106 188 octogenarians (mean age=83.75 [SD=0.35]). The 30-day mortality post-elective EVAR was higher in octogenarians (1.08% in non-octogenarians, 2.31% in octogenarians, odds ratio [OR]=2.27 [2.08-2.47], p<0.0001). Linear regression demonstrated a 0.83% increase in 30-day mortality for every 10-year age increase above 60 years old. Mortality for octogenarians increased significantly during follow-up: 11.35% (OR=1.87 [1.65-2.13], p<0.001), 22.80% (OR=1.89 [1.52-2.35], p<0.001), 32.00% (OR=1.98 [1.66-2.37], p<0.001), 47.53%, and 51.08% (OR=2.40 [1.90-3.03], p<0.001) at 1-through-5-year follow-up, respectively. The 30-day major adverse events after elective EVAR were higher in octogenarians (OR=1.75-2.83, p<0.001). Octogenarians experience higher but acceptable peri-operative morbidity and mortality compared with younger patients. However, 3-year to 5-year survival is very low among octogenarians. Our findings challenge the notion of routine intervention in elderly patients and support very careful selection for elective EVAR. Many octogenarians with peri-threshold (<6 cm) AAAs may derive no benefit from EVAR due to limited 3-year to 5-year overall survival and low risk of aneurysm rupture with conservative management. An adjusted threshold for intervention in octogenarians may be warranted. Octogenarians with infra-renal AAA are increasingly managed with elective EVAR. Previous studies have demonstrated that EVAR is safer than open repair for octogenarians, with lower peri-operative mortality and major adverse events. However, randomised trials, on which much of contemporary evidence is based, recruited a relatively younger population of participants. This systematic review and meta-analysis provides a contemporary synthesis of the literature comparing outcomes in octogenarians to younger patients. The results of this analysis, together with low rupture rates amongst octogenarians in existing literature, question the benefit of routine elective intervention for peri-threshold aneurysms and an adjusted threshold for intervention in octogenarians may be warranted.

Midterm Outcomes of Patients With Complex Aortic Aneurysms Treated Using Mixed and Matched Endoprosthesis From Different Manufacturers.

To evaluate outcomes of patients with complex aortic aneurysms (cAAs) undergoing fenestrated/branched endovascular aortic aneurysm repair (f/b-EVAR) using a combination of endoprostheses from different manufacturers. The study is a 2-center retrospective analysis of prospectively maintained databases of patients with cAAs undergoing f/b-EVAR using a combination of endoprostheses from different manufacturers from 2013 to 2023. Primary endpoints included technical success, major adverse events and reintervention rates. Technical success was defined as implantation of the device without type I or type III endoleak or conversion to open repair. Secondary endpoints included mortality and mid-term device performance. During this time, 353 patients with cAAs underwent f/b-EVARs at both centers. Of these, 80 (22.7%) required use of a combination of devices from 4 different manufacturers for repair. Fifty-one (64%) were treated for thoracoabdominal aortic aneurysms and 29 (36%) for pararenal aneurysms. Majority (74%) were male with a median age of 75 (69, 81) years and aneurysm size of 65 (59, 72) mm. Thirty-five (44%) patients required a proximal thoracic stent graft-W.L. Gore (17), Cook, Medtronic, and Terumo (6), respectively. Seventy-seven (96%) patients required a bifurcated device, including Cook Flex (34), Gore (40), and Medtronic (3). Twelve patients underwent common iliac artery aneurysm repair with a Gore iliac branched endoprosthesis. One hundred fifty-four limbs were implanted: Gore: 68, Cook: 82 and Medtronic: 4. Three hundred fourteen target vessels were incorporated. Median operating room time, estimated blood loss, fluoroscopy time and dose were 209 (186, 278) minutes, 100 (50, 663) mL, 77 (59, 100) minutes, 2385 (1415, 3885) mGy, respectively. Three endoleaks were observed on completion angiography-2 type Ic and 1 type IIIa-all of which resolved at 1 month. Fifteen MAEs were observed in 11 patients at 30 days, including 3 (3.9%) deaths, 7 renal insufficiency, 1 renal failure requiring dialysis, 2 MI and paraplegia, respectively. At a median follow-up of 400 (85, 1132) days, there were 8 reinterventions for endoleaks in 7 patients. The use of mixed devices proximal and distal to f/b-devices built to treat patients with cAAs is safe and has good mid-term results. While not yet formally assessed in randomized clinical trials or endorsed by the Food and Drug Administration (FDA), the practice of utilizing devices from various manufacturers to address complex aortic anatomy is widespread in everyday clinical settings, yet outcomes remain insufficiently documented. To our knowledge, ours is the first manuscript demonstrating that the use of endoprostheses from different manufacturers for treating patients with complex aortic aneurysms is both safe and yields favorable mid-term results. This frequently employed strategy warrants further exploration through meticulously designed clinical trials, aiming to furnish vascular specialists with a well-founded guideline based on robust clinical evidence.

