Terms Of Less Postoperative Pain Research Articles

A rare case of congenital adult pharyngeal web causing airway obstruction managed by coblation technology

Congenital pharyngeal web is a rare anomaly almost always diagnosed in the paediatric population due to airway obstruction and feeding difficulties. The combination of congenital oropharyngeal and laryngopharyngeal web in an adult is extremely rare and has not commonly been published in the literature. We experienced a 47-year-old woman undiagnosed with pharyngeal web until difficult intubation upon surgery. A 47-year-old woman diagnosed with right ovarian complex cyst was scheduled for total laparoscopic hysterectomy and bilateral salpingo-oopherectomy. pharyngeal webs were incidentally found during intubation and necessitated a reschedule of surgery and tracheostomy. The patient had no history of dysphagia, weight loss or other symptoms of airway obstruction. Fibre optic laryngoscopic examination revealed a combination of congenital oropharyngeal and laryngopharyngeal webs. Patient denied previous history of caustic agent ingestion, oral airway surgeries, chemoradiation. After 2 days, awake tracheostomy with endoscopic guided coblator assisted excision of pharyngeal web was done first, followed by total laparoscopic hysterectomy and bilateral salpingo-oopherectomy in the same sitting. Coblation assisted excision of the pharyngeal web will allow the airway to be feasible for intubation in the future. Congenital pharyngeal webs are extremely rare findings, especially in adult patients. Prediction of difficult airways preoperatively is necessary to prevent difficult airway situations. Controlled ablation of the pharyngeal web gives a good outcome in terms of less post-operative pain and blood loss.

V-046 LIRA (LAPAROSCOPIC INTRACORPOREAL RECTUS APONEUROPLASTY) WITH A MANUAL ROBOTIC LAPAROSCOPIC ARM: TECHNICAL STEPS

Abstract Introduction LIRA (Laparoscopic Intracorporeal Rectus Aponeuroplasty) is a minimally invasive technique for the tension-free repair of incisional hernias from M2 to M4, with low recurrence rate and less postoperative bulging and seroma formation than classic IPOM lap repair. Objective To describe the main steps of the LIRA focusing on the tension-free midline closure. The use of a robotic laparoscopic arm1 improved the surgeon's mobility range and ergonomy, facilitating the procedure. Methods A 42-year-old obese woman (BMI 34 Kg/m2), presented with a recurrent umbilical hernia M3W2, Hernia defect: 6cm.in width, (previous onlay repair with polypropylene mesh in 2020). Access: 3 Trocars at the midaxillary line. Posterior rectus sheaths were divided, and the defect was closed with a running 2/0 barbed suture. Then, the repair was reinforced with a tailored, round-shaped 15 cm. composite mesh2 fixed with a double crown of absorbable tacks3. No drain was used. Results Operating time: 85 minutes. The procedure was performed in an outpatient setting. The postoperative course was uneventful. Follow-up: 9 months. The patient remains asymptomatic and highly satisfied (9/10). No recurrence nor bulging has been observed. Conclusions The LIRA technique allowed a tension-free reconstruction of the abdominal midline when dealing with ventral hernias, without remarkable complications. LIRA provides the advantages of laparoscopic surgery in terms of less postoperative pain, morbidity (e.g. seroma, and less risk of infection), and no bulging. The use of robotized laparoscopic arms facilitates these quite complex procedures.

Knotless Tendoscopic Peroneal Retinaculum Repair Technique for Recurrent Peroneal Tendon Dislocation

Peroneal tendon dislocation (PTD) is sometimes diagnosed as a sports-related injury, of which many cases lead to recurrent PTD (RPTD). Superior retinaculum repair is the major operative treatment of RPTD. The technique described herein comprises 8 steps: (1) Standard tendoscopic examination, (2) debridement of the pseudo-pouch base, (3) first anchor insertion, (4) suture relay, (5) second anchor insertion and suture relay, (6) third anchor insertion and suture relay, (7) suture tightening, and (8) suture bridge. Although this tendoscopic peroneal retinaculum repair technique is complicated, expensive, and requires a longer operation time, it incorporates a double-row suture bridge. Therefore, it has a wider contact surface between the superior retinaculum repair and fibula bone and tighter fixation than does a single-row technique. Moreover, our technique is knotless and thereby avoids knot-related complications. Tendoscopy has additional advantages in terms of less postoperative pain, fewer complications, and better cosmesis. In conclusion, this knotless tendoscopic peroneal retinaculum repair technique for RPTD is a patient-friendly surgery compared with previous procedures.

