Subcostal Incision Research Articles

Symptomatic left diaphragmatic eventration in a 64-year-old male: a case report and review of management

Eventration of diaphragm, particularly in adults, are rare and often underdiagnosed, especially when symptomatic. This report presents a case of a 64-year-old male with a symptomatic left sided significant Eventration of Diaphragm, characterized by two months of left upper abdominal pain and exertional dyspnea. The patient's history included an open cholecystectomy performed three to four years prior. Radiological investigations revealed significant eventration of abdominal contents into the left thorax with a contralateral mediastinal shift. The patient underwent surgical intervention through a left subcostal incision extending 2 cm to the right of midline, where the herniated contents were reduced, and the diaphragm was plicated. Post-operative management was successful, with the patient being discharged on the fifth postoperative day. This case emphasizes the importance of timely diagnosis and surgical management of diaphragmatic hernias in symptomatic adults.

Comparison of analgesic efficacy of ultrasound-guided external oblique intercostal plane block and subcostal transversus abdominis plane block in patients undergoing upper abdominal surgery: A randomised clinical study.

Upper abdominal surgeries are associated with severe postoperative pain. External oblique intercostal (EOI) block blocks both anterior and lateral cutaneous branches of intercostal nerves. We compared the postoperative analgesic efficacy of unilateral EOI block with conventional unilateral subcostal transversus abdominis plane (TAP) block. Fifty American Society of Anesthesiologists (ASA) I/II patients scheduled for upper abdominal surgery via subcostal incision were randomly assigned to receive either EOI block (Group E) or subcostal TAP block (Group T) with 25 mL of 0.2% ropivacaine. Postoperatively, these patients received intravenous (IV) fentanyl through a patient-controlled analgesia (PCA) pump with settings of demand-only mode. The primary outcome was the time to activation of PCA postoperatively. Secondary outcomes were 24-hour opioid consumption, pain scores (at 30 minutes and at 1, 2, 4, 6, 12, and 24 hours), patient satisfaction scores (48 hours), and block-related complications. Unpaired t-test and Mann-Whitney U test were used for analysis. A P value less than 0.05 was considered to be statistically significant. Patients in Group E had an increased mean time of activation of PCA [610.28 [standard deviation (SD): 118.95)] minutes vs 409.68 (SD: 101.36) minutes] (P = 0.001). The 24-hour postoperative mean fentanyl consumption was 102.40 (SD: 25.70) μg in Group E versus 123.20 (SD: 34.38) μg in Group T (P = 0.019). Patients in Group E had better satisfaction scores (P < 0.001). Pain scores were better at 30 minutes and 6 hours. EOI block provides effective postoperative analgesia in upper abdominal surgeries as it prolongs the duration of PCA activation with a better patient satisfaction score.

Management of a liver hydatid cyst patient who fistulized the diaphragm and subsequently presented with thorax rupture: a case report

Hydatid cysts, caused by Echinococcus species, are zoonotic diseases frequently observed in endemic regions worldwide, including Turkey. It is most commonly localized in the liver, followed by the lungs. Anaphylaxis and peritonitis, which develop after cyst rupture, are the most significant complications observed in these patients. Early diagnosis and prompt surgical intervention are extremely important. This study presented an extremely rare case of a hepatic hydatid cyst ruptured into the thorax, which may have high morbidity and mortality. A 24-year-old male patient presented to our emergency department with cough, dyspnea, fever, and allergy symptoms. He had a history of hepatic hydatid cyst surgery 5 years ago. Physical examination revealed urticarial lesions on the skin. The body temperature was 39 °C, and the pulse rate was 120 beats/min. Laboratory tests revealed leukocytosis and elevated C-reactive protein. Contrast-enhanced thoracic and abdominal computed tomography was performed. Diagnostic tests revealed that the patient had a ruptured hepatic hydatid cyst in the right thoracic cavity; hence, he was scheduled for emergency surgery. Laparotomy was performed via a right subcostal incision, and the ruptured cyst was located. It was understood that this cyst had fistulized into the diaphragm during a chronic process and subsequently ruptured acutely into the thorax. Partial cystectomy was performed for a ruptured liver cyst. The diaphragm was repaired, and catheters were placed in the thorax and abdomen for drainage. There were no other postoperative complications. Rupture of hydatid cyst disease is frequently observed in endemic regions. The rupture of a hepatic hydatid cyst into the thorax is an extremely rare event. In patients presenting with pulmonary symptoms who have a history of hepatic hydatid cyst surgery, the abdomen should always be thoroughly evaluated, and emergency surgery should be performed if required.

