Objective To investigate the application value of the preoperative progressive pneumoperitoneum (PPP) in parastomal hernia repair.Methods The retrospective cross-sectional study was conducted.The clinical data of 28 patients who underwent parastomal hernia repair using PPP in the Sixth Affiliated Hospital of Sun Yat-sen University from December 2014 to February 2017 were collected.Patients received abdominal computed tomography (CT) scan after admission,and volumes of the hernia sac and abdominal cavity and (volume of the hernia sac / total volume of the abdominal cavity)× 100.0％ were respectively calculated.Open or laparoscopic parastomal hernia repair was selected based on the effects of artificial pneumoperitoneum.Observation indicators:(1) PPP situations:① completion;② changes of volumes of the hernia sac and abdominal cavity before and after PPP;③ adhesion and retraction of parastomal hernia contents after PPP;(2) surgical and postoperative recovery situations;(3) follow-up situations.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative long-term complications and recurrence of parastomal hernia up to May 2017.Measurement data with normal distribution were represented as (x)±s.Measurement data with skewed distribution were described as M (range).Repeated measurement data were evaluated with the repeated measures ANOVA.Results (1) PPP situations:① completion:28 patients received successful ultrasound-guided indwelling catcher.Twenty-four patients completed PPP,with a completion rate of 85.7％ (24/28) and an air injection volume of (3 995±531) mL,and 4 stopped PPP.Eighteen patients had varying degrees of abdominal pain,abdominal distension and scapular pain,including 17 with tolerance and 1 with disappearing of symptoms at day 6.Of 5 patients with shortness of breath,3 were improved or well tolerated through breathing exercises,and symptoms of 2 disappeared at day 7 and 9.Three patients had mild subcutaneous emphysema.The arterial CO2 tension of 1 patient was high and then returned to normal at day 7.Some patients had simultaneously multiple adverse reactions.② Changes of volumes of the hernia sac and abdominal cavity before and after PPP:volumes of the hernia sac before and after PPP were (699± 231) mL and (993 ± 332) mL,with a statistically significant difference (F=129.29,P＜0.05),and increasing volume of the hernia sac was (294± 167) mL,with an increasing rate of 43％±15％.Volumes of the abdominal cavity before and after PPP were (6 520±745)mL and (9 196± 909) mL,with a statistically significant difference (F=429.42,P＜0.05),and increasing volume of the abdominal cavity was (2 715±709)mL,with an increasing rate of 42％± 12％.(Volume of the hernia sac / total volume of the abdominal cavity) × 100.0％ before and after PPP were 9.6％ ± 2.7％ (less than or equal to 10.0％ in 20 patients,more than 10.0％ and less than or equal to 15.0％ in 6 patients,and more than 15.0％ in 2 patients) and 9.7％± 2.8％,with no statistically significant difference (F =0.44,P＞0.05).③ Adhesion and retraction of parastomal hernia contents after PPP:results of abdominal CT showed anterior abdominal bulging,abdominal contents prostrated at the base of the abdominal cavity due to gravity,and gas was full of gaps.Abdominal adhesion signs:adhesions of banded fibrous connective tissue established a connection between the base of the abdominal cavity and anterior abdominal wall,and intestinal canals were found inside the adhesions.Parastomal hernia contents of 28 patients had varying degrees of retraction to abdominal cavity,including 9 with complete retraction,13 with a great amount of retraction (retraction volume ＞50％) and 6 with a small amount of retraction (retraction volume ＜50％).Four patients were accompanied by incomplete stoma obstruction,and then obstruction disappeared or relieved after PPP.(2) Surgical and postoperative recovery situations:all the 28 patients underwent successful operations,without intestinal canal injury.Three patients received open parastomal hernia repair,including 2 receiving preperitoneal mesh repair using 8 layers Biodesign meshes (deep venous catheter for local drainage was placed and then removed at postoperative day 2 and 3) and 1 receiving Sugarbaker surgery using PCOPM mesh (peritoneal drainage-tube was placed and then removed at postoperative day 2).Other 25 patients received laparoscopic parastomal hernia repair and Sugarbaker surgery using PCOPM and Sepramesh meshes (no drainage-tube was placed).Bladder pressure of 28 patients at postoperative day 3 was (13±6)cmH2O (1 cmH2O =0.098 kPa),without an abnormal high pressure.Nine patients with postoperative complications were improved by conservative treatment,including 3 with seroma,3 with delayed stoma defecation or incomplete intestinal obstruction,2 with pulmonary infection and 1 with urinary tract infection.There were no occurrences of abdominal compartment syndrome,cardiac failure,lung failure,renal failure,other severe complications and perioperative death.Duration of postoperative hospital stay was (7.2± 1.5) days.(3) Follow-up situations:25 of 28 patients were followed up for 3-25 months,with a median time of 11 months.During follow-up,2 patients had chronic pain around the operation and a sense of discomfort and then were improved by symptomatic treatment,and 1 with parastomal hernia recurrence at postoperative month 6 after open preperitoneal mesh repair underwent again open preperitoneal mesh repair,without recurrence.There were no occurrence of tardive mesh infection and other longterm complications.Conclusion PPP in the treatment of parastomal hernia repair is safe and feasible.

