Unsuspected pulmonary vascular abnormalities associated with diaphragmatic hernia

The pulmonary vasculature of 12 newborn infants who died with unilateral diaphragmatic hernias was studied. Four developed severe ventilatory insufficiency after birth and promptly died. Their lungs were both hypoplastic and airless dur to compression by displaced abdominal viscera and mediastinal shift. Corrective surgery permitted lung expansion and adequate ventilation for one to two hours in five infants. Subsequently, ventilatory insufficiency supervened and they died. Postoperative blood gases revealed a right-to-left ductus arteriosus shunt in one infant. Ten of the infants with hernias had a significantly greater mass of muscle in pulmonary arteries than did matched controls. This may partially explain the fetal-type circulatory infants.     

Video-assisted thoracoscopic repair of an intercostal pulmonary hernia

Pulmonary hernias are extremely rare. They are usually treated with open surgical procedures. We describe a case in which a large, spontaneously acquired intercostal pulmonary hernia was successfully repaired by video-assisted thoracoscopic surgery (VATS).     

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.     

CT imaging of abdominal hernias

Most abdominal hernias can be diagnosed on the basis of findings on physical examination or plain films and barium studies. However, diagnostic dilemmas can arise when patients are obese or have had surgery. Cross-sectional CT scans can show hernias and the contents of the peritoneal sac. More important, CT findings can be used to diagnose unsuspected hernias and to distinguish hernias from masses of the abdominal wall, such as tumors, hematomas, abscesses, undescended testes, and aneurysms. This essay illustrates the CT findings in diaphragmatic hernias, internal hernias, and abdominal wall hernias.     

Combined surgical treatment with prosthesis of recurrent ventral and inguinal hernias

The presence of associated incisional and groin hernias is relatively rare and it represents an important problem in surgical treatment. The authors here report their experience of three patients treated with no reabsorbable prostheses placed according to Rives' technique for incisional hernias, and according to Stoppa's for inguinal hernias.     

Consistency of nephron filtration measurements by collection of total tubular fluid from different proximal sites

BACKGROUND: With increasing numbers of laparoscopies in gynecologic surgery as well as the use of larger trocars more post-operative hernias can be expected. Most hernias occur as Richter's hernias without peritoneal lining and contain small or large intestines or omentum. The incidence is around 1%, but rising with increasing size of trocars. About one fourth of hernias are umbilical, the rest located extraumbilical. RESULTS: The diagnosis is typically based on the presence of vomiting or nausea with an extended and painful abdomen within two weeks of surgery and can be established by a small bowel series. However, the course can be prolonged and ileus can occur up to one year following laparoscopy. In the majority of cases the hernial content was small intestines or omentum. CONCLUSIONS: In order to reduce the frequency of trocar hernias it is recommended to apply small trocars. Fascial closure must be done when trocars of 10 mm or larger have been employed and the surgeon must ensure that peritoneal tissue is not drawn into the trocar canals when removing the probes. Also, umbilical hernias must be ruled out and, if found, closure must include the complete fascial defect. There are several techniques available for fascial closure. It is concluded that all precautions including fascial suturing must be taken to reduce the 1% incidence of post-laparoscopy hernias.     

Repair of ventral hernias with expanded polytetrafluoroethylene patch

BACKGROUND: Operations for large and recurrent abdominal hernias have a high associated recurrence rate, although it is lower when prosthetic material is used. Expanded polytetrafluoroethylene (ePTFE) seems to be the best tolerated prosthetic material in surgery. METHODS: A series of 45 ventral hernias repaired using ePTFE for closure or reinforcement of the herniorrhaphy has been evaluated prospectively. Thirty-six were midline incisional hernias and nine were transverse or pararectal ventral hernias. There were 13 recurrent ventral hernias and three defects were operated as an emergency procedure. The patch was sutured to the anterior aponeurosis with a running non-absorbable suture. Some other kind of intra-abdominal procedure was undertaken in 12 cases. RESULTS: ePTFE was well tolerated. Complications occurred in five patients. Major complications were found in three patients: cutaneous necrosis requiring a myocutaneous flap; and infection of the prosthesis (primary, and secondary to enterocutaneous fistula due to diverticulitis, both requiring removal of the patch). Mean follow-up was 39 months and hernia recurrence occurred in only one patient. CONCLUSION: This clinical experience shows that ePTFE is a very reliable prosthetic material for the repair of abdominal wall hernias.     