Comparing the effects of intercostal and subcostal flank incision on post-operative pain and incisional hernia or bulge in patients undergoing open kidney surgery: A randomized clinical trial

Abstract BACKGROUND: Flank incision, a common approach in kidney surgery, has several types. This study was carried out to examine the effect of using subcostal and intercostal flank incisions on post-operative pain, incisional hernia or bulging, and incision time and wound closure time in patients undergoing open kidney surgery. MATERIALS AND METHODS: This randomized clinical trial was conducted Iran (2023–2024). Sixty-four patients were randomly divided into two groups of 32 patients, subcostal and intercostal, based on available sampling technique. The Visual Analog Scale was used to assess post-operative pain. The abdominal wall asymmetry (AWA) technique was used for both hernia and bulge, and clinical examination was done by a urology surgeon for diagnosing AWA. Data analysis was done using SPSS-23. RESULTS: In the subcostal group, a higher incidence of AWA was observed when compared to the intercostal group at 6 months post-operation, and this difference was statistically significant (P = 0.039). However, there was no significant difference between the two groups at 3 months post-operation in this regard (P &gt; 0.05). The mean pain score of patients at 24 and 72 h post-operation was significantly higher in the intercostal group than in the subcostal group (P &lt; 0.05); however, at the first hour and on day 7 post-surgery, no significant difference was found between the two groups in this regard (P &gt; 0.05). In addition, no significant differences existed between the two groups regarding incision time and wound closure time (P &gt; 0.05). CONCLUSION: Intercostal incision, when compared to subcostal incision, was associated with lower probability of development of hernia or bulge, in spite of its higher-level post-operative pain. TRIAL REGISTRATION: This study was registered with the Iranian Clinical Trials Registry under the code IRCT20230208057358N1 on 2023.02.11.

Short- and long-term morbidity after Taylor flap (oblique rectus abdominis flap) for perineal reconstruction after abdominoperineal resection: A single-center series of 140 patients

BackgroundAbdominoperineal resection (APR) leads to a substantial loss of tissue and a high rate of complications. The Taylor flap is a musculocutaneous flap used in reconstruction after APR. ObjectivesWe aimed to analyze the short and long-term morbidity of reconstruction with a Taylor flap (oblique rectus abdominis flap) after APR and to identify the risk factors for postoperative complications. MethodsWe retrospectively included all patients who had undergone APR with immediate reconstruction with a Taylor flap in our department between July 2000 and June 2018. Demographics, oncological data, treatment, and short- and long-term morbidity were reviewed. ResultsAmong the 140 patients included, we identified early minor complications in 42 patients (30%) and 14 early major complications (10%). Total necrosis of the flap requiring its removal occurred in four patients (2.8%). Eleven patients (7.9%) presented with a midline incision hernia, and seven (5%) presented with a subcostal incision hernia. No perineal hernia was found. No risk factors for the complications were identified. ConclusionThe Taylor flap is a safe procedure with few complications and limited donor site morbidity. Moreover, it prevents perineal hernias. These results confirm that the Taylor flap is a well-suited procedure for reconstruction after APR.

Subcostal bilateral internal thoracic artery harvesting with the da Vinci Single Port system: an experimental feasibility study.