Comparison of mean Postoperative Inguinodynia in patients undergoing open Inguinal Hernia Surgery with use of standard Polypropylene Heavy Weight Mesh v/s Ultra Pro light Weight Mesh

Background: Various types of meshes for inguinal hernias have been discovered to combat with chronic groin pain related problems. The data regarding these findings was variable due to difference in the cut off values used in the past in different studies to label inguinodynia and local data was scarce where HWM is still highly practiced. Aim: To compare the mean postoperative inguinodynia in patients undergoing open inguinal hernia surgery with use of standard polypropylene heavy weight mesh (HWM) v/s Ultra Pro lightweight mesh (LWM). Methodology: This is a prospective randomized controlled trail conducted at department of surgery, Services Institute of Medical Sciences, from July 2019 to June 2020. Cases were divided in two groups by using radio opaque sealed envelopes labeled as A and B. Group-A underwent Lichtenstein mesh repair by Ultra Pro LWM and group B had polypropylene heavy weight mesh (HWM). Lichtenstein mesh repair was done under spinal or general anesthesia by the experienced surgeon. Duration of surgery was also calculated (from incision to closure). Patient was followed in outpatient department at 3 months where the outcome was seen and inguinodynia was assessed. Results: The mean age was in group A was 40.66±10.52 years and 40.53 ±12.56 years in group B. The mean pain Score in group A was 2.024±0.88 and in Group-B it was 2.97 ±0.85. Conclusion: Ultra Pro LWM is more effective in terms of less postoperative pain as compared to standard polypropylene heavy weight mesh in patients undergoing open inguinal hernia surgery Keywords: Postoperative, Inguinodynia, Inguinal hernia, Standard, Polypropylene heavy weight mesh, Ultra Pro light

Bowel recovery after intra vs extracorporeal anastomosis for oncologic laparoscopic right hemicolectomy within an ERAS protocol: A retrospective study

Abstract Objective Restoring bowel continuity after laparoscopic right hemicolectomy with an intra-corporeal (IC) rather than an extracorporeal (EC) ileocolic anastomosis, may offer advantages in post-operative recovery. The aim of this study was to compare bowel function recovery between these two techniques, in a context of complete mesocolic excision within an enhanced recovery after surgery (ERAS) protocol. Methods All consecutive patients who underwent oncologic laparoscopic right hemicolectomy from January 2012 until February 2021 in our institution were included in the study. Data were gathered from the prospectively maintained official ERAS (EIAS) database and completed through our institution's electronic health records. The primary endpoint was Prolonged Postoperative Ileus (PPOI), defined as the need to insert a nasogastric tube, or refractory nausea VAS > 4, on or after the third postoperative day. Secondary endpoints were postoperative morbidity and length of hospital stay (LoS). Results 122 patients met the inclusion criteria, 36 (30%) had IC, and 86 (70%) EC anastomosis. Baseline characteristics were similar. Operative time was longer in the IC group (197 min (176–223) vs. 160 min (140–189, p<0.001). There was no difference in post-operative morbidity between groups. PPOI occurred in 2 (5.6%) patients in the IC group vs. 10 (11.6%) in the EC group (p=0.306). Patients in the IC group had an earlier first passage of gas (1.5 days (1–2) vs. 2 days (1–3), p=0.035) and stool (2 days (2–4) vs. 3 days (2–4), p=0.029). Upon multivariate analysis, pain VAS scores at 24 h, age and complications Clavien-Dindo >III, but not the anastomotic technique were independent predictors of slower bowel function recovery. IC anastomosis was an independent predictor of lower pain VAS scores at 24 h (OR 0.341, 95%CI [0.151–0.767], p=0.009) and shorter LoS (OR 0.346, 95%CI [0.132–0.910], p=0.031). Conclusion Although IC anastomosis was not significantly associated to lower rates of PPOI, it conferred advantages in terms of less post-operative pain, a trend for faster bowel recovery and shorter LoS at the expense of longer operating times.

