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Preoperative progressive pneumoperitoneum has represented an important advancement in achieving the reintroduction of large herniated volumes into the abdominal cavity. However, this technique is not free of complications. We present a case of a man in his 70s with an accidental peritoneal-cutaneous fistula, secondary to the excessive pressure of the pneumoperitoneum, during the preparation of a large incisional hernia with loss of domain intervention.

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BACKGROUND: The goal of this article was to report the results about the efficacy of treatment of chronic mesh infection (CMI) after abdominal wall hernia repair (AWHR) in one-stage management, with complete mesh explantation of infected prosthesis and simultaneous reinforcement with a biosynthetic poly-4-hydroxybutyrate absorbable (P4HB) mesh. METHODS: This is a retrospective analysis of all patients that needed mesh removal for CMI between September 2016 and January 2019 at a tertiary center. Epidemiological data, hernia characteristics, surgical, and postoperative variables (Clavien-Dindo classification) of these patients were analyzed. RESULTS: Of the 32 patients who required mesh explantation, 30 received one-stage management of CMI. In 60% of the patients, abdominal wall reconstruction was necessary after the infected mesh removal: 8 cases (26.6%) were treated with Rives-Stoppa repair, 4 (13.3%) with a fascial plication, 1 (3.3%) with anterior component separation, and 1 (3.3%) with transversus abdominis release to repair hernia defects. Three Lichtenstein (10%) and 1 Nyhus repairs (3.3%) were performed in patients with groin hernias. The most frequent postoperative complications were surgical site occurrences: seroma in 5 (20%) patients, hematoma in 2 (6.6%) patients, and wound infection in 1 (3.3%) patient. During the mean follow-up of 34.5 months (range 23-46 months), the overall recurrence rate was 3.3%. Persistent, recurrent, or new CMIs were not observed. CONCLUSIONS: In our experience, single-stage management of CMI with complete removal of infected prosthesis and replacement with a P4HB mesh is feasible with acceptable results in terms of mesh reinfection and hernia recurrence.

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OBJECTIVE: A randomized controlled trial (RCT) was undertaken to evaluate whether the prophylactic application of a specific single-use negative pressure (sNPWT) dressing on closed surgical incisions after incisional hernia (IH) repair decreases the risk of surgical site occurrences (SSOs) and the length of stay. BACKGROUND: The sNPWT dressings have been associated to several advantages like cost savings and prevention of SSOs like seroma, hematoma, dehiscence, or wound infection (SSI) in closed surgical incisions. But this beneficious effect has not been previously studied in cases of close wounds after abdominal wall hernia repairs. METHODS: An RCT was undertaken between May 2017 and January 2020 (ClinicalTrials.gov registration number NCT03576222). Participating patients, with IH type W2 or W3 according to European Hernia Society classification, were randomly assigned to receive intraoperatively either the sNPWT (PICO)(72 patients) or a conventional dressing at the end of the hernia repair (74 patients). The primary endpoint was the development of SSOs during the first 30 days after hernia repair. The secondary endpoint included length of hospital stay. Statistical analysis was performed using IBM SPSS Statistics Version 23.0. RESULTS: At 30 days postoperatively, there was significatively higher incidence of SSOs in the control group compared to the treatment group (29.8% vs 16.6%, P < 0.042). There was no SSI in the treatment group and 6 cases in the control group (0% vs 8%, P < 0.002). No significant differences regarding seroma, hematoma, wound dehiscence, and length of stay were observed between the groups. CONCLUSION: The use of prophylactic sNPWT PICO dressing for closed surgical incisions following IH repair reduces significatively the overall incidence of SSOs and the SSI at 30 days postoperatively.