Ventrolateral hernias of the abdominal wall. The anatomicopathologic, clinical and therapeutic considerations]

Ventral lateral hernias of the abdominal wall are rare. On the basis of their location we can classify them as follows: hernias of the aponeurosis of the transversus muscle, hernias of the rectal sheath and transmuscular hernias of the iliac region. In a group of 3134 hernias of the abdominal wall observed in a period of 16 years, 11 ventral lateral hernias have been encountered (0.3%). The diagnosis often presents great difficulties as the symptoms and the clinical findings are not typical. They must be differentiated from hematomas of the rectus sheath, abscess or intra-abdominal processes. Echography and Computed Tomography have an important role in their detection. Nevertheless in some patients the true diagnosis is reached only intraoperatively. The treatment generally consists in surgical correction by layer closure of the fascial or muscular defect. In selected cases the use of prosthetic material and video laparoscopic repair are indicated.     

The surgical treatment of hiatal hernias combined with diseases of the abdominal cavity organs

An experience with treatment of 210 patients with hiatal hernias is summarized, 162 (77.1%) of them having a concomitant pathology of the abdominal cavity. Most frequently the hiatal hernias were associated with gastroduodenal ulcers (48.6%), chronic cholecystitis (18.1%), ventral hernias (5.7%). A new method of correction of hiatal hernias is described which prevents the development of complications resulting from an extreme narrowing of the hiatus. Good long-term results were obtained in 55.9% of the patients, satisfactory--in 34.3% unsatisfactory in 9.8% of the patients, results of the isolated correction of the hiatus being worse that those obtained after the combined operations. A conclusion is made that well-grounded simultaneous operations for hiatal hernias are followed by perfect medico-social and economic effects.     

Adult groin hernias: new insight into their biomechanical characteristics

The biomechanical properties of the transversalis fascia and rectus abdominis aponeurosis were assessed in adult groin hernias, using a computerized-suction device (Cutometer) equipped with a 2-mm probe. Evaluations were made ex vivo on fresh samples collected from 63 patients with unilateral or bilateral hernias and 30 control subjects without hernias. Under 50 and 200 mbar suctions, there was no statistical difference between the overall mechanical properties of control and patient aponeuroses. For both 50 and 200 mbar suctions, the maximum distension (MD) and the biological elasticity (BE) of fasciae from direct hernias were significantly increased, compared with control fasciae. In the same comparison, the MD-50 and -200 and the BE-50 of patient fasciae from the non-herniated sides were also significantly increased. It is concluded that the presently reported biomechanical alterations seem to be the cause and not the consequence of the hernias. These data suggest that a functional connective tissue pathology probably plays a role in the genesis of groin hernias.     

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.     

Paraesophageal hernias in elderly patients. An indication for laparoscopic surgery

Paraesophageal hernias are uncommon conditions which appear mainly in elderly people, frequently associated with sliding hernias or gastric volvulus. Considered a high risk pathology, surgical management is preferred to avoid serious complications. Due to advanced age and operative risks, a laparoscopic approach was performed in the three patients with paraesophageal hernia. In mixed hernias, a Nissen or Toupet fundoplication and closure of the hiatal defect was carried out. In a case with gastric rotation, reduction of the herniated stomach and posterior partial fundoplication with gastropexy was performed. No postoperative complications occurred and recovery was satisfactory. Laparoscopic management seems to be a good choice for elective treatment of paraesophageal hernias in elderly patients.     

