Laparoscopic paraesophageal hernia repair with Nissen fundoplication

Laparoscopic approach to paraesophageal hernia repair is a recent application of minimally invasive videoscopic surgery. Procedures such as paraesophageal hernia repair with Nissen fundoplication that previously could only be performed as open techniques now can be performed laparoscopically. Laparoscopic approach of this major surgical repair benefits patients because of the reduced surgical time, decreased length of hospital stay, reduced hospital costs, and a reduction in loss of work time.     

Prospective randomized comparative study of laparoscopic hernioplasty and Lichtenstein tension-free hernioplasty]

To compare the laparoscopic transabdominal preperitoneal inguinal hernioplasty (TAPP) and the open Lichtenstein technique, in 1992 a prospective randomized trial was initiated. Until 1995 108 patients with 130 hernias took part in the trial: 64 TAPP (group A) and 66 Lichtenstein (group B). 22 patients had simultaneous bilateral repairs. Laparoscopic approach (group A) was able to expose otherwise-occult controlateral hernias in 3 cases and discovered a complex hernia (a hernia with more than one defect in the wall) in 2 patient in whom a direct hernia had been diagnosed before the operation. Mean operating time for monolateral operations was significantly longer in group A (p < 0.05). The corresponding figures for bilateral operations were longer in group B (p < 0.01). No intraoperative complications, conversions from TAPP to open repair, postoperative deaths. There were not less pain quicker mobility and shorter period of disability in the laparoscopic group (group A). Ten (15.6%) postoperative complications occurred in group A: local hematoma (6 cases, 9.3%), neuralgias (3 cases, 4.7%), urinary retention (1 case, 1.6%). Eight (12.1%) postoperative complications: hematomas (3 cases, 4.5%), urinary retention (3 cases, 4.5%), neuralgias (2 cases, 3%) occurred in group B. Differences were not significant. The current follow-up period is 36 months (15-54) in median. In both groups no recurrences occurred, but 3 patients in group B who were operated on for monolateral hernia (6.5%) discovered to be affected by contralateral hernia. The results of the present report suggest that TAPP does not appear to be associated with better results in terms of complications, pain or period of disability as compared to open tension free hernia repair, but the ability of the laparoscopic approach to expose otherwise-occult defects eliminated the risk of recurrences due to missed hernias.     

Management of impalpable testes: indications for abdominal exploration

Various approaches to the management of the impalpable testis in cases of cryptorchidism have been advocated. The authors' experience over the past 13 years was reviewed to try to determine an optimal approach. Of 1,305 patients with undescended testicles seen between February 1982 and December 1995, 157 boys (12.03%) had impalpable testes with 17 having bilateral impalpable testes for a total of 174 impalpable testes. A hernia sac was present in 155 impalpable testes with a testicle present in all cases. No hernia sac was found in 19 impalpable testes, five of which had no testicle present. This was confirmed by either open exploration or laparoscopy. One hundred forty-eight boys underwent groin exploration as initial treatment, 13 of these had bilateral impalpable testes. In addition to the five absent testicles with no hernia sac, one patient with a hernia sac and no testicle evident benefited from subsequent laparoscopy to identify an intraabdominal testicle. All other patients underwent routine orchidopexy or orchidectomy (one case with grossly malformed testicle). Nine boys underwent laparoscopy as initial treatment, four of these had bilateral impalpable testes. Two abnormal testicles were found and removed. Groin exploration and subsequent orchidopexy was definitive treatment in all other cases. The association of a hernia sac with an impalpable undescended testicle is very significant (P < .00001 Fisher's Exact test). The absence of a sac therefore may reflect an alternate diagnosis. When no sac is found with a testicle in the groin, this may represent an ectopic testicle. When no sac is found with no testicle, this may represent a vanishing testicle. From this experience the authors conclude that groin exploration should be the initial approach to impalpable testes. The presence of a hernia sac with an absent testicle demands further exploration; the absence of a hernia sac with an absent testicle suggests a vanishing testicle and may need no further exploration.     

n-3 fatty acid-enriched eggs, lipids, and Western diet: time for change

Laparoscopic cholecystectomy is an integral part of the general surgery operative inventory. The conventional approach may need to be modified to fit different clinical situations. We present the first reported case of a laparoscopic cholecystectomy combined with a ventral hernia repair.     

Anterior enterocele following cystectomy for intractable interstitial cystitis

PURPOSE: We clinically define the development of an anterior vaginal wall hernia following cystectomy for the management of intractable interstitial cystitis and establish surgical technique for its correction. MATERIALS AND METHODS: Of 27 women who underwent simple cystectomy and urethrectomy for intractable interstitial cystitis an anterior vaginal wall hernia developed in 3 (71, 56 and 61 years old) at 8, 14 and 16 months, respectively, postoperatively. Clinical appearance was similar to a midline cystocele but it contained bowel contents in the form of an anterior enterocele. Anterior enterocele was associated with vaginal vault prolapse in 1 patient who was treated with transvaginal sacro-spinous colpopexy. Patients with isolated anterior enterocele required a transabdominal approach with mobilization of the intestinal hernia contents and obliteration of the intervaginal abdominal wall space. RESULTS: At 12, 19 and 33 months following reconstruction prolapse has not recurred, and sexual function was restored in 1 patient. CONCLUSIONS: These cases suggest that an extended simple cystectomy performed on women with intractable interstitial cystitis may result in a weakening of the anterior vaginal wall with resultant anterior enterocele formation. When it is associated with vaginal vault prolapse a transvaginal technique may be considered but we prefer a transabdominal approach for an isolated anterior enterocele. Prevention of this entity may be warranted at the time of cystectomy.     

