Increase in endogenous thrombopoietin in healthy donors after automated plateletpheresis

Inguinoscrotal bladder hernias are uncommon clinical facts more predominant in males aged between 50 and 70. This entity has no specific clinical character and diagnosis usually happens in the course of surgical repair of inguinal hernia. In about 3%-10% cases, it appears associated to inguinal hernia. Discussion of two case-reports of patients with giant inguinoscrotal bladder hernia; one patient with synchronous association to bladder transitional carcinoma. The literature on the clinical, diagnostic and therapeutic aspects is revised. The high index of suspicion for making a pre-operative diagnosis, specially in aged patients with inguinal hernia and expanded prostate signs and symptoms is highlighted. Emphasis is placed on the need for surgical hernia repair prior to prostate and/or bladder transurethral surgery.     

Follow-up after inguinal hernia repair. Questionnaire compared with physical examination: a prospective study in 299 patients

OBJECTIVE: To assess the value of a written questionnaire in the follow-up of patients after inguinal hernia repair. DESIGN: Prospective study. SETTING: University and two district hospitals. The Netherlands. SUBJECTS: 314 patients with 362 inguinal hernias. MAIN OUTCOME MEASURES: Correlation between answers to questionnaire and clinical examination in the diagnosis of recurrent hernias. RESULTS: 13/24 recurrences (54%) after a mean follow-up of 33 months with a follow-up rate of 93% were not diagnosed by the questionnaire. CONCLUSION: Follow-up after hernia repair must be by physical examination.     

Musculo-aponeurotic flap in the treatment of inguinal hernias, apropos of 1,600 operations

Morbidity, absention and duration of cares are important factors for the treatment of groin hernias. Deep and tension free cure is a key element to decrease the rate of recurrence. Utilization of prosthesis cannot provide a rate of 100%. This must be taken into consideration for indications. Beside we must take into account specific risks of each technique. Hernia treatment cannot be unique. This parietal surgery must remain a technique with low morbidity. As for treatment of unilateral hernia, we have qualified a technique of hernioplastia depending upon theses criteria, by inguinal incision, without prosthesis. Our technique includes: A complete dissection of the inguinal canal. The resection of the sac of the hernia at the internal ring. A deep cure of the fascia transversalis. A systematic incision of discharge on the anterior face of the rectus sheath. This incision is extremely internal and constitutes a large musculo-aponeurotic flap of 8 to 12 cm that makes this cure tension free possible. In the term of 10 years, our recurrence rate is below 1% for type I or II hernias in Nyhus classification. Consequently we discuss the indications for prosthesis. They must be reserved for hernias with high recurrence risk, bilateral hernias of for recurrent hernias.     

Longitudinal follow-up of blood lymphocyte subpopulations from birth to 1 year of age

The features of the rare interstitial hernia, as seen in four children, are described. All were boys ranging in age from 7 days to 7 years. The presenting sign was swelling in the right side of the abdomen associated with undescended testis. The hernias arose at the deep inguinal ring and expanded superiorly between the internal and external oblique muscles. Repair involved a standard herniotomy and orchidopexy through an oblique inguinal incision-except in one patient with a vanishing testis. The importance of being aware of this rare type of hernia is stressed.     

Intercostal artery as a pedicled graft for myocardial revascularization: an animal experimental study

Approximately 40% of children with a clinical unilateral inguinal hernia display a patent processus vaginalis on the contralateral side; half of these children subsequently develop an inguinal hernia. The management of this problem is still controversial. Different strategies to identify patients who profit from an open contralateral exploration have been applied (diagnostic pneumoperitoneum, herniography, ultrasound). The purpose of this study was to evaluate the usefulness of intraoperative laparoscopy in a no-puncture technique through the opened hernia sack. In 75 children (age 6 months to 7 years) with clinical unilateral hernia laparoscopy (5-mm Laparoscope, 30 degrees and 70 degrees ), in cases of wide-open contralateral internal inguinal ring (Type III) an open surgical exploration was performed. Twelve patients (17%) fulfilled the laparoscopic criteria of a Type III ring. The diagnose was confirmed during open contralateral exploration. Seven children (8%) showed a patent but small processus vaginalis with a shallow internal ring. These patients were treated conservatively. In the follow-up period (median 6 months) one subsequent hernia developed. There was no technical failure, and no associated complications were seen. The median time for laparoscopy was 6 minutes. Intraoperative laparoscopy during unilateral hernia repair allows the identification of patients who profit from bilateral open surgery during the same operation with little additional operating time, and so far with no resulting complications. Application of this method may avoid a second hospitalization and operation as well as unnecessary routine bilateral open exploration. As an additional source of information through excellent visualization of the abdominal cavity, this method proved helpful to examine the incarcerated bowel after repositioning.     

