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BACKGROUND: The effects of hernia repair on testicular function remain uncertain, regardless of the technique used. Studies that analyze testicular volume and flow after hernia repair or hormonal measurements are scarce and show contradictory results. This study aimed to evaluate the impact of bilateral inguinal hernia repair on male fertility in surgical patients in whom the Lichtenstein and laparoscopic transabdominal preperitoneal (TAPP) techniques were used. METHODS: A randomized clinical trial comparing open (Lichtenstein) versus laparoscopic (TAPP) hernia repair using polypropylene mesh was performed in 48 adult patients (20 to 60 years old) with primary bilateral inguinal hernia. Patients were evaluated preoperatively and 90 and 180 postoperative (PO) days. Sex hormones (Testosterone, FSH, LH and SHGB) analysis, testicular ultrasonography, semen quality sexual activity changes and quality of life (QoL) were performed. Postoperative pain was evaluated using the visual analog scale (VAS). RESULTS: Thirty-seven patients with aged of 44 ± 11 years were included, 19 operated on Lichtenstein and 18 operated on TAPP. The surgical time was similar between techniques. The pain was greater in the Lichtenstein group on the 7th PO day. The biochemical and hormonal analyses, testicular ultrasonography (Doppler, testicular volume, and morphological findings) and sperm quality were similar between groups. However, the sperm morphology was better in the Lichtenstein group after 180 days (p < 0.05 vs. preoperative) and two patients who underwent Lichtenstein hernia repair had oligospermia after 180 days. The QoL evaluation showed a significant improvement after surgery in the following domains: physical function, role emotional, bodily pain and general health (p < 0.05). On comparison of Lichtenstein vs. TAPP none of the domains showed statistically significant differences. No patient reported sexual changes. CONCLUSION: Bilateral inguinal hernia repair with polypropylene mesh, whether using Lichtenstein or TAPP, does not impair male fertility in terms of long-term outcomes. TRIAL REGISTRATION: Approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015, Registered on Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT05799742. Enrollment of the first subject in January 2016.

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PURPOSE: The use of synthetic mesh to repair infected abdominal wall defects remains controversial. Polyvinylidene fluoride (PVDF) mesh was introduced in 2002 as an alternative to polypropylene, with the advantages of improved biostability, lowered bending stiffness, and minimum tissue response. This study aimed to evaluate the short-term outcomes of using PVDF mesh to treat infected abdominal wall defects in the elective setting. METHODS: This prospective clinical trial started in 2016 and was designed to evaluate the short- and mid-term outcomes of 38 patients submitted to abdominal wall reconstruction in the setting of active mesh infection and/or enteric fistulas (AI) when compared to a group of 38 patients submitted to clean ventral hernia repairs (CC). Patients were submitted to single-staged repairs, using onlay PVDF mesh (DynaMesh®-CICAT) reinforcement to treat their defects. RESULTS: Groups had comparable demographic characteristics. The AI group had more previous abdominal operations and required a longer operative and anesthesia time. At 30 days, surgical site occurrences were observed in 16 (42.1%) AI vs. 17 (44.7%) CC, p = 0.817; surgical site infection occurred in 4 (10.5%) AI vs. 6 (15.8%) CC, p = 0.497; and a higher number of procedural interventions were required in the CC group, 15.8 AI vs. 28.9% CC, p = 0.169. Both groups did not have chronic infections at 1 year of follow-up, and one hernia recurrence was observed in the AI group. CONCLUSIONS: The use of PVDF mesh in the infected setting presented favorable results with a low incidence of wound infection.

