B-Myb, a repressed trans-activating protein

From April 1990 to November 1996, 313 inguinal and 14 femoral hernias were repaired in 295 subjects with a mean age of 74 years (66 to 97). Concomitant diseases increasing the operative risk were present in 206 subjects (70 per cent). A mesh repair was performed with "tension-free" or "plug" techniques in all but 23 inguinal and 2 femoral herniorrhaphies where the Bassini or the Shouldice procedures were adopted. Fifty-two inguinal hernias were recurrent, 11 emergency herniorrhaphies were performed for strangulation. Almost all operations (305), including 9 emergency herniorrhaphies, were carried out under local anaesthesia. There was no perioperative mortality. Acute intestinal bleeding occurred after surgery in a subject with colon diverticulosis. One urinary retention following emergency hernia repair under general anaesthesia and 2 following elective hernia repair under local anaesthesia in 2 subjects with hypertrophy of the prostate were observed. Some episodes of hypotension and/or bradycardia were observed either during or after surgery. Local complications following inguinal hernioplasty were 5 (1.5%) scrotal hematomas, 3 (0.9%) wound infections and 1 case (0.4%) of orchitis with atrophy after repair of a recurrent hernia. There were 1 recurrence after Bassini, 1 after Shouldice, and 1 (0.4%) after mesh inguinal hernioplasty. Using local anaesthesia and a mesh repair elective surgery of inguinal and femoral hernias can be safely and effectively performed in elderly patients. Consequently, early elective surgery should be recommended to avoid the risk of an emergency operation.     

Inguinal hernia 1998--an assessment of current status

Hernia surgery has considerably changed in recent years. In the era of minimal invasive surgery classical Shouldice repair has become old-fashioned and is increasingly replaced by tension-free techniques using synthetic mesh material. Currently, Shouldice repair remains the treatment of choice in young patients with small primary hernia. Lichtenstein hernioplasty is indicated in young patients with large hernias, and in those over 35 years of age for any size of hernias. Endoscopic operations are restricted to bilateral primary hernias and recurrent hernias. In future, when used on the basis of a reasonable strategy, the variety of operative procedures offers a chance to improve the results of hernia surgery. Further studies are needed to demonstrate which hernia strategy is most reliable in terms of cost-effectiveness, patient comfort, complication and recurrence rate.     

Inguinal hernia--which method leads to the goal? Endoscopic and open surgical procedures are available

In recent years, the methods available for repair of inguinal hernia have greatly expanding, resulting in confusion as to what constitutes a suitable choice. Is it to be laparoscopy or open surgery, plastic mesh yes or no, general anesthesia or local anesthesia? Bassini's operation has now been ousted by the Shouldice procedure, which is suitable for all primary forms of hernia. The Lichtenstein procedure is readily and rapidly carried out under local anesthesia, making it suitable for use in multimorbid and old patients; the recurrence rate is low. The laparoscopic approach can be recommended for patients who, for private or occupational reasons need to be up and about again as soon as possible. It is also particularly suitable for the treatment of recurrent hernias or for the simultaneous repair of bilateral hernias. Disadvantages are the high costs, a lack of long-term results and unusual complications that are not seen in open surgery.     

Inguinal hernia repair with the Shouldice technique

The authors analyze the result of Shouldice inguinal hernia repair in 1000 patients. In a total of 1034 hernias, 966 of them were unilateral and 68 bilateral. The hernias were indirect (61.7%), direct (24.9%) and combined (3.5%). There were 102 recurrent hernias (9.9%) and the mean age of the patients was 50 years. In most cases the patients were male (96.9%) and peasants (47.6%). The post-operative follow-up was annual in 65.8% of the patients, for a period up to 10 years. The recurrence rate was 0.8% in the cases of primary hernias and 4.9% in the case of recurrent ones.     

