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.     

Organization and results of ambulatory surgery for inguinal hernia]

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.     

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.     

Lichtenstein inguinal hernia repair in a primary healthcare setting

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

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.     

Colonoscopic findings in Crohn''s disease--reproducible, but of questionable benefit

Between January, 1991 and December, 1993, 208 subjects with monolateral and 19 with bilateral inguinal hernia were submitted to herniorrhaphy. Thirty-four were recurrent hernias. All but one bilateral hernias were treated at the same time. Eight cases were operated in emergency condition for acute strangulated hernia. Two-hundred and ten operations were performed under local, 17 under general and 1 under spinal anesthesia. Herniorrhaphy was performed in 14 cases with the Bassini and in 38 with the Shouldice technique. In 191 instances the "tension-free" and in 3 the "plug" techniques were adopted utilizing a polypropylene mesh. Following local anesthesia 13 episodes of bradycardia with hypotension were recorded during the operation and 4 in the early postop period. There were no general complications. Two elderly patients developed urinary retention following general anesthesia. Local complications included 6 (2.4%) cases of infection and 4 (1.6%) cases of hematoma of the wound, and 5 (2.0%) cases of edema with infiltration of the cord. Percentage of follow-up at 1, 2 and 3 years was 96, 95, and 93 percent respectively. Five recurrences were recorded: in 1 case following Bassini repair (7.6%), in 2 following Shouldice (5.6%), and in 2 following tension-free (1.5%). Local anesthesia has been confirmed to be well accepted by the patients, effective an safe, especially in the elderly patients with high operative risk. Similarly, the tension-free hernioplasty has been confirmed as a simple, easily reproducible technique, followed by less pain and disability as compared with other types of herniorrhaphies, and more effective mainly in the treatment of recurrent hernia.     

Mesh hernioplasty using a stapler

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

Strength and functional recovery following repair of flexor digitorum superficialis in zone 2

Since 1989 we have performed 21 endoscopic hernia repairs in 19 female patients. One recurrent hernia occurred 3 months after laparoscopic preperitoneal patch repair using a single layer of resorbable mesh. Hernioscopy was developed as the transcutaneous endoscopic CO2-gas dissection and subsequent inspection of the preperitoneal hernial sac. Hernioscopic stuffing of the preperitoneal hernial sac using resorbable patch material was performed in seven direct inguinal hernias and in one femoral hernia. Postoperative pain was minimal and convalescence was short. No recurrent hernia occurred during a 1-9-month follow-up.     

Standard versus individually planned irradiation field in radiotherapy of infradiaphragmatic lymph node sites]

PURPOSE: The aim of this study was to determine the utility of scrotal sonography in the evaluation of patients with scrotal pain or swelling following inguinal hernia repair. METHODS: From our database, we identified patients who were referred for sonographic evaluation because of persistent scrotal pain or swelling after inguinal hernia repair between July 1994 and February 1996. Sonograms and medical charts were reviewed retrospectively. RESULTS: Eight patients were included in this study. Doppler sonography demonstrated evidence of testicular infarction in 2 patients and absence of intratesticular diastolic flow in 1 patient. Five patients had postoperative fluid collections with sonographically normal testes. CONCLUSIONS: Scrotal sonography can diagnose testicular infarction following hernia repair and distinguish postoperative fluid collections from recurrent hernias.     

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.     

Wheat bran- but not oat bran-enriched diets increase the mucosal height of the cecum and colon of newly weaned and aged rats

BACKGROUND: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. METHODS: 1100 patients in the age group 5-88 years who underwent ambulatory surgery during a period of 6 months were asked to complete a questionnaire 48 h after the end of the operation. In the case of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature and severity of postoperative complications. RESULTS: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with management of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. CONCLUSION: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Lichtenstein herniotomy

All standard methods of hernia repair involve suturing together tissues which are not normally in apposition. This violates the basic surgical principle that tissue must never be approximated under tension and accounts for an unacceptable number of failures. Total reinforcement of the inguinal floor with a sheet of suitable biomaterial and employment of a "tension-free" technique is a more effective approach. Since June 1984, 3250 primary inguinal hernias have been repaired at the Lichtenstein Hernia Institute by the open tension-free technique using Marlex mesh. All operations were performed under local anesthesia. Patients were discharged from the hospital within two or four hours after the operation. The patients were followed from one to 8 years by physician examination. The follow-up rate was 87%. There were four recurrences. The causes of recurrence and how to avoid them are discussed.     

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.     

