Anatomical Danger Zone in Open Inguinal Herniorrhaphy

PURPOSE: Because of complex inguinal structures, we cannot overcome the neurogenic complications in open inguinal herniorrhaphy. Nowadays, there are few studies of anatomical danger zones in open herniorrhaphy. So, in this study we would cover the danger zones in hernia surgery with a cadaver. METHODS: We studied the anatomic structures of three male cadavers. There was no anatomical variation among them. We can ascertain the running of the ilioinguinal nerve, iliohypogastric nerve, and genitofemoral nerve. RESULTS: We can see that the ilioinguinal nerve runs anterior to the spermatic cord in the inguinal canal and lies beneath the external oblique aponeurosis. The iliohypogastirc nerve runs on the anterior surface of the internal oblique muscle, and aponeurosis medial and superior to the internal ring. The genital branch of the genitofemoral nerve lies on the iliopubic tract and accompanies the cremaster vessels to form a neurovascular bundle. In these areas, we often suture the anchor in open herniorrhaphy, increasing probability of these nerves suffering injury. CONCLUSION: In open inguinal herniorrhaphy, surgeons must have a comprehensive understanding of the neural anatomy of the groin to reduce post-operative complications. Moreover, we must consider not only anatomical understanding but also surgical procedures reducing neurogenic complications. So, we suggest certain procedures to reduce nerve injury such as three dimensional mesh or the use of fibrin glue.

Laparoscopic Appendectomy for Acute Appendicitis in Children: A Comparison with Open Appendectomy

PURPOSE: The advantage of a laparoscopic appendectomy for acute appendicitis in children is controversial, with no consensus among most pediatric surgeons, particularly with regard to the operative time and hospital costs in complicated cases. The objective of this study was to examine the safety, efficacy and complications of a laparoscopic appendectomy in children compared with an open appendectomy. METHODS: Our clinical experiences of laparoscopic appendectomy (LA) and open appendectomy (OA) for simple appendicitis (SA), complicated appendicitis (CA) and no evidence of appendicitis (NA) in children, between November, 2003 and October, 2006, were reviewed. Ninety- three (93) patients underwent a LA (58 boys, 35 girls) and 194 patients an OA (128 boys, 66 girls). The mean ages of the patients having undergone LA and OA were 9.6 and 8.9 years, respectively. RESULTS: The mean operation times were similar between the LA and OA in the SA and NA groups, but was shorter for a LA than an OA in the CA group, which was also statistically significant (P=0.007). There were statistically significant differences in the postoperative duration of hospital stay between a LA and an OA in all groups (in SA, 2.8 versus 4.5 days, P<0.001 and in CA, 4.5 versus 8.4 days, P<0.001). The rates of postoperative complications were different between a LA and an OA were: for the SA group, 1.7 versus 1.0%, P=1.000; for the CA group, 0 versus 22.4%, P=0.006. CONCLUSION: Our experiences suggest that a laparoscopic appendectomy was a safe and effective procedure for any type of appendicitis in children, with a shorter hospital stay and lower rate of postoperative complications.

Suppression of iNOS Expression by NSAIDs and Acetaminophen in Vascular Smooth Muscle Cells

PURPOSE: iNOS expression in vascular smooth muscle cells (VSMC) causes the development of septic shock, and multiple organ dysfunction syndrome (MODS). For the inhibition of iNOS expression, glucocorticoids are known to inhibit iNOS expression but immunosuppression decreases its clinical availability. Recently, aspirin was reported to inhibit iNOS expression, but the mechanism and effectiveness are still unclear. In this investigation, on aspirin, several non steroidal antiinflammatory drugs (NSAIDs) were applied to clarify the inhibitory mechanism of iNOS expression and NO production in lipopolysaccharide (LPS) treated VSMCs. METHOD: VSMCs were primarily cultured from rat aorta and confirmed by immunocytochemistry of anti-smooth muscle myosin antibody. LPS, an inducer of iNOS, and NSAIDs, such as aspirin, indomethacin, ketoprofen sodium salicylate and acetaminophen were used. The concentrations of nitrite in culture media following the addition of LPS with a 1-hour pretreatment of NSAIDs were measured by spectrophotometry with griess reaction. Western blot and RT-PCR for iNOS protein and iNOS mRNA, respectively, were performed. RESULT: Acetaminophen had no effect on the inhibition of nitrite production. NSAIDs, especially ketoprofen and sodium salicylate, showed a significant inhibitory effect on nitrite production. In their mechanism, all the NSAIDs in present study inhibited iNOS mRNA and protein expression. CONCLUSION: These results suggest that the inhibitory mechanism on iNOS expression of NSAIDs is due to the inhibition of iNOS mRNA expression and subsequent inhibition of iNOS protein expression.

