Sac Reduction Research Articles

Endo-laparoscopic scrotal hernia surgery: which technique must we choose to reduce seroma-sac transection or complete sac reduction? A prospective study.

Seroma formation is one of the important postoperative problems in inguinal hernia surgery, especially after scrotal hernia surgery. The present study aimed to present primarily the incidence of seroma after reduction and transection of the hernia sac in endo-laparoscopic scrotal hernia repair, and secondarily the results of early postoperative complications. Patients were divided into two groups TAPP and TEP. These groups were also divided into transection and reduction subgroups. In the reduction group, the hernia sac was completely dissected and pulled to the peritoneal area, while in the transection group, the neck of the hernia sac was cut by ligating, and its distal part was fixed to the posterior abdominal wall. The groups were compared, and data were analyzed. The reduction was performed in 13 (43.33%) of the 30 patients included in the study, and transection in 17 (56.67%). Seroma developed in 2 (15.38%) of the reduction group and 7 (41.18%) of the transection group. There was no statistical difference between the groups (p = 0.229). Cord and testicular complications were seen in 6 (20%) patients, 5 (38.46%) in the reduction group, and 1 (5.88%) in the transection group. No statistical difference was detected between the groups (p = 0.061). Although not statistically significant, seroma was more common in transection, while cord and testicular complications were more common in reduction. If dissection of the hernia sac is difficult, the complete reduction should not be insisted on, and the neck of the sac should be transection by ligating, and its distal part should be fixed to the posterior abdominal wall.

A novel high accuracy model for automatic surgical workflow recognition using artificial intelligence in laparoscopic totally extraperitoneal inguinal hernia repair (TEP)

IntroductionArtificial intelligence and computer vision are revolutionizing the way we perceive video analysis in minimally invasive surgery. This emerging technology has increasingly been leveraged successfully for video segmentation, documentation, education, and formative assessment. New, sophisticated platforms allow pre-determined segments chosen by surgeons to be automatically presented without the need to review entire videos. This study aimed to validate and demonstrate the accuracy of the first reported AI-based computer vision algorithm that automatically recognizes surgical steps in videos of totally extraperitoneal (TEP) inguinal hernia repair.MethodsVideos of TEP procedures were manually labeled by a team of annotators trained to identify and label surgical workflow according to six major steps. For bilateral hernias, an additional change of focus step was also included. The videos were then used to train a computer vision AI algorithm. Performance accuracy was assessed in comparison to the manual annotations.ResultsA total of 619 full-length TEP videos were analyzed: 371 were used to train the model, 93 for internal validation, and the remaining 155 as a test set to evaluate algorithm accuracy. The overall accuracy for the complete procedure was 88.8%. Per-step accuracy reached the highest value for the hernia sac reduction step (94.3%) and the lowest for the preperitoneal dissection step (72.2%).ConclusionsThese results indicate that the novel AI model was able to provide fully automated video analysis with a high accuracy level. High-accuracy models leveraging AI to enable automation of surgical video analysis allow us to identify and monitor surgical performance, providing mathematical metrics that can be stored, evaluated, and compared. As such, the proposed model is capable of enabling data-driven insights to improve surgical quality and demonstrate best practices in TEP procedures.Graphical abstract

A systematic review and meta-analysis of hernia sac management in laparoscopic groin hernia mesh repair: reduction or transection?