Totally Laparoscopic Resection with Transanal Natural Orifice Specimen Extraction for Deep Endometriosis Infiltrating the Rectum

To show the surgical steps used to perform a totally laparoscopic segmental rectal resection, with intracorporeal anastomosis and transanal natural orifice specimen extraction (NOSE), in a context of deep endometriosis. Step-by-step video demonstration of the technique. Even though the combined use of intracorporeal anastomosis and NOSE has increasingly been investigated during the last decade, there is still lack of defined consensus, both in terms of patient eligibility and operative technique. In particular, experience with intracorporeal anastomosis and NOSE for treatment of deep rectal endometriosis is very limited. Preliminary reports have documented that a totally laparoscopic rectal resection is equally effective and safe compared with the conventional approach using an abdominal minilaparotomy for extracorporeal anastomosis and specimen retrieval. In comparison to the latter, intracorporeal anastomosis with NOSE seems to offer advantages in terms of less postoperative pain, fewer wound-related complications, better cosmetic results, quicker return of bowel function and shorter hospital stay. A 31-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. Preoperative ultrasonography showed partial obliteration of the Douglas' pouch due to a rectal endometriotic nodule of 42×12×18 mm in contiguity with a deeply infiltrating retrocervical lesion of 13×3×17 mm. The rectal nodule resulted in the infiltration of the tunica muscularis with a distance of 12 cm from the anal verge and a circumferential extent of 45%. A 3-dimensional laparoscopic system was used. Rectal mobilization was performed according to our standardized technique [1]. After determining the proximal and distal resection margins, the rectum was transected using a tissue sealing-device. The resected specimen was placed in a retrieval bag and pulled out through the anus. Proximal and distal resection lines were closed using a 60 mm linear endo-stapler, and a totally intracorporeal, side-to-end anastomosis was performed using a 29 mm circular stapler. The overall operative time was 85 minutes. The estimated blood loss was 10 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 5 days after surgery. The bowel endometriotic nodule measured 41×12×18 mm on the fresh unfixed specimen. Advanced surgical skills are needed to perform an effective and safe, totally laparoscopic rectal resection. The operative technique displayed in this video may contribute to the standardization of such surgical procedure. Accurate patient selection, including adequate preoperative evaluation, is of utmost importance for the best chance of surgical success.

Outcome of Laparoscopic Total Extra Peritoneal Versus Lichtenstein Repair For Treatment of Inguinal Hernia: A Randomized Control Trial


 
 
 
 OBJECTIVES: 
 To compare the outcome of laparoscopic total extra peritoneal (TEP) repair versus Lichtenstein repair (LR) of inguinal hernia in terms of post-operative pain, hematoma, seroma, wound infection and early recurrence.
 METHODOLOGY:
 This randomized control trial was conducted at Surgical Unit III, General Hospital Lahore, Pakistan during the period June 2017 to May 2018. Male patients aged up to 50 years diagnosed with unilateral, reducible primary inguinal hernia were randomized into two groups, Group A (TEP) and Group B (LR), with 38 patients each. Data was collected prospectively on structured proforma. Patients were regularly followed up for one year for early postoperative complications. Statistical analysis was done using SPSS version 26.
 RESULTS:
 Out of 76 patients, mean age for TEP was 36.72±4.50 years and LR was 34.42±6.8 years. No significant difference was found in both the groups in terms of short-term postoperative complications. LR group had comparatively high rate of postoperative complications; hematoma formation (n=3/38; 7.9%), wound infection (n=3/38; 7.9%) and seroma formation (n=1/38; 2.6%). Postoperative pain with Visual Analogue Score in TEP group on the 1st day, 3rd day, 7th day and 1 month follow up was less as compared to LR group.
 CONCLUSION:
 The present study concludes that TEP is better than LR in inguinal hernia in terms of less postoperative pain after 1 month. However, no statistical difference was found in seroma and hematoma formation and wound infection.
 
