Classification systems and groin hernias

The once simple division of groin hernias into indirect and direct inguinal and femoral components is no longer adequate to reflect a more sophisticated understanding of the pathophysiology and management of these lesions. Similarly, the availability of a concise, easy-to-use, logical, and recognizable classification scheme would facilitate a better understanding of modern repair techniques and confirmation of operative results.     

Surgical options in the management of groin hernias

Extracellular Yersinia adhering at the surface of a eukaryotic cell translocate effector Yops across the plasma membrane of the cell by a mechanism requiring YopD and YopB, the latter probably mediating pore formation. We studied the role of SycD, the intrabacterial chaperone of YopD. By producing GST-YopB hybrid proteins and SycD in Escherichia coli, we observed that SycD also binds specifically to YopB and that this binding reduces the toxicity of GST-YopB in E. coli. By analysis of a series of truncated GST-YopB proteins, we observed that SycD does not bind to a discrete segment of YopB. Using the same approach, we observed that YopD can also bind to YopB. Binding between YopB and YopD occurred even in the presence of SycD, and a complex composed of these three proteins could be immunoprecipitated from the cytoplasm of Yersinia. In a sycD mutant, the intracellular pool of YopB and YopD was greatly reduced unless the lcrV gene was also deleted. As LcrV is known to interact with YopB and YopD and to promote their secretion, we speculate that SycD prevents a premature association between YopB-YopD and LcrV.     

Adult groin hernias: new insight into their biomechanical characteristics

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

Ultrasonography for inguinal hernias in boys

BACKGROUND/PURPOSE: History taking and physical examination alone no longer meet the surgeon's need in the diagnosis of inguinal hernia. Ultrasonography (US) provides a good and safe diagnostic tool for inguinal hernias in boys. METHODS: From 1995 to 1997, 244 boys with inguinal hernias (41 bilateral and 203 unilateral), received preoperative US on both groins to confirm the diagnosis. Those with positive US findings, such as viscera or fluid in inguinal canal or widening of the internal inguinal ring, underwent surgery. RESULTS: The accuracy of diagnosis with US and clinical assessment were 97.9% and 84%, respectively. More than 95% of widening of internal inguinal rings (>4 mm) proved to be hernias. There were two direct inguinal hernias and two femoral hernias, which were misdiagnosed by clinical examination, but proved to be diagnosed correctly by US. CONCLUSIONS: US serves as a noninvasive and highly accurate diagnostic tool for inguinal hernias in boys. Using 4 mm as the upper limit of the normal diameter of the internal inguinal ring, an occult inguinal hernia can be easily detected before surgery.     

Bladder hernias

The authors report 5 cases of bladder herniation through inguinal ring. All the patients were males aged between 52 and 72 years with a mean of 63 years. The clinic symptoms were non specific. In four cases the diagnosis was made by IVP. In the fifth case the bladder herniation was discovered after an incidental opening of the bladder during a right inguinal hernia repair. Four patients were operated on for replacement of the bladder and repair of the hernial ring; the procedure followed was Mac Vay technique in two cases, Shouldice in one case and placement of a Mersuture prosthesis in another case. The fifth patient was operated on because of major constraint related to his general conditions. Results was quite satisfactory in all operated cases with a mean control of 24 months.     

Pain after groin hernia repair

Depression is one of the most common psychiatric illnesses. Its influence on brain perfusion has been demonstrated, but conflicting data exist on follow-up after drug treatment. The aim of our study was to evaluate the effects of antidepressant drugs on regional cerebral blood flow (rCBF) in patients with depression after 3 weeks and 6 months of drug therapy. Clinical criteria for depression without psychosis were met according to psychiatric evaluation. Severity of depression was evaluated with the Hamilton Depression Rating Scale (HAMD) before every scintigraphic study. rCBF was assessed using technetium-99m bicisate (Neurolite) brain single-photon emission tomography in nine patients with severe depression before the beginning of antidepressant drug therapy and 3 weeks and six months after initiation of therapy. Only patients with no change in antidepressant medication during the study were included. No antipsychotic drugs were used. Cerebellum was used as the reference region. rCBF was evaluated for eight regions in each study in three consecutive transversal slices. Follow-up studies were compared with the baseline study. The mean HAMD score was 25.5 points initially, 16 at the second examination and 8.8 after 6 months. Global CBF was decreased compared with the reference region in drug-free patients. Perfusion of left frontal and temporal regions was significantly lower (P < 0.005) in comparison with the contralateral side. After therapy, a moderate decrease in perfusion was seen in the right frontal region (P < 0.05). Perfusion decreased further after 6 months in the right frontal (P < 0.005) and temporal regions (P < 0.01). The highly significant asymmetry in perfusion between the left and right frontal and temporal lobes almost disappeared during treatment. Our findings implicate dysfunction of the frontal and temporal cortex in clinically depressed patients before specific drug treatment. Clinical improvement and decreases in HAMD score after 3 weeks and after 6 months reflect the treatment effect on mood-related rCBF changes.     

