Surgical technique: Under general anesthesia, the patient is positioned supine with the arms alongside the body on an operating table tilting on all levels, to better expose the surgical field. The initial peritoneal access is by Veress needle puncture, 2 cm below the left costal margin in the midclavicular line (Palmer’s point)  to install the pneumoperitoneum of 14 mmHg has been achieved. A 0-degree, 10 mm laparoscope and two additional trocars of 5 mm in diameters were used. Careful and complete adhesiolysis represents the first time. Then, the peritoneum is incised superiorly, 3–4 cm above the hernia defect. After complete hernia sac dissection, the preperitoneal space exposure for 5–7 cm all around the hernia defect was achieved. Then, the hernia defect was closed through percutaneous transabdominal external needle  (using spinal needle No. 18 or tip hole needle . The needle and prolene No. 0 inside it passed through the abdominal wall through the hernia defect wall to appear 1 cm from the edge of hernia defect. The prolene end was holed from the abdominal cavity and withdrawn outside the port. Then, this prolene end is holed by tissue forceps outside the port. Then, the needle and inside prolene were partial withdraw and redirected to pass through 1 cm from other edge of hernia defect. The other prolene end from inside the needle is holed by hook and brings it outside of abdominal cavity through the same port. Now, one suture is complete, which passed through both sides of hernia defect about 1 cm from hernia edge and under the floor of hernia defect, and two suture limbs outside the abdominal cavity through one port. The suture was tied extracorporeal and cut by laparoscopic scissor (Figure 1 A–D). Multiple sutures were put by same manner to produce good hernia defect closure. The intraperitoneal pressure is decreased during hernia defect closure. Then, suitable mesh was put at preperitoneal plane to cover the defect and 5 cm all around. The mesh fixation was achieved in it position using Glubran 2 (Gem srl, Viareggio, Italy) (Figure 2 A–F). The peritoneum was closed using Vicryl No. 2/0. The pneumoperitoneum was emptied under direct viewing and external pressure was applied to the hernia region and trocars sites were closed. Follow-up period ranged from 3 to 33 months (mean 26 months).
Conversely, when the defect is closed, the mesh is never in contact with the skin because the abdominal wall muscle and fascia provide a physical barrier. This may also help prevent mesh erosion of the skin and subsequent infections (Palanivelu et al., 2007; Agarwal et al., 2008; Chelala et al., 2007). Finally, a lower rate of wound and mesh infection with defect closure (Franklin et al., 2004; Palanivelu et al., 2007; Chelala et al., 2007). Recurrence rate after laparoscopic ventral hernia repair are reported to range from 4.2 to 16.7 % (Pierce et al., 2007; Heniford et al., 2003; LeBlanc, 2005; Clapp et al., 2012). Some Authors reported lower recurrence rates with defect closure from 0 to 2.9 (Franklin et al., 2004; Palanivelu et al., 2007; Agarwal et al., 2008; Chelala et al., 2007). We reported in our study of 15 patients described a laparoscopic sutured closure of the defect with mesh reinforcement and reported no recurrence during a mean follow-up of 12 months. We found in our study a recurrence rate was 6.6% in the non defect closure group. Some Authors have also considered disadvantages of closing the defect. Percutaneous sutures were associated with abdominal discomfort (up to 6 months after surgery), pain and neuralgia (Franklin et al., 2004; Jagad, 2008). The pain may be due to fixation techniques, whether tacks, sutures or a combination, and how many of each all probably play a role. Mesh fixation can be achieved using suture, tacks or a combination. In a meta-analysis, with tackers fixation associated with shorter operative time and less postoperative pain (Franklin et al., 2004; Franklin et al., 1988).we used a combination of tacks and sutures. At least four corners of the mesh were secured with transfascial sutures and then tacks were applied. In our study , rates of seroma formation about 6.6 % .We found a slightly higher incidence of seroma formation in the closure group due to the inability of the fluid collecting in the sac to drainback into the peritoneal cavity. Similar to Franklin et al. who reported rates of 15–20 % for seroma formation, in defect closure .Our results are encouraging and demonstrate the safety and feasibility of hernia defect closure. Operative times have been reported as ‘‘prolonged’’ when using transfascial or intracorporeal suturing. In Franklin’s study average OT of 68 min (21) . Our operative times were prolonged in closure group with a mean of 60min in the non- closure group and 75 min in closure group.