BackgroundThere is no consensus regarding hernia sac management during laparoscopic hernia repair, and this systematic review and meta-analysis aimed to compare the postoperative outcomes of sac reduction (RS) and sac transection (TS) during laparoscopic mesh hernia repair.MethodsWe conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 and AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines. We used the RevMan 5.4 statistical package from the Cochrane collaboration for meta-analysis. A random effects model was used.ResultsThe literature search yielded six eligible studies including 2941 patients: 821 patients in the TS group and 2120 patients in the RS group. In the pooled analysis, the TS group was associated with a lower incidence of seroma (OR = 1.71; 95% CI [1.22, 2.39], p = 0.002) and shorter hospital stay (MD = -0.07; 95% CI [-0.12, -0.02], p = 0.008). There was no significant difference between the two groups in terms of morbidity (OR = 0.87; 95% CI [0.34, 2.19], p = 0.76), operative time (MD = -4.39; 95% CI [-13.62, 4.84], p = 0.35), recurrence (OR = 2.70; 95% CI [0.50, 14.50], p = 0.25), and Postoperative pain.ConclusionsThis meta-analysis showed that hernia sac transection is associated with a lower seroma rate and shorter hospital stay with similar morbidity, operative time, recurrence, and postoperative pain compared to the reduction of the hernia sac.ProtocolThe protocol was registered in PROSPERO with ID CRD42023391730.

OC-076 LAPAROSCOPIC TAPP REPAIR FOR A LUMBAR HERNIA. STEP-BY-STEP SYSTEMATIZATION

Abstract Aim Lumbar hernias are a rare clinical entity and surgical treatment is constantly evolving and changing. We propose a systematization step-by-step guiding a safe and effective repair with similar conditions to the inguinal region. Material & Methods The patient lies down in a dorsal decubitus position with a 45° elevation of the hernia side. The first port is in the umbilicus access, and the accessory ports are along the middle line. Start the dissection by marking the anatomical limits that involve the semilunar lines, epigastric vessels, spine, and imaginary line between the iliac crest and 11 th rib. Releasing the peritoneal flat until visualizing the psoas iliacus and quadratus muscles until the 11 th ribs, preserving the avascular plane avoids nerves and vascular damage. Hernia sac reduction. Placement of a polypropylene mesh (24×22 cm) covering all the dissected areas. Mesh fixation using absorbable sutures. Closure of the peritoneum.Vacuum maneuver and bulge compression. Results Systematic standardization was applied to all patients. The mean operative time was 90 min. Outpatient surgery was achieved with a fast return to usual activity. The procedures were performed without intraoperative complications, mortality, or conversion to open surgery. Conclusions The step-by-step guide for landmarks and tips provides a safe and effective repair of this rare entity. Finally, clinical studies are needed to measure the impact of this technique's implementation in lumbar hernia repair.

V-038 ENDOSCOPIC SPIEGEL'S HERNIA REPAIR BY TOTALLY EXTRAPERITONEAL EXTENDED ETEP APPROACH

Abstract Background Spiegel's hernia is a rare form of spontaneous abdominal anterolateral hernia (0.12–2% of abdominal hernias) seen in people between 40 and 70 years old. It is often found at the weak point located at the intersection between the semilunar line and the lateral end of the arched line. Traditionally, it was repaired with an open approach, currently we have multiple minimally invasive techniques (enhanced-view total extraperitoneal eTEP, transabdominal preperitoneal, intraperitoneal onlay mesh repair…) that offer less pain, faster recovery and shorter hospital stay as well as less complications risk and better cosmetic outcomes. None of these has proven superior to others but the eTEP approach requires an extensive learning curve. Aim To show a video of an eTEP approach to Spiegel's hernia. Methods We report the case of a 51 year old woman, without previous abdominal surgery, who consulted for a lump, manually reducible, in the right iliac fossa which appeared 2 years ago, and became progressively painful. She was diagnosed pre-surgically with abdominal tomography and was scheduled electively for an eTEP repair. Results After hernia sac reduction and tension-free closure of the defect with barbed suture 0, 15×15cm polypropylene mesh is placed. Conclusion Spiegel's hernia is an infrequent type of abdominal wall defect and several techniques have been developed. Adequate selection of patients is important to identify the most suitable approach for each one. The eTEP approach allows working in a large extraperitoneal space and has been demonstrated to be safe and effective although a demanding procedure.

