Classification and surgical treatment of incisional hernia. Results of an experts' meeting.

BACKGROUND: The treatment of incisional hernia (IH) is a current problem in modern surgery. Many important aspects of incisional hernia surgery are yet to be answered, especially the choice of surgical technique and its adaptation to the individual patient. The aim of this experts' meeting was to resolve some current questions in incisional hernia surgery and to organise an international hernia register. METHODS: An international panel of ten experts met under the auspices of the European Hernia Society (GREPA) to investigate the classification and therapeutic alternatives for incisional hernia. Prior to the conference, all experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The information from this correspondence was used as a basis for panel discussion. The personal experiences of the participants and other aspects of individualised therapy were also considered. RESULTS: The expert panel suggested a new classification of incisional hernia based on localisation, size, recurrences and symptoms. All experts agreed that the fascia duplication and the fascia adaptation should only be used for small incisional hernias. Fascia duplication is of value only in the horizontal direction. The technical details and the pros and cons of each procedure were discussed for prosthetic implantation using onlay and sublay techniques and the technique of autodermal hernioplasty. CONCLUSIONS: The management of incisional hernia is currently not standardised. In order to answer relevant questions of incisional hernia surgery, an international hernia register should be established.

[The Lichtenstein plug method for repair of recurrent inguinal hernia. Indications, technique and results]. / Die Lichtenstein-Plug-Methode zur Reparation von Rezidivleistenhernien. Indikation, Technik und Ergebnisse.

The Lichtenstein plug is a cylindric polypropylene prosthesis by which small recurrent inguinal hernias can be occluded without a formal hernia repair. In a series of 245 recurrent inguinal hernia repairs from 1990 to 1994, the Lichtenstein plug was used for 55 hernias, 22.4% of all recurrencies. Early postoperative complications concerned two hematomas and one sinus formation. Re-recurrence was 3.6% (n = 2/55) after a median follow-up of 30 months. Both recurrencies could again be repaired under local anesthesia. For stage I and II recurrencies the Lichtenstein plug is the least invasive procedure and completes the operative armamentarium to the advantage of patients.

Shouldice is superior to Bassini inguinal herniorrhaphy.

The original Bassini and Shouldice methods for inguinal herniorrhaphy were tested against each other and against their respective variants that avoid permanent suturing of the internal oblique muscle. Seven hundred fifty inguinal hernia repairs were prospectively allocated to 1 of 4 groups: group A: Bassini with absorbable sutures (polyglycolic acid); group B: Bassini with nonabsorbable sutures (polyester); group C: Shouldice with four rows of polypropylene sutures; and group D: Shouldice with two rows of polypropylene sutures. Outcome was correlated to prospectively defined types and risk factors such as direct hernia, repair for recurrent hernia, hernial sac diameter greater than 8 cm, age greater than 70 years, overweight, and chronic bronchitis. Actual (not actuarial) recurrence rates were determined through clinical examination by hospital staff surgeons (not through information by letter or phone) for 93.6% of surviving patients. Local complications exclusive of recurrence, but including the redoubtable and litigious sequelae of testicular atrophy and chronic ilioinguinal pain, were significantly reduced from 6.3% (group B and C) to 2.3% by omitting permanent muscle sutures (groups A and D; P < 0.05). However, the use of slowly absorbable suture material resulted in a disproportionately high recurrence rate of 12.8% in the modified Bassini group A. The original Bassini method, ie, division of the transversalis fascia and repair with nonabsorbable sutures, as was used in group B, had an actual 2-year recurrence rate of 8.7%, still a highly significant difference compared with 3.6% and 2.3% for Shouldice groups C and D, respectively (P = 0.012). For repair of recurrent hernia, the superiority of the Shouldice technique was not statistically significant: re-recurrence rate 7.6% versus 13.5% for the original Bassini group B. Repair of recurrent hernia was the only patient-related risk factor of equal significance as the method of repair. The Shouldice technique is superior to and more than merely a reinvention of Bassini's original method. The omission of muscle sutures is physiologically sound and recommended for the Shouldice operation.

[Lichtenstein patch versus Shouldice technique in primary inguinal hernia with a high risk of recurrence]. / Lichtenstein-Patch versus Shouldice-Technik bei primären Leistenhernien mit hoher Rezidivgefährdung.

209 primary inguinal hernias in patients older than 60 years with high risk for recurrence and for surgery were randomly allocated to Shouldice repair (107 hernias) or Lichtenstein patch (102 hernias). Over a 30 months period there was one recurrence in the Lichtenstein group. The amount of local anesthetic and postoperative pain medication was significantly reduced in the Lichtenstein group, 9.8% of repairs requiring no pain medication at all, and 29.4% none on the first postoperative day. No other hernia repair is as painless, innocuous, and easily performed under local anesthesia as the Lichtenstein patch. Both, Lichtenstein and Shouldice, serve their purpose almost ideally when done correctly.