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PURPOSE: To evaluate the effect of a PP mesh on duct deferens morphology, testicular size and testosterone levels. METHODS: Forty adult male rats were distributed into groups: 1) no surgery; 2) inguinotomy; 3) mesh placed on the duct deferens; and 4) mesh placed on the spermatic funiculus. After 90 postoperative days, the inguinal region was resected, and blood samples were collected for the measurement of serum testosterone (pg/dl). The ducts deferens were sectioned in three axial sections according to the relationship with the mesh - cranial, medial and caudal. The wall thickness and duct deferens lumen area were measured. RESULTS: The morphology of the duct deferens was preserved in all groups. The mesh placement did not alter this morphology in any of the analyzed segments. Surgery, with or without mesh placement, did not alter the morphology, wall thickness or lumen area (p>0.05). In all operated groups, serum testosterone levels were similar (p>0.05) but there was a decrease in testicle size (p<0.05). CONCLUSION: Surgery, with or without mesh placement, did not alter the morphology of the duct deferens and, although this treatment resulted in testicular size reduction, it did not affect serum testosterone levels.

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Purpose To evaluate the effect of a PP mesh on duct deferens morphology, testicular size and testosterone levels. Methods Forty adult male rats were distributed into groups: 1) no surgery; 2) inguinotomy; 3) mesh placed on the duct deferens; and 4) mesh placed on the spermatic funiculus. After 90 postoperative days, the inguinal region was resected, and blood samples were collected for the measurement of serum testosterone (pg/dl). The ducts deferens were sectioned in three axial sections according to the relationship with the mesh cranial, medial and caudal. The wall thickness and duct deferens lumen area were measured. Results The morphology of the duct deferens was preserved in all groups. The mesh placement did not alter this morphology in any of the analyzed segments. Surgery, with or without mesh placement, did not alter the morphology, wall thickness or lumen area (p>0.05). In all operated groups, serum testosterone levels were similar (p>0.05) but there was a decrease in testicle size (p 0.05). Conclusion Surgery, with or without mesh placement, did not alter the morphology of the duct deferens and, although this treatment resulted in testicular size reduction, it did not affect serum testosterone levels.(AU)

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Purpose To evaluate the effect of a PP mesh on duct deferens morphology, testicular size and testosterone levels. Methods Forty adult male rats were distributed into groups: 1) no surgery; 2) inguinotomy; 3) mesh placed on the duct deferens; and 4) mesh placed on the spermatic funiculus. After 90 postoperative days, the inguinal region was resected, and blood samples were collected for the measurement of serum testosterone (pg/dl). The ducts deferens were sectioned in three axial sections according to the relationship with the mesh — cranial, medial and caudal. The wall thickness and duct deferens lumen area were measured. Results The morphology of the duct deferens was preserved in all groups. The mesh placement did not alter this morphology in any of the analyzed segments. Surgery, with or without mesh placement, did not alter the morphology, wall thickness or lumen area (p>0.05). In all operated groups, serum testosterone levels were similar (p>0.05) but there was a decrease in testicle size (p<0.05). Conclusion Surgery, with or without mesh placement, did not alter the morphology of the duct deferens and, although this treatment resulted in testicular size reduction, it did not affect serum testosterone levels.(AU)

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Obstructive jaundice as an initial manifestation of uterine cancer is extremely rare. We present a case of a 72-year-old female who presented with obstructive jaundice, supposedly for pancreatic cancer. After detailed diagnostic investigation, the cause of the jaundice was attributed to a metastatic compression of the common bile duct, from the primary neoplasm of the uterus. This case highlights the importance of including uterine cancer in the differential diagnosis of woman presenting with obstructive jaundice, even though it is very rare.

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BACKGROUND: The present clinical trial was designed to compare the results of bilateral inguinal hernia repair between patients who underwent the conventional Stoppa technique and laparoscopic total extraperitoneal repair (LTE) with a single mesh and without staple fixation. PATIENTS AND METHODS: This controlled, randomised clinical trial was conducted at General Surgery and Trauma of the Clinics Hospital, Medical School, the University of São Paulo between September 2010 and February 2011. Totally, 50 male patients, with a bilateral inguinal hernia, older than 25 years were considered eligible for the study. The following parameters were analysed during the early post-operative period: (1) The intensity of surgical trauma, operation time, C-reactive protein (CRP) levels, white blood cell count, bleeding and pain intensity; (2) quality of life assessment; and (3) post-operative complications. RESULTS: LTE procedure was longer than the Stoppa procedure (134.6 min ± 38.3 vs. 90.6 min ± 41.3; P < 0.05). The levels of CRP were higher in the Stoppa group (P < 0.05) but the number of leucocytes, haematocrit, and haemoglobin were similar between the groups (P > 0.05). There was no difference in pain during the 1st and 7th post-operative, physical functioning, physical limitation, the impact of pain on daily activities, and the Carolinas Comfort Scale during the 7th and 15th post-operative (P > 0.05). Complications occurred in 88% of Stoppa group (22 patients) and 64% in LTE group (16 patients) (P < 0.05). CONCLUSION: The comparative study between the Stoppa and LTE approaches for the bilateral inguinal hernia repair demonstrated that: (1) The LTE approach showed less surgical trauma despite the longer operation time; (2) Quality of life during the early post-operative period were similar; and (3) Complication rates were higher in the Stoppa group.