Recurrent inguinal hernia: preferred operative approach

Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 10 to 20 per cent performed for recurrence. Subsequent repairs provide considerable technical challenge, as well as substantially greater risk of developing further recurrence. Mesh repair is advocated by several specialized hernia centers, demonstrating re-recurrence rates less than 2 per cent. Detractors of this repair include cost, technical difficulty, and risk for infection. The purpose of this study was to compare results of mesh and nonmesh repairs for recurrent inguinal hernia, either using an anterior or posterior approach, at a large teaching institution. From January 1, 1985, to December 31, 1994, 146 patients underwent repair for recurrent inguinal hernia at the Veterans Administration Hospital at Memphis, Tennessee. Patients were stratified by type of repair: Lichtenstein (Mesh), open anterior (OA), Bassini, Marcy, McVay, Shouldice, and preperitoneal with or without mesh. Patient ages and weights were similar between groups. Mean operative time for Mesh repair (104 +/- 4 minutes) was longer than that for OA repairs (80 +/- 5 minutes, P < 0.05) or preperitoneal without mesh repairs (92 +/- 5 minutes, P < 0.05). Mesh-based posterior repairs had the longest operative times (116 +/- 5 minutes). Hospital stay averaged 2.8 +/- 0.3 days, similar among all groups. One wound infection (1.0%) occurred in patients undergoing Mesh repair, which required operative drainage. No patient required removal of mesh. Two patients in the Mesh group (5.9%) developed recurrence compared with four recurrences (18.0%) in patients undergoing OA repairs. Only one patient with a mesh-based posterior repair recurred (1.9%) compared to eight without mesh (21.6%, P < 0.01). Follow-up ranged from 2 to 12 years. Repair of recurrent inguinal hernia using either an anterior or posterior mesh repair technique, performed at a teaching facility, provides superior recurrence rates without increasing risk for infection or length of stay. Preperitoneal mesh based repair is the preferred technique.     

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.     

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.     

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.     

Gender-specific association of M235T polymorphism in angiotensinogen gene and diabetic nephropathy in NIDDM

Cryoanalgesia versus sham treatment was applied to the ilioinguinal and iliohypogastric nerves after mesh repair of an inguinal hernia under local anesthesia in 48 male patients in a prospective, randomized, and observer- and patient-blinded trial. Pain was scored daily during rest, while coughing, and during mobilization to the sitting position for 1 wk and weekly for 8 wk on a four-point verbal rank scale. Use of supplementary analgesics and sensory disturbances were recorded. Assessments were made for allodynia, hyperalgesia, and mechanical pain detection thresholds 8 wk postoperatively. Cumulative pain scores for the first postoperative week were equal in the two groups, as was the use of analgesics. Eight weeks postoperatively, three cases of hyperalgesia to pinprick were detected in the cryoanalgesia group, and 10 patients in the cryoanalgesia group versus 5 in the sham-treatment group reported disturbed sensibility. We conclude that cryoanalgesia of the iliohypogastrical and ilioinguinal nerve does not decrease postherniorrhaphy pain. IMPLICATIONS: Does freezing of sensory nerves in the groin reduce pain after hernia repair? Extreme cold (-60 degrees C) was applied in a double-blind, randomized study. No difference in pain scores was found. Sensory disturbances were seen in treatment and control patients. Freezing cannot be recommended for pain relief after hernia repair.     

Hospital ambulatory pediatric surgery

Since 1990, we have been conducting ambulatory pediatric surgery in an unit established solely for this purpose, supported by a team of kindergarten teachers, pediatric nurses, anesthesiologists and pediatric surgeons. This prospective investigation includes all ambulatory pediatric operations performed in our department from 1990 to 1995. In this time 3665 infants and children between the ages of 6 weeks and 18 years underwent an ambulatory operation. The ratio male to female was 4.1 to 1. The series consists of 1400 inguinal hernias, 722 inguinal testes, 191 hydroceles/funiculoceles, 75 umbilical hernias, 667 phimoses, 70 meatotomies, 59 hemangiomas, 217 endoscopies and 264 other surgical procedures. Postoperative complications defined as secondary hemorrhage, fever, obvious vomiting, urine retention and laryngospasm upon terminating anesthesia accompanied by subsequent vomiting occurred in 59 (1.6%) of all infants and children. Wound infections were seen in 0.48% (17/3517) of all patients. The recurrence rate for inguinal hernias were 0.79% and 1.12% for inguinal testes. Our experience enables us to summarize that a variety of pediatric operations can be performed today as ambulatory procedures. Nevertheless one must be prepared for the occurrence of complications and always have capacities free for inpatient care where adequate observation and treatment are available. Further improvement is necessary in quality management. In the last 20 years only a few data have been published about recurrence rates after pediatric ambulatory operations for inguinal hernias and inguinal testes. Therefore we started a prospective long- term study.     

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.