The features of contralateral manifestations after the repair of unilateral inguinal hernia

BACKGROUND/PURPOSE: Routine contralateral exploration in infants and children with unilateral clinical inguinal hernia is performed by many surgeons in a selected population of patients based on a presumed high incidence of patent processus vaginalis. Our purpose is to report the actual incidence of contralateral manifestations in infants and children after the repair of unilateral inguinal hernia. METHODS: From July 1985 through December 1995, 1,052 infants and children with unilateral inguinal hernia or hydrocele were treated in our hospital without contralateral exploration. Among them, 1,001 patients (95.2%) were followed up for 1 to 11 years to determine if contralateral hernia developed after unilateral inguinal herniorrhaphy. RESULTS: The overall incidence of contralateral hernia was 11.6% (116 of 1,001). In boys, the incidence was 13.1%, 13.7%, and 11.7% in those under 1 year, under 2 years of age, and in total, respectively. In girls, the incidence was 9.6%, 13.9%, 11.3%, in those under 1 year, under 5 years of age, and in total, respectively. The side of the initial repair did not influence the subsequent development of contralateral inguinal hernia. In children with hydrocele, the incidence of contralateral hernias was lower (7.6%). In girls with sliding hernias the contralateral occurrence was 12.5%. CONCLUSION: Given this low incidence of contralateral hernia after unilateral inguinal herniorrhaphy, the authors do not recommend contralateral exploration for infants and children with unilateral inguinal hernia.     

Positions and training of the indigenous health workforce

Laparoscopy and magnetic resonance imaging (MRI) are competetive tools in the diagnostic of non-palpable testis. Advantages and disadvantages of this methods will be demonstrate. 29 boys investigated for this indication with MRI. In case MRI failed to locate the testis laparoscopy was performed with a new miniaturized set of pediatric instruments (1.9 mm optic). The aim of laparoscopy was the identification of the spermatic duct and vessels and their topographic relation to the internal inguinal ring. All findings were verified by open surgical procedures. MRI revealed 10 inguinal and 7 abdominal testis. There was no false positive finding. In 12 boys MRI showed no testis. 4 cases were correct negative, 8 cases were false negative (32%). In these 8 MRI-negative patients laparoscopy revealed 7 inguinal and 1 abdominal testis. The optical quality of the mini-telescope was sufficient for a 100% correct diagnosis. Laparoscopy related complications did not occur. Laparoscopy proved to be a powerful low risk diagnostic method in non-palpable testis with high sensitivity and specifity (100% correct positive, 0% false negative). Therefore lapraroscopy is recommended as primary diagnostic access for this indication. In the same anesthesia a optimal therapy is possible. Nevertheless a positive MRI-finding locates the testis reliably, whereas a negative finding always needs further exploration because testis might have been missed.     

Herniography in symptomatic patients following inguinal hernia repair

Patients with symptoms at the site of a previous inguinal hernia repair may constitute a diagnostic dilemma. The usefulness of herniography in the assessment of these patients was evaluated at 54 symptomatic sites in 46 subjects. Ten persistent or recurrent hernias were shown by herniography, only 2 of which were definitely detected on physical examination. The herniogram was normal at 44 sites, of which, on physical examination, 5 were equivocal and 1 was diagnosed as a definite hernia. On the unoperated-on or asymptomatic side, a total of 14 hernias were shown herniographically. Of these hernias, 8 were not detected on physical examination. Herniography was found to be more sensitive than physical examination in detecting hernias at the symptomatic, previously operated-on sites, as well as at the unoperated-on or asymptomatic sites. When a herniogram provides corroborative evidence that hernia has not recurred, the need for reexploration may be eliminated.     