[Reinforcement of the peritoneal sack using a large prosthesis (Stoppa operation)]. / Verstärkung des Peritonealsacks mittels grosser Prothese (Operation nach Stoppa).

To avoid repeated dissection and repair of used-up defect margins a truly innovative concept of eliminating recurrent hernias has been introduced by Stoppa. A giant prosthesis of polyester is inserted through a sub-umbilical midline incision and envelopes the inferior visceral sac, which is dissected bilaterally. The prosthesis is held in place against the bony pelvis and abdominal musculature by the pressure of the abdominal viscera and without sutures; it has no slit for the spermatic cord and prevents passage of viscera through a hernial orifice, even left open.

[Bassini operation with polyglycolic acid or polyester. A prospective randomized study of 300 cases]. / Bassini-Operation mit Polyglykolsäure oder Polyester. Eine prospektiv randomisierte Studie an 300 Fällen.

In a prospectively randomized trial polyglycolic acid (PGA) was tested against polyester for recurrence rate in Bassini hernia repair. After a median observation period of 2 years a distinct but statistically insignificant difference was found (12.0% recurrence for PGA against 7.0% for polyester). Within prospectively defined risk groups statistically significant differences were found for men (15.4% PGA, 6.4% polyester) and in the presence of at least one of the risk factors obesity, bronchitis, recurrent hernia, size of hernial sac greater than 8 cm, the last of which being the strongest unfavourable variable for PGA.

[Results of surgical therapy of rectal cancer at a regional hospital]. / Ergebnisse der chirurgischen Therapie des Rectumcarcinoms an einem Regionalkrankenhaus.

The results of surgical treatment of 198 unselected consecutive cases of adenocarcinoma of the rectum at a district hospital between January 1, 1977 and June 30, 1985 are analysed. Characteristics of patients at a primary referral center include old age (47.2% greater than or equal to 70 years) and advanced tumor stage (44.4% Dukes C and D). Despite these unfavourable cohort characteristics tumor excision rate was 97.5%, the proportion of sphincter saving resections 72.0%, using exclusively a single layer hand-sutured technique. Operative mortality was 3.6 and 5.5% for sphincter saving resection and abdomino-perineal excision respectively. The uncorrected cumulative probability of survival at five years is 56.1% for women, 35.0% for men, with a definite advantage for sphincter saving resection in both sexes. Uncorrected cumulative probability of survival according to tumor stage was 72.4% for Dukes stages A and B combined, 30.0% for Dukes C and 0 for D. Where oncologically radical rectal and mesorectal excision is possible from the sole abdominal access, there, hand-sutured abdominal anastomosis is also feasible and advantageous due to resorbable suture material. Taking into account the adversities of unselected patient cohorts, progress is still being achieved in rectal carcinoma surgery without "specialisation" but with improving general surgical and anaesthesiologic techniques.

[Food-induced ileus associated with intraperitoneal adhesions]. / Nahrungsmittelileus bei intraperitonealen Adhäsionen.

Six patients were treated for food ileus within a three-year period. In three patients an obstructing phytobezoar (made up of bran, sauerkraut and pumpkin in one case each) was removed at surgery from the small intestine. In three other patients ingestion of a grapefruit, bran and turnip led to an ileus, which lasted for 3-9 days but responded to conservative treatment after 3-9 days. The common finding in all six patients was severe intraperitoneal adhesions of the small intestine (after repeated laparotomies in five, due to Crohn's disease in one). A high content of indigestible roughage in food, antacidity in conjunction with disordered gastric emptying are predisposing factors in phytobezoar formation. In addition to these well documented factors, intraperitoneal adhesions after laparotomy should also make one think of phytobezoar formation. In these circumstances gastrointestinal disorders are not rarely produced by spontaneously expelled phytobezoars. Even a complete ileus can sometimes be successfully treated by conservative measures.

[One-stage anterior resection in the therapy of high rectovaginal fistulas]. / Einzeitige anteriore Resektion in der Therapie hoher recto-vaginaler Fisteln.

In 7 patients a high recto-vaginal fistula was treated by one-stage anterior resection with hand-sutured anastomosis. The etiology of these fistulas outlines the fact that the peritoneum may wall off an inflammatory process more effectively than the vagina. Even under sterile conditions the peritoneal sealing capacity is an important factor in the healing of the rectal anastomosis. The presented hand-sutured technique takes this full into account.