We evaluated the feasibility of harvesting bilateral internal thoracic arteries with the da Vinci Single Port system (SP)through a single left-sided subcostal incision. Complete bilateral mobilization with sufficiently long conduits for multivessel grafting was possible in 2 human cadavers and 2 live porcine. Creating the subcostal access and docking the SP system took between 14 and 21 min and the total harvest time ranged from 65 to 125 min in all models. No major bleeding was observed in the live porcine and hemostasis was managed with the available instrumentation. One porcine deceased during surgery due to ventricular fibrillation followed by cardiac arrest. The robotic harvesting was technically easily reproduced by the surgeons and required no additional rib-spreading. Further studies will be required to assess if this subcostal approach with the da Vinci SP system yields true clinical benefits in patients.

Renal Cell Carcinoma With Tumor Thrombus: A Case Series in Puerto Rico.

Renal cell carcinoma (RCC) is one of the most common types of kidney cancer. While RCC tends to present as a localized tumor, a notable proportion may present with distant metastasis. In some instances, RCC may also present with intravascular tumor extension, often called tumor thrombus (TT). Its presence confers a worse prognosis and has important implications for the tumor's staging and treatment. Despite extensive documentation of RCC TT in the US, limited data exists regarding its presentation, management, and outcomes in Puerto Rico(PR). This study aims to broaden the available information on RCC TT, emphasizing surgical management and outcomes. We also provide descriptive data on patient demographics and clinical presentation to improve decision-making among clinicians caring for Puerto Rican men and women. In this single-center, retrospective study, we evaluated patients who underwent partial or total nephrectomy at Saint Luke's Episcopal Medical Center between 2018 and 2022. Data was abstracted from electronic health records (EHR). Patients without documented evidence of TT during the peri-operative period were excluded from the study. A total of 220 patient records were evaluated, of which 12met the inclusion criteria for the study. Caseswere categorized using the latestRCCTT guidelines. Central tendency measurements were used to describe the sample distribution. The mean was considered to make assumptions regarding the prevalent observations, and the median was considered to rule out possible outliers.Categorical data were evaluated using proportion analyses, including TT extension level and BMI variables. Fisher's exact test evaluated the association between the World Health Organization/International Society of Urological Pathology(WHO/ISUP) grade and TT extension level. Most patients lacked TT-related symptoms. Themost severe presenting symptom was a pulmonary embolism (8.3%). Hypertension (83.3%), BMIgreater than 25 at the time of diagnosis (75%), and type 2 diabetes mellitus (66.7%) were the most common comorbid conditions within our cohort. Nearly 75% ofpatients underwent laparoscopic radical nephrectomy with TT resection. One left-sided level III case was managed by laparoscopic-assisted open radical nephrectomy with a right subcostal incision. There were zero intraoperative complications and two postoperative complications. The histopathological reports of all cases were consistent with clear cell carcinoma, and half of the cases (n=6) were WHO/ISUP G4. All patients are alive and free of disease. RCCis a common renal neoplasm in PRthatcanpresent withintravascular tumor extension.Our findings do not establish a definitive association between BMI, tumor size, WHO/ISUP grading, and TT extension level. Our study shows that laparoscopic removal of RCC TT is a safe and effective approach. However, the generalizability of our findings is limited by the study's design and sample size. Future research should focus on identifying predictive markers, establishing effective screening protocols, and determining if our hybrid approach has comparable outcomes to the standard open approach.

Completely portal robotic lobectomy in lung cancer: is subcostal specimen removal necessary?

