Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia.

BACKGROUND: The Shouldice technique is the 'gold standard' of open non-mesh hernia repair. The aim of this study was to compare 5-year recurrence rates after Shouldice and laparoscopic transabdominal preperitoneal patch (TAPP) repair for primary inguinal hernia. METHOD: Men with a primary unilateral inguinal hernia were randomized to either Shouldice or TAPP operation. An independent observer scored the surgeons' performance. Follow-up comprised clinical examination after 1 year, a questionnaire after 2 and 3 years, and a clinical examination after 5 years. RESULTS: Between February 1993 and March 1996, 1183 patients were included. Nine hundred and twenty patients were followed for 5 years, 454 in the TAPP group and 466 in the Shouldice group. Recurrences were evenly distributed between groups throughout the follow-up period. The cumulative recurrence rate after 5 years was 6.6 per cent in the TAPP group and 6.7 per cent in the Shouldice group. Postoperative pain was a risk factor for recurrence after Shouldice operation but not after TAPP repair. There was a correlation between a low surgeon's performance score and recurrence. CONCLUSION: The 5-year recurrence rate is acceptable, with no difference between TAPP and Shouldice repair. Poor operative performance resulted in a higher recurrence rate. The TAPP operation represents an excellent alternative for primary inguinal hernia repair.

Randomized clinical trial of laparoscopic versus open appendicectomy for confirmed appendicitis.

BACKGROUND: Laparoscopy is safe for diagnostic and therapeutic purposes in patients with suspected acute appendicitis. This study compared recovery after laparoscopic (LA) and open appendicectomy (OA) for confirmed appendicitis, carried out by experienced surgeons in an educational setting. METHODS: One hundred and sixty-three patients with laparoscopically confirmed appendicitis suitable for LA were randomized prospectively to either LA or OA in a blinded fashion. The primary endpoint was time to full recovery. Secondary endpoints were operating time, complications, hospital stay and functional status. RESULTS: There was no significant difference between LA and OA in time to full recovery (9 and 11 days respectively; P = 0.225). Operating time was 55 min in the LA group and 60 min in the OA group (P = 0.416). The complication rate was 8.6 and 11.0 per cent respectively (P = 0.696), and median hospital stay was 2 days in both groups (P = 0.192). Functional status was significantly better in the LA group 7-10 days after operation (P = 0.045). CONCLUSION: There was no difference in time to full recovery after LA and OA in patients with laparoscopically confirmed appendicitis. A trend towards better physical activity was noted after the laparoscopic procedure.

Does mesh implantation affect the spermatic cord structures after inguinal hernia surgery? An experimental study in rats.

BACKGROUND: Inguinal hernia repair is the most common operation in general surgery. Prosthetic reinforcement of the inguinal area with polypropylene mesh has increased dramatically in the last decade. The aim of this study was to evaluate how different types of mesh affect the spermatic cord structures. METHODS: Thirty rats were divided into three groups. The spermatic cord was dissected free and a conventional suture repair was performed in group I, an operation mimicking the Lichtenstein operation with a heavyweight polypropylene mesh in group II and the same operation using large pore, lightweighted polypropylene/polyglactin composite mesh in group III. A vasography was performed after 90 days. The cross-sectional area of the vas deferens and s-testosterone from the spermatic vein were measured using the contralateral side as control. Light microscopy of the inguinal canal was performed and inflammation and fibrosis were graded. RESULTS: Vasography revealed patent vas deferens in all animals. In group III, there was a lower s-testosterone in the spermatic vein and a reduced cross-sectional area of the vas deferens on the operated compared to the control side. However, there was no difference in the other groups and there was no significant difference in s-testosterone levels between the groups. There was significantly more inflammation and fibrosis after mesh repair compared to suture repair, but there was no difference between the two mesh groups. Unexpectedly, polyglactin fibres were still seen in specimens in group III after 90 days. CONCLUSION: In conclusion, the only effect on the spermatic cord structures in a rat model is seen as an impaired s-testosterone production and a reduced cross-sectional area of the vas deferens after use of a low-weight composite mesh compared to the control side. No difference in inflammation or fibrosis was found between heavyweight polypropylene mesh and low-weight composite mesh.

Postoperative convalescence after inguinal hernia surgery: prospective randomized multicenter study of laparoscopic versus shouldice inguinal hernia repair in 1042 patients.

