PERITONEAL CLOSURE VERSUS NON-CLOSURE IN OPEN APPENDICECTOMIES

Acute Appendicitis is a common surgical emergency and Open Appendicectomy is widely performed. This study aims to analyze the difference of outcome in peritoneal closure versus Non closure in open appendicectomy. Adult patients (18- 65 years) admitted and operated for Acute appendicitis were studied prospectively from July 2019 to July 2020 at King George Hospital, Visakhapatnam. The intra operative time, post-operative pain, wound infection and duration of hospital stay were analyzed. Between July 2019 and July 2020 there were 86 patients with diagnosis of Acute appendicitis to the emergency casualty of KGH, Visakhapatnam and underwent Open appendicectomy. They were divided into two groups randomly, Group A: Open appendicectomy with peritoneal closure (39) and Group B: Open appendicectomy with non-closure of peritoneum (47). There was found to be a reduction in the duration of surgery, less post operative pain and shorter duration of hospital stay in patients who underwent non-closure of peritoneum compared to patients who underwent peritoneal closure. There was no difference in incidence of post-operative wound infection when compared to closure of peritoneum. Non closure of peritoneum is associated with shorter operative time, reduced requirement of post-operative analgesia and shorter duration of hospital stay and hence can be safely recommended.

Retrospective Analysis of Risk Factors for Postoperative Perineal Hernia After Endoscopic Abdominoperineal Excision for Rectal Cancer

Background: In contrast to open-surgery abdominoperineal excision (APE) for rectal cancer, postoperative perineal hernia (PPH) is reported to increase after extralevator APE and endoscopic surgery. In this study, therefore, we aimed to determine the risk factors for PPH after endoscopic APE.Methods: A total 73 patients who underwent endoscopic APE for lower rectal cancer were collected from January 2009 to March 2020, and the risk factors for PPH were analyzed retrospectively.Results: Nineteen patients (26%) developed PPH after endoscopic APE, and the diagnosis of PPH was made at 9–393 days (median: 183 days) after initial surgery. Logistic regression analysis showed that absence of pelvic peritoneal closure alone increased the incidence of PPH significantly (odds ratio; 13.76, 95% confidence interval; 1.48–1884.84, p = 0.004).Conclusions: Pelvic peritoneal closure should be performed when possible after endoscopic APE to prevent PPH.

Bowel obstruction and perforation secondary to barbed suture after minimally invasive inguinal hernia repair: report of two cases and literature review

Background Laparoscopic transabdominal preperitoneal patch (TAPP) is now commonly used in the repair of inguinal hernia. Barbed suture can be a fast and effective method of peritoneal closure. We report two rare cases of small bowel obstruction and perforation caused by barbed suture after TAPP. Cases Patient 1 is a 45-year-old man who underwent laparoscopic repair of a right inguinal hernia. Barbed suture was used to close the peritoneal defect. At 47 days after the operation, he was diagnosed with a small bowel obstruction caused by an elongated tail of the barbed suture. Emergency laparoscopic exploration was performed for removal of the embedded suture and detorsion of the volvulus. The second patient is a 50-year-old man who was admitted with a small bowel perforation one week after TAPP herniorrhaphy. Emergency exploration revealed that the tail of the barbed suture had pierced the small intestine, causing a tiny perforation. After cutting and releasing the redundant tail of the barbed suture, the serosal and muscular defect was closed with 2 absorbable single-knot sutures. Both patients have recovered well. Finally, we searched the PubMed database and reviewed the literature on the effectiveness and safety of barbed suture for TAPP. Conclusions Surgeons should understand the characteristics of barbed suture and master the technique of peritoneum closure during TAPP in order to reduce the risk of bowel obstruction and perforation.

Comparison of Peritoneal Closure Versus Non-closure After Non-infected Elective Laparotomy with a Midline Incision: A Randomized Clinical Trial

Background: There is no consensus regarding closure or non-closure of peritoneum in laparotomy, and this topic remains a controversy among surgeons. Objectives: This clinical trial aimed to compare short-term and long-term benefits of peritoneal closure with non-closure in an academic medical center. Methods: In this double-blinded two-arm parallel-group randomized trial, 124 patients undergoing laparotomy with midline incision were assessed from March 2019 to September 2019 at Imam Hossein Medical Center, Tehran, Iran. We used the Rand function of the Excel software to randomly assign 62 patients to the peritoneal closure group and 62 patients to the non-closure group. The patients were evaluated for short-term complications including wound-related fever, infection, need for analgesics, pain in the first 2, 6, 24, and 48 hours postoperatively according to the Visual Analogue scale (VAS), duration of hospitalization, as well as long-term complications including incisional hernia and intraperitoneal adhesion one year after the surgery. Statistical analysis was carried out with SPSS version 22 software. Results: The non-closure peritoneum group had a lower rate of wound-related fever, infection, and analgesic need than the peritoneal closure group, but these differences were not statistically significant (P = 0.488, P = 0.455, and P = 0.062, respectively). The adhesion rate and incisional hernia incidence one year after the surgery were not significantly different between the two groups (P = 0.363, P = 0.586). Pain intensity was significantly lower in the non-closure group than in the closure group in the first two, six, and 24 hours (P = 0.008, P = 0.004, and P = 0.047, respectively) but not significantly at 48 hours (P = 0.146). Conclusions: Peritoneum closure after non-emergency, non-infected laparotomy increases the postoperative pain while it has no benefit for long-term complications like incisional hernia or intra-peritoneal adhesion.