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PURPOSE: To compare the inflammatory response of three different meshes on abdominal hernia repair in an experimental model of incisional hernia. METHODS: Median fascial incision and skin synthesis was performed on 30 Wistar rats. After 21 days, abdominal hernia developed was corrected as follows: 1) No mesh; 2) Polypropylene mesh; and, 3) Ultrapro(r) mesh. After 21 days, the mesh and surrounding tissue were submitted to macroscopic (presence of adhesions, mesh retraction), microscopic analysis to identify and quantify the inflammatory and fibrotic response using a score based on a predefined scale of 0-3 degrees, evaluating infiltration of macrophages, giant cells, neutrophils and lymphocytes. RESULTS: No significant difference was seen among groups in adherences, fibrosis, giant cells, macrophages, neutrophils or lymphocytes (p>0.05). Mesh shrinkage was observed in all groups, but also no difference was observed between polypropylene and Ultrapro mesh (7.0±9.9 vs. 7.4±10.1, respectively, p=0.967). Post-operatory complications included fistula, abscess, dehiscence, serohematic collection and reherniation, but with no difference among groups (p=0.363). CONCLUSION: There is no difference between polypropylene (high-density) and Ultrapro(r) (low-density) meshes at 21 days after surgery in extraperitoneal use in rats, comparing inflammatory response, mesh shortening, adhesions or complications.

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PURPOSE: To compare the inflammatory response of three different meshes on abdominal hernia repair in an experimental model of incisional hernia.METHODS: Median fascial incision and skin synthesis was performed on 30 Wistar rats. After 21 days, abdominal hernia developed was corrected as follows: 1) No mesh; 2) Polypropylene mesh; and, 3) Ultrapro(r) mesh. After 21 days, the mesh and surrounding tissue were submitted to macroscopic (presence of adhesions, mesh retraction), microscopic analysis to identify and quantify the inflammatory and fibrotic response using a score based on a predefined scale of 0-3 degrees, evaluating infiltration of macrophages, giant cells, neutrophils and lymphocytes.RESULTS: No significant difference was seen among groups in adherences, fibrosis, giant cells, macrophages, neutrophils or lymphocytes (p>0.05). Mesh shrinkage was observed in all groups, but also no difference was observed between polypropylene and Ultrapro mesh (7.0±9.9 vs. 7.4±10.1, respectively, p=0.967). Post-operatory complications included fistula, abscess, dehiscence, serohematic collection and reherniation, but with no difference among groups (p=0.363).CONCLUSION:There is no difference between polypropylene (high-density) and Ultrapro(r) (low-density) meshes at 21 days after surgery in extraperitoneal use in rats, comparing inflammatory response, mesh shortening, adhesions or complications.(AU)