Congenital anomalies of the diaphragm. Personal experience with thirty-five consecutive cases

A personal experience of thirty-five consecutive patients with congenital anomalies of the diaphragm is reported. The anomalies included twenty-five Bochdalek hernias, seven diaphragmatic eventrations, and three esophageal hiatal hernias. Except for the patients with esophageal hiatal hernias, virtually all patients presented with respiratory embarrassment, twenty-seven of the thirty-five within 24 hours of birth. An especially high mortality is associated with this early onset of symptoms. The treatment was surgical with a thoracic approach used for right Bochdalek defects and eventrations, and an abdominal approach used for left Bochdalek hernias. The importance of proper preoperative and postoperative management in a well equipped neonatal intensive care unit is emphasized.     

Risks and benefits of laparoscopic hernia-plasty (TAPP). 5 years experiences with 3,400 hernia repairs

In the present study, for the first time the aspects of risk, benefit and the costs of laparoscopic hernioplasty in the transabdominal technique with preperitoneal placement of a polypropylene mesh are examined prospectively in a very large group of patients with 3,400 hernia repairs. The median operation time was 45 min for unilateral primary hernias, 50 min for unilateral recurrent hernias and 76 min for bilateral hernias. The frequency of complications showed a significant dependence on the individual steps in the development of the method and the individual learning curve. The same is true for the rate of recurrency. Whereas initially the rate of serious complications was 2.75%, the rate of minor complications 11% and the rate of recurrences 4.5% the corresponding figures are at present 0.4%, 4.4% and 0.5%. Laparoscopic hernioplasty proved to be equally as effective in the treatment of primary hernias, recurrent hernias and bilateral hernias. The large number of 11 surgeons participating proves that laparoscopic hernioplasty can be learned and that even in a teaching hospital it can be performed safely, efficiently and cost-effectively.     

Pediatric hernias and hydroceles

Hernias and hydroceles are common conditions of infancy and childhood, and inguinal hernia repair is one of the most frequently performed pediatric surgical operations. As a result of improved neonatal intensive care, more and more premature babies are being delivered, and consequently the incidence of neonatal inguinal hernia is increasing. The most important aspect of the management of neonatal inguinal hernias relate to its risk on incarceration, and emphasis is placed on this point. This article covers the embryology, incidence, clinical presentation, and treatment of groin hernias and hydroceles, as well as dealing with abdominal wall hernias other than umbilical hernias. This article places special emphasis on when a patient with a hernia or hydrocele should be referred to a pediatric surgeon.     

Incisional hernias after major laparoscopic gynecologic procedures

OBJECTIVE: Our purpose was to determine the incidence of incisional hernias after operative laparoscopy. STUDY DESIGN: A retrospective case review was performed. RESULTS: The frequency of incisional hernias at extraumbilical 10 and 12 mm trocar insertion sites was one in 429 (0.23%) cases and five in 161 (3.1%) cases, respectively; the difference is statistically significant (p = 0.007, Fisher's exact test). Incisional hernias were also significantly more common if the fascia was left open (p = 0.021), although three of the five hernias at 12 mm trocar sites occurred after attempted closure of the underlying fascia. CONCLUSION: The underlying fascia should be closed whenever a 10 mm or larger trocar is placed at an extraumbilical site during laparoscopy. The peritoneum may also require closure at 12 mm trocar sites if the trocar is placed through, rather than lateral to, the rectus sheath.     

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.     

Infertility as a consequence of bilateral herniorrhaphies

The involvement of internal genitalia in inguinal hernias occurring in female infants and children has been reported. We present here an interesting infertility problem as a consequence of accidental "tubal ligation* secondary to bilateral inguinal herniorrhaphies during childhood. Several postulated etiologic factors in the development of such hernias are presented, and the potential occurrence of similar problems in other individuals is emphasized. We urge very meticulous technique when such hernias are repaired, and we reiterate the importance of a thorough medical history during infertility investigation. The potential frequency of this uncommon but devastating problem presenting in an infertility investigation may be underestimated. Additionally, it is conceivable that, with the increasing survival rates of prematurely born infants who are at increased risk for such hernias, this problem may become more frequent.     

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.