Successful Open Repair of a Thoracoabdominal Aortic Aneurysm After Multiple Failed Endovascular Treatments in a 22-Years-Old Individual With Loeys-Dietz Syndrome.

Loeys-Dietz syndrome is a rare genetically triggered disease characterized by aortic involvement, predisposing individuals to aneurysm and dissection at young age. Open repair is considered the treatment of choice despite the fact that it is associated with significant morbidity and mortality rates. On the other hand, endovascular treatment may be also considered an acceptable option in specific cases such as emergency or in patients unfit for open surgery or when landing zones are within surgical grafts. We report the case of a thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR) in a 22-year-old male patient diagnosed with type 2 Loeys-Dietz syndrome, treated by means of a TAAA replacement with a 30-mm multi-branched "Coselli" aortic graft (Vascutek, Renfrewshire, Scotland, UK) after multiple previously interventions, including a thoracic endovascular aortic repair (TEVAR) and a custom made endograft for the visceral aorta.

Computed Tomography Analysis of the Nasal Septal Deviation and Related Paranasal Sinus Pathologies

Purpose: Nasal Septum Deviation (NSD), which is defined as a dislocated septum, is a prevalent condition that is mostly asymptomatic; however, it can cause difficulties such as nasal obstruction and rhinosinusitis symptoms. Other Paranasal Sinuses (PNS) disorders, e.g., Osteo Meatal Complex (OMC) obstruction, have been assumed to be correlated with NSD. This study investigates the possible correlation of specific radiological findings of PNS pathologies in patients with or without the existence and direction of NSD. We also discussed the different types of NSD and their incidence among different groups stored by age, gender, etc. Materials and Methods: This is a cross-sectional study conducted at multiple imaging centers in Iran between July 2019 and February 2020 to estimate the prevalence of deviated nasal septum and correlate between NSD and other findings using paranasal sinus scans. All the individuals who met the inclusion and exclusion criteria were included in the study. NSD types have been classified based on Mladina's method. Results: We prospectively reviewed PNS Computed Tomography (CT) scans obtained from 254 cases (82 men and 172 women), aged 18 to 81 years (mean: 35.53), evaluated over seven months. Out of 254 cases, 135 (53 %) patients had NSD, without any direction predominance (right-sided vs. left-sided), and equally distributed between genders. The most common NSD types were type V with a frequency of 42.22% and type III with a frequency of 24.44%. Other PNS CT findings were also investigated in our patients, like OMC obstruction, pansinusitis, mucocele, air-fluid level, mucosal thickening, and concha bullosa. There was no statistically significant correlation between any of these pathologies and NSD (P-value &gt; 0.05). Conclusion: Although NSD was observed in more than half of our cases' PNS CTs, there was no significant correlation between NSD and other findings in most subjects. This reveals that the effectiveness of septal repair surgeries in relieving patients' symptoms might not be as high as expected.

Trash Feet and Mesenteric Ischemia as a Rare Manifestation of a Complicated Abdominal Aortic Aneurysm: A Case Report.