Laparoscopic repair and groin hernia surgery

Over the past 15 years, laparoscopic herniorrhaphy has made the transition from an experimental to a proven procedure. With increasing laparoscopic skills in the surgical community, many surgeons are now faced with the question of when to recommend laparoscopic herniorrhaphy to their patients. A surgeon's best hernia repair is the one with which they have had the greatest experience. This results in the lowest recurrence and complication rate in his or her hands. Certainly, simple, unilateral hernias and bilateral hernias can be repaired with either anterior or laparoscopic techniques. Many times, laparoscopic herniorrhaphy is too much surgery for a young patient with a unilateral hernia. In such a case, repair is best performed with the patient under local anesthesia. Also, young patients in whom it is advantageous to avoid mesh should not undergo laparoscopic herniorrhaphy. The authors prefer laparoscopic TEP herniorrhaphy in patients with recurrent hernias, bilateral hernias, and unilateral hernias with a suspected contralateral hernia. There is also a consensus that patients with multiple recurrent hernias in whom a preperitoneal repair is appropriate are best served with a laparoscopic repair. Surgeons without advanced laparoscopic skills or without the time to develop the skills necessary to perform laparoscopic herniorrhaphy should consider referring patients with recurrent hernias to surgeons with experience in TEP. TEP is preferable to TAPP because of its lower complication and recurrence rates and in the authors' hands is the "best repair." TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy. Complication and recurrence rates, although initially higher than traditional repairs, have now fallen to equal or lower levels at centers experienced in laparoscopic techniques. Prospective randomized trials prove that when patients are selected properly and surgeons are adequately trained and proctored, laparoscopic herniorrhaphy can be performed with acceptably low incidences of recurrence and complications.     

Lichtenstein herniotomy

All standard methods of hernia repair involve suturing together tissues which are not normally in apposition. This violates the basic surgical principle that tissue must never be approximated under tension and accounts for an unacceptable number of failures. Total reinforcement of the inguinal floor with a sheet of suitable biomaterial and employment of a "tension-free" technique is a more effective approach. Since June 1984, 3250 primary inguinal hernias have been repaired at the Lichtenstein Hernia Institute by the open tension-free technique using Marlex mesh. All operations were performed under local anesthesia. Patients were discharged from the hospital within two or four hours after the operation. The patients were followed from one to 8 years by physician examination. The follow-up rate was 87%. There were four recurrences. The causes of recurrence and how to avoid them are discussed.     

10 years experience in performing Shouldice operation

206 male patients were operated for primary direct and indirect inguinal hernia, or both, by Shouldice technique at general surgical departments of Madadeni Hospital, Newcastle, South Africa, Pásztó Hospital and Szolnok MAV Hospital, Hungary between 1986 and 1996. Mean age was 51 yrs +/- 15 yrs (17-91 yrs). The operations were performed by the original way of Shouldice described that type of hernia repair in 1945. 175 patients had spinal and 31 patients had local anesthesia with intravenous fluid and sedation respectively. Studies indicate that collagen metabolic dysfunction plays a major rule in the etiology of groin hernia. Until this is more clearly defined, surgeons will continue to repair groin hernias constitute 15% of operations in general surgery. In approach to groin hernia, the best view for examination of the inguinal region can be obtained by Shouldice technique to decide the proper surgical intervention to repair groin hernia. With low recurrence rate and rapid rehabilitation, author reports 2% of recurrence rate, the Shouldice operation highly recommended.     

Management of complicated incisional hernias with underlay-technique implanted polypropylene mesh. An effective technique in French hernia surgery