Interest in inguinal hernia surgery has increased significantly with the introduction of new operating techniques during the past decade. This multicenter study compared short-term results in patients treated by the laparoscopic transabdominal preperitoneal patch technique (TAPP; n = 518) and the Shouldice technique (n = 524). We evaluated demographics, operative data, complications, hospital stay, postoperative pain, use of cs, functional status, sick leave, and complaints up to 3 months postoperatively. The median operating time was shorter in the Shouldice group (55 vs. 65 min), but there were no significant differences in complication rates, and major complications were rare. The hospital stay was 1 day or less in over 98% of cases in both groups, but more operations were performed on outpatient basis in the Shouldice group. In the TAPP group postoperative pain and analgesic consumption were less, postoperative functional status was better, and sick leave was shorter (10 vs. 14 days). These results show that the two methods are equally safe and have few major complications. The TAPP operation is associated with less postoperative pain, better postoperative functional status, and shorter sick leave, but at the price of a longer operating time.

Endoscopic repair of bilateral inguinal hernias--short and late outcome.

BACKGROUND: In the last decade there have been dramatic changes in the treatment of inguinal hernia with the introduction of mesh techniques including laparoscopic repair. There is still some controversy regarding the treatment of bilateral inguinal hernia but simultaneous operation has gained popularity. The aim of this study was to evaluate the outcome of laparoscopic simultaneous bilateral hernia with regard to complications, recurrence rate, and late discomfort. METHODS: A retrospective analysis was made of 168 patients operated simultaneously for bilateral inguinal hernia using the laparoscopic technique between October 1993 and December 1998. Complications were registered and a follow-up was performed using a combination of questionnaire and selective clinical examination. RESULTS: Complications were seen in 23 patients (13.8%), the majority minor. Ninety-five percent of the patients were followed for a median of 36 months. The recurrence rate was 2.7%. Twenty-six of the follow-up patients (15.5%) reported some discomfort. CONCLUSIONS: We conclude that simultaneous laparoscopic operation for bilateral inguinal hernia is safe, with complications, recurrence rate and late discomfort are equivalent to those seen after unilateral operation.

Isolation and characterization of porcine circovirus type 2 from pigs showing signs of post-weaning multisystemic wasting syndrome in The Netherlands.

Pigs with wasting syndrome were examined for macroscopic and histopathological lesions, and for porcine circovirus (PCV). Histopathological lesions were comparable to those previously documented for post-weaning multisystemic wasting syndrome (PMWS). In addition, in seven out of ten examined PMWS-affected pigs focal-to-slight mononuclear meningitis and focal cerebral mononuclear infiltrates (4 out of 10) were observed. A virus was isolated from organs and sera from pigs showing wasting syndrome. An immunoperoxidase monolayer assay and an indirect immunofluorescence assay were performed on the infected PK-15 and Dulac cell cultures, respectively, and both assays indicated the presence of PCV type 2 (PCV2). The nested-polymerase chain reaction (nPCR) technique, based on the use of PCV2 specific oligonucleotides, revealed specific amplified products of 481 bp. Nucleotide sequence analysis of the entire genome of the Dutch PCV isolate 24657 NL showed a homology with known nucleotide sequences of porcine PCV type 1 (PCV1) and PCV2 isolates of 77.1% and >96%, respectively. This is the first report of the isolation and characterization of PCV2 in PMWS-affected pigs in the Netherlands.

Reduction of the prevalence of pseudorabies virus-infected breeding pigs by use of intensive regional vaccination.

The influence of an intensive vaccination program on prevalence of pseudorabies virus (PRV)-infected breeding pigs was examined in a region where the disease was enzootic. In a 2-year period, significantly (P < 0.005) greater decrease in the prevalence of PRV-infected breeding pigs was observed in herds participating in the regional vaccination program and in herds outside the trial region that intensified PRV vaccination during the study than in herds that applied routine PRV control measures. In the regional vaccination program, introduction of breeding stock from outside the area was significantly (P < 0.05) associated with higher prevalence of PRV-infected pigs at the end of the study. These results indicate that transmission of PRV can be markedly reduced by use of an accurately applied intensive vaccination program.

Intensive regional vaccination with a gI-deleted vaccine markedly reduces pseudorabies virus infections.

The development of marker vaccines against pseudorabies virus (PRV) and companion diagnostic tests have enabled us to perform a unique field trial. In this study, the effect of intensive regional vaccination on pig-finishing herd immunity was directly measured by comparing the seroprevalence of antibodies to glycoprotein I in trial and control groups. The seroprevalence of infected finishing herds in the trial region decreased from 81% at the start of the trial to 19% after 2 years (p < 0.001). The mean seroprevalence of infected pigs in these herds diminished from 49 to 5% (p < 0.001). In the control group, representing routine PRV control, no significant change in seroprevalences was noticed.

[An intrauterine and prenatal fasciola hepatica infection in a dairy herd in South Netherlands]. / Een intra-uteriene en prenatale leverbotinfectie op een rundveebedrijf in Zuid-Nederland.

A intra-uterine infection with Fasciola hepatica in a three years old cow is proved on a milking cow herd in the South of the Netherlands. Two calves showed to have a prenatal infection. Further investigations on the farm revealed a general presence of this parasite.