วารสารศัลยศาสตร์ไทย

Comparison of Mesh Fixation and Non-fixation in Totally Extraperitoneal Hernia Repair: A Randomized Controlled Trial

ธรรมนิตย์ วรวรรณธนะชัย, กุลรัตน์ บริรักษ์วาณิชย์ — Fri, 28 Jun 2024 00:00:00 +0700

Objective: Many studies have shown that non-fixation of mesh in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is safe and has no disadvantage compared to mesh fixation; however, most studies contain limited information on hernia-defect size. The purpose of this study was to compare the clinical outcome of non-fixation and fixation of mesh in consecutive elective laparoscopic TEP inguinal hernia repair in any type and size of hernia defect classified by the European Hernia Society (EHS) groin hernia classification to be a part of the level 1 evidence about technique of fixation in TEP.

Patients and Methods: One hundred and ten hernia repairs in 101 patients were enrolled in the trial between July 2022 and August 2023. The patients were randomized to the mesh fixation group (n = 55) or the non-fixation group (n = 55). The primary outcomes were chronic groin pain and recurrence at 6 months. The secondary outcomes were operative time, conversion rates, pain scores, analgesic requirement, time to regular activity, complications, and length of stay. A person blinded to the method of fixation performed statistical analysis.

Results: There were no significant differences between the two groups in baseline demographic characteristics, including age, BMI, sex, ASA classification, EHS hernia classification, and incidence of recurrent defect. More than 90% of hernia defects were larger than 1.5 cm, and more than 25% of defects were > 3 cm. They were statistically similar in both groups in terms of chronic groin pain, operative time, conversion rates, pain scores, analgesic requirement, time to regular activity, length of stay, and complications. Neither group had a recurrence at a minimum follow-up of 6 months.

Conclusions: There was no statistical significance in chronic groin pain and recurrence between fixation and non-fixation groups. The non-fixation approach should be adopted routinely and safely in laparoscopic TEP hernia repair. Even the tack fixation technique applied in this study was not associated with the risk of significant pain level and chronic groin pain; however, it is associated with high operative cost, so it should be used only in very selected situations in TEP.

Clinical Outcomes Following Surgical Revascularization for Acute Lower Limb Ischemia

อาคม เสือสาวะถี, กฤตวิทย์ กฤตยามณีรัตน์, ธิติ วรรณศิริ, ธนพล สุภาผล — Fri, 28 Jun 2024 00:00:00 +0700

Objectives: To assess the clinical outcomes of surgical revascularization in patients diagnosed with acute lower limb ischemia (ALI). The primary outcome was defined as the limb salvage rate within 30 days after surgery.

Methods: This is a retrospective single-center study. The target population was recruited from the Prapokklao Hospital database between January 2019 – December 2023. Patients who were diagnosed with acute occlusion of the artery according to the International Classification of Disease 10th Revision (ICD-10) code I74.0, I74.3, and I74.5 were identified. Medical records were analyzed for demography, clinical presentation, etiology, Rutherford severity classification, revascularization procedures, major amputation, mortality within 30 days after revascularization, and data during follow-up.

Results: This study enrolled a total of 70 patients, 46 men (65.71%) and 77 affected limbs. The mean age was 65.67 years (SD 13.69 years), and the median was 65 years, ranging from 19 to 94 years. Co-morbidities: 42 (60%) hypertension, 28 (40%) peripheral arterial disease, 26 (37.14%) atrial fibrillation. Etiologies: 36 (51.43%) thrombosis (34.29% in-situ thrombosis of the native vessel) and 34 (48.57%) embolism. Rutherford classification of severity categories I, IIa, and IIb was 1 (1.42%), 21 (30.0%), and 48 (68.58%), respectively. The modalities of revascularization included 70 (100 %) thromboembolectomy with a Fogarty catheter, 30 (42.86%) intra-arterial angioplasty with balloon or stent, 8 (11.43%) bypass procedure, 6 (8.57%) endarterectomy and 8 (11.42%) fasciotomy. Technical success was 98.57 %. The mean operative time was 195.07 minutes (SD 95.51 minutes). The median hospital stay was 8 days. Post-operative complications were 8 (11.43%) bleeding, 7 (10%) compartment syndrome, 5 (7.14%) reperfusion injury, 5 (7.14%) acute kidney injury, 2 (2.86%) pneumonia and 1 (1.43%) acute myocardial infarction. The 30-day major amputation rate and mortality were 10.0% and 5.71%, respectively. At 30 days, sixty-three patients (90%) had limb salvage, and Four (5.71%) patients had died.