Diaphragmatic Hernia Post Liver Transplant With Thrombosis of the Hepatic Artery Due to Median Arcuate Ligament Syndrome: A Case Report

Acquired diaphragmatic hernia (ADH) is a rare complication after liver surgery in adult and pediatric patients. In the literature, a few low case series have been reported. Its incidence is estimated to be between 0.74% and 2.9%. Main descriptions of ADH concern liver resection for tumors, living donor hepatic donation in adult patients, and partial liver graft transplant in children [1,2]. We encountered a rare case of ADH in the postoperative time of a liver transplant with thrombosis of hepatic artery due to median arcuate ligament syndrome (MALS). The patient was a 65-year-old woman diagnosed with symptomatic hepatorenal polycystic disease who underwent a liver transplant with an isogroup graft from a cardiac-dead donor. During the first postoperative day, the rutinary color Doppler ultrasonography showed absent artery hepatic flow, and angiography suggested thrombosis of the hepatic artery (HA). With these findings, exploratory laparotomy was done. We performed thrombectomy and liberation of the celiac artery from the median arcuate ligament by dividing its fibers. At discharge, the liver function was normal, and Doppler showed good blood flow in the HA. At fourth postoperative month, she presented in the urgency unit with upper abdominal pain and vomiting. Radiologic and endoscopic evaluation revealed an incarcerated diaphragmatic hernia and signs of gastric ischemia. After emergency laparotomy and evaluation of the left hemithorax, we performed hernial sac reduction with recovery of gastric hypoperfusion. The diaphragmatic hernia was repaired. Diaphragmatic hernia is a rarely reported complication of liver transplant and should be considered a potential late complication [1].

V-047 LAPAROSCOPIC TEP- RECURRENT MASSIVE REDUCICLE COMPLETE SCROTAL HERNIA

Abstract The patient was 67 yrs old gentlemen. Swelling over the Left groin for the last one and half year with recent onset discomfort. He was operated on same side 2 years back with open suregry. On clinical examination - large scrotal reducile hernia was observed, another reducible herinia primary was obseved on right side. He was also having symptoms of bladder outlet obstruction for which tablet. silodosin was started. A complete workup was done and patiemt was told about need for folys post operative. He underwent surgery for same under general anesthesia. (video enclosed). The post operative period was eneventful and on follow up of 8 months there is no recurrence. Why laparoscopy - Hernia was reducible, recurrence was on medial aspect. Less tone of abdominal was musculature. Challaanges in laparoscopy - Hernia sac reduction. Opening of sac may happen loss of TEP space, Management of sac, Large mesh covering all defects, post operative seroma, Mesh fixation mutiple places and surggical mangement of contrallaetral hernia in same setting.

P-130 LAPAROSCOPIC LUMBAR HERNIA REPAIR. BASED ON ANATOMICAL LANDMARKS AND SAFETY STATEMENTS

Abstract Aim Lumbar hernias are a rare clinical entity (less than 1% of all abdominal hernias) and their surgical treatment is constantly evolving and changing. The aim is to propose a technical systematization of the steps and landmarks to perform a safe and effective repair of an infrequent pathology. Material & methods We use a tapp approach. The patient is placed in a dorsal decubitus position with a 45° elevation of the hernia side. The first port in the umbilicus access and two ports are placed along the middle line. Start the dissection using novel articulated instruments marking the anatomical limits of the rectangular trapezoid that involves the semilunar lines, epigastric vessels, spine, and imaginary line between the iliac crest and 11 th rib. Releasing the peritoneal flat until visualizing the psoas and quadratus muscles until the 12th rib, preserving the avascular plane avoids nerves and vascular damage. Hernia sac reduction. Tension-free or not closure of the orifice. Placement of a polypropylene mesh covering all the dissected areas. Mesh fixation using absorbable suture. Closure of the peritoneum.Vacuum maneuver and bulge compression. Results The systematic standardization has been applied to all patients. The mean operative time was 90 min. The articulated instruments were useful and allowed safe maneuvers. Outpatient surgery was achieved with a fast return to normal activity. The procedures were performed without intraoperative complications, mortality, or conversion to open surgery. Conclusion The step-by-step guide for anatomical landmarks and proven statements offers a safe and effective repair of this rare entity.

