Laparoscopic repair of recurrent inguinal hernias.

BACKGROUND: Repair of recurrent inguinal hernias is associated with recurrence rates as high as 30% and complication rates higher than for primary hernias. PATIENTS AND METHODS: In a prospective study, results were evaluated after laparoscopic transabdominal preperitoneal hernia repair in 192 patients with 200 recurrent inguinal hernias. A total of 132 hernia repairs followed one previous repair, 41 followed two repairs, 17 followed three repairs, 6 followed four, 3 followed five, and 1 followed six previous repairs. The surgical technique is described. RESULTS: Follow-up ranged from 9 to 31 months (mean 18.4). Twelve patients (6%) had groin seromas or hematomas; 3 (1.5%) had transient thigh numbness. One patient (0.5%) underwent laparoscopy a second time because of a large hematoma. In 1 patient (0.5%), a staple on the n. cutaneus femoris lateralis was removed laparoscopically. Patients described postoperative pain as being much less severe compared with their previous operation. Of the total group, 76% of patients were able to return to work within 2 weeks of surgery. One recurrence (0.5%) occurred after 6 months because of too small a prosthetic mesh. CONCLUSIONS: This laparoscopic technique can be applied to recurrent hernias, even in difficult cases, with low morbidity rates. Recurrence rates as low as for laparoscopic repair of primary hernias can be expected.

Sonography in the postoperative evaluation of laparoscopic inguinal hernia repair.

We evaluated the use of sonography as a means of assessing hernial occlusion and possible postoperative changes such as hematomas or seromas in the inguinal and scrotal regions after 1139 laparoscopic repairs of hernias between August 1992 and November 1994. Changes after laparoscopic hernia repair were found in 307 patients (27%). Hematomas or seromas were seen in 132 patients, protrusion of the prosthetic mesh in 17, mesh infection in two, and small bowel entrapment in an insufficient peritoneal suture in two. Recurrences were diagnosed correctly in six patients, mobile preperitoneal lipomas in five. Sonography is useful in the evaluation of complications after laparoscopic hernia repair, including recurrent hernia. In the absence of symptoms, sonography is not indicated.

[Laparoscopic surgery of inguinal hernia by transperitoneal implantation of an artificial mesh. Technique and early results]. / Laparoskopische Leistenhernienoperation durch transperitoneale Implantation eines Kunststoffnetzes. Technik und Frühergebnisse.

We report on 250 patients with 342 inguinal hernias operated laparoscopically by pre-peritoneal implantation of a prosthetic mesh. 167 hernias were indirect, 175 direct, including 92 bilateral, 71 recurrent and 4 femoral hernias. There were four major complications: two lesions of the urinary bladder, treated in one case by laparotomy and two foreign body reactions against the mesh, which had to be removed. Two recurrences (0.6%) occurred during a 2-12 months follow-up. The mean hospital stay was 4 (3-10) days. Return to full activity was possible after one week.

[The effect of sonography on the therapeutic outcome in posttraumatic, postoperative and inflammatory soft tissue lesions]. / Einfluss der Sonographie auf das therapeutische Vorgehen bei posttraumatischen, postoperativen und entzündlichen Weichteilläsionen.

A total of 135 patients with a suspected diagnosis of post-traumatic, postoperative or inflammatory soft-tissue lesions were examined by ultrasound. The majority of patients (n = 48) showed post-traumatic soft-tissue hematomas with or without muscle rupture. Post-operative hematomas were found in 23 and hematomas after anticoagulation therapy in 4 patients. Inflammatory soft-tissue lesions were diagnosed in 14 patients and inflammatory tendon lesions in 16. The ultrasonographic diagnoses and therapeutic consequences were compared retrospectively. Therapeutic management was based upon the clinical signs and sonographic findings. Ultrasonically guided needle aspiration is of diagnostic value and is performed as a therapeutic modality as well.

[The value of seminal vesicle sonography in transrectal ultrasonic examination of the prostate]. / Die Wertigkeit der Samenbläschensonographie bei transrektalen Ultraschalluntersuchungen der Prostata.

During the course of four and a half years, transrectal sonography was performed in 724 men; in each case the seminal vesicles and prostate were evaluated. In 149 examinations, changes were found in the seminal vesicles and in 143 of these, the sonographic finding suggested that the changes were due to prostatic disease. In 95 histologically proven prostatic carcinomas, infiltration of the seminal vesicles could be demonstrated. In three patients there was an empyema and in three others a malformation of the seminal vesicles. Prostatic sonography is essential for accurate diagnosis of the basic abnormality.

The value of sonography in the diagnosis and follow-up of patients with blunt renal trauma.