Abdominal aortic aneurysms and atheromatous plaques are well-established potential culprits in the development of cholesterol embolization. This embolic phenomenon can result in the occlusion of peripheral arteries in the forefoot or toes, commonly referred to as "trash foot". A 61-year old patient exhibited severe symptoms and signs of lower limb and mesenteric ischemia, represented clinically by abdominal pain, hematochezia, and bilateral plantar necrotic lesions, attributed to embolization from a previously unknown large infrarenal abdominal aortic aneurysm. Diagnosis was confirmed by performing angio-CT of the abdomen, an angiologic examination, as well as colonoscopy. The patient underwent open surgical repair of the aortic aneurysm and received intravenous prostanoids, resulting in a successful outcome with resolution of bowel ischemia and complete recovery of bilateral foot lesions with no tissue loss. Cholesterol embolization syndrome seldom manifests with its complete clinical spectrum. Identifying and addressing the underlying cause is crucial, with a focus on potential abdominal aortic aneurysms. A combined approach involving surgical repair and prostanoid therapy may offer a viable option for patients experiencing severe manifestations.

Prenatal Surgery for Open Fetal Spina Bifida in Patients with Obesity: A Review of Current Evidence and Future Directions.

Background: Obesity rates have significantly increased globally, affecting up to 40% of women of childbearing age in the United States. While prenatal repair of open fetal spina bifida has shown improved outcomes, most fetal surgery centers exclude patients with a body mass index (BMI) ≥ 35 kg/m2 based on criteria from the Management of Myelomeningocele Study (MOMS) trial. This exclusion raises concerns about healthcare equity and highlights a significant knowledge gap regarding the safety and efficacy of fetal spina bifida repair in patients with obesity. Objective: To review the current state of knowledge regarding open fetal surgery for fetal spina bifida in patients with obesity, focusing on safety, efficacy, and clinical considerations. Methods: A comprehensive literature search was conducted using the PubMed and EMBASE databases, covering articles from the inception of the databases to April 2024. Studies discussing fetal surgery for neural tube defects and documenting BMI measurements and their impact on surgical outcomes, published in peer-reviewed journals, and available in English were included. Quantitative data were extracted into an Excel sheet, and data synthesis was conducted using the R programming language (version 4.3.3). Results: Three retrospective studies examining outcomes of prenatal open spina bifida repair in a total of 43 patients with a BMI ≥ 35 kg/m2 were identified. These studies did not report significant adverse maternal or fetal outcomes compared to patients with lower BMIs. Our pooled analysis revealed a perinatal mortality rate of 6.1% (95% CI: 1.76-18.92%), with 28.0% (95% CI: 14.0-48.2%) experiencing the premature rupture of membranes and 82.0% (95% CI: 29.2-98.0%) delivering preterm (<37 weeks). Membrane separation was reported in 10.3% of cases (95% CI: 3.3-27.7%), the mean gestational age at birth was 34.3 weeks (95% CI: 32.3-36.3), and the average birth weight was 2651.5 g (95% CI: 2473.7-2829.4). Additionally, 40.1% (95% CI: 23.1-60.0%) required a ventriculoperitoneal shunt. Conclusion: While current evidence suggests that fetal spina bifida repair may be feasible in patients with obesity, significant limitations in the existing body of research were identified. These include small sample sizes, retrospective designs, and a lack of long-term follow-up data. There is an urgent need for large-scale, prospective, multicenter studies to definitively establish the safety and efficacy of fetal spina bifida repair in patients with obesity. Such research is crucial for developing evidence-based guidelines, improving clinical outcomes, and addressing healthcare disparities in this growing patient population with obesity.