Influence of the hernia sac treatment method on the occurrence of seroma after laparoscopic transabdominal preperitoneal hernia repair

PurposeTo determine whether transection of the hernia sac during laparoscopic transabdominal preperitoneal hernia repair (TAPP) affects the occurrence of seroma, and to explore the risk factors for seroma. MethodsIn total, 330 consecutive male patients with indirect inguinal hernia who underwent TAPP repair at the Qingdao University Affiliated Hospital from January 2020 to June 2021 were retrospectively enrolled in this study. According to the intraoperative hernia sac treatment, patients were divided into a completely reduced sac group and a transected sac group. ResultsAmong the 330 inguinal hernia male patients, 240 received hernia sac reduction and 90 received hernia sac transection. Fifty-four patients developed seroma, with an incidence of 16.4%. In patients with a hernia defect measuring ≥3 cm and extension into the scrotum, the difference in the incidence of seroma between the two treatment groups approached significance (P = 0.052). The risk factors for seroma, high body mass index, hernia sac ≥3 cm, extension of the hernia into the scrotum and operation time were significantly associated with postoperative seroma. ConclusionThis study showed that the incidence of seroma after TAPP was as high as 16.4%. For patients with a hernia sac that is too large and descended extends into the scrotum, transection may be better than complete dissection of the hernia sac and preventive measures should be taken for patients with high body mass index, hernia sac measuring ≥3 cm, and a high risk of the hernia extending into the scrotum.

Long-term anticoagulation is associated with type II endoleaks and failure of sac regression after endovascular aneurysm repair

ObjectiveWithin the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm. MethodsRetrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm. ResultsThere were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants. ConclusionsThese data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.

Preperitoneal space, is it an ideal layer for endoscopic sublay repair of ventral hernia?

Preperitoneal space, is it an ideal layer for endoscopic sublay repair of ventral hernia?

The Management of Indirect Inguinal Hernia Sac in Laparoscopic Inguinal Hernia Repair: A Systemic Review of Literature.

The aim of this study is to investigate the current management strategy of indirect hernia sac during laparoscopic inguinal hernia repair. The aim was to evaluate the various indirect hernia sac management strategies when performing laparoscopic inguinal hernia repair. Major databases (PubMed, Embase, Springer, and Cochrane Library). MeSH and free-text searching include "laparoscopic inguinal hernia" "TAPP," "TEP," "inguinal hernia," "indirect inguinal hernia sac," "distal sac," "sac transection," "sac ligation," and "sac reduction." The present study enrolled 7 trials, 4 studies compared the results of indirect hernia sac transection and complete sac reduction. The pooled results indicated that indirect hernia sac transection was associated increased seroma formation (odds ratio=2.74, 95% confidence interval: 1.41-4.31), and there was no statistical difference in the incidence of postoperative pain, operative time, hernia recurrence, and time to return to normal activity between the sac transection and sac reduction groups. Two studies reported the application of adjuncts in the management of distal sac during laparoscopic large inguinoscrotal hernia repair. The seroma formation could be reduced by adjuncts of fixing the distal hernia sac to posterior abdominal wall with either suture or tacks. Indirect sac transection during laparoscopic indirect inguinal hernia repair is associated with a higher incidence of postoperative seroma. Additional adjuncts to the divided distal hernia sac, including distal sac fixation with either suture or tacks, are effective methods to prevent postoperative seroma.

Totally Extraperitoneal Herniorrhaphy (TEP): Lessons Learned from Anatomical Observations.

