P129 THORACIC VS. ABDOMINAL APPROACHES FOR DIAPHRAGMATIC HERNIA REPAIR: A NATIONWIDE STUDY OF CLINICAL OUTCOMES

Aim “To compare the outcomes of different surgical approaches for diaphragmatic hernia (DH) repair.” Material and Methods “Adult patients with a principal admitting diagnosis of uncomplicated DH registered in the National Inpatient Sample in the period 2010-2015 were included. Patients with obstruction, gangrene, or congenital hernias were excluded. The primary outcome was in-hospital mortality. Secondary outcomes were the incidence of complications, length of stay, and hospital charges. A multivariate logistic regression model adjusted by age, sex, elective admission, comorbidities, and hospital characteristics was used to analyze the impact of the surgical approach on the evaluated outcomes.” Results “A total of 14910 patients with DH were included (median age 65 years, 74% women). Abdominal approaches were the most commonly performed (78.9% laparoscopy and 13.6% open). Patients that underwent open abdominal and thoracic repairs had a higher risk of complications (sepsis, pneumonia, surgical site infection, prolonged postoperative ileus, and acute myocardial infarction), longer hospital stay, higher total hospital costs, and a significantly higher risk of mortality (OR 2.62. 95% CI 1.59-4.30 and OR 4.60; 95% CI 2.37-8.91, respectively) compared to patients that underwent laparoscopic abdominal repair. Individuals whose DH repair was performed through thoracoscopy had a similar mortality risk to those who underwent laparoscopic abdominal repair (OR 0.87; 95% CI 0.11-6.43).” Conclusions “Nowadays, laparoscopy has become the most used approach for DH repair. In the present cohort, it was associated with better outcomes in terms of complications, length of hospital stay, and mortality, as well as lower health costs. Additional studies assessing hernia characteristics are required to validate this result.”

Mesh-less laparoscopic treatment of apical prolapse

The pelvic organ prolapse (POP) is a common gynaecological problem, affecting nearly 50% of women over 40. The sacrocolpopexy using a synthetic mesh is now considered the “gold standard” for management of women with apical prolapse. In April 2019 the FDA placed a ban on the production of transvaginal meshes for prolapse due to late complications. The meshes for abdominal repair of POP are still used, but in future they may also be prohibited. The goal of the following video is to present a mesh-less modification of two techniques used for apical organ prolapse, the sacrocolpopexy and the pectopexy.

Novel Extravesical Versus Transvesical Technique for Abdominal Repair of Vesicovaginal Fistula

Objectives: To compare the transvesical transabdominal repair of vesicovaginal fistula with novel extravesical transabdominal repair with respect to operative time, blood loss, hospital stay, catheterization time, postoperative lower urinary tract symptoms, urodynamic changes, and recurrence rate. Methods: A prospective randomized controlled study of 94 consecutive female patients who underwent transabdominal vesicovaginal fistula (VVF) repair from March 2013 to March 2018 in our center. The patients had high vesicovaginal fistula that could not be operated on transvaginally: 47 cases were treated with extravesical transabdominal technique, and 47 cases were treated with transvesical transabdominal technique. The primary endpoint is the functional outcome regarding postoperative lower urinary tract symptoms (LUTS); secondary outcomes are early recovery and success rates. The follow-up period was 3 months for reporting and dealing with any complications. Results: There was no significant difference between the groups regarding demographic data. Extravesical repair of VVF had significantly higher (106.56±10.46 min) operating time than transvesical repair (95.08±7.6 min) P <0.001. There was no significant difference regarding intraoperative blood loss between the extravesical (365.42±81.29 mL) and transvesical (353.12±73.9 mL) groups; P = 0.44). The extravesical group had a significant shorter hospital stay (62.35±12.25 hours) than the transvesical repair group (85.07±12.0 hours) P < 0.001. Postoperative storage LUTS 6 weeks assessed by Overactive Bladder Symptom Score was significantly lower for extravesical repair (1.75±0.59) than for transvesical repair (6.87±2.24) P = 0.001). This was confirmed by urodynamic evaluation. Two patients (4.2%) in the transvesical group but none in the extravesical group experienced fistula recurrence. Conclusions: The extravesical transabdominal approach for repair of vesicovaginal fistula is a novel, successful, and versatile technique with reduced hospital stay, reduced postoperative LUTS and possibly fewer recurrences than the transvesical technique, and should be considered for all VVF requiring abdominal repair.

Surgical management of vesicovaginal fistula repair: Our experience.

Objectives: The results of our study would generate useful baseline database which would help the surgeons to manage these fistulae and their related complications properly. Study Design: Non-randomized Clinical Control Trial study. Setting: Department of Urology, Bahawal Victoria Hospital, Bahawalpur and Shahida Islam Medical College, Lodhran. Period: From July 2015 to June 2016. Material & Methods: Total 150 women with vesico-vaginal fistula (VVF) on cystoscopy of either age were selected. Patients with history of recurrence of fistula, multiple fistulae, radiation and severe vaginal scarring were excluded. The transvaginal management was approached in cases of simple fistula, VVF located at trigone of bladder while transabdominal route was preferred when the fistula site could not be easily accessed per vagina, when VVF was above trigone or when the VVF was complex. These patients were followed for 6 weeks at 2 week time interval. Results: Age range in this study was from 20 to 60 years with mean age of 38.18 ± 10.64 years. Majority of patients were (41.72%) with medium sized fistula. In 92 patients, abdominal repair was done while in 52 patients vaginal repair was done. Unsuccessful repair was seen in 14 (9.33%), infection in 25 (16.67%) and recurrent fistula formation in 21 (14.0%) patients. Conclusion: This study concluded that the frequency of unsuccessful repair and recurrent fistula is more after vaginal repair compared to abdominal repair while infection rate was more after abdominal repair.