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PURPOSE: To compare the inflammatory response of three different meshes on abdominal hernia repair in an experimental model of incisional hernia. METHODS: Median fascial incision and skin synthesis was performed on 30 Wistar rats. After 21 days, abdominal hernia developed was corrected as follows: 1) No mesh; 2) Polypropylene mesh; and, 3) Ultrapro(r) mesh. After 21 days, the mesh and surrounding tissue were submitted to macroscopic (presence of adhesions, mesh retraction), microscopic analysis to identify and quantify the inflammatory and fibrotic response using a score based on a predefined scale of 0-3 degrees, evaluating infiltration of macrophages, giant cells, neutrophils and lymphocytes. RESULTS: No significant difference was seen among groups in adherences, fibrosis, giant cells, macrophages, neutrophils or lymphocytes (p>0.05). Mesh shrinkage was observed in all groups, but also no difference was observed between polypropylene and Ultrapro mesh (7.0±9.9 vs. 7.4±10.1, respectively, p=0.967). Post-operatory complications included fistula, abscess, dehiscence, serohematic collection and reherniation, but with no difference among groups (p=0.363). CONCLUSION: There is no difference between polypropylene (high-density) and Ultrapro(r) (low-density) meshes at 21 days after surgery in extraperitoneal use in rats, comparing inflammatory response, mesh shortening, adhesions or complications. .

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OBJECTIVE: to present our experience with scheduled reoperations in 15 patients with intra-abdominal sepsis. METHODS: we have applied a more effective technique consisting of temporary abdominal closure with a nylon mesh sheet containing a zipper. We performed reoperations in the operating room under general anesthesia at an average interval of 84 hours. The revision consisted of debridement of necrotic material and vigorous lavage of the involved peritoneal area. The mean age of patients was 38.7 years (range, 15 to 72 years); 11 patients were male, and four were female. RESULTS: forty percent of infections were due to necrotizing pancreatitis. Sixty percent were due to perforation of the intestinal viscus secondary to inflammation, vascular occlusion or trauma. We performed a total of 48 reoperations, an average of 3.2 surgeries per patient. The mesh-zipper device was left in place for an average of 13 days. An intestinal ostomy was present adjacent to the zipper in four patients and did not present a problem for patient management. Mortality was 26.6%. No fistulas resulted from this technique. When intra-abdominal disease was under control, the mesh-zipper device was removed, and the fascia was closed in all patients. In three patients, the wound was closed primarily, and in 12 it was allowed to close by secondary intent. Two patients developed hernia; one was incisional and one was in the drain incision. CONCLUSION: the planned reoperation for manual lavage and debridement of the abdomen through a nylon mesh-zipper combination was rapid, simple, and well-tolerated. It permitted effective management of severe septic peritonitis, easy wound care and primary closure of the abdominal wall.

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OBJECTIVE: To present our experience with scheduled reoperations in 15 patients with intra-abdominal sepsis. METHODS: we have applied a more effective technique consisting of temporary abdominal closure with a nylon mesh sheet containing a zipper. We performed reoperations in the operating room under general anesthesia at an average interval of 84 hours. The revision consisted of debridement of necrotic material and vigorous lavage of the involved peritoneal area. The mean age of patients was 38.7 years (range, 15 to 72 years); 11 patients were male, and four were female. RESULTS: forty percent of infections were due to necrotizing pancreatitis. Sixty percent were due to perforation of the intestinal viscus secondary to inflammation, vascular occlusion or trauma. We performed a total of 48 reoperations, an average of 3.2 surgeries per patient. The mesh-zipper device was left in place for an average of 13 days. An intestinal ostomy was present adjacent to the zipper in four patients and did not present a problem for patient management. Mortality was 26.6%. No fistulas resulted from this technique. When intra-abdominal disease was under control, the mesh-zipper device was removed, and the fascia was closed in all patients. In three patients, the wound was closed primarily, and in 12 it was allowed to close by secondary intent. Two patients developed hernia; one was incisional and one was in the drain incision. CONCLUSION: the planned reoperation for manual lavage and debridement of the abdomen through a nylon mesh-zipper combination was rapid, simple, and well-tolerated. It permitted effective management of severe septic peritonitis, easy wound care and primary closure of the abdominal wall.