Background: Ventral hernia is one of the most common abdominal wall her- nias. Several procedures have been used for hernia repair. During the last few decades, the open surgical approach has been the standard technique for her- nia repair. During the past 10 years, laparoscopic repair of ventral hernia has become increasingly established in clinical practice and aimed to be an ac- ceptable and successful technique. There are many techniques used in lapa- roscopic ventral hernia repair and the most commonly used is fixation of mesh without closing the defect or closing the defect before fixation of mesh. Aim of the Study: The aim of this study is to compare outcomes and results of closure versus non-closure of ventral hernia defect during laparoscopic ventral hernia repair in tow center and report our experience in laparoscopic ventral hernia repair. Patients and Methods: This is comparative prospective study between laparoscopic ventral hernia repair without closure of the defect and with closure of the defect before fixation of the mesh. 60 patients were divided into 2 groups: Group 1 treated with laparoscopic ventral hernia repair without defect closure and group 2 treated with laparoscopic ventral hernia repair with hernia defect closure, and we followed up the patients in both groups for operative outcomes and post-operative complications, hospital stay, recurrences, patients’ satisfactions. Results: Operative time was longer in group 2—closure group than in group 1—non-closure group. Post opera- tive seroma is 65% in group 1 and 16% in group 2. Recurrence occurs in one patient [3.33%] in group 2 versus 4 patients [13.33%] in group 1. Conclu- sion: Laparoscopic ventral hernia repair is safe and feasible, although lapa- roscopic ventral hernia repair without closure of the defect is easy with less operative time and does not need extra-experience in intra-corporeal suturing How to cite this paper: Mohamed Yousef
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examined pre-incisional versus post-incisional injection of bupivacaine, using a saline injection as a control. It was noted that there was not a significant difference between the bupivacaine pre-and post-incisional groups in pain reduction, but there was a significant difference in these groups compared to the saline groups. This study did address the use of other analgesics (acetaminophen) when assessing the VAS score, but the researchers did not note doses or frequency of those analgesics and did not systematically assess whether post-surgical analgesic use was decreased by local anesthetic infiltration (Molliex et al., 1996). This study suggests that in tonsillectomy either pre- or- post-incisional infiltration of bupivacaine may produce a reduction in post-surgical pain when compared to the saline (control) group. In a study of local anesthetic infiltration in Iliac Crest bone harvesting surgery it was also reported that this technique reduced post-procedural pain compared to a control group but there was no examination of the effect of local anesthetics on post- procedural analgesic consumption (Chern et al., 1999). The majority of studies that examine local anesthetic infiltration report variable changes in post-surgical visual analog scale pain score but few note whether other analgesics were used and the doses used (Chern et al., 1999; Hoard et al., 1998; Schaan et al., 2004; Todd & Reed, 1991). To our knowledge, the current study is the first in the literature to examine surgical hernia repair and demonstrate a reduction in both VAS and post-surgical opioid consumption with local anesthetic infiltration at the time of wound closure.
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In our study the fascial defects varies from 5 to 9 cm and all hernia repair using the prosthetic mesh agree with most surgeons who still believe prosthetic mesh repair is the standard of care for the non complex hernia patient with a fascial defect greater than 2 cm. Also there are no enough number of randomized controlled trials that support the use of mesh versus primary repair for non complex hernias with defects sizing 6 cm or less  .
prevalent in low-income countries. Elective open-heart repair with midline sternotomy and cardiopulmonary bypass has been considered as the golden standard for the closure of the ASD. Although surgical closure has been proved safe and effective, it is still associated with midline sternotomy and cardiopulmonary bypass in a longer hospital stay. The midline incisions would also reserve the physical and psychological trauma for the patients in their future. Meanwhile, there have been only a few reports about surgical repair of the ASD in the older patients until now. In addition, old patients are usually complicated by pulmonary arterial hyperten- sion and bad body condition, which means more risk to surgery and CPB. With the development of various devices, percutaneous transcatheter occlusions of ASD gradually become another choice for selected patients, especially those with secundum ASD. Clinical experi- ence with device closure of ASD is increasing, and com- plications seem to be limited in various studies. Compared with those of surgical approaches, device clo- sure has the advantage of bringing less discomfort to patients and leaving no incisional scar. However, due to the big size or the deficient rim of the ASD of those older patients, percutaneous approach sometimes could not be utilized for closure. A certain failure rate percen- tage exists in those patients with big size or the deficient rims of ASD, such as residual shunts, subsequent mal- position and embolization of the device. Furthermore, due to expensive equipments and high cost might be required, many hospital in the low-income nations have no resources on developing this technology. Thus, we applied a minimally invasive technique, intraoperative device closure of those older ASD patients, imitating percutaneous closure of ASD.
The Congenital Diaphragmatic Hernia Study Group writing committee is as follows: Kevin P. Lally, MD, MS (University of Texas Medical School and Children’s Me- morial Hermann Hospital), Pamela A. Lally, MD (Uni- versity of Texas Medical School and Children’s Memorial Hermann Hospital), Robert E. Lasky, PhD (University of Texas Medical School and Children’s Memorial Her- mann Hospital), Dick Tibboel, MD (Sophia Children’s Hospital), Tom Jaksic, MD, PhD (Children’s Hospital Boston), Jay M. Wilson, MD (Children’s Hospital Bos- ton), Bjorn Frenckner, MD (Astrid Lindgren Children’s Hospital), Krista P. Van Meurs, MD (Stanford University School of Medicine and Lucile Packard Children’s Hos- pital), Desmond J. Bohn, MD (Hospital for Sick Chil- dren), Carl F. Davis, MD (Royal Hospital for Sick Chil- dren), and Ronald B. Hirschl, MD (University of Michigan).