Background Totally extraperitoneal herniorrhaphy (TEP) is a therapeutic challenge because of its complex anatomical location in inguinal region. The aim of this study was to describe the related surgical anatomy through laparoscopic observation and share the lessons learned from a review of 250 primary inguinal hernia repair procedures performed at our hospital from January 2013 to November 2019. Patients and Methods. There were 245 men and 5 women (median age: 63.2 years). Right hernia (60.2%) was the most common site. Indirect hernia (60.5%) was the most common abnormality. The classification of type II (65.0%) was the most common form. Surgical techniques comprised retromuscular approach using cauterized dissection, management of variations of arcuate line, Retzius space and Bogros space dissection, hernia sac reduction, and mesh positioning. Results The incidence of peritoneum injury was in 27 (10.1%). No epigastric vessels were injured. There were 8 (3%) hematoma and 18 (6.8%) seroma. No mesh infection, chronic pain, and recurrence were found after follow-up of an average of 35 months. Conclusion A good understanding of the anatomically complex nature in the inguinal region can make it easier and safer to learn the TEP approach. Early and midterm outcomes after TEP are satisfactory.

Aneurysm Volumes After Endovascular Repair of Ruptured vs Intact Aortic Aneurysms: A Retrospective Observational Study

Purpose To compare changes in abdominal aortic aneurysm (AAA) sac volume between endovascular aneurysm repairs (EVAR) performed for ruptured (rEVAR) vs intact (iEVAR) AAAs and to determine the impact of early volume shrinkage on future complications. Materials and Methods A retrospective analysis was performed of all patients undergoing standard infrarenal EVAR from 2002 to 2016 at a tertiary referral institution. Only patients with degenerative AAAs and with 30-day and 1-year computed tomography angiography (CTA) imaging were included. Early sac shrinkage was defined as a volume sac reduction >10% between the first (<30-day) and the 1-year CTA. The primary endpoint was to compare AAA sac volume changes between patients undergoing rEVAR (n=51; mean age 71.0±8.5 years; 46 men) vs iEVAR (n=393; mean age 72.3±7.5 years; 350 men). Results are reported as the mean difference with the interquartile range (IQR Q1, Q3). The secondary endpoint was freedom from aneurysm-related complications after 1 year as determined by regression analysis; the results are presented as the hazard ratio (HR) and 95% confidence interval (CI). Results At baseline, the rEVAR group had larger aneurysms (p<0.001) and shorter (p<0.001) and more angulated (p=0.028) necks. Aneurysm sac volume decreased more in the rEVAR group during the first year [−26.3% (IQR −38.8%, −12.5%)] vs the iEVAR group [−11.9% (IQR −27.5%, 0); p<0.001]. However, after the first year, the change in sac volume was similar between the groups [−3.8% (IQR −32.9%, 31.9%) for rEVAR and −1.5% (IQR −20.9%, 13.6%) for iEVAR, p=0.74]. Endoleak occurrence during follow-up was similar between the groups. In the overall population, patients with early sac shrinkage had a lower incidence of complications after the 1-year examination (adjusted HR 0.59, 95% CI 0.39 to 0.89, p=0.01). Conclusion EVAR patients treated for rupture have more pronounced aneurysm sac shrinkage compared with iEVAR patients during the first year after EVAR. Patients presenting with early shrinkage are less likely to encounter late complications. These parameters may be considered when tailoring surveillance protocols.