Early combined arthroscopic and open management of combined ACL and PCL tibial spine avulsion in a knee dislocation: A case report

A 35-year-old man presented with right knee pain following a tree stump landing on his leg two days prior. Evaluation revealed a knee dislocation injury (KD III M) with displaced avulsion fractures of the anterior cruciate ligament and posterior cruciate ligament, with the fragments flipped 180 degrees. Additional injuries identified through preoperative imaging (computer tomography, magnetic resonance imaging) and physical examination included bony medial patellofemoral ligament tear, bony posterolateral corner injury, complete medial collateral ligament tear, and medial/lateral meniscus root bony avulsions. The injury was treated utilizing a single-staged arthroscopic and open ligament repair and reconstruction. Bicruciate avulsion fractures in the setting of a knee dislocation injury is a challenging surgical problem in which arthroscopic management of bicruciate tibial spine injuries can be utilized successfully.

Sex-specific differences in alive hospital discharge following infrarenal abdominal aortic aneurysm repair.

A longer time to alive hospital discharge following infrarenal abdominal aortic aneurysm (AAA) repair is associated with reduced patient-satisfaction and increased length of stay, hospital-acquired deconditioning, infection and costs. This study investigated sex-specific differences in, and drivers of, the rate of alive hospital discharge. Examination of UK National Vascular Registry (UK NVR), 2014-2019 and Swedish National Patient Registry (SE NPR) elective AAA patients, 2010-2018, for endovascular (EVAR) or open (OAR) aneurysm repair. Cox models assessed sex-specific difference in rate of alive hospital discharge, adjusting for co-morbidity, anatomy, standard-of-care, post-operative complications, and year, with in-hospital death as the competing risk. 29,751 AAA repairs (UK NVR -EVAR 12518:1532; OAR 6803:837; SE NPR - EVAR 4234:792; OAR 2638:497, men:women) were assessed. For EVAR, the unadjusted rate of alive hospital discharge was ∼25% lower for women (UK NVR HR 0.75 [0.71-0.80], p<.001; SE NPR HR 0.75 [0.69-0.81], p<.001). Following adjustment the sex-specific hazard ratio narrowed but remained significant (UK NVR: HR 0.83 [0.79-0.88], p<.001; SE NPR HR 0.83 [0.76-0.89], p<.001). For OAR, the rate of alive hospital discharge was 23-27% lower for women (UK NVR HR 0.73 [0.67-0.78], p<.001; SE NPR HR 0.77 [0.70-0.85], p<.001). Following adjustment the sex-specific hazard ratio narrowed (UK NVR HR 0.82 [0.76-0.88], p<.001; SE NPR HR 0.79 [0.72-0.88], p<.001) but remained significant. Women have a 25% lower rate of alive discharge after aortic surgery, despite adjustment for pre/peri- and postoperative parameters. Efforts to increase rate of alive hospital discharge for women should be sought.

Penile Mondor's disease after open hernia repair surgery: A case report.

Penile Mondor's disease (PMD) is a rare syndrome characterized by sclerosis after superficial thrombophlebitis of the superficial penile veins. The most usual appearance of PMD is a tender, palpable, painful, and sometimes visible cord on the dorsal surface of the penis. Its pathogenesis is still unclear, and a standardized treatment has not been established. A 54-year-old male patient presented with a left-sided indirect reducible inguinal hernia. The patient underwent Lichtenstein's procedure for inguinal hernia repair. On the tenth postoperative day, he returned with PMD confirmed by Doppler ultrasonography examination. Treatment with 4000 UI low molecular weight heparin (LMWH) daily for three weeks resolved the symptoms, but mild venous ectasia just to the proximal part of the penis remained. The exact cause of PMD is not well understood, but various studies have identified certain factors associated with an increased risk of the condition. Out of various potential factors that could trigger PMD, the repair of an inguinal hernia has been reported only once. Treatment may involve pain management, anti-inflammatory medications, anticoagulants, and, in some cases, surgery. PMD after open hernia repair surgery is a very rare benign condition. Correct diagnosis and prompt treatment allowed symptom resolution. Residual venous ectasia has no clinical significance other than a cosmetic appearance.