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INTRODUCCIÓN: Las hernias incisionales secundarias al trasplante renal (HITR) se consideran hernias complejas debido a su localización lateral a la vaina del músculo recto abdominal. También influyen la presencia del injerto en la fosa iliaca y la proximidad del área inguinal, el margen costal y los huesos iliacos como rebordes de difícil fijación de la prótesis. Además, estos pacientes presentan connotaciones específicas, como el tratamiento con inmunosupresores, que podrían alterar la evolución postoperatoria. El objetivo del estudio fue analizar los resultados obtenidos en la reparación de las HITR en un hospital terciario, comparando estos datos con la literatura internacional. MÉTODOS: Estudio observacional retrospectivo, desde el 1 de enero de 2011 al 31 de enero de 2018, de los pacientes operados de HITR en nuestra unidad. Análisis de factores preoperatorios, intraoperatorios y de complicaciones postoperatorias observados durante el seguimiento. RESULTADOS: Se operaron 25 pacientes, encontrando un índice de recidiva herniaria del 4% tras un seguimiento mediano de 27,5 meses (20-39). La técnica más utilizada fue la separación posterior de componentes con liberación del transverso en un 42%, seguida de la reparación preperitoneal en un 27% y la reparación interoblicuos en un 12%. La morbilidad postoperatoria global fue del 23%, siendo las más frecuentes las relacionadas con el sitio quirúrgico (12%). CONCLUSIONES: La reparación de las HITR es un procedimiento seguro en nuestro centro, con un índice de recidiva herniaria aceptable, aunque no exento de complicaciones

INTRODUCTION: Incisional hernias secondary to renal transplantation (IHRT) are considered complex hernias because they are lateral to the sheath of the rectus abdominis muscle. The presence of the graft in the iliac fossa and the proximity to the inguinal area, costal margin and iliac bones, as zones with difficult fixation for prostheses, increases repair complexity. In addition, these patients have specific characteristics, such as treatment with immunosuppressive medication, that could alter postoperative evolution. The objective of this study was to analyze the results obtained in IHRT repair at a tertiary hospital, and to compare these data with the international literature. METHODS: Retrospective observational study of patients treated surgically for IHRT in our unit from January 1, 2011 to January 31, 2018. Preoperative conditions, intraoperative factors and postoperative complications during follow-up were analyzed. RESULTS: Twenty-five patients underwent hernia repair, finding a 4% hernia recurrence rate during a median follow-up of 27.5 months (20-39). The most frequently used technique was the posterior transversus abdominis release component separation technique in 42%, followed by preperitoneal repair in 27% and interoblique repair in 12%. The overall postoperative morbidity was 23%, which was frequently related to the surgical site (12%). CONCLUSIONS: IHRT repair is a safe procedure at our medical center, with an acceptable rate of hernia recurrence, but it is not without complications

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BACKGROUND: The goal of our study was to compare results in patients with large midline incisional hernia using modified anterior component separation versus preoperative botulinum toxin and following Rives repair, with a focus on surgical site occurrences, possibility of fascial closure, duration of hospital stay, and hernia recurrence rate. METHODS: From to March 2016 to June 2019, a prospective comparative study was performed in 80 consecutive patients with large midline incisional hernias and hernia transverse diameters between 11 and 17 cm under elective hernia repair at our tertiary center. Two groups were analyzed prospectively: 40 patients with preoperative botulinum toxin administration and following open Rives repair (botulinum toxin group) were compared with 40 patients who underwent open component separation during that period (component separation group). RESULTS: All large midline incisional hernias were classified W3, with mean transverse and longitudinal defect diameters of 14.9 cm (11.8-16.5) and 24 cm (11-28), respectively. Complete fascial closure was possible in all patients in the preoperative botulinum toxin group. No complications occurred during the administration of preoperative botulinum toxin, but surgical site complications were most frequent in the component separation group, especially skin necrosis (12.5%, P = .020). At a median of 19.6 months (range, 11-35) of postoperative follow-up, 2 cases of hernia recurrence (8.9%) were reported, all of them in the component separation group. CONCLUSION: Botulinum toxin allows getting a successful downstaging from surgical repair to Rives technique in patients with large midline incisional hernia, especially with hernia transverse diameters between 11 and 17 cm. These results contribute to minimize disadvantages associated to the anterior component separation.