Usefulness of Laparoscopic-assisted Surgery for the Treatment of Colonic Diverticulitis

PURPOSE: Colonic diverticulitis was rare in Korea in the past. However, it is progressively increasing probably because of a prolonged life span and a westernized diet pattern. Especially, right-sided colonic diverticulitis is difficult to differentiated from acute appendicitis. The purpose of this study was to verify the usefulness of laparoscopic-assisted surgery for the diagnosis and treatment of colonic diverticulitis. METHODS: We retrospectively reviewed 65 patients with colonic diverticulitis who underwent surgery from January 1998 to December 2002. RESULTS: The mean age of the patients was 36.3 years. Males were more prevalent than females (1.6:1). Abdominal ultrasonography (USG) was used as a diagnostic tool in 40 cases (61.5%), abdominal USG with colon enema in 8 cases (12.3%), and abdominal USG with abdominal CT in 4 cases (6.2%). The preoperative diagnosis was acute appendicitis in 52 patients (80.0%), perforated diverticulitis in 10 patients (15.4%), peritonitis in 2 patients (3.5%), and peptic ulcer perforation in 1 patient (1.5%). The postoperative diagnosis was simple diverticulitis in 47 cases (72.3%). The cecum was the most commonly involved area (55 cases, 84.6%). The types of open surgery were an appendectomy in 17 cases (26.1%), a right hemicolectomy in 17 cases (26.1%), a cecectomy in 6 cases (9.2%). The types of laparoscopic- assisted surgery were an appendectomy in 17 cases (26.1%), a laparoscopic-assisted right hemicolectomy in 4 cases (6.2%), and an anterior resection in 1 case (1.5%). The postoperative complication rate was 11.9% (5 cases). All of these occurred with the open technique, but no statistically significant difference existed between the complication rates for the two operative procedures (P=0.158). The mortality rate was zero for both operative procedures. The length of hospital stay (4.72+/-4.3 vs 10.1+/-6.2)(P=0.001) was significantly shorter in the laparoscopic-assisted group than in the open group. CONCLUSIONS: Preoperative diagnosis is sometimes difficult in patients with colonic diverticulitis. We consider laparoscopic-assisted surgery to be a useful diagnostic and therapeutic modality in such cases. The laparoscopic technique offers particular advantages to diverticulitis patients because of the short hospital stay and the low morbidity and mortality rates.

Interactions of Nitric Oxide and Antioxidants in Hypoxia-Reoxygenation Injury

PURPOSE: An ischemia-reperfusion injury leads to profound functional and structural alterations of vascular smooth muscle cells (VSMC). It is still not clear whether hypoxia- reoxygenation and antioxidants affect the nitric oxide (NO) synthesis of VSMC. This study tried to investigate the effects of antioxidants on NO production, inducible nitric oxide synthase (iNOS) and the expression of NFkappaB p65, during the hypoxia-reoxygenation of VSMC cultures. METHODS: The VSMCs were primarily cultured from rat aortae, and confirmed by immunoreaction with the anti- smooth muscle myosin antibody. The condition of the hypoxia was verified by measuring the PO2 and PCO2 of the culture media. The concentrations of nitrite in the culture media were measured by the Griess reaction. Western blottings for the iNOS and NFkappaB p65 proteins were performed. L-NAME was used as an NOS inhibitor. Vitamins C and E, Glutathione (GSH), lipoic acid and dihydrolipoic acid (DHLA) were used as antioxidants. RESULTS: The iNOS protein was induced in the VSMC by 24 hours of hypoxia, which increased the nitrite in the VSMC culture medium. The reoxygenation profoundly increased the iNOS protein expression and nitrite concentration. The L- NAME, vitamins C and E, GSH, lipoic acid and DHLA decreased the nitrite productions during hypoxia and the hypoxia-reoxygenation, whereas, the expressions of the iNOS and NFkappaB p65 proteins were not influenced. CONCLUSION: We concluded that hypoxia-reoxygenation induced the iNOS protein, and the subsequent production of NO in the VSMC. The antioxidants and the NOS inhibitor decreased the NO production during the hypoxia-reoxygenation, but did not affect the expressions of the iNOS and NFkappaB p65 proteins