 
 
 

Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review.

Introduction Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform. Evidence acquisition We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. Evidence synthesis A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study. Conclusions The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.

Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review

Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform. We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study. The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.

Short- and long-term outcomes for transvaginal specimen extraction versus minilaparotomy after robotic anterior resection for colorectal cancer: a mono-institution retrospective study

BackgroundColorectal cancer resection surgery with transvaginal specimen extraction is becoming increasingly accepted and used by surgeons. However, few publications on robotic anterior sigmoid colon and rectal cancer resection with transvaginal specimen extraction (TVSE) have been reported, and a clinical outcome comparison between conventional robotic minilaparotomy (LAP) and transvaginal specimen extraction in anterior sigmoid colon and rectal cancer resection has not been performed. The current study compared the short- and long-term outcomes of TVSE and LAP for sigmoid colon cancer and rectal cancer in a mono-institution.MethodsFrom December 2014 to October 2018, 45 patients who underwent TVSE and 45 patients who underwent LAP matched by tumor location, tumor stage, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, gender, and age at the same period were included in the current study. The short- and long-term outcomes of TVSE and LAP were discussed.ResultsNo significant differences were found in patient characteristics. For the short-term outcomes, the operative time in the TVSE group was longer than that in the LAP group, and the postoperative pain and additional analgesia were lower in the TVSE group. Patients in the TVSE group required slightly less time to pass first flatus. There were no significant differences in overall complications, time to regular diet, length of hospital stay after surgery, estimated blood loss, or pathological outcomes. For long-term outcomes, the 3-year overall survival (94.9% vs. 91.7%, p = 0.702) and 3-year disease-free survival (88.4% vs. 86.2%, p = 0.758) were comparable between the two groups.ConclusionThe robotic TVSE is safe and feasible in selected sigmoid/upper rectal cancer patients with tumor diameter < 5 cm. This approach has slightly better short-term outcomes in terms of less postoperative pain and less analgesic requirements without any significant difference in long-term outcomes.

LAPAROSCOPIC TRANS-ABDOMINAL PREPERITONEAL VERSUS LICHTENSTEIN REPAIR OF INGUINAL HERNIA: A COMPARATIVE STUDY.

Objectives: To compare Laparoscopic transabdominal preperitoneal (TAPP) to open Lichtenstein inguinal hernia repair for operation time, acute postoperative pain, complications, hospital stay, time to return to work to find out which has better outcome. Study Design: A prospective randomised controlled trial. Setting: QAMC/BVH Bahawalpur; Pakistan. Period: July 2017 to June 2018. Methodology: It included 50 patients, 32 in Lichtenstein group and 18 in TAPP group above the age of 18 years. Operation time, acute postoperative pain, complications, hospital stay, time to return to work were compared in two groups. Data analysis was done on SPSS 23 version. Results: Mean age of patients were 45±9.79 and 44.95±9.82 in Lichtenstein and laparoscopic group, 96% were male. Operation time was 37.96±13.66 vs. 48.77±9.99 (Min), hospital stay 2.28±0.79 vs.1.55±0.63 (Days), time to return to work 13.20±4.75 vs.10.47±3.59 (Days) in Lichtenstein and laparoscopic group respectively. Pain score was 6.1±1.9 vs. 5.2±0.94 in Lichtenstein and laparoscopic group. In immediate complications haematoma 6.25% vs. 0%, seroma 3.12% vs. 11.11%, wound infection 9.37% vs.5.55%, visceral injury 0% vs. 5.5% in Lichtenstein to laparoscopic group respectively. In long term complications chronic pain 28.12% vs.11.11%, recurrence 3.12% vs.0%, port site hernia 0% vs. 5.55%, numbness 9.37% vs. 0% in Lichtenstein and Laparoscopic group respectively. Mortality was nil in both groups. Conclusion: Although there is insignificant difference in complication rate, Laparoscopic hernia repair is better than Lichtenstein repair in terms of less postoperative pain, less hospital stay and early return to work.