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Objectives: Preoperative botulinum toxin type A (BT) and progressive pneumoperitoneum (PPP) are useful tools in the preparation of patients with loss of domain hernias (LODH). The purpose of our retrospective study is to report our experience in the treatment of 100 consecutive patients with LODH, with the combined use of these techniques. Methods: Of the 753 patients operated on for ventral incisional hernia between June 2010 and December 2018 in our hospital, 100 patients with LODH were analyzed retrospectively. Diameters of abdominal cavity and hernia sac, and volumes of incisional hernia (VIH) and abdominal cavity (VAC) were calculated from CT scan, based on the index of Tanaka. Results: The median insufflated volume of air for PPP was 8,600 ± 4,200 cc (4,500-15,250). BT administration time was 38.2 days (33-48). A significant average reduction of 15% of the VIH/VAC ratio was observed on CT scan after the combination of PPP and BT (p = 0.001). Anterior component separation (CST) and transversus abdominis release (TAR) were the most frequent repair techniques. Complete fascial closure was possible in 97%, and mesh bridging was needed in three cases. In postoperative follow-up of 34.5 months (11-62), we reported eight cases of hernia recurrence (8%). Conclusion: PPP and BT are useful tools in the treatment of LODH. These techniques significantly reduce the VIH/VAC ratio, allowing the reduction of the hernia content into the abdominal cavity, which represents a key factor in the management of these hernias.

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INTRODUCTION: Incisional hernias secondary to renal transplantation (IHRT) are considered complex hernias because they are lateral to the sheath of the rectus abdominis muscle. The presence of the graft in the iliac fossa and the proximity to the inguinal area, costal margin and iliac bones, as zones with difficult fixation for prostheses, increases repair complexity. In addition, these patients have specific characteristics, such as treatment with immunosuppressive medication, that could alter postoperative evolution. The objective of this study was to analyze the results obtained in IHRT repair at a tertiary hospital, and to compare these data with the international literature. METHODS: Retrospective observational study of patients treated surgically for IHRT in our unit from January 1, 2011 to January 31, 2018. Preoperative conditions, intraoperative factors and postoperative complications during follow-up were analyzed. RESULTS: Twenty-five patients underwent hernia repair, finding a 4% hernia recurrence rate during a median follow-up of 27.5 months (20-39). The most frequently used technique was the posterior transversus abdominis release component separation technique in 42%, followed by preperitoneal repair in 27% and interoblique repair in 12%. The overall postoperative morbidity was 23%, which was frequently related to the surgical site (12%). CONCLUSIONS: IHRT repair is a safe procedure at our medical center, with an acceptable rate of hernia recurrence, but it is not without complications.

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Preoperative progressive pneumoperitoneum and botulinum toxin type A are useful tools in the preparation of patients with loss of domain hernias. Both procedures are complementary in the surgical repair, especially with the use of prosthetic techniques without tension, that allow a integral management of these patients. The aim of this paper is to update concepts related to both procedures, emphasizing the advantages that take place in the preoperative management of loss of domain hernias.

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El neumoperitoneo progresivo preoperatorio y la toxina botulínica tipo A son herramientas útiles en la preparación de los pacientes con hernias gigantes que han perdido el domicilio. Ambos procedimientos son armas complementarias del procedimiento quirúrgico, especialmente con el uso de técnicas protésicas sin tensión, que permiten el manejo integral de estos pacientes. Este artículo tiene por objeto actualizar conceptos relacionados con ambos procedimientos, incidiendo en las ventajas que aportan en el manejo preoperatorio de las hernias gigantes que han perdido el domicilio (AU)

Preoperative progressive pneumoperitoneum and botulinum toxin type A are useful tools in the preparation of patients with loss of domain hernias. Both procedures are complementary in the surgical repair, especially with the use of prosthetic techniques without tension, that allow a integral management of these patients. The aim of this paper is to update concepts related to both procedures, emphasizing the advantages that take place in the preoperative management of loss of domain hernias (AU)

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BACKGROUND: The main objective was to identify predictive factors associated with prosthesis infection and mesh explantation after abdominal wall hernia repair (AWHR). METHODS: This is a retrospective review of all patients who underwent AWHR from January 2004 to May 2014 at a tertiary center. Multivariate analysis identified predictors of mesh infection and explantation after AWHR. RESULTS: From 3,470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. Steroid or immunosuppressive drugs use (odds ratio [OR] 2.22; confidence interval [CI] 1.16 to 3.95), urgent repair (OR 5.06; CI 2.21 to 8.60), and postoperative surgical site infection (OR 2.9; CI 1.55 to 4.10) were predictive of mesh infection. Predictors of mesh explantation were type of mesh (OR 3.13; CI 1.71 to 5.21), onlay position (OR 3.51; CI 1.23 to 6.12), and associated enterotomy in the same procedure (OR 5.17; CI 2.05 to 7.12). CONCLUSIONS: Immunosuppressive drugs use, urgent repair, and postoperative surgical site infection are predictive of mesh infection. Risk factors of prosthesis explantation are polytetrafluoroethylene mesh, onlay mesh position, and associated enterotomy in the same procedure.