Predictors of Aneurysm Sac Shrinkage Utilizing a Global Registry

Aneurysm sac remodeling is a complex multifactorial process with unknown factors influencing sac regression after endovascular aortic aneurysm repair (EVAR). We sought to identify factors associated with this process by analyzing data obtained from patients treated with the GORE EXCLUDER endovascular aneurysm repair (EVAR) endoprosthesis from December 2010 to October 2016 enrolled in the Global Registry for Endovascular Aortic Treatment (GREAT). All patients enrolled in GREAT with three years CT angiography (CTA) follow-up in each of the three successive years after EVAR were included. The percentage of sac size reduction toward device diameter was calculated and used as a surrogate for sac regression with the formula used being: sac size reduction = ((AAA baseline diameter - AAA diameter at follow-up)/(AAA baseline diameter - device diameter))∗100. The cohort was divided into two groups in accordance with the percentage of aneurysm sac reduction at three years; one with the top quartile of patients and the other with the lowest three quartiles. Demographic and procedural variables were analyzed using univariate and regression modeling to determine factors predictive of sac regression. There were 3265 subjects enrolled with follow-up as of May 2018 of which 526 (16.2%) had three years of CTA surveillance. Overall aneurysm sac size decreased from a mean of 58.0mm (Std Dev: 10.4, range: 34.2, 100.0) to a mean of 49.3mm (Std Dev: 14.1, range: 0, 140) for a percentage reduction toward device diameter of a mean 28.2% (Std Dev: 39.0, range: -103.7, 183.9). On multivariate logistic regression model; two factors proved to be statistically significant contributors to a larger percentage reduction in aneurysm sac: a conical neck (odds ratio [OR]=1.64, P-value=0.023) and a larger proximal device diameter (OR=1.09, P-value=0.023). On the other hand, two factors were negative predictors of sac shrinkage, namely: old age (OR=0.96, P-value=0.002) and larger baseline aneurysm sac diameter (OR=0.98, P-value=0.028). Aneurysms with conical necks and larger proximal device neck diameters have an increased percentage change in sac size over time after EVAR. Older age and larger initial diameters of aneurysms were negatively associated with percentage change in sac size as well as sac regression. Further study is needed to determine the clinical utility of these observations and applicability across multiple endoprosthesis platforms.

Biology of flowering as an element in the red raspberry breeding, focused on avoiding interference in embryo sac development and reduction in drupelet numbers

Biology of flowering as an element in the red raspberry breeding, focused on avoiding interference in embryo sac development and reduction in drupelet numbers

A randomized study on laparoscopic total extraperitoneal inguinal hernia repair with hernia sac transection vs complete sac reduction.

The management of the hernia sac is the core step of laparoscopic indirect inguinal hernioplasty. In this study, a randomized controlled trial was conducted to evaluate the clinical effect of laparoscopic total extraperitoneal inguinal herniorrhaphy (TEP) with hernia sac transection and complete sac reduction. From May 2017 to May 2018, 70 patients aged 18-75 with primary indirect inguinal hernia in our hospital were randomly divided into a transected sac group (TS) and a completely reduced sac group (RS). The primary outcomes compared between the two groups were the hernia sac treatment time, operation time, and the incidence of seroma formation after operation. Secondary outcomes included acute pain, chronic pain (pain which lasted for at least 3months), hospital stay, recurrence rate, and other complications. There were no significant differences in baseline demographic characteristics including age, sex, hernia type, size of hernia defect, and follow-up time between the two groups. The times required for hernia sac separation and operation in the TS group were significantly shorter than in the control group (6.1 ± 2.3 vs. 25 ± 5.8min for hernia sac separation, p < 0.01; and 35.10 ± 3.50 vs. 54.40 ± 4.20min for operation, p < 0.01). There was no significant difference in hospitalization time, incidence of acute pain, seroma formation, or urinary retention between the two groups. During the 12-month follow-up period, chronic pain, early recurrence, and other complications were not found in either group. Both the hernia sac transection technique and the complete sac reduction technique are safe and reliable. The hernia sac transection technique is a simple and effective hernia sac treatment method. It reduces the operation time and does not increase seroma or acute or chronic pain. It is valuable and likely to be popularly applied.