Incisional hernia repair with conventional techniques (simple closure, Mayo-technique) is associated with unacceptable recurrence rates of 30-50%. Therefore, surgical repair using different prosthetic biomaterials is becoming increasingly popular. Further to favourable results by French hernia surgeons, we studied the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias. METHOD: After preparation and excision of the entire hernia sac, the posterior rectus sheath is freed from the muscle bellies on both sides. The peritoneum and posterior rectus sheaths are closed with a continuous looped polyglyconate suture. The prosthesis used for midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The anterior rectus sheath is closed with a continuous suture. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. RESULTS: Between January 1996 and August 1997 we performed a total of 33 incisional hernia repairs (14 primary hernias, 19 recurrent hernias) using this technique (16 women, 17 men, mean age 56.19 +/- 12.92 years). Local complications occurred in four patients (12%): superficial wound infection (n = 2), postoperative bleeding, requiring reoperation (n = 1), minor hemato-seroma (n = 1). One patient suddenly died on the 3rd post-operative day from severe pulmonary embolism (mortality 3%). Twenty-two patients with a minimum follow up to 6 months were re-examined clinically. The average follow-up time for this group was 9 months (range 6-17 months). To date no recurrent hernias have been observed. There were only minor complaints like "a feeling of tension" in the abdominal wall (n = 3) and slight pain under physical stress (n = 6). CONCLUSIONS: The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high-risk patients (obesity, obstructive lung disease) and complicated hernias. The aforementioned technique of underlay prosthetic repair using polypropylene mesh fixed onto the posterior rectus sheath allows for anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates.     

Risperidone is associated with blunting of D-fenfluramine evoked serotonergic responses in schizophrenia

A prospective randomized study of 106 patients with unilateral primary inguinal hernia who underwent "tension-free" mesh repair was carried out. Fifty-nine procedures (group A) were performed by a single experienced surgeon and 47 (group B) procedures were performed by a team of residents each with an experience level of less than ten cases. In group A the length of operation was statistically shorter; local anesthesia was more frequently used in group A, while intra-operative sedation and general anesthesia were more frequently used in group B. A subgroup of twenty patients (group C) operated on by residents with a personal experience of at least 5 tension free repairs was selected. No statistically significant difference in operation time and in anesthesia used were found between group A and group C. No significant difference was found between group A and group B in morbidity rate, mean postoperative stay, median time to return to work, and recurrence rate. Because easy, efficacy, and minimally invasive, the tension-free mesh repair remains the gold standard in the treatment of inguinal hernia.     

Laparoscopic hernia surgery--status of minimal invasive techniques in a spectrum of surgical indications

Endoscopic surgery led in the nineties to a discussion on surgical treatment of hernias. At the present time there are three groups of operative procedures: the conventional procedure--Shouldice, Bassini--the open tension-free procedure with implantation of a mesh--Lichtenstein, Gilbert-Rutkow--and the endoscopic procedure (predominantly transabdominal preperitoneal hernioplasty (TAPP) and total extraperitoneal hernioplasty (TEP)). The debate on the optimal therapy of hernias is understandable in view of the large number of hernia operations which are carried out. Numerous studies, some randomized, have demonstrated both the advantages and the disadvantages of the individual operative procedures. In addition to the recurrence rate and the complications, the cost factor and the associated socio-economic aspects of the particular operation play an increasingly important role in the decision on the method that should be used. In December 1995 some Austrian surgeons, who concerned themselves with problems of hernia repair already before the definitive introduction of laparoscopic hernia repair in today's surgery, came together on the occasion of a "Consensus Conference". During the meeting a summary of all relevant aspects of the complex of problems was worked out and summarized in a catalog of indications for the different operative interventions. The main statement was that the traditional open surgery, which can be performed under local anesthesia is indicated for an unilateral primary hernia. In case of an unclear finding at the contralateral side, as well as in case of a recurrent hernia, an endoscopic procedure is indicated. Meanwhile the Hernia Forum of Zürs ("Zürser Hernienforum") was founded. The function of this forum is the realization of a prospective randomized study for hernia repair in Austria.     

Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report

The incidence of inguinal hernias in pregnancy is 1:1000 about. Much more frequent are uterine leiomyomas, reported in 0.5-2.6% cases. We describe a rare case of a 31 old woman at the 20th week of pregnancy affected with a torsion of uterine leiomyoma associated with right inguinal incarcerated hernia, operated urgently (myomectomy and Bassini inguinal plastic).     

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair

BACKGROUND: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). METHODS: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. RESULTS: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. CONCLUSIONS: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced.     

