The medical demands of the special athlete

BACKGROUND AND AIMS: Before choosing between open and laparoscopic preperitoneal tension-free repair, a study comparing their safety and short-term outcome was needed. No randomised studies comparing the two hernia repair techniques have hitherto been published. MATERIAL AND METHODS: A prospective randomised study was carried out comparing laparoscopic transabdominal preperitoneal mesh herniorrhaphy (n = 24) to open preperitoneal mesh herniorrhaphy (n = 25). RESULTS: When comparing unilateral repairs, the mean operation time was significantly (P < 0.01) shorter in the open group (55 min) than in the laparoscopic group (66 min). Pain on movement (P < 0.05) and pain on coughing (P < 0.01) receded more rapidly in the laparoscopic group. The median time before return to work or normal activity was 7 days (range 1-60) in laparoscopic and 5 days (1-30) in open repair. There were five (21%) complications associated with the laparoscopic procedure, while the open procedure resulted in two (8%) complications. After a median follow-up of 18 months the recurrence rate in the laparoscopic group was 13% and in the open group 8%. CONCLUSIONS: In this study the open method was associated with fewer complications and recurrences than the laparoscopic technique. Despite the decreased postoperative discomfort after laparoscopic repair, there was no significant difference in median time before return to work or normal activity. These results together with the higher cost of the laparoscopic procedure suggest that the open method is more suitable at least for unilateral hernias.     

Mesh hernioplasty using a stapler

BACKGROUND: The recent development of laparoscopic hernioplasty has evoked extensive re-examination of the safety and effectiveness of using synthetic mesh materials in hernia surgery. We have investigated the efficacy of anterior stapling mesh repair in the treatment of inguinal hernia. METHODS: From July 1993 to June 1994, a modified open mesh hernioplasty using staples for anchorage has been performed in 127 patients. RESULTS: The mean age of patients was 61.4 +/- 13.0 years. Over 90% of them were operated on under local anaesthesia. The operation time ranged from 30 to 95 min with a median of 39 min. Only sixteen patients (12.6%) required postoperative parenteral analgesics and the median time for resuming daily activities was 7 days. Apart from two patients with reactionary haemorrhage, there was no other significant complication observed. Only one recurrence was encountered over the 26-month median follow-up period. CONCLUSIONS: We conclude that the modified mesh hernia repair with a stapling device is a feasible, inexpensive and safe procedure that is well tolerated under local anaesthesia by most patients.     

Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study

BACKGROUND: Laparoscopic hernia repair has often been criticized for its high costs. METHODS: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. RESULTS: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. CONCLUSION: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.     

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.     

Double-gracilis anorectal neosphincter: technique of reconstruction after necrosis of the distal part of the muscles

BACKGROUND: The Lichtenstein tension-free repair has become the standard method for repairing inguinal hernia in many surgical units. This study compared two methods of mesh fixation. METHODS: Fifty men undergoing unilateral primary Lichtenstein inguinal hernia repair under general anaesthesia were randomized into two groups. In the control group polypropylene mesh was secured with 2/0 polypropylene sutures and the skin closed with subcuticular 3/0 polydioxanone. In the study group polypropylene mesh was secured with skin staples and the skin was closed with staples from the same staple gun. Duration of the operation was recorded. Early follow-up was achieved by patient review at 6 weeks and postal questionnaire at 12 weeks. RESULTS: The operation was significantly shorter when staples were used (median 20 min 0 s versus 29 min 30 s, P < 0.001). There was no significant difference in the incidence of postoperative complications or pain score. The study group reported earlier return to normal activity (4 weeks 0 days versus 6 weeks 2 days, P < 0.01) although there was no difference in the time taken to return to work or driving. CONCLUSION: The use of skin staples to secure mesh in the Lichtenstein inguinal hernia repair significantly reduced the duration of the operation and was as effective as conventional mesh fixation with polypropylene in the short term.     

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.     

Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair

BACKGROUND: Inguinal hernias can be repaired by laparoscopic techniques, which have had better results than open surgery in several small studies. METHODS: We performed a randomized, multicenter trial in which 487 patients with inguinal hernias were treated by extraperitoneal laparoscopic repair and 507 patients were treated by conventional anterior repair. We recorded information about postoperative recovery and complications and examined the patients for recurrences one and six weeks, six months, and one and two years after surgery. RESULTS: Six patients in the open-surgery group but none in the laparoscopic-surgery group had wound abscesses (P=0.03), and the patients in the laparoscopic-surgery group had a more rapid recovery (median time to the resumption of normal daily activity, 6 vs. 10 days; time to the return to work, 14 vs. 21 days; and time to the resumption of athletic activities, 24 vs. 36 days; P<0.001 for all comparisons). With a median follow-up of 607 days, 31 patients (6 percent) in the open-surgery group had recurrences, as compared with 17 patients (3 percent) in the laparoscopic-surgery group (P=0.05). All but three of the recurrences in the latter group were within one year after surgery and were caused by surgeon-related errors. In the open-surgery group, 15 patients had recurrences during the first year, and 16 during the second year. Follow-up was complete for 97 percent of the patients. CONCLUSIONS: Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair.     

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost

OBJECTIVE: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN: A randomised controlled trial of 403 patients with inguinal hernias. SETTING: Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.     

Lichtenstein inguinal hernia repair in a primary healthcare setting

BACKGROUND: Given the generally accepted poor outcome of inguinal hernia repair when using nylon darn, and the recent interest in low-tension mesh repair, an attempt was made to demonstrate the feasibility, outcome and patient perception of providing Lichtenstein inguinal hernia repair, using local anaesthesia, wholly within the primary healthcare sector. METHODS: A prospective study reviewed clinical outcome and patient perception in 100 adults referred with inguinal hernia only. No selection was made regarding age, sex, American Society of Anesthesiologists status or previous repairs. Recurrence, pain, infection, return to full function and associated complications were assessed at 24 h, 1 and 6 weeks, and 1 year. Local Community Health Councils assessed patient perception. RESULTS: In the first 100 patients (age range 21-83 (mean(s.d.) 60(14.7)) years; 58 of employable age; 92 men; ten recurrent hernias), no recurrences have occurred at 1 year. Infection rate was 3 per cent. Pain was maximal in the first 24-48 h (median visual analogue scale 5, range 0-10) and reduced rapidly (median 1) at 1 week. Mean time to return to work or full normal activity was 8 days. Some 85 operations were performed within 1 month of diagnosis. In all, 86 patients returned the patient satisfaction questionnaire and 98 per cent of these were 'very pleased' with the service. CONCLUSION: In highly motivated primary healthcare centres, inguinal hernia repair can be undertaken effectively, providing high patient satisfaction, minimal complications and low recurrence rates using the Lichtenstein technique.     

Bilateral synchronous adrenal myelolipomas: a case report

BACKGROUND: This study was undertaken to assess the outcome of Lichtenstein's tension-free mesh inguinal herniorrhaphy as practised by surgeons in a provincial centre in Taranaki, New Zealand. METHODS: A prospective audit was carried out on all patients who underwent this procedure in Taranaki. They were followed up at 1 month and again at 1 year. Results were entered on a standardized pro forma. RESULTS: One hundred and twenty-four patients underwent 134 repairs by four different surgeons and their registrars. Eighty-two per cent of them had a general anaesthetic, and 13% had local anaesthestic. Twenty-five per cent of the repairs were performed as day surgery and a further 53% required overnight stays. Complication rates were 6% in hospital, 12.7% at I month and 8% at 1 year. Recurrence occurred in one repair (0.9%) and there were no cases of mesh rejection. The wound infection rate was 3% and all were minor. Only 45% of the patients who had an inguinal hemiorrhaphy were employed and they took an average of 16 days (range 2-30) to return to work. Over half felt that that they could have returned to normal activities within 2 weeks. CONCLUSIONS: The Lichtenstein technique of inguinal herniorrhaphy is a technically simple, reliable procedure with minimal morbidity and patients may expect a reasonably prompt return to work and to normal activities.     

The effect of Gynostemma pentaphyllum mak (GP) on carcinogenesis of the golden hamster cheek pouch induced by DMBA]