Comparative Study between Laparoscopic Assisted and Traditional Vaginal Hysterectomy

Introduction: The choice of hysterectomy approach depends on the reason for hysterectomy, the overall health of the patient and surgeon’s experience. The choice of technique dictates hospital stay and healing time.&#x0D; Objective: To compare the efficacy and outcome of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) and traditional Vaginal Hysterectomy (VH).&#x0D; Materials and Method: A total of 100 patients were purposively selected for this prospective comparative study during the period of January 2011 to January 2013 in CMH, Dhaka and Hitech Multicare Hospital. Non-malignant patients undergoing LAVH and VH by the same surgeon were included in this study. Clinical variables such as operative time, operative cost, blood loss, quantity of analgesics used and hospital stay were observed in both cases for comparison. Several other variables were also observed as postoperative complications such as amount of haemoglobin decrease, rise of temperature, urinary tract infection, vault granuloma in both the cases.&#x0D; Results: There was no significant difference in terms of age, parity, body weight, uterine weight. The mean estimated blood loss in VH (100±32.8 ml) was significantly lower compared to LAVH (126.5±39.8 ml) group. Comparing the relief of post-operative pain, less analgesic was required, rapid patient recovery, and hospital stay time was less in LAVH group than VH group.&#x0D; Conclusion: LAVH is clinically beneficial in terms of less post-operative pain and less quantity of analgesia used, rapid patients’ recovery and shorter hospital stay than VH. It is useful for patients who prefer laparoscopy for cosmetic purpose.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.13(2) 2017: 29-31

A comparative study between conventional skin sutures, staples adhesive skin glue for surgical skin closure

Background: The signature of a surgeon is ‘scar’. Skin closure technique should be technically easy, acceptable, speedy and economical. Sutures and staples remain the mainstay of techniques. However, the use of GLUE is increasing in clinical practice. Authors compared all the three techniques in terms of time efficacy, post-operative pain, wound complications, cosmesis and cost-effectiveness.Methods: A 2-year prospective randomized controlled study was conducted on 90 healthy patients comparing tissue glue, staplers and sutures in primary wound closures following elective surgeries in the Department of General Surgery at BRAMC (October 2015 to October 2017).Results: The patients in the three groups were analyzed using chi-square, ANOVA, Fisher Exact test, and results were formulated. Staples consumed less time for application with a mean of 53.3 seconds when compared to glue (103.97 seconds) and sutures (294.97 seconds). Glue gave best results in terms of less post-operative pain. Mean VAS score calculated at 12,24,48,72 hrs was 63.13,42.10,16.94,7.27 and at 7 days was 4.73. The wound ASEPSIS score calculated on 3rd, 5th, and 7th day. Cosmesis score on 7th day, 1st month and 5th month was calculated using modified hollander and VAS cosmesis scale. Mean score with glue was 5.83,88.90 and 96.13 respectively. Cost of material including length of hospital stay for glue was also effective with 3.47 days on an average. All the above proved statistical significance.Conclusions: Staples application is faster, consumes less significant time than glue and sutures. Skin glue gives the best results in terms of less post-operative pain, wound asepsis, better cosmesis and cost-effectiveness. The concept of tissue glue is a safe, attractive, and effective alternate over other conventional methods of wound closures following elective surgeries.