Comparison of Intraoperative and Postoperative morbidity between in situ and extra-abdominal Uterine repair at Cesarean delivery

In-situ and extra abdominal repair of uterine wound during cesarean section are two valid approaches. This study was carried out to compare intra operative and post operative morbidity in women undergoing caesarean delivery using these two techniques. This is a prospective interventional randomized controlled study. The study subjects include 170 women undergoing Lower segment caesarean section (LSCS) at Southern Railway HQ hospital, Chennai. Intra operative and post operative parameters were analysed in all the study subjects. In in-situ group, 12.6 % women experienced intra operative pain and 30.1% women in extra abdominal group. Intra operative nausea and vomiting was seen in 16.1% women in in-situ group and 28.9% women in extra abdominal group. 1.1% women in in-situ had post-operative febrile morbidity and 8.4 % had in extra abdominal group. The median fall in haemoglobin was 1.30 g/dL and 1.40 g/dL in in-situ and extra abdominal group respectively. In-situ repair of the uterine wound at cesarean delivery is associated with lesser incidence of intra operative pain , intra operative nausea or vomiting and post operative febrile morbidity compared to extra abdominal repair technique.

Uterine Exteriorization vs. In situ Repair of Cesarean Section: A Comparative Study at a Tertiary Care Hospital

Background: Exteriorization, a valuable repair of uterus technique during cesarean section, requires removal of uterus temporarily from the abdominal cavity to repair the incision. The objective of this study was to compare the postoperative symptoms of intra-abdominal to extra-abdominal repair of the uterine incision during caesarean procedure. Methods: A quasi experimental study done in the Obstetrics and Gynecology unit of Ziauddin University Hospital, Kamari and Clifton Campus, Karachi from 1st January 2017 to 30th June 2017. A total of 190 patients were divided into two groups (95 patients in each). In group A Uterine incision was closed extra abdominally and in Group B the closure was done intra-abdominally. The rate of nausea, vomiting, hospital stay, wound infection, fever, returns of bowel sounds, blood loss, and uterine trauma was measured between the two groups. Statistical analyses were done by applying independent sample t-test and chi-square tests. Results: Exteriorization was better option above age 35 years and elective cesarean section(C/S) patients with less Intensity of pain and hospital stay (3 days) but the results were not statistically significant. Caesarean Section, hemoglobin both pre and post-operative, blood transfusion, the return of bowel sound after surgery, surgical site infection and uterine trauma between the two groups showed no significant difference. Conclusion: The postoperative management of Exteriorization was better compared to intra-abdominal repair but the results were not significant. Exteriorization is an easy, convenient and valid option without complications and can be used especially in cases where difficulty in visualization of uterine scar and hemostasis is at stake.

Comparison between Intra-abdominal and Extra-abdominal Repair of the Uterus with Relation to Intraoperative Haemodynamic Changes in Patients Undergoing LSCS under Spinal Anaesthesia: A Cohort Study

Introduction: Exteriorisation of the uterus during caesarean section offers the benefit of faster repair of uterine incision, reduced blood loss and shorter Duration of Surgery (DOS). However, this technique has been associated with haemodynamic disturbances in the intraoperative period particularly while repositioning the uterus into the abdominal cavit y af ter repairing it. This could prove detrimental for the patient, if not corrected promptly. Aim: To assess whether exteriorisation of the uterus for the repair of uterine incision has an effect on the haemodynamic changes and comparing the same with the intra-abdominal repair technique of uterine incision. Materials and Methods: ASA I and II pregnant females undergoing elective/emergency caesarean section under spinal anaesthesia for various obstetric indications were enrolled in this cohort study. The duration of study was 6 months after getting approval from IEC (September 2019 to February 2020). As per the discretion of the operating surgeon, the uterus of the patients undergoing caesarean section was repaired either intra-abdominally (Group I) or after exteriorisation of the uterus (Group E) and the patients were grouped accordingly. Haemodynamic monitoring was done every 5 minutes after giving spinal anaesthesia until the completion of the caesarean section using a standard automated multi-parameter monitor. Data was recorded and the two groups were compared with regard to the haemodynamic changes during intraoperative period, DOS, the incidence of any adverse events namely nausea and vomiting and Time To First Rescue Analgesia (TTFRA) in the postoperative period. Unpaired t-test was used to compare and analyse the data between the two groups, where ever applicable. A p-value of less than 0.05 was considered statistically significant. Chi-square test was used for qualitative data analysis. Results: Analysis of data between the two groups showed a significant fall in Systolic and Diastolic Blood Pressure (SBP and DBP) in Group E compared to Group I at 10 minutes [p=0.046 (SBP) and p=0.039 (DBP)], 30 minutes [p=0.047 (SBP) and p=0.002 (DBP)] and 35 minutes [p=0.046 (SBP) and p=0.006 (DBP)] time interval after giving spinal anaesthesia which was attributed to uterine exteriorisation to repair the uterine incision in Group E. The incidence of nausea, hypotension and pelvic discomfort was also significantly higher in Group E compared to Group I. Owing to less uterine handling, patients in Group I secured analgesia for a significantly longer time (TTFRA=244 min) in the postoperative period compared to patients in Group E (TTFRA=217 min) (p≤0.001). Conclusion: Extra-abdominal repair of the uterine incision carries the risk of haemodynamic disturbances associated with nausea and vomiting.