Eighty-eight patients with blunt renal trauma were examined sonographically. Rupture of the kidney was diagnosed in 41 patients and contusion of the kidney in 45. The correlation between operative findings, sonography and urography showed positive sonographic findings to be correct in all patients with rupture of the kidney. In 4 patients with normal sonograms, the diagnosis of a contusion was based on the urographic results. Three patients underwent angiography. An intimal lesion was seen in 2 and a tear of the renal artery in 1. The results of our investigation suggest that sonography should be applied in the first place in the evaluation of blunt renal trauma. It is the investigation of choice during follow-up after surgical as well as conservative therapy.

Transrectal ultrasonography as a follow-up method in prostatic carcinoma after external beam and interstitial radiotherapy.

Transrectal ultrasonography and ultrasonometrics were employed for follow-up in a total of 28 prostatic carcinoma patients subjected to external beam or interstitial radiotherapy. These two methods permit more accurate staging of prostatic carcinoma and have also proved to be valuable in the follow-up care of patients suffering from locoregional prostatic carcinoma. Of the 20 patients subjected to external beam radiotherapy four patients initially did not show capsular infiltration, 2B2, 2A2, whereas 16 patients presented with infiltration of the capsule and seminal vesicles. After external beam radiotherapy the ultrasonomorphologic findings of four patients revealed a sharply demarcated capsule and unremarkable seminal vesicles, which indicated tumour regression. Of five patients with infiltration of the pelvic floor and/or seminal vesicles, three showed definite tumour regression, whereas the ultrasonograms of the other two patients demonstrated tumour progression despite radiotherapy. In eight patients the greatest reduction in tumour volume was found one year after interstitial radiotherapy. Only one patient, initially presenting with slight infiltration of the capsule, was shown to have infiltration of the capsule and seminal vesicles after interstitial radiotherapy. At follow-up, evaluation of the echo patterns in these patients was inaccurate on account of the dense echoes reflected by the seeds implanted.

Ultrasound in patients with blunt renal trauma managed by surgery.

We investigated 24 patients with blunt renal trauma by excretory urography plus nephrotomography and ultrasound. The results of these investigations were correlated with the operative findings. The ultrasound diagnosis was correct in 16 of 18 patients with parenchymal injuries. Injuries to the renal pelvis, ureter and renal pedicle were suspected only in connection with excretory urography. Ultrasound provides an excellent inexpensive noninvasive diagnostic tool for the initial diagnostic study of patients with blunt renal trauma.

Clinical significance of sonography of the ureter.

The relevance of sonography compared with conventional methods is demonstrated by means of 103 patients investigated with obstruction of the ureter. The knowledge of the exact topographic anatomy of the ureter in all sections enables the experienced investigator to demonstrate cause and position of ureteral obstruction by sonography in up to 75% of cases. Ultrasound is not sufficiently accurate to be used as the primary modality, but could be the initial modality in specific circumstances such as pregnancy, children or patients with a history of reaction to contrast media.

[Value of sonography following pancreas transplantation]. / Der Stellenwert der Sonographie nach Pankreastransplantation.

The authors report on 15 patients with pancreas transplants hospitalised at their clinic and treated appropriately between 1979 and 1984. Nine of these patients were subjected to control sonography directly after the operation and subsequently once weekly. The sonographic findings were compared with laboratory data and the clinical course of the patients' condition. One woman patient was subjected to control via CT. The clinical findings agreed with the laboratory values and the sonographic results. Hence, sonography after pancreas transplantation is an important "must". However, it is imperative to combine this with suitable laboratory tests and with a close watch on the clinical course in order to arrive at a relevant conclusion.

[Sonographic monitoring in blunt abdominal injuries in children]. / Die sonographische Uberwachung beim kindlichen stumpfen Bauchtrauma.

Sonography is nowadays the most important examination in diagnosing lesions of the parenchymatous organs after blunt abdominal trauma. Also for monitoring this method is recommended. Under the premises of 1. no clinical deterioration, 2. the possibility for repeated ultrasound investigations, and 3. readiness to operate at any moment it is possible to treat traumatized parenchymatous organs conservatively. This is of utmost importance in paediatric surgery because of the risk of overwhelming postsplenectomy infection after splenectomy especially for young children. Examples for conservative treatment for trauma to spleen, liver and kidney are discussed.

[Sonographic diagnosis of an aneurysm of the superior mesenteric artery]. / Sonographische Diagnose eines Aneurysmas der A. mesenterica superior.

This is a report on a patient with a mycotic aneurysm of the superior mesenteric artery proved by histology. Because of a marked intolerance of contrast media we abstained from angiography. It is shown that real-time sonography gives a definite diagnosis, if the multiple vascular structures of the upper abdomen are precisely identified.

[Value of sonography for acute diagnosis and for further examination of blunt abdominal trauma in children]. / Die Bedeutung der Sonographie als Akutdiagnostikum und zur Verlaufsbeobachtung beim stumpfen Bauchtrauma im Kindesalter.