AIM: of this study is to compare two similar groups presenting inguinal herniae, one group having laparoscopic herniography and the other having a Bassini or Fruchaud repair. METHOD: Since September 1994, in our department, patients presenting with symptoms of unilateral or bilateral inguinal herniae to our practice were offered the transperitoneal or preperitoneal approach as an alternative of open surgical repair. We considered the first 50 patients operated by laparoscopic technic (35 M and 15 F), age between 22-72 years (group A), and similar group operated by Bassini or Fruchaud technic (group B). All the patients had general anesthesia and perioperative antibiotics. In the group A we used Prolene, Mercilene or Plastex mesh. The following parameters were assessed: 1) operative time from incision to closure: 2) amount and type of analgesia required postoperatively; 3) morbidity related to the procedure; 4) interval before returning to full activity; 5) early recurrence rate; 6) hospital cost. RESULTS: The mean operative time for unilateral herniae in group A was 70 +/- 10 minutes versus 40 +/- 12 minutes in group B. Group A required to return to work was significantly shorter for the patients in group A (7 +/- 3 days) compared with group B patients (25 +/- 10 days). Although no recurrent herniae have yet been found in patients from either group; follow-up was only 2-18 months in the two groups. The cost of hospital care of group A patients exceeded that of group B by approximately 1.7 more. IN CONCLUSION: was consider that although is more expensive, the laparoscopic procedure in treatment of inguinal herniae, has more benefits for the patients.     

Endoscopically guided percutaneous repair of inguinal hernia through a 2-cm incision. Minihernia repair

BACKGROUND: The laparoscopic repair of inguinal hernia is still controversial. Transabdominal preperitoneal repair violates the peritoneal cavity and may result in visceral injuries or intestinal obstruction. The laparoscopic extraperitoneal approach has the disadvantage of being technically demanding and requires extensive extraperitoneal mobilization. The Lichtenstein repair gives good long-term results, is easy to learn, can be performed under local anesthesia, but requires a larger incision. METHODS: We describe a novel percutaneous tension-free prosthetic mesh repair performed through a 2-cm groin incision. The inguinal canal is traversed with the aid of a 5-mm video-endoscope and the canal is widened using specially designed balloons. Spermatic cord mobilization, identification and excision of the indirect sac, and posterior wall repair are carried out under endoscopic guidance. RESULTS: Between October 1993 and July 1995, 85 primary inguinal hernia repairs (48 indirect and 33 direct) were performed on 81 patients (80 men, one woman) by the author (A.D.). The mean age was 41 years (range 17-83 years). Six repairs were performed under local anesthetic. Mean operative time was 42 min (range 25-74). Mean hospital stay was 1.2 days (0-3 days). The mean return to normal activity was 8 days (2-10 days). Eight complications have occurred: a serous wound discharge, two scrotal hematomas, a scrotal swelling that resolved spontaneously, wound pain lasting 2 weeks, an episode of urinary retention, and two recurrences early in the series (follow-up 1-22 months). CONCLUSION: The endoscopically guided percutaneous hernia repair avoids the disadvantages of laparoscopy (i.e., lack of stereoscopic vision, reduced tactile feedback, unfamiliar anatomical approach, risk of visceral injury), yet the use of endoscopic instrumentation allows operation through a 2-cm incision. The minihernia repair thus combines the virtues of an open tension-free repair with minimal access trauma.     

Videolaparoscopic treatment of paraesophageal hiatal hernia

STUDY AIM: The aim of this prospective study was to report the results of videolaparoscopic repair in a series of ten patients with paraesophageal hernia. PATIENTS AND METHODS: From January 1982 to September 1998, ten patients (three men and seven women, mean age: 68 years [range: 42-87]) were operated on for paraesophageal hernia. An intrathoracic gastric volvulus was present in four patients, a severe anemia in four and two were asymptomatic. All interventions were performed laparoscopically and included sac resection, crura closure and realization of a posterior gastric valve on 270 degrees. RESULTS: There was one irruption of gastric juice in the bronchial tree at the beginning of the anesthesia which required assisted ventilation for 3 days. The mean follow-up was 17.5 months (range: 3-50). There was no postoperative diarrhea and no gas bloat syndrome. Eight patients complained of postoperative dysphagia which disappeared within 6 weeks, except in one patient with esophageal motility disorder postoperatively discovered. None of the patients had postoperative gastroesophageal reflux. A chest X-ray performed after 1 year detected no hernia recurrence in seven patients. There was no recurrent anemia after 6 months. CONCLUSION: The videolaparoscopic repair of paraesophageal hernias is feasible without any technical difficulties even in aged patients with precarious physical conditions. The results are good with a mean follow-up of 17.5 months.     