Lower recurrence rate with heavyweight mesh compared to lightweight mesh in laparoscopic totally extra-peritoneal (TEP) repair of groin hernia: a nationwide population-based register study

PurposeLightweight meshes (LWM) have shown benefits compared to heavyweight meshes (HWM) in terms of less postoperative pain and stiffness in open inguinal hernia repair. It appears to have similar advantages also in TEP, but concerns exist if it may be associated with higher recurrence rates. The aim of the study was to compare reoperation rate for recurrence of LWM to HWM in laparoscopic totally extra-peritoneal (TEP) repair.MethodsAll groin hernias operated on with TEP between 1 January 2005 and 31 December 2013 at surgical units participating in The Swedish Hernia Register were eligible. Data included clinically important hernia variables. Primary endpoint was reoperation for recurrence. Median follow-up time was 6.1 years (0–11.5) with minimum 2.5 years postoperatively.ResultsIn total, 13,839 repairs were included for statistical analysis and 491 were re-operated for recurrence. Multivariate analysis demonstrated significantly increased risk of reoperation for recurrence in LWM 4.0% (HR 1.56, P < 0.001) compared to HWM 3.2%. This was most evident in direct hernias (HR 1.75, P < 0.001) and in hernia repairs with a defect > 3 cm (HR 1.54, P < 0.021). The risk of recurrence with use of LWM in indirect hernias and in hernia repairs with a defect < 1.5 cm was more comparable to HWM.ConclusionsLightweight meshes were associated with an increased risk of reoperation for recurrence compared to HWM. While direct hernias and larger hernia defects may benefit from HWM to avoid increased recurrence rates, LWM is recommended to be used in indirect and smaller hernia defects in TEP repair.

Single Versus Multi-Incisional Video-Assisted Thoracic Surgery: A Systematic Review and Meta-analysis.

Video-Assisted Thoracic Surgery (VATS) is conventionally performed through multiple small incisions (C-VATS). Recent studies have reported encouraging results with the single-incision VATS (S-VATS) over the conventional technique. However, these studies were either small in size, unfocused, nonuniform, retrospective, lacking follow-up information, or focused on pain. We aim to validate previously reported results in a single large meta-analysis, including only the best evidence studies available. Systematic review of the PubMed archive was conducted to include only full English articles with Newcastle Ottawa Scale score ≥7. The primary outcome was the complications rate while secondary outcomes were operative time, resected lymph nodes (LNs), chest tube duration, estimated blood loss, length of postoperative stay (LOS), and postoperative pain on day 1 after surgery. Odds ratio and standard mean difference were used as effect estimates. Random model and leave-one-out analysis were used. A total of 39 studies were included with 4635 patients (1686 S-VATS versus 2949 C-VATS). S-VATS has resulted in significantly less postoperative pain (P < .001), blood loss (P = .006), LOS (P < .001), and chest tube duration (P < .001). In lung cancer patients, the number of retrieved LNs was similar to that of C-VATS (P > .05). Subgroup comparison of the rate of complications between lung resections versus other intrathoracic procedures, lung cancer versus pneumothorax, and lung cancer versus other lung-only lesions did not show any significant differences between the groups. Performing S-VATS technique has shown superior postoperative outcomes over the C-VATS technique in the treatment of thoracic disorders. Substantial benefit was confirmed in terms of less postoperative pain, blood loss, drainage time, and postoperative hospital stay.

Comparing Early Outcomes using Non Absorbable Polypropylene Mesh and Partially Absorbable Composite Mesh through Laparoscopic Transabdominal Preperitoneal Repair of Inguinal Hernia.

Laparoscopic hernia repair is in vogue in the present era. Both the operating surgeon and the patient are concerned about the postoperative inguinodynia which has now replaced recurrence as the predominant factor affecting quality of life. Our study aimed to compare early postoperative outcomes with the standard non absorbablepolypropylene and the newer partially absorbable composite meshes. A total of 60 patients with unilateral uncomplicated inguinal hernia were included in the study and randomly divided into two groups, one each for one kind of mesh. Patients underwent Transabdominal Preperitoneal (TAPP) repair of hernia after taking written informed consent. Follow up was done in the immediate postoperative period and at three months. Patients were compared for inguinodynia, sensation of heaviness, seroma/haematoma formation and return to work activities. Standard statistical tests were applied and a p-value <0.05 was taken as significant. Patients in the composite group complain of significantly less pain as compared to those with the non absorbable mesh at three months (p-value 0.003). They also report less sensation of heaviness over the groin area. However, incidence of seroma formation was higher in the composite group (20%) when compared to the non absorbable group (6.67%). An earlier return to work was seen in the patients with composite mesh. Use of composite mesh in TAPP is associated with better patient outcomes in terms of less postoperative pain and an earlier return to work.