For the investigation of the abdomen following blunt trauma there are, in addition to clinical examination, peritoneal lavage, laparoscopy, sonography, CT and scintigraphy. Sonography has proved particularly reliable without stressing the patient. This has been demonstrated by the examination of 73 children in whom there was only one false positive and no false negative finding. Sonography is valuable not only as a diagnostic method, but is useful for the follow-up of patients with intraperitoneal or retroperitoneal injuries. Particularly in children, a conservative attitude is often justifiable, since recovery frequently follows without surgery (seven out of 30 children in our clinical material, who had sonographic evidence of parenchymal injuries).

[Echographic differential diagnosis of scrotal contents. A contribution to evaluation of the method]. / Echographische Differentialdiagnostik des Skrotalinhaltes. Ein Beitrag zur Wertigkeit der Methode.

Ten patients were selected from a clinical material comprising 336 sonograms of the scrotal contents in order to discuss the differential diagnosis of testicular and extra-testicular conditions. The decision whether a tumour is testicular or extra-testicular does not usually pose a problem, but may be impossible for small peripheral tumours. The shape of the epididymis and vas deferens and the structure of the testes is of significance in the differentiation between torsion and epididymitis. Rare diseases--myxoliposarcoma, infiltrating urothelial carcinomas from the bladder growing along the vas, lymphangiomas--are considered in the differential diagnosis of space-occupying lesions. Lymphangiomas produce a typical appearance on ultrasound. The criteria for the diagnosis testicular trauma, rupture, parenchymal tears and haematocoeles are defined. Differentiating liquid from solid is rarely a problem. A testicular abscess in the presence of chronic orchitis can simulate a solid tumour.

[Percutaneous ultrasound-controlled drainage of liver abscesses]. / Zur percutanen ultraschallgezielten Drainage von Leberabscessen.

By means of 20 liver abscesses in fourteen patients it is described how percutaneous drainage of abscesses can be applied. Method, technique, indications, contraindications as well as possible complications of this procedure are described and illustrated in four cases. In addition both principal differences and common features of percutaneous sonographic drainage and incision of the abscess are described. It is also stated which method is to be preferred in the individual case.

[Use of an improved simultaneous film cassette in linear tomography]. / Anwendung einer verbesserten Simultanschichtkassette in der linearen Tomographie.

An improved simultaneous tomography cassette according to P. Landau was tried out for four months using four tomographs in routine work. The mode of operation is based on accurate control of the relative speeds of the individual x-ray films resulting in simultaneous imaging of 6 equidistant tomographic levels. Clinical testing was effected in 80 cases: nephrotomography, of the lungs, the hilum, and the skeleton. In particular, the article describes imaging of the renal arteries by simultaneous tomography for the purpose of finding out the cause of hypertension, and if there is suspicion of a space-occupying growth in the kidney, basing on the urogram. The specific advantages of this technique are, on the one hand, improved diagnostic efficiency (the tomograms are taken during the same respiratory phase, more rapid diagnosis especially with accident patients), and, on the other hand, an important reduction in the x-ray exposure of the patient; furthermore, the life of the x-ray tube is prolonged, and there is a definite saving of time for both patient and personnel, the image quality being comparable with that of single-layer tomography.

[Diagnosis of congenital pleuropericardial defects]. / Zur Diagnostik angeborener pleuroperikardialer Defekte.

Pleuro-pericardial defects have been found incidentally during post mortems or chest surgery but, because of their usual lack of symptoms, are rarely found otherwise. If suspicion of such a malformation arises, it should be clarified because of possible herniation of the atrium or ventricle. The necessary diagnostic steps are discussed in relation to two patients and the value of chest x-rays is stressed. A pleuro-pericardial defect should be diagnosed because of the typical radiological changes of the cardiac contour. Only in exceptional cases should it be necessary to induce a diagnostic pneumothorax or to perform an exploratory thoracotomy.

[Comparative histopathologic and sonomorphological prostate studies]. / Vergleichende histopathologische und sonomorphologische Prostatauntersuchungen.

Ten cadaver prostates were divided into 50 sections and corresponding sections were compared, using ultrasound, with respect to their echogenic structure and histomorphology. The results of normal prostatic tissues, benign prostatic hyperplasia and prostatic carcinomas are described and discussed. It was shown that malignant prostatic lesions showed echo-poor sonograms in vitro. This observation is supported by our clinical experience. Possible explanations are discussed.

[Sonography of the lower urinary tract]. / Sonographie des unteren Harntraktes.

According to literature and to our experiences sonography should be the first investigation of the lower urinary tract in children, if there is suspicion of obstruction or malformation. In many cases the localisation of obstruction or the diagnosis of malformation can be found. Furthermore by sonographic follow-up studies of ureter obstructions by tumors, by concrements or after surgery, the normal radiographic investigations like urography or retrograde pyelography can be reduced. Sonography is a valuable enrichment for investigations of functional and morphological changes of the urinary bladder, especially for the classification of bladder tumors: whereas the diagnosis of urethral diseases still is found by clinical investigations and conventional radiological procedures.