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BACKGROUND: To compare the results with complete mesh removal (CMR) versus partial mesh removal (PMR) in the treatment of mesh infection after abdominal wall hernia repair (AWHR). METHODS: Retrospective review of all patients who underwent surgery for mesh infection between January 2004 and May 2014 at a tertiary center. RESULTS: Of 3470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. CMR was achieved on 38 occasions, while PMR was undertaken ten times. We observed more postoperative complications in CMR than PMR group (p = 0.04). Three patients with intestinal fistula were reoperated in postoperative period after a difficult mesh removal; one of them died due to multiple organ failure. The overall recurrence rate after explantation was 47.9%: recurrence was more frequent in CMR group (p = 0.001), although persistent or new mesh infection was observed more frequently with PMR (p = 0.001). CONCLUSIONS: Although PMR has less postoperative morbidity, shorter duration of hospitalization and lower rate of recurrence than CMR, prosthetic infection persists in up to 50% of cases.

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INTRODUCCIÓN: La coledocolitiasis es la causa más común de ictericia obstructiva y ocurre en un 5-10% de los pacientes que presentan colelitiasis. OBJETIVOS: Elaboración un modelo predictivo preoperatorio de coledocolitiasis. MATERIAL Y MÉTODOS: Estudio prospectivo de 556 pacientes ingresados en nuestros servicios por patología biliar. Análisis comparativo de variables preoperatorias clínicas, analíticas y ecográficas de los pacientes sin coledocolitiasis frente a las de los 65 pacientes con dicho hallazgo. Análisis multivariante de regresión logística para obtener un modelo predictivo de coledocolitiasis, determinando sensibilidad, especificidad, valores predictivos positivo (VPP) y negativo (VPN). RESULTADOS: Los factores predictivos de coledocolitiasis fueron la existencia de historia biliar previa (antecedentes de cólicos biliares, colecistitis, coledocolitiasis o pancreatitis aguda biliar) (p = 0,021; OR = 2.225; IC 95%: 1.130-4.381), las cifras de BT al ingreso superior a 4 mg/dl (p = 0,046; OR = 2.403; IC 95%: 1.106-5.685), el valor de la FA al ingreso superior a 150 mg/dl (p = 0.022; OR = 2.631; IC 95%: 1.386-6.231), cifras de la GGT superiores a 100 (p = 0,035; OR = 2,10; IC 95%: 1.345-5.850), y el hallazgo ecográfico de dilatación de la vía biliar (p = 0,034; OR = 3.063; IC 95%: 1.086-8.649). Un score superior a 5 conlleva una especificidad y VPP de 100% para detectar coledocolitiasis, y un score inferior a 3, una sensibilidad y un VPN del 100% para descartarla. CONCLUSIONES: El score obtenido descarta o confirma preoperatoriamente la existencia de coledocolitiasis, y permite al paciente beneficiarse directamente de la colecistectomía laparoscópica (CL) o de la realización previa de colangiopancreatografía retrógrada endoscópica (CPRE)

INTRODUCTION: Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis. OBJECTIVES: To design a preoperative predictive score for choledocholithiasis. MATERIAL AND METHODS: A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p=0.021, OR=2.225, 95% CI: 1.130-4.381), total bilirubin values >4mg/dl (p=0.046, OR=2.403, 95% CI: 1.106-5.685), alkaline phosphatase values >150mg/dl (p=0.022 income, OR=2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values >100mg/dl (p=0.035, OR=2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct >8mm (p=0.034, OR=3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis. CONCLUSIONS: The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP)

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INTRODUCTION: Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis. OBJECTIVES: To design a preoperative predictive score for choledocholithiasis. MATERIAL AND METHODS: A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p=0.021, OR=2.225, 95% CI: 1.130-4.381), total bilirubin values >4mg/dl (p=0.046, OR=2.403, 95% CI: 1.106-5.685), alkaline phosphatase values >150mg/dl (p=0.022 income, OR=2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values >100mg/dl (p=0.035, OR=2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct >8mm (p=0.034, OR=3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis. CONCLUSIONS: The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP).