Induction of antitumor immune response by NK-cell-sensitive target cells transfected by B7-1 gene

The aim of the study was to evaluate the safety and efficacy of TVT (tension-free vaginal tape) for the surgical treatment of stress urinary incontinence. The design was a prospective open multicenter study including six centers, each operating an approximately 20 patients. In total 131 patients suffering from genuine stress incontinence were included. They were followed for at least 1 year using a specific protocol for objective and subjective evaluation of the outcome. All patients underwent the operation under local anesthesia. Mean operation time was 28 minutes (range 19-41 minutes); 119 (91%) of the patients were cured according to the protocol and another 9 (7%) were significantly improved. There were 3 (2%) failures. The majority of the patients (about 90%) were operated upon on a day-care basis, which implied that they were released from the hospital within 24 hours, with no postoperative catheterization. No defect healing and no tape rejection occurred. Three patients needed an indwelling catheter for 3 days. In 1 patient catheterization was necessary for more than 10 days. Two uncomplicated hematomas and one uncomplicated bladder perforation occurred. Based on the results, we conclude that TVT is a safe and effective ambulatory procedure for surgical treatment of genuine stress urinary incontinence.     

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Early results

BACKGROUND: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. METHODS: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). RESULTS: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. CONCLUSIONS: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.     

Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up

OBJECTIVE: To compare outcome and costs between laparoscopic and open hernia repair. DESIGN: Prospective randomised study. SETTING: One university and two district hospitals in Sweden. SUBJECTS: 200 men aged 25-75 years. MAIN OUTCOME MEASURES: Operating time, hospital stay, complications, and time to recovery. A cost-minimisation-analysis was used in which the total costs were calculated for a defined period of time for each option. RESULT: The one year follow-up rate was 98%. Mean (SD) operation times in the laparoscopic and open groups were 72 (30) and 62 (25) minutes, respectively (p = 0.009). Hospital stay and complication rates did not differ between the groups. Among employees the mean (SD) periods off work in the laparoscopic and open groups were 10 (8) and 23 (21) days, respectively (p = 0.0001). The mean direct costs of the laparoscopic operation were increased by SEK 4037 (US$ 483) but the savings in indirect costs resulting from earlier return to work were SEK 11392 (US$ 1364). CONCLUSIONS: Laparoscopic hernia repair gave the employed patients faster recovery and return to work, and was the most cost-effective strategy provided that both direct and indirect costs were included.     

Laparoscopic hernia repair in Leicester General Hospital: a prospective audit of 94 patients

Conventional hernia repair is effective in terms of cure but is associated with considerable postoperative pain and delay in return to normal activity. Laparoscopic repair has the potential to reduce pain and speed return to normal activity, but there have been few published reports of the outcome of this operation in the UK. We present a prospective audit of 94 patients who underwent laparoscopic repair. Of the 94 patients, 87 (92.6%) were male and 7 (7.4%) were female. Thirteen of the repairs were bilateral and 12 were recurrent. Two had to be converted to open repair. The mean operating time for unilateral repair was 56 min and for bilateral repair 98 min. Sixty-three patients (67%) were discharged within 24 h and 21 (22.4%) were discharged within 48 h. There were minor complications in 20 patients (21%), eight of whom (8.5%) developed a haematoma. The other minor complications included seromas (2), bruising at the site of the entry port (2), hyperaesthesia in the groin (2), port hernia (1), shoulder tip pain after surgery (3) and postoperative urinary retention (2). Nine (9.5%) patients claimed to have had no pain or discomfort at all; 35 (37.2%) were pain and discomfort free in 2 weeks. Thirty-two (34%) patients returned to normal activities in 2 weeks. With a median follow-up of 8 months 3 (3.2%) recurrences were noted. It is emphasised that this series represents a learning curve and that the operation is developmental. We are now restricting laparoscopic repair to recurrent and bilateral hernias where the technique offers particular advantages.     

Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results

BACKGROUND: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias >/=4 cm2) is being used in a prospective, multicenter, long-term study. METHODS: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. RESULTS: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. CONCLUSIONS: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.     

Effectiveness of influenza vaccination in patients undergoing regular dialysis treatments

From October 1994 to March 1996 158 inguinal or femoral hernias were repaired in 124 patients through a total extraperitoneal approach. The repairs were done with polypropylene mesh. The patients were seen 6 to 8 weeks postop; until today 57 patients were seen 12 months postop. This method favours an early return to work. Patients with unilateral hernias returned to work after an average of 14 days, patients with bilateral hernias after an average of 19 days. Complications were rare and mostly minor. So far we have seen no recurrences and no mesh related complications. We consider the laparoscopic extraperitoneal mesh repair a safe procedure for inguinal and femoral hernias.     

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.