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.     

Laparoscopic repair of recurrent ventral hernias

Break down after repair of recurrent ventral hernias can exceed 50 per cent. Laparoscopic techniques offer an alternative. This study evaluated the efficacy of the laparoscopic approach for recurrent ventral hernias. A retrospective review on all patients with a recurrent ventral hernia who underwent laparoscopic repair at our institution from August 1995 to June 1997 was performed. Demographic, operative, postoperative, and follow-up data were collected. Thirty-one patients underwent an attempted laparoscopic ventral hernia repair. Sixteen were for recurrent hernias; 15 were successfully repaired laparoscopically. The patients were typically obese (mean body mass index, 30 kg/m2), had an average of 2.4 previous open repairs (range, 1-7), and six patients had previously placed intra-abdominal mesh. An average of 3.5 (range, 1-16) defects were found per patient with a mean total hernia size of 130 cm2 (6-480 cm2). In all cases, expanded polytetrafluoroethylene mesh (average, 299 cm2) was secured with transabdominal sutures. Postoperatively patients required an average of 19 mg of narcotics (MSO4 equivalent). Bowel function returned in 1.7 days. Length of stay averaged 2.0 days (1-4 days). There were two complications: cellulitis, which resolved with antibiotics, and skin break-down, which required mesh removal. With follow-up averaging 18 months (7-29 months), there is one recurrence; the case in which the mesh was removed. Laparoscopic repair of recurrent ventral hernia seems promising. Decreased hospital stays, postoperative pain, wound complications, and a low rate of recurrence are benefits of this technique.     

Late mesh rejection as a complication to transabdominal preperitoneal laparoscopic hernia repair

BACKGROUND: The use of a mesh in transabdominal preperitoneal laparoscopic hernia repair (TAPP) caries the risk of late rejection or infectious complications related to the mesh. The aim of this study was to describe the extent of these complications. METHODS: We performed a retrospective study of 500 consecutive patients with TAPP for inguinal hernia. Results: Late mesh rejection was observed in three patients at 5-19 months after surgery. The mesh was removed via a suprapubic midline incision. At 3-4 month's follow-up, none of the patients had recurrence of the hernia, even though no hernia repair had been done. CONCLUSION: Late mesh rejection is a potential complication of TAPP and has to be considered when choosing the surgical method of hernia 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.     

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes

BACKGROUND: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. METHODS: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. RESULTS: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. CONCLUSIONS: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain.     

The effect of 12 months'' treatment with eicosapentaenoic acid in five children with cystic fibrosis

BACKGROUND: The use and indications for laparoscopy have been increasing. As part of this trend, a new algorithm may emerge for pediatric trauma in which laparoscopic techniques are used in hemodynamically stable patients with suspected hollow viscus perforation. CASE REPORT: We present a case in which laparoscopy was successfully used in a pediatric trauma patient as a diagnostic and therapeutic modality. A 4-year-old boy was a back-seat passenger in a head-on collision motor vehicle accident. He was restrained by a lap seat belt. He sustained a concussion, a large forehead laceration and a seat belt abdominal injury. On admission, he complained of abdominal pain. Physical examination revealed a soft, non-distended abdomen with moderate diffuse tenderness. He was hemodynamically stable. Computerized tomography of the abdomen revealed free fluid in the pelvis. No abnormalities were detected in the liver or spleen. Because of clinical deterioration and suspected intestinal perforation, diagnostic laparoscopy was utilized instead of proceeding directly to celiotomy. At laparoscopy a jejunal perforation was found and successfully repaired laparoscopically. Large hematomas were seen in the mesentery, as well as an unsuspected splenic laceration. No active bleeding was found. The patient recovered uneventfully and was discharged 5 days following the surgical procedure. CONCLUSION: This case illustrates the efficacy of using early laparoscopy in children with abdominal trauma when diagnosis is difficult and hollow viscus injury is suspected.     

Short-term outcome of laparoscopic paraesophageal hernia repair. A case series of 58 consecutive patients

BACKGROUND: The purpose of this study is to determine the morbidity, mortality, and short-term outcomes associated with laparoscopic paraesophageal hernia repair (LPHR). METHODS: A series of 58 consecutive LPHRs performed by the author were reviewed with an average 1-year follow-up. Morbidity and mortality rates were compared with historical series of open repairs. Anatomy and technical considerations pertinent to LPHR were reviewed. RESULTS: There were no procedure-related or perioperative deaths in this series of patients undergoing LPHR. Four major complications occurred (7%), two of which required reoperation, all in urgently repaired patients. One patient required conversion to laparotomy (1. 7%). Based on symptoms, there were no reherniations. No patients had long-term dysphagia worse than preoperatively. Preoperative symptoms of chest pain, esophageal obstruction, hemorrhage, and reflux were resolved in all patients. CONCLUSIONS: LPHR is safe, effective, and compares favorably to historical series of open paraesophageal hernia repair.     

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.     

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.     

Laparoscopy for chronic abdominal pain

BACKGROUND: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. METHODS: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. RESULTS: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. CONCLUSIONS: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain.     