Background The best place for specimen extraction is a relevant question since either after robotic or video-thoracoscopic lobectomy, both intercostal and subcostal routes can be potential extraction routes. In this study, we studied completely portal robotic lobectomies (CPRL-4) for pulmonary neoplasms to investigate the efficacy and feasibility of subcostal specimen removal by comparing the two techniques. Material and Methods Between January 2014 and July 2021, data from 90 patients who underwent robotic thoracic surgery with a Da Vinci Surgical System SI (Intuitive Surgical Inc., Mountain View, California, USA) were collected and retrospectively analyzed. Out of 90 patients, we analyzed 36 CPRL-4 cases. We removed specimens traditionally via intercostal utility thoracotomy in the first 22 patients (group A) and via subcostal incision in the next consecutive 14 patients (group B). Operative parameters, postoperative parameters, the visual analog scale (VAS) and SF36 life quality scoring were comparatively analyzed. Results The mean docking time was significantly higher in group B than in group A (26.2 ± 5.3 vs 17.8 ± 4.1) (p = .001). In terms of early-stage postoperative pain, group B had significantly lower pain scores compared to group A (p < .05). There was no significant difference between the groups in terms of SF36 life quality scoring. Conclusion We can conclude that performing a subcostal incision is not a sophisticated process, though it significantly prolongs the docking time. Although our study is based on a small group, we noticed that removing the specimen through the subcostal incision after CPRL-4 is potentially useful, has several advantages and it is a practical, feasible, and safe method. Clinical Registration Number 2018/57

Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study).

Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostlycomprises ofretrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias. We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: 1. Creating a query. 2. Building an expert panel. 3. Executing the Delphi rounds. 4. Analysing, presenting, and reporting the Delphi results. More than 70% of agreement was defined as a consensus statement. The 22 experts who agreed to participate in this Delphi process for Subcostal Hernias (SCH) comprised 7 UK surgeons, 6 mainland European surgeons, 4 Indians, 3 from the USA, and 2 from Southeast Asia. This Delphi study on subcostal hernias achieved consensus on the following areas-use of mesh in elective cases; the retromuscular position with strong discouragement for onlay mesh; use of macroporous medium-weight polypropylene mesh; use of the subcostal incision over midline incision if there is no previous midline incision; TAR over ACST; defect closure where MAS is used; transverse suturing over vertical suturing for closure of circular defects; and use of peritoneal flap when necessary. This Delphi consensus defines subcostal hernias and gives insight into theconsensus for incision, dissection plane, mesh placement, mesh type, and mesh fixation for these hernias.

External oblique intercostal block in open nephrectomy patients - A zenith in analgesia for anterolateral upper abdominal surgeries: A case series

Open nephrectomy is a common surgery usually performed for malignant and non-malignant renal pathologies. The external oblique intercostal block (EOIB) blocks the anterior and lateral cutaneous nerves from T6 to T10 and provides somatic analgesia. We present a case series of the use of EOIB in patients undergoing open nephrectomy by subcostal incision. Ten patients were given EOIB, which included patients undergoing simple nephrectomy for non-functioning kidneys and radical nephrectomy for renal mass. The patients had satisfactory numerical rating scale scores, mostly &lt;4 for 24 h. Post-operative opioid consumption was minimal. The external oblique fascial plain block is a novel thoracic block that provides reliable upper thoracoabdominal somatic analgesia. It can certainly be considered a suitable option in surgeries such as nephrectomies that involve an upper lateral abdominal wall incision.

To assess the safety of laparoscopy in patients with CSF catheters draining distally into the abdomen.

This study evaluates the safety of laparoscopic procedures in patients with cerebrospinal fluid (CSF) catheters draining distally into the abdomen. A systematic search across PubMed, Scopus, and Ovid databases using pertinent keywords yielded 47 relevant papers, encompassing 197 cases, for analysis. In the pediatric cohort (n = 129), male (49.6%) and female (34.1%) cases were reported, while gender remained unspecified in 16.3%. Shunt indications included unspecified (126 cases) and Meningomyelocele (3 cases). Laparoscopic procedures encompassed gastric (72.1%), urologic (21.7%), and other (6.2%) indications. Peri-operative shunt management included subcostal incision and clamping (1), ICP monitoring and drainage (2), and distal shunt flow confirmation (1). The prevalent complication was mechanical obstruction (10.1%), followed by pseudocyst formation (1.5%) and infection (2.3%). In the adult cohort (n = 61), males (60.6%) and females (39.3%) with a median age of 55 years were observed. Management strategies encompassed sponge packing and mobilization (11), distal shunt flow confirmation (2), shunt clamping (3), Transcranial Doppler monitoring (2), and no manipulation (30). Shunt infection emerged as the primary complication (2). Overall, 24 patients encountered VP shunt-related complications post-laparoscopy. This study underscores the safety of laparoscopic interventions in patients with ventriculoperitoneal or lumboperitoneal shunts when facilitated by interdisciplinary cooperation. A meticulous preoperative assessment for shunt track localization, intraoperative visualization of shunt tip with CSF flow, vigilant perioperative anesthetic monitoring, and shunt dysfunction surveillance are crucial for favorable outcomes in laparoscopic procedures for these patients.