Laparoscopic evaluation for a contralateral patent processus vaginalis: part III

OBJECTIVES: Between May 1, 1992 and August 1, 1996, 759 consecutive children younger than 10 years of age were evaluated and treated for known inguinal hernia. These children were participating in a prospective investigation of the potential role of diagnostic laparoscopy in the evaluation of the contralateral inguinal anatomy. The initial two series of data (parts I and II of this three-part series) were previously presented at the 1993 and 1995 American Academy of Pediatrics meetings. METHODS: Of 759 patients, 100 children were diagnosed with bilateral inguinal hernias and therefore did not undergo laparoscopy. Thirty-two patients did not undergo laparoscopic evaluation due to technical difficulties or complicated clinical situations. The patient's contralateral inguinal region was carefully examined under anesthesia, and predictions were made regarding the likelihood of contralateral patent processus vaginalis (CPPV). Six hundred twenty-seven children underwent diagnostic laparoscopy to confirm the presence or absence of CPPV. Laparoscopy was initially exclusively performed through the umbilicus prior to repair of the known hernia, but over the last 26 months, 250 children successfully underwent laparoscopy through the ipsilateral hernia sac. RESULTS: Of patients younger than 1 year of age, 114 were diagnosed with both a known unilateral hernia and CPPV, whereas 132 had a unilateral hernia only (46% versus 54%). Among children older than 1 year of age, 148 (39%) were diagnosed with unilateral hernia and CPPV, and 233 (61%) were diagnosed with a unilateral hernia alone. After examination under anesthesia, 233 of the 627 patients were suspected of having a CPPV, and 107 were confirmed at laparoscopy (46%). The remaining 394 patients were not believed to have a CPPV. Normal inguinal anatomy was confirmed in 234 patients (59%), but 160 patients were found at laparoscopy to have a CPPV (41%). CONCLUSIONS: A contralateral patent processus vaginalis may be present in a surprising number of young patients being evaluated for a known inguinal hernia. Laparoscopy can be performed without a separate incision when the ipsilateral hernia sac is of sufficient width to allow passage of the scope. Laparoscopy is the best method for evaluating the contralateral inguinal region, particularly in younger children, as it prevents unnecessary inguinal exploration and it decreases the risk that the child will later present with a clinical contralateral hernia.     

Inhibition of fos-jun-DNA complex formation by dihydroguaiaretic acid and in vitro cytotoxic effects on cancer cells

The main cause of acquired inguinal hernia is weakness of Fruchaud's deep muscolofascial floor, following metabolically-determined collagen disorders. A technique for the anterior reinforcement of this structure with polypropylene mesh is described here. Following intermuscular decollement, the mesh is placed in direct contact with the surface formed by the transversalis fascia and the transversus abdominis muscle and stretched as extensively as possible. Because the posterior aspect of the inguinal canal is the true barrier to abdominal pressure, the author believe that its direct reinforcement, without interposition of the internal oblique muscle, constitutes the most correct anatomo-surgical approach to hernia repair. This is the case for both indirect hernias, in which the internal ring is reconstructed at a deeper level, and for direct hernias, in which the "tent effect" of the prosthesis is prevented. Ninety-two primary inguinal hernias (56 indirect, 29 direct and 7 direct and indirect) in 87 patients were repaired with this technique. Seventy-nine patients were followed up from 2 to 24 months. Early complications included: 7 ecchymosis, 3 seromas, 2 subcutaneous infections, 3 testicular swellings. Incision and testicular pain for longer than 6 months occurred in 2 cases. No prosthetic infections or recurrences have been detected up to the present.     

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.     

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.     