A Case of Familial Adenomatous Polyposis Combined with Hepatocellular Carcinoma

Familial adenomatous polyposis (FAP) is an autosomal dominant disease characterized by formation of multiple colorectal adenomas with nearly 100 percent potential for malignant transformation. FAP is a rare condition with an incidence of 1 in 10,000 live births. Germline mutations in the adenomatous polyposis coli gene (APC) located on chromosome 5q21 have been founded in many patients with FAP. Patients with FAP can have extracolonic manifestations of their disease. These include tumors of the upper gastrointestinal tract (hamartomatous polyps, adenomas, carcinomas), small intestine adenomas or cacinoma, bile duct adenomas, papillary thyroid carcinoma, osteomas of the mandible, skull, and long bones, a variety of soft tissue lesions, including fibromas, lipomas, and desmoid tumors, congenital hypertrophy of the retinal pigment epithelium (CHRPE) and hepatoblastoma. Hepatocellular carcinoma combined with FAP is a very rare condition. Just 8 cases of Hepatocellular carcinoma with a history of FAP have been reported in the literature. We now present a report of a case of Hepatocellular carcinoma with FAP (Gardner's syndrome) in a 19 year-old girl.

Lichtenstein's Tension-Free Repair of Groin Hernias: A Single-Surgeon Experience with 321 Cases

PURPOSE: Tension-free hernioplasty has become the most popular procedure for the repair of groin hernias in the United States and United Kingdom. The purpose of this study is to describe a 7-year personal experience with Lichtenstein's tension-free groin hernia repair under local anesthesia. METHODS: We retrospectively studied the clinical outcome of 321 cases of Lichtenstein repairs, performed consecutively by an experienced surgeon between Jan. 1994 and Dec. 2000. RESULTS: Of the 321 cases, 242 (75.4%) were indirect, 34 (10.6%) were direct, 8 (2.5%) were femoral, 7 (2.2%) were pantaloon, and 30 (9.3%) were recurred hernias. The mean age was 55 years; 91% were male. The mean number of injections of analgesics required in the postoperative period was 3.2. The mean hospital stay following repair was 2.7 days. Complications occurred in 23 cases (7.1%). Most of these were minor, consisting of five cases of bruising or hematomas (1.6%), four superficial infections (1.3%), three seromas (0.9%), two hydroceles (0.6%), six patients with persisting groin pain for more than a month (1.8%), one foreign body granuloma, one urinary retention, and one testicular atrophy. There were no recurrences or operative deaths. CONCLUSION: Lichtenstein's tension-free hernioplasty is an easy and simple technique with less pain, minor complications and only rare instances of recurrence. This procedure can be performed on a same-day basis under local anesthesia. Lichtenstein repair may be the most promising technique for the repair of groin hernias.

Submucosal Gastric Actinomycosis in a Hematemesis Patient

We experienced a case of submucosal gastric actinomycosis, presenting as bleeding. The 65-year-old woman had a symptom of epigastric pain, without any other intra-abdominal disease entity. A gastrofiberscopic study demonstrated a submucosal mass lesion with bleeding at the fundus. Because of the bleeding, laparotomy was undertaken, and a abscess containing a large mass was found at the gastric fundus, and total gastrectomy undertaken. Histological examination revealed a giant acute ulcer with a submucosal abscess due to actinomycosis. Because of its rarity, submucosal gastric actinomycosis is an entity overlooked by most surgeons. We report upon this case of submucosal gastric actinomycosis and include a review of the literature.