External Oblique Intercostal Plane Block for Open Cholecystectomy - A Novel Technique

Abstract The conversion of laparoscopic to open cholecystectomy with a large oblique subcostal incision may be associated with severe pain, leading to basilar atelectasis, delayed post-operative recovery and respiratory failure. Various techniques like thoracic epidural block, paravertebral blocks, erector spine block, transverse abdominis plane blocks and anterior quadratus lumboram plane block can be practised to alleviate the pain. In this particular case, we describe an External Oblique Intercostal Block which was given for postoperative analgesia after open cholecystectomy.

RETRACTED ARTICLE: The effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy: a randomized, double-blinded, controlled study

BackgroundWe aimed to investigate the effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy.MethodsEighty 18–70 years old, American Society of Anesthesiologists level I-III patients scheduled for hepatectomy with a J-shaped subcostal incision were enrolled and randomized to receive either intermittent bolus paravertebral ropivacaine (0.5% loading, 0.2% infusion) or 0.9% saline infusion at 1:1 ratio (25 ml loading before surgery, 0.125 ml/kg/h bolus for postoperative 48 h). The primary outcome was set as postoperative 48 h cumulative intravenous morphine consumption recorded by a patient-controlled analgesic pump.ResultsThirty-eight patients in each group completed the study. The cumulative morphine consumptions were lower in the paravertebral block than control group at postoperative 24 (difference -10.5 mg, 95%CI -16 mg to -6 mg, P < 0.001) and 48 (difference -12 mg, 95%CI -19.5 mg to -5 mg, P = 0.001) hours. The pain numerical rating scales at rest were lower in the paravertebral block than control group at postoperative 4 h (difference -2, 95%CI -3 to -1, P < 0.001). The active pain numerical rating scales were lower in the paravertebral block than control group at postoperative 12 h (difference -1, 95%CI -2 to 0, P = 0.005). Three months postoperatively, the paravertebral block group had lower rates of hypoesthesia (OR 0.28, 95%CI 0.11 to 0.75, P = 0.009) and numbness (OR 0.26, 95%CI 0.07 to 0.88, P = 0.024) than the control group.ConclusionsIntermittent bolus paravertebral block provided an opioid-sparing effect and enhanced recovery both in hospital and after discharge in patients undergoing hepatectomy. Trial registrationclinicaltrials.gov (NCT04304274), date: 11/03/2020.

Use of Infrared Thermography for Abdominoplasty Procedures in Patients with Extensive Subcostal Scars: A Preliminary Analysis.

Subcostal scars may increase the risk of healing complications in abdominoplasty. The authors evaluated the use of thermography as a potential tool for patient selection and surgery planning to avoid complications and improve abdominoplasty outcomes. Two candidates for abdominoplasty procedures who presented with extensive subcostal scars were submitted to an infrared thermography protocol at all phases of the procedure: preoperative, intraoperative, and postoperative at 1 and 6 months. The preoperative thermography for both patients revealed near-normal abdominal wall perfusion. The thermograms captured intraoperatively during flap elevation did not show perfusion deficits on the upper abdominal flap. At 1 month and 6 months postoperative, dynamic thermography for both patients showed normal to near-normal perfusion. The procedures had a complication-free course with a good aesthetic result. Plastic surgeons may be reluctant to perform a full abdominoplasty in patients with a previous subcostal incision. In this preliminary analysis, we raise the potential usefulness of thermography for patients with recent subcostal scars and/or important comorbidities as a strategy for adequate patient and technique selection, avoiding possible complications. Future studies, with an increased number of patients and adequate statistical analysis, may allow us to validate the utility of thermography in these cases and reassure that the presence of previous extensive subcostal scars may not be a contraindication for a full abdominoplasty, especially if they are not recent.