The Impact of Body Composition on Mortality and Hospital Length of Stay after Endovascular and Open Aortic Aneurysm Repair: A Retrospective Cohort Study.

Background: Sarcopenia is an indicator of preoperative frailty and a patient-specific risk factor for poor prognosis in elderly surgical patients. Some studies have explored the prognostic significance of body composition parameters in relation to perioperative mortality after aortic repair and to mid- and long-term survival following endovascular aneurysm repair (EVAR). This study aimed to comprehensively investigate the effects of various body composition parameters, including but not limited to sarcopenia, on short- and long-term mortality as well as the length of hospital stay in two large cohorts of patients undergoing open surgical aortic repair (OSR) or EVAR. Methods: A single-institution retrospective cohort study included patients who underwent EVAR or OSR from January 2010 to December 2017. Several parameters of body composition on axial CT angiography images were analyzed, such as skeletal muscle area (SMA) with derived skeletal muscle index (SMI), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Results: 477 patients were included: 250 treated by OSR and 227 by EVAR; the mean age was 70.8 years (OSR) and 76.3 years (EVAR), with a mean follow-up of 54 months. Sarcopenia was associated with a prolonged length of hospital stay in EVAR patients but not in OSR patients (β coefficient 3.22; p-value 0.022 vs. β coefficient 0.391; p-value 0.696). Sarcopenia was an elevated one-year mortality risk post-EVAR compared to those without sarcopenia (p-value for the log-rank test 0.05). SMA and SMI were associated with long-term mortality in EVAR patients even after adjusting for multiple confounders (HR 0.98, p-value 0.003; HR 0.97, p-value 0.032). The analysis of the OSR cohort did not show a significant correlation between short- and long-term mortality and sarcopenia indicators. Conclusions: The results suggest that body composition could predict increased mortality and longer hospital stays in patients undergoing EVAR procedures. These findings were not confirmed in the cohort of patients who underwent OSR. Patients with sarcopenia and pre-operative malnutrition should be critically assessed to define the indication for treatment in this predominantly elderly and morbid cohort, despite EVAR procedures being less invasive. Body composition evaluation is an inexpensive and reproducible tool that can contribute to an improved decision-making process by identifying patients who will benefit most from EVAR, ensuring a more personalized and cost-effective treatment strategy. Further studies are planned to explore the added value of integrating body composition into a comprehensive risk stratification before aortic surgery.

Application of Closed Incision Negative Pressure Wound Therapy in Ventral Hernia Repair Surgery Using a Polypropylene Mesh: A Randomized Clinical Trial.

Background and Objectives: Surgical site infections (SSIs) are a significant complication following ventral hernia repair, potentially leading to prolonged hospital stays and increased morbidity. This study aimed to evaluate whether closed incision negative pressure wound therapy (ciNPWT) reduces the incidence of SSI after ventral hernia repair with polypropylene mesh compared to standard wound care. Materials and Methods: A randomized study was conducted with 100 patients undergoing ventral hernia repair using a polypropylene mesh. Participants were divided into two groups: a control group (n=50), which received standard sterile gauze dressing with an iodine-based disinfectant, and an intervention group (n=50), treated with the ciNPWT system (Vivano® by HARTMANN) for 5 days postoperatively. The primary outcome was the incidence of SSI within one year after surgery. Secondary outcomes included the influence of factors such as age, sex, smoking status, and hernia size on SSI occurrence. The study was approved by the Ethics Committee at the University Hospital Ostrava, adhering to the ethical standards of the Helsinki Declaration. Results: The incidence of SSI was lower in the ciNPWT group compared to the standard care group (4% vs. 12%), though this difference did not reach statistical significance. No significant effect of sex or smoking status on SSI was observed. The control group had a shorter mean length of hospital stay. Larger hernias in the non-ciNPWT group were more prone to SSIs, as expected. Conclusions: Although limited by a small sample size, the findings suggest that ciNPWT may be associated with a reduced rate of SSI following ventral hernia repair. Further studies with larger populations are needed to confirm these results.

