[Lumbar hernias in adults. Apropos of 4 cases and review of the literature]. / Les hernies lombaires de l'adulte. Rapport de 4 observations et revue de la littérature.

Lumbar hernias are rare (2% of abdominal wall hernias). Symptomatology consists frequently only of an arch formation seen best with the patient sitting and when coughing. In adults it is twice as frequent in women and on the left side. Acute events, dominated by incarceration of a digestive segment, particularly colic, often suggest the diagnosis (10% of cases). Diagnosis is simple when confronted with a large hernia, but difficulties arise with those less than 5 cm in diameter, often diagnosed as a lipoma or parietal tumor. Conventional radiographs and ultrasound images are usually sufficient to establish the correct diagnosis and to determine the content of the hernial sac, but computed tomography scans can provide data on the exact limits of the defect and allow evaluation of possible problems during surgical repair. Rarely congenital (10%), these hernias occur either secondary to a violent lumbo-abdomino-pelvic injury (25%) or following surgical intervention to the lumbar region (50% of cases). Small hernias can be repaired using the direct approach but larger deficits require the insertion of a reinforcing non absorbable prosthesis. Long term results, both for the 4 cases reported and those published in the literature, were assessed as satisfactory.

[Should routine exploratory laparotomy be performed in the presence of an abdominal wound? Discussion apropos of 176 cases]. / Le dogme de la laparotomie exploratrice doit-il être maintenu en présence d'une plaie de l'abdomen? Discussion à propos de 176 observations.

Management of abdominal wounds is presently the subject of discussion between the partisans of routine laparotomy and those preferring "armed" surveillance. Results of study of a series of 176 abdominal wounds subjected to surgical dogma showed: that the diagnosis of non penetrating wounds (17.6%) was not always evident, due either to their anatomical localization (frontier region wounds) or to insufficient local exploration in urgent cases (6.6% of false-negatives), that the existence of serious clinical signs (50 cases) was always associated with one or more visceral lesions, requiring urgent laparotomy with a morbidity of 20% and a mortality of 8% (4 cases), that in the case of asymptomatic penetrating wounds (96 cases), routine laparotomy did nevertheless allow the diagnosis of visceral lesions in 50 cases (including 23 major lesions) but was of no utility in 46 cases (31.5% of blind laparotomies for the total series). The elevated proportion of useless laparotomies (30% in the literature), the result of a dogmatic attitude, or the risk of a delayed intervention (5 to 8%) in the series practising the selective method, led to a modification in the authors' attitude. The existence of serious signs should obviously result in a laparotomy. In their absence, and when confronted with a penetrating or doubtful (frontier region) wound, an exploratory celioscopy is proposed to ensure complete abdominal exploration, to confirm the presence or absence of penetration, to treat minimal lesions and to perform a classical laparotomy in case of evident necessity.

[Gallstone obstruction of the common bile duct, a severe form of biliary lithiasis. Choice of treatment]. / L'empierrement du cholédoque, une forme grave de lithiase biliaire. Quel traitement choisir?

Collection of 10 or more stones in the extrahepatic common bile duct causes lithiasic obstruction of the CBD, a fairly rare entity observed in less than 10% of cases of bile duct lithiasis. This study is based on 35 cases recorded over 10 years, including 60% in patients aged more than 75 years. Endoscopic treatment was attempted in 28% of patients and was totally successful in one case our of four only because of insufficient removal of obstruction after sphincterotomy. Surgery, either necessary (8 cases) or systematic (25 cases) combines cholecystectomy, choledocotomy and biliary fiberendoscopy for a complete treatment minimizing the risks of residual lithiasis. While biliodigestive anastomoses prevailed (58%) during the first years of this study, external biliary drainage was most often chosen during the last 5 years. This surgery in aged patients still entails high morbidity (25%) and considerable mortality (9%). Better efficacy may be provided in the future by the combination of fiberendoscopic means and of lithotrity for aged subjects at high surgical risks.

[What is the role of elective surgery in diverticular sigmoiditis?]. / Quelle place pour la chirurgie "à froid" dans les sigmoïdites diverticulaires?