The Trend of Cholecystectomies After the Introduction of Laparoscopic Surgery in a District Hospital in Abuja, North Central Nigeria.

Background Laparoscopic cholecystectomy is not readily available in secondary care hospitals in Nigeria, even though it is now the gold standard for the treatment of cholelithiasis and other gallbladder diseases worldwide. Thus, many hospitals in Nigeria still offer open cholecystectomies. This retrospective study investigated the trend of cholecystectomies performed in the general surgery unit of a district hospital in Abuja before and after the commencement of laparoscopic surgery services in 2016. Methodology This retrospective study was conducted in Asokoro District Hospital, Abuja, Nigeria The records of all patients who underwent a cholecystectomy from January 2000 to December 2019 were retrieved and analyzed for the number, types, and rate of cholecystectomies performed per year. All open cholecystectomies were performed via a right subcostal incision, whereas all laparoscopic cholecystectomies were performed via the standard four-port incisions approach. Results A total of 96 patients underwent cholecystectomies from January 2000 to December 2019. In total, 50 (52.08%) open cholecystectomies were performed in 20 years with a yearly average of 2.5, and 46 (47.92%) laparoscopic cholecystectomies were performed in four years with a yearly average of 11.5. The trend of open cholecystectomies in four years dropped from three (30%) in 2016 to one (5.26%) in 2019, whereas laparoscopic cholecystectomies increased from seven (70%)to 18 (94.74%) within the same period. Conclusions There is a drop in the trend of open cholecystectomies and an increase in both laparoscopic and total cholecystectomies in our hospital. We recommend adequate capacity and subsidized laparoscopic cholecystectomy for secondary healthcare facilities in Nigeria.

Another Tool in the Quest for the Perfect Living Liver Donor Operation.

Living donor surgeons must balance donor safety with regard to bleeding, vascular injury, and biliary complications while minimizing short-term pain and long-term abdominal wall function. At the same time, living donor patients are usually deeply concerned about the recipient’s outcomes. Reduced donor morbidity at the cost of increased recipient complications is not acceptable. In this issue, Park et al report their experience with 448 consecutive donors who underwent living donor right hepatectomy by a single surgeon over the course of 5 y.1 One hundred eighty-seven of these donors underwent a mini-incision compared with the conventional J-shaped incision. The team functions within a center that performed more than 1600 donor right hepatectomies over the 5-y period. Right hepatectomy is a physiologically significant operation with risks related to loss of hepatic parenchyma. Many donor surgeons have argued that due to the risks of the surgery including hepatic failure, vascular injury, and biliary complications, the open approach should remain the primary approach.2 However, minimally invasive approaches have been introduced starting with Cherqui et al in 20023 and for right hepatectomies in 2013.4 Although a few centers have embraced the full laparoscopic approach for near donors, adoption broadly in the community of donor surgeons has been slow. Ten years after the initial right hepatectomy reports, fully laparoscopic donor hepatectomy surgery remains isolated to a few centers.5,6 As the authors mention, mini-incision, laparoscopy-assisted and hand-assisted approaches, have been introduced to minimize abdominal wall injury while reducing the learning curve associated with fully laparoscopic approach. Park et al show that excellent outcomes can be achieved for the donors and the recipients using an 8.5- to 13-cm right subcostal incision. They demonstrated low rates of biliary and vascular complications for both donors and recipients. Authors note that when they started mini-incision living donor right hepatectomy, they avoided larger liver and higher body mass index patients or patients with large inferior right hepatic veins. Later in their experience, they develop increased comfort with higher body mass index patients. Interestingly, at the authors’ institution, only 5% of the right hepatectomies are performed laparoscopically, and 3 of the 5 performing donor hepatectomies only perform mini-incision on selected patients. This rigorous selection of patients highlights challenges for broader application of smaller incisions even at the most experienced centers in the world. Making a minimally invasive donor operation safer, more easily reproducible, and with a shortened learning curve is the ideal all donor surgeons should be striving toward. Park et al have shown that mini-incision right donor hepatectomy can be part of that toolbox but likely the perfect operation is still out there waiting to be developed.