Effects of dietary coconut oil, butter and safflower oil on plasma lipids, lipoproteins and lathosterol levels

BACKGROUND: Complications that develop in groin hernias, such as irreducibility and obstruction, with or without strangulation may make an easily treatable condition a life-threatening one. Identification of risk factors that may predict development would help place the patient in a high-risk group. Priority admission and early elective surgery for such a patient would avoid significant mortality and morbidity. METHODS: This is a 10-year combined prospective and retrospective study of children and adults. Records of complicated groin hernias were identified from July 1985 to July 1995 from the outpatient department and available inpatient medical records. The same number of controls of simple uncomplicated hernias were then chosen using random number tables from among the large number belonging to the same time period. These two groups were then compared and analysed using statistical methods for age, sex, side of hernia, site of hernia (inguinal/femoral), duration of hernia, length of the waiting list for elective surgery, and contents of the hernial sac along with some other parameters to identify patients with high-risk factors. RESULTS: Age was found to be a significant risk factor and predicted complications in both elderly adults and very young children. Sex of the patient (male) and side of hernia (right) were significant risk factors in children only. Site of hernia was an important risk factor and adults with femoral hernia were most likely to experience complications. Duration of hernia for less than a year proved to be the most important risk factor for both children and adults. The majority of patients with complicated hernias had not presented earlier in the outpatient department, which implies that most hernias that become complicated do so within a very short time before patient referral. Mortality was high in patients with coexisting diseases, while morbidity was affected by viability of contents of the hernial sac which in turn was directly affected by duration of irreducibility or delay in presentation. CONCLUSIONS: The risk factors useful in predicting complications in an adult patient with groin hernia were age (older age group), duration of hernia (short duration), type of hernia (femoral more than inguinal) and coexisting medical illness. In children, the risk factors were age (very young), gender (male), short duration of hernia and side (right side).     

Adaptation of a fiber-reinforced restorative system to the rehabilitation of endodontically treated teeth

OBJECTIVE: Review of international literature reveals eight reported cases of laparoscopic obturator hernia repair. Non-specific signs and symptoms make the diagnosis of an obturator hernia difficult. Laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias. METHODS AND PROCEDURES: A 35 year old woman presented with lower abdominal pain, vaginal bleeding, and dyspareunia. During gynecological diagnostic laparoscopy, a pelvic floor hernia was suspected, and a general surgical evaluation was sought. At a subsequent laparoscopy, the diagnosis of a left direct inguinal and a right obturator hernia was made. Both were repaired laparoscopically with polypropylene mesh. RESULTS: At follow-up at one and six weeks postoperatively, the patient's complaints of pain had completely resolved. CONCLUSION: The diagnosis of obturator hernia is problematic. The usual presenting signs and symptoms are non-specific. Without conclusive historical or physical findings, laparoscopy is an excellent method for diagnosing obturator hernia. This entity, once diagnosed laparoscopically, can be repaired simultaneously via laparoscopic mesh technique.     

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.     

Preperitoneal prosthesis implantation in surgical management of recurrent inguinal hernia. Retrospective evaluation of our results 1989-1994

Recurrent inguinal hernia represents a great problem in surgery given the frequency of this operation, with a recurrence rate of 0.5-8%. Re-recurrence after repair without implantation of a prosthesis occurs in 1-23% of cases. We analyzed our results of patients with recurrent inguinal hernia, operated according to the method of Stoppa. Between 1989 and July 1994 there were 58 operations upon 55 patients with an average age of 65 years, 79% of whom had unilateral and 21% bilateral hernias. 89% of all patients underwent surgery because of a recurrent inguinal hernia. A Marlex mesh was used in 79% of the case. All patients were followed up (mean 35 months, minimum 12 months). Early complications consisted in one hematoma (1.7%), which had to be drained, as well as one early recurrence (1.7%). No infections were observed. The overall recurrence rate was 12%. However, 60% of all recurrences occurred in the few first years after introduction of this technique at our clinic; with growing number of operations and experience with Stoppa's technique, we obtained a recurrence rate of 6-7% per year. In our opinion, supported by the results of other studies, Stoppa's technique is a successful method in the treatment of recurrent inguinal hernia.     