From Bassini to tension-free mesh hernia repair. Review of 1409 consecutive cases

The short and long-term results of traditional and tension-free inguinal hernia repairs have been assessed in three surgical units. In order to standardise the results, hernias were classified according with Nyhus. There were 109 type I, 311 type II, 854 type III, and 125 type IV hernias. Follow-up was possible in 1201 patients (1249 hernia repairs). Postoperative course, postoperative pain, and recurrences were analysed. Recurrences ranged from 0.7% up to 9.3%. The tension-free methods of repair provided the most important advantages in term of low recurrence rate and early return to work even if, in our series, recurrences resulted mainly related to the type of hernia than to the type of repair. The Authors conclude that any hernia repair should be sized to the type of hernia defect in order to avoid over-treatment and abusive placing of a foreign body such as polypropylene mesh.     

The Lichtenstein open "tension-free" mesh repair of inguinal hernias

All standard methods of hernia repair involve suturing together tissues which are not normally in apposition. This violates the basic surgical principle that tissue must never be approximated under tension and thus accounts for an unacceptable number of failures. A total reinforcement of the inguinal floor with a sheet of suitable biomaterial and the employment of a "tension-free" technique is a more effective approach. Since June of 1984, 4,000 primary inguinal hernias have been repaired on an outpatient basis and under local anesthesia at the Lichtenstein Hernia Institute by the open "tension-free" technique using Marlex mesh. The patients were followed from one to 11 years (mean of 5 years) by physician examination. The follow-up rate was 87%. There were four recurrences. The causes of recurrence and how to avoid them are discussed herein. Three of the recurrences occurred at the public tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the public bone. One recurrence was caused by disruption of the lower edge of the mesh from the shelving margin of Poupart's ligament. The error here was the utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of taxity, was required.     

New possibility in inguino-femoral hernia repair: laparoscopic herniaplasty

The development of minimally invasive surgery brought up the challenge: to repair the frequent inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year: "transabdominal preperitoneal" technique was used in 61 cases und "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated on, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was no wound infection, or general complication. Spontaneously dissolving seroma/hematoma of the spermatic cord was noticed and detected by ultrasound in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%), considered to be caused by technical inexperience, these patients were treated successfully with the "intraperitoneal onlay mesh" technique. In the authors' opinion there are definite advantages of laparoscopic hernioplasty, namely the minimal postoperative pain, early mobilization, shorter hospital stay and early restoration of full physical activity (in 1-2 weeks) as well as the known disadvantages of this technique (narcosis, longer operative time, intraperitoneal procedure, higher costs).     

Evaluation of the Bassini reconstruction principle for inguinal hernia

In a prospective study, 100 adult male patients with clinically diagnosed inguinal hernias underwent surgery. The operation method was the Bassini repair. The operation always included splitting of the transversal fascia, that after review of the relevant literature obviously is not part of the usual applied operation technique. Therefore the "Bassini method" could be falsely afflicted with a relatively high recurrence rate. At the follow up clinical examination, performed at least 1 year after surgery, a 3.8% recurrence rate was found. It can be recommended that it should be continued to apply Bassini repair to all types of inguinal hernias. A classification of posterior inguinal wall is suggested: under poor anatomical conditions, i.e. "used" fascia transversalis and "elevated" internus muscle a three-fold risk of recurrence can be expected. In this situation the operative correction according to Bassini should be avoided and a procedure to repair or cover the defect should be performed first.     

Effect of starvation on organ blood flow in the senescent rat

Since the first true hernioplasty performed by Edoardo Bassini more than 100 years ago (1884) all surgical reconstruction techniques have shared a common defect i.e. tension on suture line. This is the first etiologic factor of recurrent hernia. On the contrary by the use of modern prosthetic materials (mesh and plug) it is now possible to marriage all hernia repairs without distorting normal body anatomy and avoid undesirable tensions. The technique proposed is simple, efficient, characterized by a rapid performing procedure, giving way to an excellent clinical outcome: postoperative pain relief permitting the patient to resume in a short time his normal physical activities. In this paper the authors present their experience in wall defects reconstruction by means of outpatient surgery and in general anesthesia in the period spanning from 1994 to 1996. Five different types of hernia mesh in hernioplasty procedures were evaluated and used.     