Conclusion: Clinical outcomes following surgical revascularization for acute lower limb ischemia in our hospital showed high technical success and limb salvage rates. The limb salvage rate was 90.0%, and the mortality rate was 5.71%.

Decoding Factors Influencing Post-Operative Outcomes in Surgical Residents' Minor Surgeries

Fri, 28 Jun 2024 00:00:00 +0700

Objective: Effective surgical residency training is essential for developing competent surgeons. The first year of training focuses on basic knowledge and fundamental surgical skills. Consequently, minor surgical procedures suit first-year surgical residents with minimal complexity and low complication rates. This pilot study aimed to evaluate the complications associated with surgical residency practice and examine the factors associated with these complications.

Materials and Methods: This study employed a single-center retrospective review method to evaluate the complications arising from surgical residents' minor operations and identify the factors associated with these complications. Data were collected at Siriraj Hospital over three consecutive years, from 2016 to 2018.

Results: During the study period, a total of 1,572 minor operations were performed by surgical residents. The overall complication rate was 4.3%, which included surgical site infections, wound dehiscence, hematoma or bleeding, seroma, and superficial skin necrosis. Among the surgical site infection cases, an operative time exceeding 30 minutes (OR 13.3, p-value = 0.00) and lesion size larger than two centimeters (OR 5.24, p-value = 0.01) were significant influencing factors for complications. Conversely, residents' background characteristics and the presence of a 'July effect' did not significantly impact surgical outcomes.

Conclusion: The rate of complications associated with minor operations performed by residents at Siriraj Hospital was comparable to the findings from other studies. The most common complications were wound dehiscence and surgical site infections. Operative time and lesion size were significant factors affecting complications. The results of this study can contribute to enhancing surgical residency training.

Case Report on a Mitten Hand Contracture in Epidermolysis Bullosa

Wee Yi Lim, Teck Ree Law — Fri, 28 Jun 2024 00:00:00 +0700

Epidermolysis Bullosa is a disorder characterized by skin fragility. Repetitive injury followed by healing can result in severe deformity due to scarring. The available evidence on whether surgery enhances hand function is somewhat inconclusive because there is a shortage of large, well-controlled studies. Nevertheless, the majority of the data suggest that surgery has the potential to enhance hand function. We present a case of Epidermolysis Bullosa in a 6-year-old patient who presented with bilateral mitten hand deformity. Right-hand contracture, pseudosyndactyly release, and defect resurfacing with a full-thickness skin graft (FTSG) were done. The patient had a smooth recovery and regained the ability to grasp objects.

Identification of a Pathogenic Germline Variant in the BRCA2 Gene in a Patient Diagnosed with Ductal Carcinoma in Situ (DCIS): A Case Report and Review of the Literature

ภาณุพงศ์ สุขป่าน, กัญญนัช กนกวิรุฬห์, สุรศักดิ์ สังขทัต — Fri, 28 Jun 2024 00:00:00 +0700

Advances in sequencing technology are rapidly progressing, leading to reduced costs and enhanced accessibility to genetic testing for cancers. Thailand, classified as a middle-income nation, integrates Universal Coverage of public health insurance to encompass germline genetic testing for breast cancer (BC) patients and their relatives who are at high risk of Hereditary Breast and Ovarian Cancer Syndrome (HBOC). In this study, we describe the case of a 48-year-old woman diagnosed with Ductal Carcinoma in Situ (DCIS) who underwent genetic testing, which revealed the presence of a pathogenic germline variant in the BRCA2 gene. The test was also conducted on three children. The findings indicate that two of three children carry pathogenic germline variants similar to those identified in their mother. The patient and their family members, who presented with both inherited and non-inherited BRCA2 germline mutations, underwent counseling sessions delivered by certified genetic counselors. Moreover, implementing cancer surveillance and risk reduction strategies for individuals with inherited BRCA2 germline mutations, encompassing BC, ovarian cancer, prostate cancer, pancreatic cancer, and malignant melanoma, offers significant advantages for this familial cohort.