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For the last two decades, general and digestive surgeons have attempted to improve the postoperative course of surgical patients. Classical perioperative treatment can be described as a period of preoperative dehydration caused by fasting and intensive colon preparation followed by fluid overload generally due to excessively prolonged serum therapy. There is also perioperative surgical stress, the trauma of surgery itself, and a long period of drainage and nasogastric tubes. The patient is thus literally confined to bed and mobilization is, at the very least, difficult. Moreover, the use of opiates delays intestinal peristalsis and consequently oral nutrition. All together, these factors prolong the length of hospital stay and hamper recovery. All these perioperative treatment modalities have been questioned by Kehlet, resulting in a set of new, more realistic and evidence-based modalities, currently known as the fast-track program. The aim of this program is to decrease perioperative stress, reduce organ involvement produced by surgical trauma and hasten the patient's general recovery. Major advantages of this program consist not only of shorter length of hospital stay but also of a concurrent improvement in patients' quality of life and a reduction in mortality. The present review article analyzes all these modalities, with special emphasis on laparoscopic colorectal surgery. This approach is presented as one of the elements of the fast-track program.

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Desde las 2 últimas décadas, los cirujanos dedicados a la cirugía general y digestiva intentan hacer más digno el curso postoperatorio de los pacientes sometidos a una intervención quirúrgica. El tratamiento peroperatorio clásico se puede resumir como un período de deshidratación preoperatoria causada por el ayuno preoperatorio y una preparación intensiva de colon seguida en el curso postoperatorio por un período de encharcamiento producido por un tratamiento con suero por lo general prolongado y excesivo. A todo ello se acumula el estrés quirúrgico peroperatorio, el traumatismo quirúrgico infligido y un largo período de drenajes y sonda nasogástrica. Todo ello hace que el paciente esté literalmente "fijo" a la cama y la movilización sea al menos dificultosa. Además, el uso de opiáceos retrasa la aparición del peristaltismo intestinal y, con ello, la alimentación por vía oral. Todo ello hace que la estancia del paciente sea larga y su recuperación llena de dificultades. La puesta en duda de todas estas modalidades de tratamiento peroperatorias, realizado por Kehlet, ha resultado en una suma de nuevas modalidades, más realistas y basadas en la evidencia, actualmente llamado programa fast-track o trayecto rápido. Su fin es el de disminuir el estrés peroperatorio, la afectación orgánica producida por el traumatismo quirúrgico y acelerar la recuperación general del paciente. Importantes ventajas de este programa no son sólo la estancia más corta, sino al mismo tiempo un aumento de la calidad de vida de los pacientes, y una disminución de la morbilidad. En este artículo de revisión se analizan todas estas modalidades, sobre todo en relación con la cirugía colorrectal y en especial su abordaje laparoscópico. En él se llega a definir este abordaje laparoscópico como una parte más de este programa fast-track (AU)

For the last two decades, general and digestive surgeons have attempted to improve the postoperative course of surgical patients. Classical perioperative treatment can be described as a period of preoperative dehydration caused by fasting and intensive colon preparation followed by fluid overload generally due to excessively prolonged serum therapy. There is also perioperative surgical stress, the trauma of surgery itself, and a long period of drainage and nasogastric tubes. The patient is thus literally confined to bed and mobilization is, at the very least, difficult. Moreover, the use of opiates delays intestinal peristalsis and consequently oral nutrition. All together, these factors prolong the length of hospital stay and hamper recovery. All these perioperative treatment modalities have been questioned by Kehlet, resulting in a set of new, more realistic and evidence-based modalities, currently known as the fast-track program. The aim of this program is to decrease perioperative stress, reduce organ involvement produced by surgical trauma and hasten the patient's general recovery. Major advantages of this program consist not only of shorter length of hospital stay but also of a concurrent improvement in patients' quality of life and a reduction in mortality. The present review article analyzes all these modalities, with special emphasis on laparoscopic colorectal surgery. This approach is presented as one of the elements of the fast-track program (AU)

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