Quale paziente non operare? Le evidenze della Letteratura. Ferdinando Agresta

Transcription

1 Quale paziente non operare? Le evidenze della Letteratura Ferdinando Agresta

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5 A semi serious history of laparoscopy by Nicola Basso Gangemi Edt, 2003

6 c c The «hernia surgeon» The «BOSS» The «PROMISING ONCOLOGIST SURGEON»

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8 I AM AN ENTHUSIASTIC LAPAROSCOPIC SURGEON BUT I HAVE WELL IN MIND THAT OPEN SURGERY IS STILL THE GOLD STANDARD

9 Disclaimer / Disclosure I am not a statistician or Scientist/Mathematic I am a General Surgeon, and I have almost 25 years of experience trying to repair abdominal wall hernias applying (studying) graft materials. The following are my observations

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12 As doctor and surgeons our mission is to treat patients to the best of our knowledge and expertise. The exponential knowledge eruption and the nearly daily skill-related technology advances in minimal invasive surgery make it more than ever mandatory that we, surgeons and doctors, humbly examine, analyze and objectively audit our own practice we have to recognise and discard our acquired biases, and base our diagnostic procedures and surgical therapy on hard evidence Fingerhut A. Do we need consensus conferences? Surg Endosc 2002; 16:

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14 First published: 16 March 2011

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18 2018

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21 Incisional hernia: which indications?..since 3 cm in diameter. a maximun size it is not specified in the Litterature but it depends on the surgeon s experience the size of the defect should be considered according to the patient s soma..(omissis) (GoR B; LE IIb) Small incisional hernia Minor morbidity big incisional hernia Major morbidity

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24 Results: In the analysed time period patients undergoing elective laparoscopic incisional hernia repair were recorded, of which 14.4% (n=1949) did not receive AP. The overall SSI rate showed no significant difference when directly comparing patients with (0.74%) and without AP (0.97%; p=0.262). In the multivariable analysis the presence of patient related risk factors (p=0.015) and defect size>10 cm (p=0.035) significantly increased the rates of SSI and complication-related reoperations Conclusions: In cases of laparoscopic incisional hernia repair in patients without risk factors and moderate hernia diameter (< 10 cm), routine administration of AP in laparoscopic incisional hernia repair does not seem to be justified.

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26 2018 In summary, according to the present findings, the larger the hernia, the greater the risk for early surgical complications, including significant complications such as respiratory decompensation. As hernias often grow in size over time, delaying repair may result in a larger hernia to repair and therefore greater risk for complications. Thus, the risks of waiting for improvements in a patient s condition, such as waiting for weight loss, should be balanced against the risks related to possible growth in the hernia over time

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30 .even though complications, conversions, and additional recurrences may be more frequent

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35 Selection criteria are: Absence of marked bowel distension; Absence of peritonitis and high-septic-risk situations, such as entero-cutaneous fistulas; Absence of hemodynamic instability and severe comorbid conditions, such as heart and lung diseases, which preclude the use of pneumoperitoneum.

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