Objective:To explore the efficacy and safety of laparoscopic Dor fundoplication in treating gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG).Methods:A retrospective analysis was conducted on 11 patients undergoing laparoscopic Dor fundoplication between Oct 2021 and Oct 2023. These patients had previously undergone LSG due to obesity and related metabolic diseases and developed GERD postoperatively. The GerdQ scale scores, results of endoscopy, upper gastrointestinal radiography, and gastric window color Doppler ultrasonography were analyzed.Result:Surgeries were successfully performed in these 11 patients. After esophageal hiatus repair, 10 patients underwent reinforcement of the diaphragmatic crus using biological or synthetic anti-adhesion patches. The average operative time was (120±31) minutes, and the average postoperative hospital stay was (9±3) days. Follow-up at 6 months revealed complete resolution of GERD symptoms in 10 patients. Intraoperatively one patient sustained injuries to the left hepatic vein and esophagus. Postoperative complications included one case of intestinal obstruction and one case of dysphagia, one patient failed to get experience improvement in GERD symptoms. All complications were managed successfully except for one needing re-admission for interventional esophageal balloon dilation due to dysphagia.Conclusion:Laparoscopic Dor fundoplication serves as a safe and effective revision surgery for GERD following LSG.

Background and Aims:The repair of giant incisional hernia is challenging,as closing the significant defect in the abdominal wall can lead to life-threatening complications like abdominal compartment syndrome(ACS).Botulinum toxin type A(BTA)can temporarily relax the abdominal wall muscles,facilitating defect repair,while preoperative progressive pneumoperitoneum(PPP)can increase intra-abdominal volume,reducing intra-abdominal pressure caused by hernia content reintegration.Combining BTA with PPP for the preoperative preparation of giant incisional hernia repair may have a complementary effect.This study was conducted to evaluate the clinical value of combining BTA and PPP in the repair of giant abdominal incisional hernia. Methods:The clinical data of 213 patients with giant abdominal incisional hernia treated at the Sixth Affiliated Hospital of Sun Yat-sen University from December 2015 to December 2019 were retrospectively analyzed.Two weeks after receiving combined BTA and PPP treatment,changes in bilateral abdominal wall muscle,intra-abdominal adhesions,abdominal circumference,abdominal cavity volume,and hernia sac volume ratio were assessed using CT.Intraoperative details,incidence of complications,and postoperative follow-up outcomes were recorded. Results:Following combined BTA and PPP treatment,CT scan showed a significant extension of bilateral lateral abdominal wall muscles towards the midline in all 213 patients,with an average increase of 2.45(1.53-3.29)cm on the left side and 2.54(1.68-3.40)cm on the right side;muscle thickness was reduced by an average of 0.84(0.64-1.00)cm on the left and 0.82(0.62-1.05)cm on the right,the average distance between viscera and the abdominal wall increased to(7.52±1.78)cm,with a mean increase of 6.1(4.2-6.9)cm;the mean increase in abdominal cavity volume was 1 802(1 494.98-2 316.26)mL,and the hernia sac volume ratio decreased by an average of 9％(6％-12％),all changes were statistically significant(P＜0.05).Post-PPP CT scan revealed no abdominal adhesions in 18 patients(8.45％),while 195 patients(91.55％)had varying degrees of adhesions,including 39 cases(18.31％)of sheet adhesions and 156 cases(73.24％)of mixed adhesions.Adhesions mainly consisted of omentum and intestinal tissues in 59.15％of cases.There were 43 cases(20.19％)of grade Ⅰ complications during the BTA-PPP process,including abdominal pain(28 cases),shoulder pain(9 cases),subcutaneous emphysema(6 cases),and dyspnea(3 cases).Dyspnea improved with oxygen therapy,while other complications required no special intervention.All 213 patients successfully underwent laparoscopic incisional hernia repair without conversion to open surgery or organ resection for volume reduction.Fascial closure was achieved in 209 cases(98.12％),with 4 cases(1.88％)having incomplete defect closure.The average time for adhesiolysis was 28(11.00-44.50)min,with a total operative time of 178.0(132.50-255.00)min and an average blood loss of 20(10-30)mL.The median intra-abdominal pressure(IAP)after operation was between 10 mmHg(9.00-12.00 mmHg),Among them,47 cases(22.07％)had IAP exceeding 12 mmHg,and after implementing proactive measures such as diuresis and diachoresis to reduce intra-abdominal contents,the IAP in these patients decreased to below 12 mmHg.No severe complications such as skin flap necrosis or ACS were observed.There were no deaths within postoperative 30 d,and during a follow-up period of 26(16.50-33.00)months,13 cases(6.10％)had surgical site events,including infections in 5 cases(2.35％),seromas in 7 cases(3.29％),and hematoma in 1 case(0.47％),with no hernia recurrence. Conclusion:The combination of BTA and PPP not only aids in identifying abdominal wall adhesion areas,improving preoperative surgical planning and enhancing surgical safety,but also significantly increases abdominal cavity volume and extends lateral abdominal wall muscles,facilitating the closure of giant incisional hernia defects and reducing the incidence of severe postoperative complications like ACS.This approach is worthy of clinical promotion.