Systemic Analgesia versus Continuous Erector Spinae Plane Block (ESPB) Infusion During Paediatric Nephrectomy: A Randomized, Controlled Trial.

A subcostal flank incision is required for open radical nephrectomy, which is a surgical procedure used to remove tumors of the kidney that are malignant. The erector spinae plane block (ESPB) and continuous catheter use in children are receiving more and more support by paediatric regional anaesthesiologists. Our objective was to compare systemic analgesic to continuous ESPB for pain relief in paediatric patients undergoing open radical nephrectomy. Sixty children with cancer ASA I or II and undergoing open radical nephrectomy between the ages of two and seven participated in this prospective, randomized, controlled, and open label study. The cases were divided into two equal groups (E and T groups); Group E received ipsilateral continuous ultrasound-guided ESPB at T9 (thoracic vertebrae), with a bolus of 0.4 mL/kg bupivacaine 0.25%. Immediately postoperatively, Group E (ESPB group) received continuous ESPB with a PCA (patient controlled analgesia) pump at a rate of 0.2 mL/kg/hour bupivacaine 0.125%. Group T (Tramadol group), Tramadol hydrochloride was administered intravenously at a dose of 2 mg/kg/8hour, which could be increased to 2 mg/kg/6hours. Then, we followed up on patients' total analgesic consumption for 48 hours following surgery, as well as the time it took for them to request rescue analgesic, their FLACC and sedation scores, and their hemodynamics and side effects immediately following surgery as well as at 2, 4, 6, 8, 12, 18, 24, 36, and 48 hours. A highly significant difference in total tramadol consumed in group T 11.97 ± 1.13 mg/kg while group E was 2.07± 1.54 mg/kg (p < 0.001). 100% patients in group T requested analgesia compared to 46.7% patients in group E (p < 0.001). From 2 to 48 hour, FLACC significantly decreased in E compared to T group (p≤ 0.006) at all-time points. Ultrasound-guided continuous ESPB significantly provided better postoperative pain relief, reduced postoperative tramadol consumption and reduced pain scores compared with the use of tramadol alone, in paediatric cancer patients undergoing nephrectomy.

Low incisional hernia incidence using a large-bite, low-tension technique for celiotomy closure

BackgroundIncisional herniae (IH) are reported in 5–>20 % of patients undergoing open celiotomy, and can be linked to closure technique. The STITCH randomized trial favors a small bite technique for midline celiotomy closure with a 1-year IH rate of 13 % over larger bites (23 %). MethodsA continuous musculofascial mass closure with absorbable looped #1 PDS suture with 2-cm bite size was used for all open celiotomies. IH frequency and associated clinicopathologic factors were retrospectively analyzed from prospective data in 336 consecutive patients undergoing visceral resections by a single surgeon. ResultsThe study population included 192 men and 144 women, 81 % of whom had a cancer diagnosis, who underwent hepatobiliary, pancreatic, gastroesophageal, and colorectal resections, or a combination. The majority of patients (84 %) had subcostal incisions, and 10 % received a midline incision. At a median follow-up of 19.5 months, the overall IH rate was 3.3 %. Hernia rates were 2.5 % for subcostal margin, 2.9 % for midline, and 5.5 % for other incisions (p = 0.006). Median time to hernia detection was 492 days. Factors associated with IH were increased weight, abdominal depth/girth, male sex, spleen size, visceral fat, and body height (p ≤ 0.04 for all), but not type of resection, prior operations, underlying diagnosis, weight loss, adjuvant chemotherapy or radiation, incision length or suture to incision ratio. ConclusionsThe described technique leads to a low IH rate of <3 % in subcostal or midline incisions, and can be recommended for routine use. The observed results appear superior to those of the STITCH trial, even for the smaller midline incision cohort.