Preperitoneal herniation as a complication of tansabdominal preperitoneal patch plasty: a report of two cases

Background Preperitoneal herniation is a rare complication after transabdominal preperitoneal patch plasty (TAPP) and may be caused by inadequate peritoneal closure. We herein report two cases of postoperative small bowel obstruction due to preperitoneal herniation through a disrupted peritoneum. Case presentation Two men in their 70s were admitted to our center because of small bowel obstruction after TAPP. After examinations and unsuccessful conservative treatment, emergency laparoscopic exploration was performed. Preperitoneal herniation through the disrupted peritoneum was found. The herniated small bowel was reduced and the peritoneum was properly reclosed. The patients recovered and were discharged with normal bowel function. Conclusions Inadequate peritoneal closure may cause preperitoneal herniation and lead to postoperative small bowel obstruction and even death. Hernia surgeons can avoid this complication by improving their suture technique and paying attention to the procedure details.

Review of Unsafe Changes in the Practice of Cesarean Section with Analysis of Flaws in the Interpretation of Statistics and the Evidence

Cesarean section is the commonest major operation. Unfortunately, many recent practice-changes have been rushed based on flawed interpretation limited data that are debated in this review. The discussion includes non-closure of the peritoneum, the 39-week rule for elective cesarean, incorrect implementation of four-category urgency classification, and abdominal entry with excessive blunt force. It took NASA two fatal space-shuttle disasters over 18 years to change its culture of dismissing reasoning and observations in addition to numerical data. Reasoning becomes even more important when there is emerging data, especially in soft sciences like medicine. This review discusses flawed science behind the change to “non-closure of peritoneum” in details (and other changes briefly). This practice change was based on narrow mistaken considerations and solely on statistical significance, studying irrelevant short-term outcomes like increased requirement of analgesia. Several statistical mistakes in interpreting this evidence with wider applications are discussed. This weak/flawed evidence has been subsequently disproven by large randomized controlled trials. Small reduction in operating time should never have been a consideration. The merit of hypothesis favoring peritoneal closure to prevent adhesions is very strong to begin with. More importantly, the meta-analysis of available studies shows that closing peritoneum significantly reduces the formation of adhesions, particularly the severe ones. Extensive adhesion of uterus to the abdominal wall is relatively rare to reach statistical significance in small studies but is clinically highly significant due to operative complications. The rushed mistaken recommendation of non-closure of peritoneum should not have been made. However, reversing these changes is perceived as admitting errors, and there is simply no interest in doing so with detriment of the patients. Guidelines should now change their advice on many important aspects of cesarean, as discussed in this review.

Initial experience using a handheld fully articulating software-driven laparoscopic needle driver in TAPP inguinal hernia repair

Background The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a widely performed minimally invasive operation, but can present considerable ergonomic challenges for the surgeon. Our objective was to determine if a novel handheld software-driven laparoscopic articulating needle driver can mitigate these difficulties. Methods The video recordings of a consecutive series of TAPP cases by a single surgeon using the articulating device were compared with a series of cases using straight-stick laparoscopy. Two critical steps of the procedure were analyzed for time: mesh fixation and peritoneal suture closure. These steps were then compared before and after 10 initial consecutive cases to analyze whether the surgeon demonstrated improvement. A cost analysis was also performed between the two techniques. Results For mesh fixation, the surgeon averaged 227 s using tacker devices, compared with 462.4 s using the novel laparoscopic device (p = 0.06). For the peritoneal closure component of the operation, the surgeon improved the time per suture pass during closure from 60.61 s during the first 10 cases to 38.84 s after the first 10 cases (p = 0.0004), which was comparable to the time per stitch for standard laparoscopy (34.8 s vs 34.84 s, p = 0.997). Left-sided inguinal hernia repairs using the articulating device demonstrated a significantly longer time per stitch during peritoneal closure compared to the right side after first 10 cases (left: 40.62 s; right: 27.91, p = 0.005). Our direct cost analysis demonstrated that suture closure of the peritoneum using the articulating device was more cost-effective than tack fixation. Conclusions After only a 10 case initial experience, a laparoscopic hand-held articulating needle driver is comparable to standard laparoscopy to complete suture mesh fixation and peritoneal closure for TAPP inguinal hernia repair. Further, the feasibility of suture mesh fixation minimizes the need for costly tacker devices. This instrument appears to be a promising tool in this largely minimally invasive era of hernia repair.