Effect of Guanylate Cyclase Inhibition on the Concentration of Nitrite in Culture Medium of Vascular Smooth Muscle Cell

PURPOSE: Nitric oxide (NO) exerts the relaxant effect in vascular smooth muscle cells (VSMC) by activating soluble guanylate cyclase (sGC), which produces cyclic guanidine monophosphate (cGMP) in the cell. This study was undertaken to investigate the mechanism of the inhibitory actions of sGC inhibitors, LY 83583 and methylene blue in the VSMC. METHODS: VSMC was primarily cultured from rat aorta and confirmed by immunocytochemistry of anti-smooth muscle myosin antibody. Bacterial lipopolysacchride (LPS), an inducer of inducible nitric oxide synthase (iNOS) and sodium nitroprusside (SNP), an NO donor, were uesd to increase NO within VSMC. The changes in concentrations of nitrite in culture media by an addition of LPS or SNP with a pretreatment of LY 83583 or methylene blue were measured by the spectrophotometry with griess regent and absorbance at 550 nm. Western blot and RT-PCR for iNOS and iNOS mRNA, respectively were performed. RESULTS: LPS and SNP increased nitrite concentration. LY 83583 potentiated the increase in nitrite concentration by LPS and SNP. LY 83583 also increased expressions of iNOS protein and mRNA induced by LPS. Methylene blue has no effect on nitrite concentration increased by LPS or SNP, and it did not affect the expressions of iNOS protein or mRNA induced by LPS. CONCLUSION: These results suggest that the mechanism of inhibitory actions of LY83583 and methylene blue on sGC are different each other: LY83583 interferes the interaction of sGC and NO resulting positive feedback increase in iNOS gene expression, but methylene blue eliminates NO from cytosol inducing no compensatory effect.

Surgical Excision of Accessory Axillary Breast Tissues

BACKGROUND: Accessory axillary breast tissue is present in approximately 2% to 6% of women, but receives little attention in the surgical literature. Furthermore, a carcinoma, as well as other pathologic changes, can arise within accessory axillary breast tissue. METHODS: Between January 1990 and December 1997 at our clinic, 83 patients underwent surgical removal of accessory axillary breast tissue. All the patients were female, and the ages ranged from 14 to 57 years, with a median of 33.8. The clinical characteristics, indications, and techniques of surgical removal, pathologic findings, and postoperative results were analyzed. RESULTS: The major clinical manifestations were axillary mass (95.2%), pain and/or tenderness (41%), and cyclic change of size (21.7%). In most patients, these symptoms appeared first during puberty (25.3%) and pregnancy (43.4%). On examination, the mass was in the right axilla in 35 patients (42.2%), the left axilla in 19 patients (22.9%) and both axillae in 29 patients (34.9%), and 3 patients had rudimentary accessory nipples. Surgical removal was performed for cosmetic problems (61.5%), clinical symptoms (21.7%), and suspicion of pathologic lesions (9.6%). The excised breast tissue varied in size from 2.5 cm to 14 cm with a median of 6.2 cm. The pathological findings demonstrated ductal dilatation in 21 patients (25.3%), chronic inflammation in 4 patients (4.8%), fibrocystic changes in 3 patients (3.6%) and lactating adenosis in 2 patients (2.4%). Postoperative complications developed in 8 patients (8.3%), and seroma was the most common. In our study, none of the patients experienced recurrence of disease, and 96.4% of the patients enjoyed cosmetically satisfying outcomes. CONCLUSIONS: In conclusion, from our experience, the treatment of choice for accessory axillary breast tissue is surgical removal, which eliminates the clinical symptoms and the aesthetical deformity and provides tissue to rule out any pathologic changes including malignancy. For cosmetically satisfying outcomes, a scar hidden from sight and balanced shapes of both axillae should be kept in mind during the operation.