Antisecretory drugs like ranitidine, omeprazole, or somatostatin (Octreotide) can reduce fistula output. When compared to TPN alone, Octreotide does not improve overall closure rate but in a collected series, the closure time decreased significantly from 50 days with TPN alone to 5 to 10 days when Octreotide was also used, Boike et al reported on 27 patients with ECF, treated with Octreotide and showed decreased fistula output by 55% in first 24 hours. A 77% spontaneous closure rate was achieved with TPN and Octreotide after an average of 5.8 ± 2.7 days, compared with 4 to 6 weeks of TPN alone.
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study to focus exclusively on the multisystem burden of disease at the time of discharge. Furthermore, when patients are classified by their defect size, the varying rates of morbidity at the time of discharge can be clearly delineated, as opposed to grouping all patients with CDH together and reporting their overall rates of morbidity. Among our cohort of patients, the need for supplemental oxygen or pulmonary medication at the time of discharge ranged from 5.5% to 63% based on defect size. Longitudinal studies of patients with CDH suggest that pulmonary morbidity may improve after discharge, with rates of pulmonary sequelae such as recurrent respiratory tract infections and chronic lung disease ranging from 10% to 22%. 19, 20 One study
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A majority of ASDs today are closed by a variety of catheter- based devices, although the Amplatzer ASD occluder is the only Food and Drug Administration (FDA)-approved device at this time. The success rate and morbidity are nearly equal with the two approaches. Current published studies comparing device closure versus surgical closure with anatomically similar defects show a device success rate of 80% to 95.7%, compared with 95% to 100% success of surgical closure, though the success of device closures continues to evolve. Complications requiring treatment occur in 0% to 8% of device closures and 23% to 24% of surgical closures, and mean length of hospital stay is 1 day in the device group versus 3.4 days in the surgical group. Continual advances in the hardware and experience with device closures are improving the success rate of these catheter- based approaches.
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or those with mild symptoms (a majority of patients with PFO) may not experience such a significant improvement after the procedure when compared to patients with ASD, in whom effective occlusion of the defect is associated with resolution of significant ailments. Quality of life between patients with ASD and PFO before the procedure did not differ in the subscales of BP, MH, VT, and GH. The ex- istence of comorbidities, such as arterial hypertension, episodes of AF, dyspnea and palpitations, as well as the use
Although we tried to control the patient’s condition with medication, pulmonary edema was not controlled and liver enzymes were elevated due to hepatic congestion. AST/ALT level was elevated to 808/116 U/L, and total bilirubin level was elevated to 6.2 mg/dL. Therefore, we decided to treat the remnant septal defect percutaneously using the VSD occluder. On day 15, the right femoral artery and vein were cannulated under local anesthesia. The VSD was crossed from right ventricle to left ventricle through remnant VSD using a Judkin’s 5 French right catheter, and Terumo wire using a retrograde arterial approach. The VSD Occluder had a maximum size of 16 mm (AMPLATZER™ Muscular VSD Occluder device, St Jude Medical, St Paul, MN, USA). The device was placed at an appropriate site across the VSD and then released (Figure 6). Successful implantation of the
around the margins of the hernia defect (Fig. 1d). After overlapped with the psoas muscle, the posterior edge of the mesh was extra-peritoneally fixed to the psoas muscle by interrupted sutures (Fig. 1e) and/or synthetic cyanoacrylic glue (COMPONT, Beijing Com- pont Medical Devices CO.,LTD., Beijing, P.R. China). In case the inferior margin of the defect was beyond the iliac crest, the dissection was extended and the mesh was fixed to the Cooper’s ligament (Fig. 1f ). On the other hand, if the superior margin of the defect was close to subcostal margin, the mesh was im- planted with at least 5 cm overlap to the diaphragm, avoiding fixation to the diaphragm to prevent associ- ated cardiovascular and pulmonary complications. When fixation was finished, the mesh can be anatom- ically considered as the peritoneum. Therefore, the colon can be restored to natural anatomical position through interrupted sutures to the mesh, making use of the reserved peritoneum above the white line of Toldt (Fig. 1g). The gravity effect from the colon can stabilize the mesh in the early postoperative stage. When finishing the repair, the mesh was implanted posteriorly into extra-peritoneal space and anteriorly into peritoneal cavity, i.e., partial extra-peritoneal pos- ition (Fig. 1g). Finally, the cavity was reviewed (Fig. 1h), all trocars were removed and the abdomen was deflated.