From 1981 to 1991 inclusive, 188 operations were carried out for diverticular sigmoiditis. One hundred and thirty-nine patients were operated in emergency for acute complications (123) or fistulae (16), and another 49 had surgery scheduled outside acute crisis periods. Mortality and morbidity respectively are 16.5 and 31% in the first group, against 0 and 12% in the second one. Similarly, the stay in hospital varies from 13 days for scheduled surgery to 23 days for emergent surgery, the latter also requiring to account for risks and for the duration of a second operation that is far from exceptional (40%). Considering the severity of some evolutive complications, the authors advocate early radical surgery for symptomatic diverticular sigmoiditis, after the second crisis or as soon as the first one if it has been severe, and in young subjects and patients at risks.

[Incidentally discovered adrenal tumors. Apropos of 20 cases]. / Les incidentalomes surrénaliens. A propos de 20 cas.

According to Glazer, the term of incidentaloma describes an adrenal tumor discovered incidentally during acomputed tomographyscan and by extension to all masses discovered whatever the imaging process. Twenty patients have been operated during the last 10 years. The discovering circumstances are not specific, except the ecography and CT Scan. Complementary examinations include biological tests aiming at showing a possible hormonal secretion and more specific examinations MIBG scintygraphy and magnetic resonance imaging. The tumors often large (80% more than 5 cm long) and solid (75%) have all been removed by transperitoneal approach (13) or lombotomy. Post operative course was approach unevertful. The histological study showed 6 metastasis, 5 benign kystic lesions, 3 hematomas, 3 adenomas, 2 adrenalcortical carcinoma and 1 ganglioneuroma. A review of the literature series leads us to evaluate the frequency and risk of incidentalomas and to consider the necessary examination and the strategy to be adopted in front of such lesions. The evaluation of hormone status, the recourse to specific imaging seems necessary whereas the guided needle biopsy does not present any risk and should be reserved for very special cases. A decisional scheme is proposed, which ains at removing all voluminous and/or secreting tumors. Small lesions behind 35 mm will have to be examined closely and will be removed if they grow larger or persist.

[Results of surgery in 144 cases for aneurysms of the infra-renal abdominal aorta in patients over 75 years of age]. / Résultats de 114 interventions pour des anévrysmes de l'aorte abdominale sous-rénale chez des patients âgés de 75 ans et plus.

114 patients aged over 75 underwent surgery for aneurysm of the infra-renal abdominal aorta in the University Teaching Hospitals in Nantes and Angers between 1979 and 1988. A retrospective study of these patients was performed to evaluate the immediate and long-term results. The mean age of the patients was 79 (+/- 4) years, the oldest being 94. 70% were men. Half of the patients underwent emergency or semi-emergency surgery (52 cases). Cardiovascular factors (in particular coronary insufficiency in 17% of cases) were the most common risk factors. In all cases grafting after laying open the aneurysm was performed, with an aorto-aortic graft in 32% of patients, an aorto-iliac graft in 37% or an aorto-bifemoral graft in 27% of patients. Combined intestinal revascularisation was performed in 10% of case either involving the inferior mesenteric artery or at least one internal iliac artery; renal revascularisation was performed in 3.5% of cases. 75% of patients underwent simple grafting. The mean duration of hospitalisation was 14 days (+/- 6), including a mean period of 7 days in ICU. 36 patients (31%) died in the first post-operative month. The mortality rate in patients who underwent emergency surgery for a complication of the aneurysm (essentially rupture) was 61% versus 6' for elective surgery. 96% of the patients who survived the first post-operative month were independent at the end of the study or at the time of their death.(ABSTRACT TRUNCATED AT 250 WORDS)

[Infected arterial aneurysms. Anatomo-clinical and surgical aspects apropos of 12 cases]. / Anévrysmes infectieux artériels. Aspects anatomocliniques et chirurgicaux à propos de 12 observations.

Twelve cases of mycotic aneurysm are reported. These rare lesions (2 to 3% of all aneurysms) may affect all arteries. Primary aneurysm is currently the most frequent type observed in France, with onset being related to a bacteremia or septicemia with development on an atheromatous lesion (8 of the 12 cases in this series). Manifestations are often misleading or diagnosis delayed in relation to the infectious process, apart from in rupture, which is the commonest cause of detection of aneurysm (half of the present series). Ideal surgical treatment is exclusion with extra-anatomic revascularization: but revascularization in situ has been reported by many authors (6 of the 12 cases in this series). Localization of aneurysm determines surgical procedure and also very variable mortality rate: 4 of the 12 patients in this series.