Comparison of Long-term Clinical Outcomes according to the Change in the Rectocele Depth between Transanal and Transvaginal Repairs for a Symptomatic Rectocele

PURPOSE: This study was aimed to compare the results of a transanal repair with those of a transvaginal levatorplasty and to determine the long-term clinical outcomes according to the change in the depth of the rectocele after the procedure. METHODS: Of 50 women who underwent a rectocele repair from March 2005 to February 2007, 26 women (group A) received a transanal repair, and 24 (group B) received a transvaginal repair with or without levatorplasty. At 12 months after the procedures, 45 (group A/B, 22/23 women) among the 50 women completed physiologic studies, including anal manometry and defecography, and clinical-outcome measurements. The variations of the clinical outcomes with changes in the depth of the rectocele were also evaluated in 42 women (group A/B, 20/22) at the median follow-up of 50 months. RESULTS: On the defecographic findings, the postoperative depth of the rectocele decreased significantly in both groups (group A vs. B, 1.91 +/- 0.20 vs. 2.25 +/- 0.46, P = 0.040). At 12 months after surgery, 17 women in each group (group A/B, 77/75%) reported improvement of their symptoms. However, only 11 and 13 women (group A/B, 55/59%) of groups A and B, respectively, maintained their improvement at the median follow-up of 50 months. Better results were reported in patients with a greater change in the depth of their rectocele (> or =4 cm) after the procedure (P = 0.001) CONCLUSION: In both procedures, clinical outcomes might become progressively worse as the length of the follow-up is increased.

Comparison of Inguinal Hernia in both Sexes and Laparoscopic Surgery for Female Patients

PURPOSE: Unlike males, inguinal hernia surgery in females is an uncommon surgical procedure. The efficacy of laparoscopic surgery for female hernia must be proven. This study compared the clinical characteristics of male and female hernia as well as the efficacy of laparoscopic surgery with that of open surgery in female hernia. METHODS: From March 2007 to February 2011, one surgeon (C.S.) at the authors' institution operated on 965 patients (male/female=884/81) who were each more than 19 years old. The female patients were divided into the laparoscopic (n=67, TEP/TAPP=66/1) and open surgery groups (n=14). RESULTS: The mean age of the female patients was lower than that of the male patients. The incidence of bilateral and direct hernia was higher in the male patients but the incidence of femoral hernia was higher in the female patients (0.6 vs. 8.6%, p<0.001). Among the 81 female patients, the mean age of the patients with femoral hernia was higher than that of the patients with other types of hernia (56.4+/-12.5/43.0+/-15.1, p<0.026). The operation times and pain scores of the two groups 7 days after surgery were comparable. CONCLUSION: The findings revealed a higher incidence of femoral hernia in the female patients than male patients. Patients with a femoral hernia were older than those with other types of hernia. Therefore, laparoscopic surgery must be considered for elderly female patients who have a high incidence of femoral hernia.

A Totally Extraperitoneal (TEP) Laparoscopic Approach to Incarcerated Inguinal Hernia / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic herniorrhaphy (LH) has an advantage for evaluating the viability of incarcerated bowel. In this retrospective study, we aimed to review the data for use of the TEP technique in treating incarcerated hernias in order to document the feasibility of the laparoscopic procedure. METHODS: During a 2-year period from January 2008 to December 2009, one surgeon (C.S) at our institution operated on 27 patients with acutely (n=3) or chronically (n=24) incarcerated hernia. Incarcerated hernias were divided into acute or chronic types arbitrarily, based on who had symptoms of acute abdominal pain and signs of intestinal obstruction. For acute cases, the TEP procedure was done following laparoscopic transperitoneal evaluation to assess viability of the incarcerated bowel. RESULTS: All patients except one having a femoral hernia were male. Mean age was 41 years old (range, 25~75). No case converted from a laparoscopic to an open procedure. Two acute incarcerated cases contained a segment of small bowel and the other contained small bowel and omentum. All acute cases were operated on successfully on an emergency basis by laparoscopic TEP repair. All chronic cases contained omentum without bowel. In one case of acute and seven cases of chronic type, a small inguinal incision was made to reduce hernia contents. No recurrence was noticed at a mean of 13 months of follow-up. CONCLUSION: If there is no entrapment of bowel in chronic incarcerated cases, the TEP procedure will be satisfactory. It may be reasonable, however, to evaluate viability of bowel transperitoneally before doing a TEP procedure in acute cases.