OBJECTIVETo investigate the efficacy of single-hand four-needle suture with sled-shaped needle three-tail fixed stitch in closure of pesudohernia sac of direct hernia under transabdominal preperitoneal (TAPP) inguinal hernia repair.

METHODSA randomized controlled trail was conducted on adult patients with unilateral direct inguinal hernia undergoing laparoscopic TAPP repair from January 2014 to January 2018 at the Sixth Affiliated Hospital of Sun Yat-sen University. A total of 156 patients were enrolled prospectively in the study and were randomly divided into single-hand four-needle suture group (trial group, 76 cases) and traditional tacking group (control group, 80 cases). In trial group, sled-shaped needle three-tail knot-free stitch was applied to the continuous four-needle suture. The sled-shaped needle three-tail fixed stitch was made as follows: straighten the tail of a 3-0, 1/2-circle looper VICRYL Rapide into a sled shape; use suture overlap method to make and tighten a single knot; thread the end of the needle into the single knot loop;knot two ends of the thread next to the first knot; tighten the second knot, leaving about 12 cm to the end of the needle;cut the end of the loop (leaving about 0.6 cm) and the other end of the thread(leaving about 1.5 cm). In the control group, a hernia repair tack was used to fix the pseudohernia sac on pectineal ligament. This study was approved by the Hospital Ethics Committee(approval number: L2014ZSLYEC-016). Operation time, pseudoherina sac closure time, hospitalization cost, morbidity of postoperative complication, VAS score and postoperative recurrence were compared between two groups.

RESULTSAll the patients completed operations successfully. There were no significant differences between trial group and control group in age [(60.2±0.4) years vs. (61.1±0.7) years)], gender (male ratio 93.4% vs. 92.5%), BMI [(25.1±0.2) kg/m vs. (24.9±0.2) kg/m ], defection area [(16.1±0.4) cm vs. (15.7±0.7) cm ] (all P > 0.05). As compared to control group, trial group had longer operative time[(34.2±1.9) minutes vs. (30.3±1.1) minutes, t=5.484, P=0.045], longer closure time of psudohernia sac [(4.2±0.5) minutes vs. (1.8±0.7) minutes, t=7.423, P=0.031], but lower VAS score (3.2±0.1 vs. 5.3±0.6, t=-3.186, P=0.015) and lower total cost [(9 897.3±104.4) yuan vs. (12 325.6±169.7) yuan, t=-3.972, P=0.023]. No severe complication and death were found in either groups intra-operatively and postoperatively. No mesh infection and relapse occurred during postoperative follow-up of 1-24 (12.0±1.2) months. During follow-up, seroma occurred in 2 cases (2.6%) of trial group and 3 cases (3.8%) of control group without significant difference (χ =1.284, P=0.799), and all were absorbed and disappeared within 30 days after local application of mirabilite.

CONCLUSIONCompared to tack fix method, single-hand four-needle suture with sled-shaped needle three-tail fixed stitch can effectively close pseudohernia sac, reduce hospitalization cost and ameliorate postoperative pain in TAPP repair, which is worth promotion.

Hernia, Inguinal ; surgery ; Herniorrhaphy ; methods ; Humans ; Laparoscopy ; Male ; Middle Aged ; Surgical Mesh ; Suture Techniques ; Sutures ; Treatment Outcome