V-025 ETEP-RS: EXTENDED TOTALLY EXTRAPERITONEAL RIVES-STOPPA TECHNIQUE FOR SMALL VENTRAL HERNIA

Abstract Aim The aim is to describe the laparoscopic surgical technique of eTEP with 3 trocars from the upper port in a 52-year-old male patient who presented 3 small ventral hernias Material &amp; Methods Recently, the surgical technique of ventral hernia repair, Rives-Stoppa e-TEP eventroplasty (eTEP-RS) has been introduced. First, 2 subcostal incisions are made. By introducing the dissector balloon through both retromuscular spaces up to the linea arcuata, the retromuscular space is exposed. Great care must be taken to preserve the neurovascular bundles at semilunar line. A 5mm trocar is placed on the right flank to perfom the epigastric crossover maniobre by incising the medial aspect of rigth posterior sheath. The dissection of the left retromuscular space is performed. The midline dissection is progressed to the retzius, completing the Rives retromuscular space. The hernia sacs are dissected and reduced. Finally, posterior rectus sheaths and the linea alba are sutured with 2/0 absorbable self-locking continuous barb suture and a mesh is placed in the retromuscular space. Results The patient was discharged the next postoperative day with good pain control. To date, he does not present data on hernia recurrence. Conclusions The repair of abdominal wall defects via endoscopic eTEP Rives-Stoppa with three trocars is a feasible and reproducible technique that meets the criteria of ideal open surgery and is safe for the patient. In addition, it offers advantages such as less postoperative pain, less need for analgesia, favors rapid and safe recovery, added to an excellent aesthetic result.

V-028 HYBRID (LAPAROSCOPIC AND OPEN) REPAIR WITH REVERSE TAR TO TREAT A LATERAL INCISIONAL HERNIA WITH DENERVATION OF THE RIGHT ABDOMINAL MUSCLES

Abstract Aim Lateral incisional hernias with denervation of the muscles of the abdominal wall are a problem difficult to solve. The repair of the defect does not guarantee a functionality of the abdominal muscles if the lack of force of the abdominal wall is not solved. With the technique we present there is a minimally invasive reinforcement of the mid lateral wall affected. Material and Method 54 yo female. Previous surgeries: biliary cystadenoma 2014 by Makuuchi laparotomy (2 surgeries), Ooforectomy 2011, Hysterectomy 2013, Mamoplasty 2001, 3 vertebral surgeries. Six months after the surgery she felt a growing lump in the right side of the incision. Physical exam: right lateral incisional hernia and small umbilical hernia. Asymmetry of the abdominal wall because of flaccidity of the right abdominal muscles. Ultrasound Voluminous incisional hernia in the right flank dependent of the right transverse sub-costal incision with a hernia ring of 20mm and hernia sac 60mm of diameter increasing with Vasalva maneuvers. Surgical technique Hybrid approach laparoscopic and lateral by e-TEP to dissect the retrorectal bilateral space and lateral preperitoneal approach with reverse TAR. A macroporous polipropilene preperitoneal mesh is placed from the right psoas to left semilunar line and from top to bottom of the abdominal wall. Result Discharged 2nd po. day without complications. 5 months after surgery she has a symmetric abdominal wall without recurrence. Conclusion Hybrid technique to repair lateral hernias with denervation allows a wide repair with low morbidity and good tolerance with excellent result in abdominal functionality.