Pubic osteotomy in obturator gliding hernia

Hernias of the obturator foramen are rare. They are described mostly in elderly female patients in poor health. Often the correct diagnosis is stumbled upon as a result of surprising intraoperative findings. Surgical therapy is indicated often by the clinical symptoms of an incarcerated hernia. Herniation of the entire urinary bladder with hemorrhagic infarction has never been described before. For an anatomical reduction of the hernia it was necessary to resect the superior pubic ramus. For plastic reconstruction a marlex mesh was used.     

Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication

Postoperative paraoesophageal hiatus hernia occurred in 17 of 253 patients who underwent laparoscopic fundoplication at five different hospitals. Ten patients have undergone subsequent surgical revision, eight by an open technique and two by laparoscopy. This complication may have important implications for the technique of laparoscopic fundoplication, as it is possible that routine posterior repair of the diaphragmatic hiatus may greatly reduce the risk. Early postoperative contrast radiology may also achieve earlier diagnosis, enabling correction to be undertaken by laparoscopy.     

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.     

New possibility in inguino-femoral hernia repair: laparoscopic herniaplasty

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

Discriminability in length of lines in the Müller-Lyer figure

OBJECTIVE: To compare patients' health-related quality of life after systemic methotrexate therapy versus laparoscopic salpingostomy for tubal pregnancy. DESIGN: Multicenter randomized clinical trial. SETTING: Departments of obstetrics and gynecology of six Dutch hospitals. PATIENT(S): Hemodynamically stable patients with a laparoscopically confirmed unruptured tubal pregnancy without signs of active bleeding, who were randomly assigned to undergo either systemic methotrexate therapy or laparoscopic salpingostomy. INTERVENTION(S): Standard health-related quality of life questionnaires administered before and 2 days, 2 weeks, 4 weeks. and 16 weeks after confirmative laparoscopy. MAIN OUTCOME MEASURE(S): Health-related quality of life. RESULT(S): Health-related quality of life was impaired most severely 2 days after confirmative laparoscopy in both treatment groups and improved during follow-up. Health-related quality of life was impaired more severely after systemic methotrexate therapy than after laparoscopic salpingostomy. Medically treated patients had more limitations in physical functioning, role functioning, and social functioning; had worse health perceptions, less energy, more pain, more physical symptoms, and a worse overall quality of life; and were more depressed than surgically treated patients. CONCLUSION(S): Systemic methotrexate therapy had a more negative impact on patients' health-related quality of life than did laparoscopic salpingostomy. This negative impact on patients' health-related quality of life of systemic methotrexate therapy should be taken into account when deciding on the appropriate therapy for tubal pregnancy.     

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.     

Complications of laparoscopic paraesophageal hernia repair

The complications of laparoscopic paraesophageal hernia repair at two institutions were reviewed to determine the rate and type of complications. A total of 76 patients underwent laparoscopic paraesophageal hernia repair between December 1992 and April 1996. Seventy-one of them had fundoplication (6 required a Collis-Nissen procedure). Five patients underwent hernia reduction and gastropexy only. There was one conversion to laparotomy. Traumatic visceral injury occurred in eight patients (11%) (gastric lacerations in 3, esophageal lacerations in 2, and bougie dilator perforations in 3). All lacerations were repaired intraoperatively except for one that was not recognized until postoperative day 2. Vagus nerve injuries occurred in at least three patients. Three delayed perforations occurred in the postoperative period (4%) (2 gastric and 1 esophageal). Two patients had pulmonary complications, two had gastroparesis, and one had fever of unknown origin. Seven patients required reoperation for gastroparesis (n = 2), dysphagia after mesh hiatal closure of the hiatus (n = 1), or recurrent herniation (n = 4). There were two deaths (3%): one from septic complications and one from myocardial infarction. Paraesophageal hernia repair took significantly longer (3.7 hours) than standard fundoplication (2.5 hours) in a concurrent series (P <0.05). Laparoscopic paraesophageal hernia repair is feasible but challenging. The overall complication rate, although significant, is lower than that for nonsurgically managed paraesophageal hernia.     

Experience with 300 laparoscopic inguinal hernia repairs with up to 3 years follow-up

The long-term results of 300 laparoscopic inguinal hernia repairs are reported with 11 cases followed up more than 3 years, 104 cases more than 2 years, and 225 cases more than 1 year. There were five early failures owing to the use of too small a piece of mesh. There have been no long-term recurrences. The results indicate that transabdominal preperitoneal laparoscopic mesh repair of hernias is a satisfactory technique with a low recurrence rate and a low major complication rate (4%). Patients have found the procedure to be remarkably pain free and 51% have taken no analgesics after discharge from hospital. Of the patients, 78% returned to work within 2 weeks of the operation. These results suggest that laparoscopic hernia repair can be performed safely with excellent long-term results.     

Evaluation of early computed tomographic findings in acute ischemic stroke

OBJECTIVE: We describe CT findings after laparoscopic repair of ventral hernia with emphasis on formation of postoperative fluid collections that can mimic recurrent bowel herniation or infected postoperative fluid collections. CONCLUSION: The porous property of the mesh used in laparoscopic repair of ventral hernia allows reaccumulation of fluid in the existing hernia sac or spaces in the subcutaneous tissues that can be created by laparoscopic manipulation. These fluid collections should be expected and are differentiated from infected fluid collections or hernia recurrence by clinical presentation, laboratory data, and lack of ancillary features associated with true hernia such as presence of hernia sac, herniated mesentery, or bowel obstruction.