Chronic inguinal pain after transperitoneal mesh implantation. Case report of net shrinkage

The implantation of a mesh is an essential step in laparoscopic inguinal hernia surgery. We present the case of a 22-year-old man who developed an unspecific and refractory syndrome of inguinal pain after a TAPP procedure for a primary inguinal hernia. Repeated reoperation for removement of clips and nerve transection were unsuccessful. By a transinguinal approach, 18 months after the first operation we removed a preperitoneal Prolene mesh which had shrunk and folded to 30% of its original size. The problem of biocompatibility of meshes currently used in inguinal hernia surgery is discussed.     

Two cases of Morgagni's hernia

Two cases of Morgagni's hernia comprising protrusion of the omentum alone are reported. The treated patients were 65- and 63-year-old obese women. They were referred to our hospital because of chest pain or vomiting accompanied by abnormal shadow in right cardiophrenic angle on chest roentgenogram. Computed tomogram (CT) demonstrated a mass of fat density behind the sternum for the both patients. The first patient was diagnosed as Morgagni's hernia by pneumoperitoneum, and surgical repair was done by the transabdominal approach. Magnetic resonance imaging (MRI) was carried out for the second patient, and showed intrathoracic mass lesion which was continuous with the subphrenic tissue. Although the second patient was diagnosed as mediastinal lipoma, median sternotomy revealed that the mass lesion was Morgagni's hernia. Postoperatively, both patients recovered uneventfully. The Morgagni's hernia has been reported to be about 3% of all diaphragmatic hernia. This disease may be discovered either because it causes respiratory or gastrointestinal complaints, or because an abnormal shadow in right cardiophrenic angle on a chest roentgenogram. If air-filled structures are present in the hernia, a barium study will confirm the diagnosis. In a case with a hernia containing only omentum, the diagnosis is difficult. CT has been regarded as the procedure of choice by several authors. The coronal and sagittal views of MRI can demonstrate the relationship between the herniated structures and the diaphragm, heart, pericardium. We emphasize the role of MRI for the diagnosis of Morgagni's hernia.     

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.     

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.     

Thyrotoxicosis presenting as a life threatening hypokalaemic paralysis: investigation of the Na/K pump in isolated leucocytes

Laparoscopic femoral herniorrhaphy using a preperitoneal plug and patch appears to be a feasible laparoscopic approach to femoral hernia. A modified preperitoneal femoral hernia repair with mesh and resection of incarcerated small bowel has been successfully completed under laparoscopic guidance in a 64-year-old patient with incarcerated femoral hernia. To our knowledge, this is the first such case reported in the United States. With further experience, laparoscopic femoral herniorrhaphy could provide a viable alternative to the standard treatment of femoral hernia.     

Patterns of fetal perinasal fluid flow in cases of congenital diaphragmatic hernia

OBJECTIVE(S): Our purpose was to expand the previous reported series of observations of fetal perinasal fluid flow in cases of antenatally diagnosed congenital diaphragmatic hernia, characterize the timing parameters of the fetal breath cycle, and define the relationship of fetal perinasal fluid flow and the diaphragmatic component of fetal breathing movements. Our hypothesis was that characteristics of diaphragm-related and nondiaphragm-related perinasal fluid flow and other breath cycle characteristics differ in cases of congenital diaphragmatic hernia compared with controls. STUDY DESIGN: Fetal perinasal fluid flow velocity and fetal chest wall movements were studied in 24 cases of uncomplicated pregnancy, and flow was studied in 24 cases of antenatally diagnosed congenital diaphragmatic hernia at gestational ages ranging from 30 to 41 weeks. The examination of fetal perinasal fluid flow velocity was performed with use of an ultrasonography system applying color flow and spectral Doppler analysis. Breath-to-breath interval, time of inspiration, time of expiration, and peak inspiratory and expiratory velocities were determined for each type of perinasal flow. RESULTS: The study revealed that the time of expiration in cases of congenital diaphragmatic hernia at 30 to 36 and 37 to 41 weeks of gestation was significantly shorter than in cases of uncomplicated pregnancy. The ratio of time of inspiration and breath-to-breath interval in cases of diaphragmatic hernia was approximately 30% higher (p = 0.001) at 30 to 36 weeks of gestation than in cases of uncomplicated pregnancy. The study also showed that in cases of congenital diaphragmatic hernia the expiratory peak velocity ratio at 30 to 36 weeks of gestation was significantly lower than in cases of uncomplicated pregnancy. CONCLUSIONS: We conclude that by Doppler ultrasonography measurements of fetal perinasal fluid flow, in cases of congenital diaphragmatic hernia, we can evaluate the timing parameters of fetal diaphragm-related breath cycles, the relationship of intraalveolar and intraamniotic pressures, and fetal upper respiratory tract resistance. Fetuses with diaphragmatic hernia spent significantly more time with diaphragm-nonrelated perinasal flow than did fetuses in cases of uncomplicated pregnancy, which can cause the increased loss of lung liquid and consequently be associated with pulmonary insufficiency in the early neonatal period.     

