Role of laparoscopy in management of unexplained chronic abdominal pain

Objective: Patients with chronic abdominal pain [CAP] can undergo numerous diagnostic tests with failure to detect any structural or biochemical abnormality. This study was undertaken to assess the diagnostic and therapeutic role of laparoscopy in patients with unexplained chronic abdominal pain [UCAP]

Patients and Methods: Diagnostic laparoscopy was performed for 56 patients with UCAP not diagnosed by usual clinical examination and investigations. Their mean age was 27.8 years. In 36 patients [64.3%] the diagnostic procedures was extended to operative laparoscopy

Results: UCAP represent 22.6% of the patients complaining of CAP and it is common in females [71.3%] than in males. The most frequent Iaparoscopic findings detected were abdominal adhesions [26.8%], endometriosis [14.2%], chronic appendicitis [12.5%], pelvic varicosities [8.9%], internal ring for clinically undiagnosed indirect inguinal hernia [5.4%], uterine myoma [3.6%] and abdominal-pelvic tuberculosis [1.8%]. In 21.4% of patients with UCAP, laparoscopy did not reveal any pathologic findings in the abdomen. Laparoscopic Operative interventions were in the form of adhesiolysis in 26.8%, ablation of drainage and cauterization of endometriotic tissue in 12.5%, laparoscopic appendectomy in 12.5%, laparoscopic transabdominal preperitoneal hernioplasty in 5.4% and salpingostomy for chronic tubal ectopic in 3.6%. Other lines of treatment were given for 9 patients [16.1%] with pathologic findings. Follow up for 6 months revealed, pain relief in 53.5%, [mitt reduction in 26.7% and persistent pain in 19.8%

Conclusions: Diagnostic laparoscopy in UCAP is a significant procedure, which increase our understanding of many underlying abdominal disorders. However, it should be undertaken only after complete diagnostic evaluation has been carried out. It permits the effective surgical treatment of many conditions encountered at time of diagnostic laparoscopy

Abdominal versus posterior sagittal mesh rectopexy in the treatment of complete rectal prolapse in adults

Background: Several operations have been proposed to correct rectal prolapse, which can be done either via trans abdominal or perineal approach but the best operation for rectal prolapse still remains a controversial subject

Patients and methods: Twenty-four patients with complete rectal prolapse were randomly divided into two groups, group I, comprised 12 patients underwent abdominal posterior mesh rectopexy [APMR] and group II, comprised 12 patients underwent posterior sagittal mesh rectopexy [PSMR]. Preoperative assessment of the patients included full history taking, thorough general examination, meticulous perineal examination with digital assessment of the sphincter tone, barium eneml and colonoscopy. Patients with fecal incontinence were evaluated by anal manometry and endoanal ultrasonograph

Results: Mass protruding through the anus on straining was the commonest complaint in 100%, constipation in 75%, pruritus ani in 62.5% and incontinence to flatus in 25%, to loose stool in 12.5% and to solid stool in 8.3%. The average operative time was 103 minutes in group I [APMR] and 74 minutes in group II [PSMR]. There were no technical problems during both procedures. All patients were followed up regularly for a period ranged between 12 30 months. Recurrence was reported in 2 patients [16.6%] of group II [PSMR] and no recurrence in group I [APMR]. Among the 9 male patients of both groups no postoperative sexual changes were reported. Four patients [33.3%] of group I and 3 patients [25%] of group II had postoperative temporary constipation. The patients presented with preoperative anal incontinence to flatus and to loose stool regained continence within 2 months postoperatively, while 2 patients [one in each group] presented with incontinent to solid stool [8.3%] required surgical correction

Conclusions: In patients who are able to tolerate a major operation without undue risk, the abdominal approach is preferred, because the recurrence rate is low, and the complications rate are acceptable. Posterior sagittal approach may be better for patients with fecal incontinence because of simultaneous post anal repair, however, it is associated with higher incidence of recurrence. Also because of the minimal dissection, short operative time, use of spinal anesthesia, and rapid recovery, this procedure can be used in patients with marked compromised general condition

prospective randomized study of subfascial versus prefascial polypropylene mesh reinforcement of midline wound closure after vertical banded gastroplasty in morbid obese patients