Gastroschisis is not rare in our population. Birth weight, early reach to the hospital where operative facilities are available , early closure with selection of patients for ‘ minimal intervention management’ even in district hospital has significant role in the survival of these patients. Adequate supportive measures like TPN, neonatal ICU and increase awareness of our general people about this disease will further increases the survival rate significantly.
Device-associated endocarditis is a rare but important complication of percutaneous closure of atrial septal de- fect, PFO, and, currently, VSD. To the best of our knowl- edge, this is the first report of a child who had endocar- ditis after VSD closure with an Amplatzer device and was treated successfully with conservative treatment. This case has significant clinical implications, because despite the rarity of this complication, failure of conservative treatment could necessitate major open-heart surgery. The complication occurred despite intravenous cefonicid treatment before VSD closure. The increasing use of intracardiac devices may require a reevaluation of the possible need for administration of prophylactic antibi- otics before, during, or after the procedure and the type of antibiotics to be given. This case further emphasizes the importance of close follow-up, including color Dopp- ler echocardiography, after intracardiac device insertion to exclude thrombosis and the development of infective endocarditis.
A combination of TEE or intracardiac echocardiography and fluoroscopy is used to deliver, position, and deploy the closure device. The patient is required to have optimal hydra- tion with intravenous fluid and is kept nil by mouth if general anesthesia is used. Venous access from the right femoral vein is obtained. Using a 6F sheath, an Amplatz stiff wire crosses the defect and is placed in the superior pulmonary vein. The size of the sheath is determined by the size of the device. The common procedural risks include air embolization and technical difficulties in crossing the defect, which may be due to cardiac rotation or chamber remodeling. Multimodality imaging provides ancillary information to confirm crossing of the defect and balloon positioning for sizing. 6
Congenital heart defects have the largest proportion of organ malformation in neonates. They occur in eight to ten out of every 1,000 children born in the USA. In adulthood even 1 out of 150 is expected to suffer from a congenital heart defect [1, 5]. These heart defects can involve the interior walls of the heart, the valves and the arteries/veins carrying blood to the heart. In general, they have negative effects regarding the normal blood How through the heart which can lead to severe symptoms. The blood flow might be slowed down, shunt in the wrong direction or blocked completely, which ultimately may lead to death [6, 7]. There are different kinds of congenital heart defects depending on the position where they occur and which anatomical structure they affect, e.g. Pulmonary or aortic stenosis, ventricular septal defect or tetralogy of Fallot. The third most common among these is the atrial septal defect, thus a hole between the left and right atrial chamber. The clinical treatment differs depending on the kind of defect as well as the severity in each special case , The first transcatheter device closure of an ASD was reported by King and Mills in 1976. The transcatheter is nowadays the most common treatment for the ASD defect type 2 called secundum ASD [9, 6],
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abdominal cavity for adhesions of the bowel loops. The 10 mm port is created under vision and the scope is changed to 10mm. Subsequently all ports are created, open laparoscopy is hardly working ports in the left and right hypochondrium. The camera port is placed far enough from the defect so that there is no difficulty in visualizing the proximal area of the defect during fixation of mesh. The upper abdominal hernias which are usually rare are performed by placing similar ports in the lower abdomen. Trocars are placed on the lateral abdominal wall on the opposite side of the defect.
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Other anomalies associated with CDH may have an important influence on survival and it was recently re- ported that pulmonary hypoplasia is critical [2, 3]. Ac- curate diagnosis of both CDH and the abdominal wall defect is required because the timing of surgical treat- ment for CDH is important. In patients with both anom- alies, underestimation of CDH or overestimation of the abdominal cavity volume can occur. There have been re- ports on diagnosis of CDH after abdominal wall closure or of CDH causing symptoms such as severe respiratory distress or circulatory instability after the abdominal wall
In this contemporary, multiinstitu- tional cohort, patients with Down syn- drome undergoing congenital heart disease surgery did not have a signiﬁ- cant mortality risk, in comparison with patients without Down syndrome, for the most common congenital heart disease operations performed in this population. The subgroup of patients with Down syndrome with a function- ally univentricular heart undergoing staged palliation did have signiﬁcantly increased in-hospital mortality rates, compared with patients without Down syndrome. Patients undergoing atrial septal defect repair, ventricular septal defect repair, or tetralogy of Fallot re- pair appear to have prolonged lengths of stay, as well as more postoperative complications, including infections, re- spiratory complications, and pulmo- nary hypertension. A greater propor- tion of patients with Down syndrome undergoing ventricular septal defect repair also developed complete heart block requiring pacemaker place- ment. Anticipation and early imple- mentation of prevention and treat- ment measures may help to reduce these postoperative morbidities in pa- tients with Down syndrome undergo- ing congenital heart disease surgery.
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