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.     

Laparoscopic repair and groin hernia surgery

Over the past 15 years, laparoscopic herniorrhaphy has made the transition from an experimental to a proven procedure. With increasing laparoscopic skills in the surgical community, many surgeons are now faced with the question of when to recommend laparoscopic herniorrhaphy to their patients. A surgeon's best hernia repair is the one with which they have had the greatest experience. This results in the lowest recurrence and complication rate in his or her hands. Certainly, simple, unilateral hernias and bilateral hernias can be repaired with either anterior or laparoscopic techniques. Many times, laparoscopic herniorrhaphy is too much surgery for a young patient with a unilateral hernia. In such a case, repair is best performed with the patient under local anesthesia. Also, young patients in whom it is advantageous to avoid mesh should not undergo laparoscopic herniorrhaphy. The authors prefer laparoscopic TEP herniorrhaphy in patients with recurrent hernias, bilateral hernias, and unilateral hernias with a suspected contralateral hernia. There is also a consensus that patients with multiple recurrent hernias in whom a preperitoneal repair is appropriate are best served with a laparoscopic repair. Surgeons without advanced laparoscopic skills or without the time to develop the skills necessary to perform laparoscopic herniorrhaphy should consider referring patients with recurrent hernias to surgeons with experience in TEP. TEP is preferable to TAPP because of its lower complication and recurrence rates and in the authors' hands is the "best repair." TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy. Complication and recurrence rates, although initially higher than traditional repairs, have now fallen to equal or lower levels at centers experienced in laparoscopic techniques. Prospective randomized trials prove that when patients are selected properly and surgeons are adequately trained and proctored, laparoscopic herniorrhaphy can be performed with acceptably low incidences of recurrence and complications.     

Sliding door technique for the repair of midline incisional hernias

We describe a technique that enables the autologous repair of large midline incisional hernias by restoring the functional musculoaponeurotic support of the abdominal wall. Unlike other methods of hernia repair, the essential step of the sliding door technique is the complete release of the rectus abdominis muscles from the anterior and posterior layers of their sheaths. The released muscles are thus overlapped and sutured together without tension. Another step of the technique is the release of both rectus sheaths by incising the aponeuroses of the external oblique muscles. We report on the use of this technique in 10 patients with midline incisional hernias (mean size of the abdominal musculofascial defect 14 x 11 cm). The patients were examined 14 months to 5.5 years after hernia repair. Two postoperative complications occurred: one marginal skin necrosis and one subcutaneous seroma. Recurrences were not observed. Ultrasound examination showed that the rectus muscles maintained their overlapped position postoperatively. Clinical muscle testing indicated that the strength of the released rectus muscles provides functional support to the reconstructed anterior abdominal wall.     

CT imaging of abdominal hernias

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

Adult presentation of unusual diaphragmatic hernias

Clinical studies have demonstrated that patients sustain prolonged behavioral deficits following traumatic brain injury, in some cases culminating in the cognitive and histopathological hallmarks of Alzheimer's disease. However, few studies have examined the long-term consequences of experimental traumatic brain injury. In the present study, anesthetized male Sprague-Dawley rats (n = 185) were subjected to severe lateral fluid-percussion brain injury (n = 115) or sham injury (n = 70) and evaluated up to one year post-injury for cognitive and neurological deficits and histopathological changes. Compared with sham-injured controls, brain-injured animals showed a spatial learning impairment that persisted up to one year post-injury. In addition, deficits in specific neurologic motor function tasks also persisted up to one year post-injury. Immunohistochemistry using multiple antibodies to the amyloid precursor protein and/or amyloid precursor protein-like proteins revealed novel axonal degeneration in the striatum, corpus callosum and injured cortex up to one year post-injury and in the thalamus up to six months post-injury. Histologic evaluation of injured brains demonstrated a progressive expansion of the cortical cavity, enlargement of the lateral ventricles, deformation of the hippocampus, and thalamic calcifications. Taken together, these findings indicate that experimental traumatic brain injury can cause long-term cognitive and neurologic motor dysfunction accompanied by continuing neurodegeneration.     

Paraesophageal hernias in elderly patients. An indication for laparoscopic surgery

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