OBJETIVO: Apresentar nossa experiência com reoperações agendadas em 15 pacientes com sepse intra-abdominal. MÉTODOS: foi empregada uma técnica mais eficaz que consiste em fechamento abdominal temporário com uma folha de malha de nylon contendo um zíper. Realizamos as reoperações no centro cirúrgico, sob anestesia geral, com um intervalo médio de 84 horas. A revisão consistiu de desbridamento de material necrosado e lavagem vigorosa da área peritoneal envolvida. A média de idade dos pacientes foi 38,7 anos; 11 pacientes eram do sexo masculino e quatro do sexo feminino. RESULTADOS: Quarenta por cento das infecções foram devido à pancreatite necrosante. Sessenta por cento foram ocasionadas por perfuração intestinal secundária à inflamação, oclusão vascular ou trauma. Foram realizadas 48 reoperações, média de 3,2 operações por paciente. O dispositivo tela-zíper foi deixado no local por uma média de 13 dias. Um estoma intestinal estava presente ao lado do zíper em quatro pacientes e não ocasionou complicação para o paciente. A mortalidade foi 26,6%. Nenhuma fístula resultou dessa técnica. Quando a doença intra-abdominal estava sob controle, o dispositivo de fecho do tipo de rede foi removido, e a fáscia foi fechada em todos os pacientes. Em três pacientes, a ferida foi fechada primariamente, em 12 permitiu-se fechar por intenção secundária. Dois pacientes desenvolveram hérnia: uma incisional e outra na incisão de drenagem. CONCLUSÃO: A nova operação prevista para lavagem manual e desbridamento do abdômen através de uma combinação de tela-zíper em nylon foi rápida, simples e bem tolerada, permitindo uma gestão eficaz da peritonite séptica grave, fácil tratamento das feridas e fechamento primário da parede abdominal.

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INTRODUCTION: Infected incisional hernias are common in kidney transplant patients. Treating them in immunosuppressed patients can take months, increasing costs and implying loss of working productivity. Abdominal wall prostheses have not been used in infected immunosuppressed patients because of poor infection control. We evaluated the outcome of the surgical treatment of these patients with polypropylene mesh to shorten the hospitalization time and patient recovery. The records of 462 consecutive kidney transplant patients (March 2000 to February 2004) were reviewed. Of these 462 patients, 13 (2.8%) had infected or contaminated herniations at the transplant incision. They developed between 2 and 60 days (mean 14) after transplantation. The racial distribution was not significant, but herniations were more common in patients from cadaveric donors (4.5% versus 0%, P = 0.005). Predisposing factors were found in 6 patients (46.2%) and included complications from transplant surgery in 2, obesity in 1, leukopenia in 3, sepsis in 1, diabetes mellitus in 1, and wall weakness in 1 patient (3 had more than one risk factor). TECHNICAL CONSIDERATIONS: A prospective protocol of surgical correction with polypropylene mesh was established. After wound cleansing with normal saline, repair was done by primary fascial approximation and polypropylene mesh reinforcement. Broad-spectrum antibiotics and large-bore drains were used. Follow-up ranged from 1 to 40 months (mean 14.5). All patients did well except for one recurrence, 14 months after correction. CONCLUSIONS: Surgical repair with polypropylene mesh is safe and effective in treating infected or contaminated herniations in kidney transplant patients, with an acceptable (9.1%) incidence of recurrence.

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O emprego de nutriçäo parenteral no pré-operatório de doentes com câncer tem sido intensamente questionado. A nutriçäo parenteral é efetiva em reverter deficiências, no entanto no câncer os resultados nem sempre säo os desejados, além de representar terapêutica que näo está isenta de riscos e é de custo elevado. A divergência dos resultados obtidos na literatura é explicada pela falta de critérios na seleçäo dos doentes, neoplasias em fases diferentes de evoluçäo, períodos variáveis de duraçäo da terapêutica nutricional e distintos graus de comprometimento nutricional. Uma revisäo crítica mostra que muitos trabalhos falham em mostrar efeitos benéficos na nutriçäo pré-operatória e o seu uso rotineiro em doentes näo selecionados, näo está justificado. Este artigo procura rever a validade da nutriçäo parenteral pré-operatória no doente com câncer e qual o período mínimo para que seja efetiva.