Recurrent inguinal hernia: preferred operative approach

Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 10 to 20 per cent performed for recurrence. Subsequent repairs provide considerable technical challenge, as well as substantially greater risk of developing further recurrence. Mesh repair is advocated by several specialized hernia centers, demonstrating re-recurrence rates less than 2 per cent. Detractors of this repair include cost, technical difficulty, and risk for infection. The purpose of this study was to compare results of mesh and nonmesh repairs for recurrent inguinal hernia, either using an anterior or posterior approach, at a large teaching institution. From January 1, 1985, to December 31, 1994, 146 patients underwent repair for recurrent inguinal hernia at the Veterans Administration Hospital at Memphis, Tennessee. Patients were stratified by type of repair: Lichtenstein (Mesh), open anterior (OA), Bassini, Marcy, McVay, Shouldice, and preperitoneal with or without mesh. Patient ages and weights were similar between groups. Mean operative time for Mesh repair (104 +/- 4 minutes) was longer than that for OA repairs (80 +/- 5 minutes, P < 0.05) or preperitoneal without mesh repairs (92 +/- 5 minutes, P < 0.05). Mesh-based posterior repairs had the longest operative times (116 +/- 5 minutes). Hospital stay averaged 2.8 +/- 0.3 days, similar among all groups. One wound infection (1.0%) occurred in patients undergoing Mesh repair, which required operative drainage. No patient required removal of mesh. Two patients in the Mesh group (5.9%) developed recurrence compared with four recurrences (18.0%) in patients undergoing OA repairs. Only one patient with a mesh-based posterior repair recurred (1.9%) compared to eight without mesh (21.6%, P < 0.01). Follow-up ranged from 2 to 12 years. Repair of recurrent inguinal hernia using either an anterior or posterior mesh repair technique, performed at a teaching facility, provides superior recurrence rates without increasing risk for infection or length of stay. Preperitoneal mesh based repair is the preferred technique.     

The Bassini-Houdard type herniorhaphy. Long-term results and factors of recurrence

The aim of this long term study was to confirm that long term results are worsening with time and to establish the factors favourising recurrence. The study was retrospective and concerned 751 inguinal herniorraphies, performed from 1972 to 1982 according to the Bassini procedure modified by Houdard. The mean follow-up was 180.3 +/- 45.2 months (16.2-250.6). Available information was collected for 565 (75.3%) cases. The recurrence rate was 10%. The mean time between operation and recurrence was 102 +/- 65.6 months (6.1-226.3). The recurrence rate was lower for indirect hernias (4.7%) than for the group of direct, combined and sliding hernias (16%), (p < 0.00001). For recurrent hernias the recurrence rate was 22% versus 8.9% in primary herniorraphies (p > 0.01). This study suggests that recurrences can occur a long time after primary surgery because of parietal weakening with time; the low recurrence rate in indirect hernias does not justify the use of prostheses in this type of hernias, then higher rate in direct, combined, sliding and recurrent hernias warrants wider use of prostheses.     

Formulaic methods of estimating calorie requirements in mechanically ventilated obese patients: a reappraisal

We reviewed 410 cases, 365 males and 45 females, mean age 64 years, of inguinal and femoral hernia, from 1/1/1991 to 31/12/1994, repaired with Lichtenstein and Trabucco techniques. Recurrent hernias repaired were 36 (8,8%). Local anesthesia was used in 82% and follow-up has ranged from 6 months to 4 years. The meshes used are made with a single layer of polipropylene and the Trabucco plugs T1 were made by hand at the operating table. In our experience these two techniques are simple, but is very important, before application of the mesh, a correct dissection of inguinal region. We made a complete excision of cremasteric fibers preservig, if possible, the genital branch of the genitofemoral nerve. The transversalis fascia is introflected and sutured in direct hernia repair or when there are a loss of tissues. The preliminary results obtained with the "tension free" hernioplasty are satisfying. The most important complications were 9 hematomas and an important and persistent inguinal neuralgia in 1 case. There were no recurrences, but we must considered the short follow-up period.