Prognostic Value of Initial Aneurysmal Sac Regression after EVAR

The objective of the study was to evaluate the impact of initial aneurysmal sacreduction after endovascular aneurysm repair on the evolution of aneurysmal sac over follow-up. A retrospective cohort study was made of patients subjected to elective treatment between January 2005 and December 2014, with a minimum follow-up of 18months. An analysis was made of the evolution of the aneurysmal sac according to its condition one year after surgery, defining of two groups: A (sac reduction) and B (stable sac). Follow-up by computed tomography (CT) angiography was made after one month and then every 6months or annually, depending on the presence of endoleak. A total of 128 patients were included. Fifty-one patients (39.8%) showed a significant decrease in diameter during the first year (group A), whereas 77 patients (60.2%) showed no initial decrease (group B). Preoperative CT angiography showed the patients in group A to have larger aneurysms (63.5mm vs. 59.25; P=0.048), a greater presence of posterior thrombus (68.6% vs. 30.7%; P<0.001), and fewer patent lumbar vessels (56.9% vs. 83.1%; P=0.001). The prevalence of endoleak at some point during follow-up was lower in group A (31.4% vs. 74% in group B; P<0.001), and 100% of all aneurysmal growths were associated to the presence of endoleak. After 5years, significant differences were observed in the growth-free rate (96.9% in group A vs. 85.2% in group B; hazard ratio [HR] 4.8 [1.1-21.4; P=0.036]) and in the reintervention-free rate (95,7% vs. 84.6%; HR 6.6 [0.8-52.4; P=0.07]). No reoperation in group A was due to type II endoleak. The aneurysmal sac can be expected to take a favorable course in those cases characterized by initial aneurysmal sac reduction. These findings may imply a change in the follow-up protocol, even in cases with type II endoleak.

Four-year experience with the Endurant stent-graft for abdominal aortic and common iliac artery aneurysms in 50 consecutive Japanese patients.

To evaluate the 4-year results of the Endurant stent-graft in the treatment of abdominal aortic aneurysm (AAA) or common iliac artery aneurysm (CIAA). Between June 2012 and January 2014, 50 consecutive Japanese AAA and CIAA patients were treated with the Endurant stent-graft at Tokyo Medical University Hospital. Estimated freedom from overall mortality, aneurysm-related mortality, and secondary interventions at 4 years was 61.7%, 97.9%, and 78.6%, respectively. At 4 years, the maximum sac diameter decreased by >5 mm in 24% of the patients, remained stable in 52%, and increased by >5 mm in 24%. The average aneurysm sac reduction was 0.4 to 1.3 mm within 5 years. Multivariate analyses detected female gender (HR: 7.40, P=0.021) and type IV endoleak (HR: 5.34, P=0.009) as a significant risk factor for secondary intervention. Four-year clinical outcomes of the Endurant stent-graft remained positive in Japanese patients with AAA and CIAA, although 24% of the patients needed a secondary intervention. The aneurysm sac was stable in most of the patients, whereas the aneurysm sac reduction was small. These results suggest that careful imaging follow-up must be continued to determine the durability of the Endurant stent-graft in patients with small aneurysm sac reduction.

Laparoscopic trans-abdominal pre-peritoneal (TAPP) surgery for incarcerated inguinal hernia repair.

This series was aimed to analyze feasibility, safety and postoperative quality of life of trans-abdominal pre-peritoneal repair in incarcerated hernia; the rationale was a safe hernia reduction, more accurate abdomen exploration, diagnosis and treatment of contralateral unknown hernia. With a minimum follow-up of 30 months, 20 urgent incarcerated inguinal hernia patients were submitted to TAPP. Signs of strangulation, peritonitis and major comorbidity were exclusion criteria. Feasibility and safety were evaluated by ability to hernia reduction, conversion rate, operative time, perioperative mortality, morbidity, hospital stay, prosthesis infection and recurrence. Finally, quality of life was assessed by acute and chronic pain score, recovery of normal activities, return to work and patients' satisfactionsurvey. Under vision sac reduction was always achieved, incision of internal ring during the reduction manoeuvre was necessary in 40% of pts, intraoperative complications, conversions or perioperative mortality were not observed. In one case (5%) partial omentectomy was necessary. Contralateral hernia was diagnosed and repaired in 20%. Median operative time was 81.3 min, postoperative minor complications were recorded in 5 patients (25%), median in hospital stay was 2 days. After a median follow-up of 39 months, 1 patient recurred (5%). Acute pain, was scored 3 as median value (range 1-5), only one patient scored 2 as chronic pain during follow-up. Laparoscopic approach for incarcerated inguinal hernia repair is not the standard treatment. In our experience, with the limit of a single-surgeon series, selected patients showed satisfactory results in terms of feasibility, safety, postoperative quality of life and patients' satisfaction were observed. Few series about this topic were published. More prospective trials are needed.