Tendón de Aquiles anatomía e insuficiencia

Introduction: the main aspects of Achilles tendon (AT) insufficiency were determined through the review of classic texts and current literature on the topic, to acquire the various conceptual and therapeutic tools in clinical practice. Methodology: we used the PubMed, Clinical Key, Embase, Cochrane and Lilacs search engines, including references in Spanish and English published between 1980 and 2020. Articles were reviewed using the CONSORT, STROBE or PRISMA guidelines, as appropriate. Results: 30 articles directly related to the topic were selected. Meta-analyses, systematic reviews, prospective and observational studies, and narrative reviews were included. Discussion: there is a wide spectrum of intrinsic and extrinsic predisposing risk factors for the development of AT insufficiency, but its etiology remains unclear. The mainstay treatment for tendinopathies in general, is rehabilitation provided by trained personnel. The surgical approach, by percutaneous or open surgical release techniques, is reserved for cases in which conservative approaches fail. Nonsurgical treatment for ruptured AT has shown excellent outcomes if patients undergo a strict rehabilitation process following diagnosis, however, in our socioeconomic context, tendon repair surgery continues to be a first-line therapeutic pillar. Conclusion: this review provides basic concepts and their correlation with biomechanics, indispensable for an early diagnosis and successful treatment.

Gastric Volvulus in Association with Bockdalekhernia in Adult Patient (Case Report)

Purpose: Bochdalek hernia (BH) in adulthood is rare. Symptomatic BH in adults is rarer, but may lead to fatal complications. Patients with acute gastric volvulus on diaphragmatic hernia are a diagnostic and therapeutic emergency.Materials and Methods: A 22-year-old male patient presented to our emergency department with a two-day history of severe epigastric pain. The pain was dull in nature with dyspnea on lying supine. Findings: The stomach was within the thorax on the left side due to left diaphragmatic hernia of a nontraumatic cause, diagnosed by chest radiograph, and computed tomography (CT). The patient was prepared for the open surgical repair, to close the defect. The patient recovered with accepted general condition and was discharged 5 days later. In conclusion, in our case, we report this rare presentation of BH with gastric volvulus as an urgent condition that needs to be diagnosed as early as possible to prevent fatal complications. Implications to Theory, Practice and Policy: A diagnosis of an adult diaphragmatic hernia should always be kept in mind in patients with overlapping abdominal and respiratory symptoms with or without a history of trauma.

Postoperative Pain Management in Patients Undergoing Hernia Repair Surgery. A cross-sectional study

Background: Hernia repair surgery is the most frequently performed surgical operation across the world and pain management after the surgery is important to avoid chronic pain and improve the quality of life. Objectives: to assess the effectiveness of acetaminophen monotherapy against combination analgesic regimens (acetaminophen plus pethidine or parecoxib) in managing postoperative pain in individuals having hernia repair surgery. Methods: This was a cross-sectional study on patients who were 18-65 years old and had elective hernia repair surgery. Participants were assigned to three groups: Group A was given IV acetaminophen along with IM pethidine, Group B was given IV acetaminophen with IV parecoxib and Group C was given IV acetaminophen alone. Pain was evaluated by Numeric Rating Scale (NRS) at various time intervals within 24 hours following surgery. Data were analysed employing repeated measures analysis of variance (ANOVA) and multiple regression analysis. Results: The research had a total of 259 patients. In comparison to Group C, patients in Groups A and B consistently reported far lower pain scores. Group C had the greatest mean pain score (7.91) at 45 minutes post-surgery, whereas Groups A and B demonstrated lower ratings (5.99 and 6.87). Pethidine and parecoxib when paired with acetaminophen were equally effective, as evidenced by the lack of a significant difference between Groups A and B. If acetaminophen monotherapy was used, combination treatment produced better pain relief. Conclusion: Following hernia repair surgery, combination analgesic regimens comprising acetaminophen and either pethidine or parecoxib are more successful at reducing postoperative pain than acetaminophen monotherapy. As a normal procedure, multimodal analgesia should be taken into account to reduce the incidence of chronic pain and enhance patient recovery.