Laparoscopic herniorrhaphy in girls

BACKGROUND/PURPOSE: Laparoscopy has been used to evaluate the contralateral side in inguinal hernias. Once a hernia was identified in such procedures, laparoscopy was terminated and a conventional groin exploration was undertaken. This study presents a purely laparoscopic approach using miniature instruments without the use of a groin incision. METHODS: The technique was applied in 14 girls (median age, 6.5 years). The laparoscope was inserted via the umbilicus. Two 1.7- or 2-mm instruments were advanced (without a trocar) trough the abdominal wall for intraabdominal suturing of the open inguinal rings by the placement of two to three Z-sutures. RESULTS: With this procedure the diagnosis is easy, although the placing of miniature suturing needs practice. When there is doubt about an inguinal ring during laparoscopy, an open processus vaginalis also can be sutured using the same approach. There were no recurrences or complications. The longest follow-up period is 1 year. CONCLUSIONS: A purely laparoscopic approach using miniature instruments combines diagnosis and immediate treatment without the need for conversion to another technique. There is rapid recovery and excellent cosmetic results.     

The silent epidural abscess as a complication of acute otitis media in children

Vesical hernia is defines as a vesical shift associated to a direct or indirect inguinal hernia. It accounts for 0.4-3% of all inguinal hernias, but the existence of a massive vesical hernia formation at the inguinoscrotal level is uncommon; a total of 114 cases have been found in the literature. Clinically it should be suspected every time an inguinoscrotal hernia is found in patients over 50 years old with urinary flow obstruction. Diagnosis is usually reached through serial voiding cystouretrography (SVCU). The preferred treatment should be extraperitoneal inguinal herniorrhaphy associated to correction of the obstructive process.     

Perioperative transfusion, postoperative infection, and recurrence of head and neck cancer

BACKGROUND: Considering the high recurrence rate after conventional inguinal hernia repair, the totally preperitoneal endoscopic inguinal hernia repair has been used. METHODS: The present experience of the authors embraces 1085 patients with a total of 1717 inguinal hernias, including 200 recurrences. The operative technique is described with emphasis on pitfalls and tricks. RESULTS: Analysis of the data concerning the first 403 patients with 1 year complete follow-up reveals a mean (SEM) operating time of 42 (1.2) min for unilateral and 58 (1.0) min for bilateral hernia repair. Mean (SEM) postoperative hospital stay was 2 (0.04) days. Complication rates during and after operation were 0.3% and 3.3% respectively. The morbidity rate at 1 month after operation was 3.5%. The recurrence rate was 0.3% at 1-year follow-up. CONCLUSION: Totally preperitoneal endoscopic inguinal hernia repair is safe and reproducible for any type of primary or recurrent inguinal hernia, even in patients with previous subumbilical surgery or severe systemic disease. Careful follow-up is mandatory to assess the late recurrence rate.     

Damage to the inguino-femoral nerves in the treatment of hernias. An anatomical hazard of traditional and laparoscopic techniques

Laparoscopic techniques currently constitute an alternative proposed for the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the anatomical relations of these nerves with the subperitoneal fascia transversalis and inguinal fossae. An anatomical study consisting of dissection of nonembalmed cadavres, allowed, after evisceration, dissection of the lumbar plexus and its terminal branches, particularly those supplying the inguinofemoral region: iliohypogastric and ilio-inguinal nerves, the genitofemoral nerve, the femoral nerve and the lateral cutaneous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguinal ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterior parietal peritoneum describes three folds formed by the outline of the epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring from Hesselbach's triangle, the zone of weakness of direct inguinal hernia. The iliac psoas muscle pass laterally underneath the inguinal ligament, while the external iliac vessels, subsequently becoming the femoral vessels, are located medially. Pectineal ligament lies on the posterior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, either transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pectineal ligament and anterior abdominal wall. On the other hand, the nerves at risk of being damaged are situated laterally: the ilio-inguinal and ilio-hypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cutaneous nerve of the thigh under the inguinal ligament close to the anterior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal ligament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament to avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.