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.     

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.     

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.     

Acute traumatic abdominal hernia: case reports

Traumatic abdominal hernia is a rare injury with most reports documenting only one or two such cases. We describe five cases that were recognized during a 22-year period at a single trauma center. Physical examination often revealed abdominal wall tenderness and ecchymosis, but confirmation of hernia required additional testing in four of five patients. Two patients sustained muscle avulsion from the iliac crest which was likely a result of obesity and high riding seatbelts. In three of the patients a computed tomographic scan of the abdomen was instrumental in making the diagnosis. Surgical repair of the hernia was accomplished in three patients. The other two patients were managed nonsurgically. This report documents that an individualized approach to these patients is appropriate. Diagnosis may be difficult and immediate surgery does not prevent late sequelae. Management guidelines based upon a review of the English language literature on traumatic abdominal wall hernias are presented.     

Measurement of DNA in intervertebral disc and other autofluorescent cartilages using the dye hoechst 33258

BACKGROUND AND OBJECTIVES: Morgagni hernias are unusual congenital diaphragmatic hernias that are generally asymptomatic and discovered incidentally. Surgical treatment is indicated once the diagnosis is made. These hernias have traditionally been repaired by the open abdominal or thoracic approaches. We report a case of Morgagni hernia repaired successfully via the laparoscopic approach. METHODS AND RESULTS: The patient was noted to have a large anteromedial diaphragmatic hernia by chest radiograph and CT imaging. He underwent laparoscopy, during which the hernia was reduced and the defect repaired with mesh placement. We used intracorporeal suture placement to anchor the mesh. The patient recovered uneventfully after a short hospitalization. CONCLUSIONS: The laparoscopic approach for repair of Morgagni hernias offers diagnostic advantages as well as the potential for reduced morbidity when compared to laparotomy. We report intracorporeal knot-tying for fixation of the mesh to be a secure and satisfactory means to achieve the laparoscopic repair.     

Controlled trial of preperitoneal local anaesthetic for reducing pain following laparoscopic hernia repair

BACKGROUND: A prospective randomized trial was performed to determine whether local anaesthetic solutions injected into the preperitoneal space may provide additional pain relief following transabdominal preperitoneal laparoscopic hernia repair. METHODS: One hundred patients undergoing transabdominal preperitoneal laparoscopic hernia repair were allocated randomly to receive (1) bupivacaine 1.5 mg/kg, (2) bupivacaine 1.5 mg/kg with 1 in 200000 adrenaline, (3) bupivacaine 3 mg/kg or (4) saline instilled into the preperitoneal space at the end of the operation. An independent clinical assessor determined the level of pain using a visual analogue pain score and noted the parenteral and oral analgesia requirements at 4, 8, 12 and 24 h after operation. Results: At each of the time intervals, there was no significant difference between the groups for pain scores (at 24 h, P = 0.71) or the number of doses of either morphine (at 24 h, P = 0.73) or oral analgesia (at 24 h, P = 0.89). There was also no significant difference in the time to return to normal activity or work between the groups. CONCLUSION: This study suggests that instilling local anaesthetic into the preperitoneal space has no significant effect on postoperative pain relief requirement following laparoscopic hernia repair. Other methods of reducing postoperative pain should be sought that may facilitate day-case laparoscopic hernia surgery.     

Classification systems for groin hernias

All groin hernia classifications are somewhat arbitrary and artificial. Currently, there is no consensus among either general surgeons or hernia specialists as to a preferred system. A survey by Zollinger in 1998 of hernia specialists in North American and Europe showed, that although the Nyhus, Gilbert, and Schumpelick-Arit systems were commonly used, the majority of these specialists still used the traditional classification for groin hernias. It is apparent that only the traditional classification of groin hernias has stood the test of time. As stated by Fitzgibbons, "the primary purpose of a classification system for any disease is to stratify for severity so that reasonable comparisons can be made between various treatment strategies." Given the multiplicity of operative techniques and approaches for the repair of groin hernias, it appears that no one classification system can satisfy all. With time, it is likely that we surgeons will settle upon a given operation for a specific type of inguinal hernia. For that given operation to be accepted as proven best, however, it is essential the competing operations be applied to simliar (classified) groups of groin hernia patients.     

Laparoscopic repair of a paraesophageal hiatal hernia with gastric volvulus

We report the case of a massive paraesophageal hiatal hernia with gastric volvulus which presented with the symptom of a precordial sense of pressure for over two years, which was successfully treated with laparoscopic surgery. The patient is presently in good condition, without any recurrence of either the hiatal hernia or other symptoms one year after surgery. This approach is considered to be a safe and effective procedure, and it also provides for rapid recovery from the operation.