The Current Status of Open Inguinal Hernia Repair in Adults: A Narrative Review

Open inguinal hernia repairs can be divided into mesh-based repairs and sutured based repairs. Mesh-based repairs are the most popular open inguinal hernia repair with the Lichtenstein repair being the most common surgical procedure. The sutured based repairs are not commonly performed with the Shouldice repair being the most popular repair, but the Desarda repair is slowly emerging as a viable sutured based repair. We have conducted this review article to look the current state of the varies types of repairs for open inguinal hernia repair including their complications and recurrence rate. We also looked at the effect of chronic pain in open inguinal hernia repair.

The DySLOH Study: Comparative Evaluation of the Results between the ProFlor and Lichtenstein Techniques for Open Inguinal Hernia Repair-A Randomized Controlled Trial.

Background: The Lichtenstein open anterior approach with static flat meshes, the most popular inguinal hernia repair technique, has raised concerns regarding mesh fixation, defect patency, and poor quality biological response. To address these issues, the 3D dynamic ProFlor scaffold promoting a fixation-free hernia defect obliteration has been developed as an alternative. Methods: The results of open inguinal hernia repair with the ProFlor approach compared with those of the Lichtenstein repair were evaluated. Results: In a time frame of 24 months, two cohorts of patients were enrolled, 95 in the ProFlor group and 93 in the Lichtenstein group. ProFlor demonstrated superior outcomes compared to the Lichtenstein technique, with shorter procedure times, decreased intraoperative complications, and lower rates of postoperative complications. Additionally, ProFlor provided enhanced postoperative pain relief, a faster return to daily activities, and no long-term discomfort. No chronic pain was reported in the ProFlor group and 11.8% reported chronic pain in the Lichtenstein group. Conclusions: The results highlight the need to reevaluate the conventional Lichtenstein approach and align it with recent scientific progress. Further consideration of the evolving understanding of inguinal pathophysiology and groin protrusion genesis is crucial for advancing surgical techniques.

Shouldice versus Lichtenstein inguinal hernia repair: A meta-analysis of randomized controlled trials.

The Lichtenstein technique is the standard treatment for adult open inguinal hernia repair. Among the non-mesh repair techniques, Shouldice has shown the best results and is comparable to mesh repairs in selected cases. Due to the risk of chronic groin pain associated with the Lichtenstein technique, Shouldice has increased in popularity, and some surgeons have adopted it as a viable first-line option. MEDLINE, Cochrane, Central Register of Clinical Trials, and EMBASE for randomized controlled trials (RCT) published until February 2024. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed using the Cochran Q test and I2 statistics with p-values <0.10 and I2 > 25% considered significant. Statistical analysis was performed using R Software, version 4.1.2. Fourteen RCTs comprising 2784 patients were included, of whom 1379 (47.5%) were submitted to the Shouldice hernia repair and 1513 (52.5%) to the Lichtenstein technique. Shouldice was associated with a significant increase in the recurrence rate (4.2% vs. 0.9%; RR 3.68; 95% CI 2.05-6.60; p<0.001; I2=0%) compared with Lichtenstein. The number needed to treat (NNT) to prevent one Shouldice recurrence was 30.3. There were no significant differences between groups in chronic pain, urinary retention, bladder injury, testicular atrophy, wound infection, hematoma-seroma, or hypesthesia. The Lichtenstein technique was associated with reduced recurrence rates compared with Shouldice in patients undergoing inguinal hernia repair. However, the overall recurrence rate with the Shouldice technique was still low (4.2%), suggesting that it may be a viable option in selected patients.

Endovascular Management of a Chronic Type A Aortic Dissection: Case Report.

Branched endograft exclusion of chronic type A dissections resulting from a TEVAR complication is a minimally-invasive approach to consider in very fragile patients to mitigate the potential risks associated with conventional open surgical repair.