Background: Incisional hernia is a common problem following a midline vertical incision in all patients undergoing open bariatric procedures

Patients and methods: The present study was conducted on 30 morbid obese patients who underwent vertical banded gastroplasty [VBG] operation through upper midline incision. The patients were randomly divided into three groups. Group I: Patients for whom the midline abdominal incisions were reinforced by subfascial preperitoneal polypropylene mesh before closure of the linea alba. Group II: The midline abdominal incisions were reinforced by prefascial subcutaneous polypropylene mesh after closure of the linea alba. Group III: The linea alba was closed en-mass with continues polypropylene No 1 sutures [standard closure]

Results: The mean age was 30.4 years. Twenty-four patients were females [80%] and six were males [20%]. The mean body mass index was 45.4kg/m2. The commonest associated medical conditions were, osteoarthritis detected in 18 patients [60%], hypertension in 17 patients [56.7%], type II diabetes mellitus in 15 patients [50%]. Most of the patients presented with more than one associated medical condition as, osteoarthritis 6' hypertension. The mean time of incision closure was 36 minutes in group I, 31 minutes in group II and 15.4minutes in group III. Early postoperative wound complications were, superficial wound infection in one patient of group I [10%], in 3 patients of group II[30%] and in one patient of group III[10%] . Partial wound disruption in 2 patients of group 11[20%] and in one patient of group III[10%]. Subcutaneous seroma in one patient of group I[10%], 3 patients of group II[30%] and one patient of group III [10%]. During the period of follow up [mean of 22 months], chronic pain at the scar site was reported in 2 patients of group 100%], 3 patients of group II[30%] and one patient of group III[10%]. Incisional hernia reported in 3 patients of group Ill [30%]

Conclusion: The subfascial placement of the mesh has many advantages over prefascial position, as, the possibility of bowel obstruction or fistula formation is not present, likewise, the risks of seroma and wound infection were minimized. The subfascial technique also does not initiate adhesions between the subcutaneous tissue and rectus sheath with subsequent difficult dissection during late dermolipectomy if needed. Subfascial placement of the mesh is a very simple technique and is recommended as an ideal method for closure of the midline abdominal incisions in morbid obese patients

prospective randomized study of tension-free herniorrhaphy [modified Shouldice repair] versus tension-free hernioplasty [Lichtenstein repair] in primary inguinal hernia

Objective: Ideal technique for effective inguinal hernia repair is still controversial

Patients and methods: The presented study was conducted on 80 male patients with uncomplicated unilateral primary inguinal hernia. The patients were randomly selected either for modified Shouldice repair [36 patients] or Liechtenstein repairs [44 patients]. Patients were followed postoperatively for 2 years

Results: The mean age of the patients was 34.4 years for Shouldice group and 32.710! Lichtenstein group. The mean operative time was 74 minutes for modified Shouldice repair and 56 minutes for Lichtenstein repair. No intra-operative complication! occurred in patients of both groups. Postoperatively, in the Shouldn't: group, 18 patients [50%] reported slight pain, 12 [33.3%] reported moderate pain and 6 [17.7%] reported severe pain, while in the Liechtenstein group, 11 patients [25%] reported no pain, 20 patients [45.6%] reported slight pain and 13 [29.4%] reported moderate pain. The patients a] Lichtenstein group required postoperative analgesia less than patients of Shouldice group. The mean hospital stay was 4 days for Shouldice group and 2 days for Lichtenstein group. The mean time of return to unrestricted physical activities was 16 days In Shouldice group and 12 days in the Lichtenstein group. Early postoperative complications were. inguinal seroma reported In one patient [2.8%] of the Shouldice group and in 3 patients [6.9%] of the Lichtenstein group and superficial wound infection In 2 patient! [5.6%] of Shouldice group and in one patient [2.3%] of Lichtenstein group. During the period of follow-up, pain at the surgical site was reported in 6 patients [16.7%] of Shouldice group and in 12 patients [27.3%] of Lichtenstein group, feeling of a foreign body in the groin was reported in 16 patients [36.4%] of Lichtenstein group. There was no statistically significant difference between pre-and postoperative spermogram and Doppler flow parameters for both groups

Conclusion: Both techniques are largely equivalent with advantage for the mesh repair because of easier performance, shorter operative time and rapid return to full physical activities