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A presença de nutrientes na luz intestinal e essencial para a adaptaçao estrutural e funcional do segmento intestinal remanescente apos enterectomia extensa. O proposito deste estudo foi o de avaliar a influencia de dietas com fontes nitrogenadas diferentes na adaptaçao intestinal apos ressecçao de 80% de jejuno-ileo. Administramos dietas `a base de aminoacidos (A), hidrolisado de proteinas (H), caseina (C) e dieta-padrao (P), em um modelo experimental padronizado. O grupo enterectomizado (E) foi comparado com um grupo controle (C), cada qual composto por 20 animais. Dividimos os grupos C e E em 4 subgrupos,A, H, C e P (n = 5), aos quais administramos as respectivas dietas. Avaliamos a evoluçao ponderal, niveis sericos de proteinas totais e albumina e alteraçoes histologicas e parametros morfometricos - fraçao de volume, profundidade da cripta, altura da vilosidade, indice metafasico e taxa de produçao celular horaria nascelulas da mucosa intestinal, apos periodo adaptativo de 30 dias. Os resultados mostraram ganho ponderal mais acentuado e melhor resposta adaptativa intestinal, estatisticamente significante (p < 0,005), nos animais enterectomizados aos quais administrou-se a dieta-padrao. Concluimos ter esta um melhor efeito na resposta adaptativa intestinal, apos enterectomia extensa

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A remoçäo do fator causal sempre que possível, a restauraçäo precoce das estruturas lesada e a limpeza da cavidade, consistem a base do tratamento das peritonites agudas. A instituiçäo de terapêutica medicamentosa adequada e o emprego de medidas de suporte devem ser associados quando houver necessidade. Diversas säo as maneiras de se tentar o controle da infecçäo peritoneal, compreendendo desde a simples intra-operatória, até o desbridamento radical, sendo consenso geral a necessidade de lavagem da cavidade abdominal com soluçäo salina. A laparostomia com reoperaçöes programadas constitui uma alternativa e deve ser empregadas em casos selecionados. A utilizaçäo de substâncias coadjuvantes tópicas associadas ao fluido de irrigaçäo peritoneal, como os antibióticos, antissépticos, imunoestimulantes, heparina, agentes fibrinolíticos e outras, seja durante o ato operatório, constitui-se aspecto controverso, näo existindo estudos conclusivos a respeito. Os autores fazem uma revisäo do tratamento cirúrgico da peritonite aguda, procurando discutir os principais métodos de limpeza da cavidade e o papel dos agentes farmacológicos intra-peritoneais no combate à infecçäo

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A coledocoduodenostomia látero-lateral é uma técnica de derivaçäo bileo-digestiva muito empregada nas obstruçöes benignas e malignas da via biliar. A ocorrência de fístulas ou estenose da anastomose, o refluxo do conteúdo duodenal para a árvore biliar e o acúmulo de cálculos e resíduos alimentares no coto coledociano distal - Sump Syndrome como causas de colangite pós-operatória, säo as principais críticas a sua utilizaçäo. Os autores apresentam uma modificaçäo técnica, empregada em 11 doentes portadores de coledocolitíase, capaz de ocluir o coto coledociano com o objetivo de prevenir a ocorrência da "Síndrome do colédoco distal"

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A ocorrência de falências orgânicas no doente cirúrgico tem sido amplamente reconhecida, especialmente na vigência de complicaçöes infecciosas pós-operatórias. Embora o exato mecanismo desencadeante seja desconhecido, a infecçäo é a variável clínica mais importante na instalaçäo da insuficiência de múltiplos órgäos, principalmente a partir de foco intra-peritoneal. A açäo das endotoxinas, os distúrbios metabólicos característicos da sepse e a produçäo de inúmeros mediadores humorais, parecem ser os principais fatores etiopatogênicos capazes de alterar a microcirculaçäo, produzindo hipoperfusäo tecidual, lesäo celular irreversivel e falência de múltiplos órgäos e sistemas. Os autores fazem uma revisäo dos mecanismos fisiopatológicos da sepse capazes de determinar falência orgânica, discutindo sua repercussäo na microcirculaçäo e destacando a açäo dos principais mediadores humorais envolvido, ditos mediadores da falência orgânica

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