STAPLED HEMORRHOIDECTOMY

Stapled hemorrhoidectomy has been recently advocated as a procedure of choicefor prolapsed hemorrhoids. Studies consistently show that this newer technique is associatedwith less postoperative pain and may be cost effective; however others have questioned its moregeneralized application. Study Design: Randomized controlled trial. Setting: Tertiary hospitalsettings at Services Institute of Medical Sciences, and Ittefaq Hopsital Trust, Lahore. Period:2002 to 2007. Patients &amp; Methods: Short and long-term outcomes of stapled and conventionalhemorrhoidectomy were compared. 538 patients with Grade II, III &amp; IV hemorrhoids wererandomized to undergo either stapled (n=251) or conventional hemorrhoidectomy (n=287).Perioperative and postoperative complications, length of hospital stay, patient satisfactionand long-term recurrence rates for at least 5 postoperative years were analyzed. Results:In the short term, patients undergoing stapled hemorrhoidectomy (n=251) were associatedwith less operative time, less postoperative pain, shorter hospital stay and acceptable overallfirst post-op year patient satisfaction score as compared to patients undergoing conventionalhemorrhoidectomy (n=287). In the long-term however; there were significantly higher ratesof recurrence and tenesmus in stapled group. Over the postoperative years, these rates ofcomplications increased significantly among patients undergoing stapled hemorrhoidectomy.The subgroup analysis showed that Grade IV patients undergoing stapled hemorrhoidectomyhad higher long term postoperative complication rate and poor patient satisfaction scores asopposed to Grade III hemorrhoid patients and had to undergo secondary surgical interventions.Conclusions: The stapled hemorrhoidectomy is an acceptable treatment for selected patientswith Grade II &amp; III hemorrhoids in terms of less postoperative pain and shorter hospital stayat expense of mildly higher long- term recurrence rate; however for grade IV hemorrhoidsstapled hemorrhoidectomy is clearly is an ‘under treatment’ in the long-term as opposed toconventional hemorrhoidectomy.

A prospective comparative study of Lichtenstein's mesh hernioplasty performed under local and spinal anesthesia

Background: The present study was designed to compare Lichtenstein’s hernioplasty performed under local anesthesia and spinal anesthesia in terms of intra operative and short term post-operative events. Methods: In this study total 244 adult patients (236 male &amp; 8 female) of primary uncomplicated unilateral inguinal hernia operated for open tension free mesh hernioplasty were included. 114 patients were operated under local anesthesia and 130 under spinal anesthesia. The two groups were compared for intra operative &amp; short term (30 days) post-operative events, hospital stay and return to activity. Results: The two groups were similar in terms of intra operative events like nausea, vomiting, hypotension &amp; arrhythmias. Local wound complications like edema, ecchymosis, infection and seroma formation were comparable in both groups and clinically insignificant. However there was advantage for the local anesthesia group in terms of less post-operative pain, less anesthesia related complications, less urinary retention, faster discharge from hospital, faster return to activity and lesser cost of treatment. Conclusions: The study comparing local anesthesia with spinal anesthesia showed advantage for the local anesthesia group in terms of less post-operative pain, less anesthesia related complications, less urinary retention, faster discharge from hospital, faster return to activity and lesser cost of treatment. Thus open inguinal hernioplasty performed under local anesthesia is well suited for our smaller community-based, regional, and teaching hospitals.