The Incidence of the Occult Contralateral Hernia in Patients Undergoing Total Extraperitoneal (TEP) Repair of a Left Inguinal Hernia / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic herniorrhaphy (LH) can be used to examine the asymptomatic contralateral side and repair occult contralateral hernias coincidentally with reduced morbidity. In this prospective study, we evaluated the results of diagnostic exploration of the right side during total extraperitoneal (TEP) laparoscopic repair of left side inguinal hernias. METHODS: A prospective study of 100 consecutive male patients undergoing TEP repair by a single surgeon (C.S) between January and June 2008 was conducted. Two cases that had transabdominal preperitoneal (TAPP) prosthetic repair and one intraperitoneal onlay mesh (IPOM) were excluded. We routinely explored the contralateral side to determine the incidence of right side occult hernia. RESULTS: The mean age was 52 (range; 18~82 years). Among the 100 patients, 17 had bilateral, 52 right and 31 left hernias on physical examination prior to surgery. Three of 31 diagnosed preoperatively as left inguinal hernia were confirmed to have occult right hernias (3/31, 9.7%). Among the three patients, two patients with a direct type had the same type of hernia as on the contralateral side (2/10, 20%). Another one patient with an indirect type had direct type of hernia on the contralateral side (1/21, 4.8%). CONCLUSION: Given the low incidence of contralateral side occult hernia with indirect types of hernias, routine exploration may not be indicated during TEP repair. However, it might be, reasonable to explore the contralateral side in patients with a direct type of hernia because of the higher incidence of contralateral occult hernias.

Laparoscopic Resection of Rectal Cancer: Oncologic Results of 110 Patients with Minimum 2-year Follow-up after a Curative Resection

PURPOSE: This study aimed to assess the oncologic outcomes after a laparoscopic resection in rectal cancer patients with minimum 2-year follow-up. METHODS: Among the 312 patients undergoing a laparoscopic rectal cancer resection between Jan. 2000 and Dec. 2004 at Hansol Hospital, 110 patients who had been followed-up for longer than 24 months (mean 33, range 24~56) after the curative resection were included in this study. Two patients (1.8%) received preoperative chemoradiation. Five patients (4.5%) received radiotherapy postoperatively. RESULTS: TNM stage was 0 in 5 patients, I in 25 (22.7%), II in 35 (31.8%), and III in 45 (40.9%). The T stage was as follows; Tis:T1:T2:T3:T4=4.5%:3.6%:25.5%:40.9%:25.5%. A protective ileostomy was performed in nine patients. The mean operative time was 208 minutes, and the mean blood loss was 179 ml. The mean number of removed lymph nodes was 18, and the mean distal margin was 3.0 cm. The radial margin was positive in one case. Conversion was required in three cases (2.7%). The overall morbidity rate was 17.2%. Anastomotic leak age occurred in five patients (5.5%). There was no operative mortality. During 33 months of mean follow-up, distant metastases and local recurrence were seen in 17 (15.5%) and 5 patients (4.5%), respectively. None had port-site recurrence. For the 94 patients with rectal cancer within 12 cm from the anal verge, the rate of local recurrence was 5.3%. The overall survival rate was 88.9% at 3 years (stage 0, I: 100.0%, stage II: 100.0%, stage III: 72.6%). The disease free survival rate was 78.8% at 3 years (stage 0, I: 100.0%, stage II: 88.6%, stage III: 56.9%). CONCLUSIONS: A laparoscopic resection of rectal cancer provides an acceptable safety profile. If the highly selective indications for radiotherapy (6.3%) and the rather high volume of advanced cancers (stage III 40.9%, T3/4 66.4%) of this study are considered, a 4.5% local recurrence rate is promising. Optimal surgery for rectal cancer by using a laparoscopic technique may reduce the need for radiotherapy.

Hirschsprung's Disease in Adults

Hirschsprung's disease is a disorder caused by the absence of ganglion cells in the colon and rectum. It has an incidence of 1 in 5000 births, the majority diagnosed and treated in the neonatal period due to symptoms of intestinal obstruction. Persistence of Hirschsprung's disease into adulthood is very rare. In such patients, prolonged periods of constipation are a common problem. For the diagnosis, a colon study and anorectal manometry are performed, and the presence of the disease is confirmed by an excisional biopsy proving the absence of the ganglion cell in Auerbach and Meissner's plexus. Although various surgical procedures have been performed, there is no obvious optimal choice for treatment of Hirschsprung's disease in adolescents and adults. We experienced two cases of Hirschsprung's disease, confirmed by a rectal biopsy, in 20-year patients. Prior to a definitive operation, a sigmoid loop colostomy was performed due to severe dilatation of the left colon and rectum. Six months later, one patient was treated using Duhamel's procedure, and the other by using a proctosigmoidectomy and coloanal anastomosis. No postoperative complications were observed, and the patients had bowel movements three to four times a day. Despite its infrequent incidence, adult Hirschsprung's disease should be suspected in patients who have had lifelong constipation. Several successful surgical treatments have been used for treatment of patients with adult Hirschsprung's disease. In our cases, the functional results of Duhamels' procedure and of a proctosigmoidectomy with coloanal anastomosis were satisfactory.