A comparative study between laparoscopic inguinal hernia repair and open inguinal hernia repair

Background: Repair of inguinal hernia by the laparoscopic hernioplasty over open hernioplasty is preferable in terms of less postoperative pain and morbidity, wound complications, postoperative pain, early resumption of activity and work and better cosmetic results. Laparoscopic hernioplasty by totally extraperitoneal repair (TEP) technically eliminates the hazards of intra operational injuries. Methods: The study designed was an prospective, open labeled, randomized, comparative, two armed study during a period from December 2010–October 2012. After taking written consent from the patients were randomly allocated to two groups consisting 25 in each. Group OH were operated with open tension free Lichtenstein’s hernioplasty. Group TEP operated by laparoscopic totally extraperitoneal repair using mesh. Surgical variables and clinical outcomes were measured. Results: During the study no major life threatening complications were reported in either group only peritoneal breach was encountered intraoperatively in the TEP group and the difference found to be significant (p value = 0.000). Post operatively necessity of drain was seen in 9 patients out of 30 in TEP group. There were three (12%) cases of immediate mesh displacement in TEP group but none in the OH group. It was observed that the mean time taken to complete a laparoscopic hernia repair was significantly higher (p value = 0.000) in TEP compared to open procedure. The postoperative pain score and need of analgesics, presence of surgical site infections were more in OH group compared to TEP group. The time taken for resumption of daily activities and work was earlier in patients treated with TEP compared to open surgery (p <0.005) and good significant cosmetic results was also observed with the same group only (p <0.00). Conclusions: Laparoscopic hernia repair is safe and provide less postoperative morbidity in experienced hands compared to open hernia repair.

What is the Technique without a Proper Classification?

Dear Sir, We read with interest the commentary by Morelli [1] and we are in agreement with the need to investigate the classifications evolution in association with the treatment techniques. This is the important conceptual message which is contained within the commentary. In fact, also in our experience [2], the classification has a significant effect on patient selection and choice of treatment.Recently, small randomized-controlled trials comparing stapled haemorrhoidopexy (SH) with traditional excisional surgery have shown it to be less painful and that is associated with quick recovery [3-6]. The reports also suggest a better patient’s acceptance and a higher compliance with day-case procedures potentially making it more economical. At the same time, several studies comparing SH and Milligan-Morgan (M-M) surgery demonstrated that stapled technique, associated with less pain in the immediate postoperative period, presents a higher risk of recurrence and residual prolapse, with necessity of reintervention and some other symptomatic treatment in long term follow-up [7-9]. Recently, several studies reported a higher percentage of haemorrhoid recurrence after SH, especially in patients with fourth degree haemorrhoids. They suggest that the treatment of second, third and fourth degree haemorrhoids by SH technique, gives optimal results in terms of less postoperative pain, faster return to work and shorter hospital stay, indicating a higher recurrence rate in fourth-degree haemorrhoids patients when the long-term evaluation is considered [8,10,11]. Therefore even if the SH is a safe and effective treatment for haemorrhoids, needs a rigorous patients selection. Furthermore, by applying the SH technique, there is the risk of intraoperative and immediate postoperative complications, such as closing or perforation of rectum, pelvic sepsis and mechanical circular suture dehiscence [10,11].Basing on the clinical evidence and literature revision, the decision to use SH or M-M, should be primarily based on the priorities and preferences of the patient (pain reduction and a rapid return to work / activities in the short-term, or reduction in the risk of recurrence in the long term), and the preference of the surgeon [12].A new technique based on doppler-guided ligation of the terminal branches of the superior haemorrhoidal artery was introduced in 1995 as an alternative to haemorrhoidectomy. Several studies reported that there are some terminal branches from the superior rectal artery-corresponding to the distribution of the anal cushions which varies widely in number and position.The rationale of this treatment was later supported by the findings from vascular studies, which demonstrated that patients with haemorrhoids had increased caliber and arterial blood flow of the terminal branch of the superior rectal arteries. Therefore, ligating the arterial supply to haemorrhoidal tissue by suture ligation may improve haemorrhoidal symptoms. DGHAL is most effective for second- or third-degree haemorrhoidsIn a study of Miyamoto et al. [13] is described that there were always more than three (usually six) terminal branches of haemorrhoidal