[Inflammatory stenoses of the rectal anastomosis: a complication of nonresorbable suture material]. / Entzündliche Stenosen der Rectumanastomose: Eine Komplikation des nichtresorbierbaren Nahtmaterials.

Inflammatory anastomotic stenosis requiring reoperation developed in 8 patients within 9 months to 12 years after rectal resection. The clinical course in combination with the macroscopic and histologic findings allowed to identify nonabsorbable suture material leading to stenosis trough acute and chronic-proliferative foreign body reactions in all cases. The danger of stenosis arises generally in infectious tissue in which synthetic absorbable are superior to all nonabsorbable materials.

[Anterior single-stage resection with a manual suture as the standard operation of the proximal and middle third of the rectum]. / Einzeitige anteriore Resektion mit manueller Naht als Regeloperation des cranialen und mittleren Rectumdrittels.

Of a total of 146 restorative resections 129 one-stage anterior resections were performed in a series of 203 tumours of the rectum. The hand-sutured one-layer anastomosis, well established for the upper third of the rectum, can be equally well effected after resection of the middle third. For this purpose the dissection of the extraperitoneal rectum is carried down as far as to the pectinate line, comparable to the abdominal phase of rectal excision. When the anococcygeal raphe is cut the pectinate line becomes visible upon traction and the anastomosis is readily established from within the abdomen. After release of traction it glides down into it's narrow final embedment in the depth of the pelvis from which a potential dehiscence never becomes apparent before the 7th postoperative day. By this time conservative management without protective colostomy is possible, provided absorbable suture material and adequate drainage are used. Dehiscence rate was 12.4%, operative mortality 1.5%. Single components of reliability of the anastomosis are particularly well visualized and controlled with the hand-suture technique.

[Pragmatic status determination of transduodenal sphincterotomy]. / Eine pragmatische Standortbestimmung der transduodenalen Sphincterotomie.

Of a total of 1791 biliary tract operations from 1977-1984 transduodenal sphincterotomy was performed in 6.3% of 1720 primary and in 63.4% of 71 secondary operations, altogether in 154 cases. In primary operations papillary and suprapapillary choledocholithiasis was the indication in 83.5% of sphincterotomies. In these cases papillary stenosis is not considered separately because sphincterotomy is the preferred approach to stone removal in retroduodenal choledocholithiasis. Without retroduodenal choledocholithiasis and irreversible, organic papillary stenosis was found in 0.7%, a reversible, functional papillary stenosis in 2.8% of primary cases. However, in secondary operations isolated papillary stenosis without choledocholithiasis was the indication in 24.4% of sphincterotomies. The mean age of these patients was 68, the mean interval to the first operation 26 years. Operative mortality was 1.9% for sphincterotomy, 0.6% for all operations. Late results were satisfactory in 96.3% of sphincterotomies. Endoscopic papillotomy is considered the treatment of choice for residual papillary stenosis after cholecystectomy. When the comparative risks and intraoperative findings are well accounted for, transduodenal sphincterotomy becomes a safe and reliable procedure for the serious and tangible condition of retroduodenal choledocholithiasis.

[The influence of pretreatment with specific antibodies on Renal Xenograft Rejection (author's transl)]. / Beeinflussung der Nierenxenotransplantation durch Vorperfusion mit spezifischen Antikörpern.

26 pig kidneys were perfused in a "Gambro" kidney perfusion machine. The perfusates used were unmodified canine plasma and serum, as well as complement-free plasma, gamma-globulin solutions obtained from dogs immunized against pig leucocytes (ALG) and 2-mercapto-ethanol treated ALG (2 ME-ALG). The typical pig-to-dog xenograft rejection was reproduced by ex vivo perfusion with native dog plasma and serum. Using complement-free dog plasma, ALG and 2 ME-ALG pig kidneys could be perfused for several hours without significant increase in perfusion resistance. 22 pig kidneys, pretreated by perfusion for 2 hours with complement-free dog plasma, ALG and 2 ME-ALG, were transplanted on to the vessels of the neck of recipient dogs. Grafts pretreated with decomplemented dog plasma and 2 ME-ALG were rejected in the usual fashion within 5 to 20 min. Pretreatment with ALG resulted in a prolongation of graft function for 80 to 100 min. It is suggested that ALG exerted a transient blocking effect on the cytotoxic action of recipient IgM resembling passive enhancement; this phenomenon may be limited to sites with low antigen density, corresponding to in vitro findings of passive enhancement on cells with low surface antigen density.

Thoracic endoscopic sympathectomy in palmar and axillary hyperhidrosis.

An endoscopic technique is described for thoracic sympathectomy. After establishment of a pneumothorax, the thoracoscope is introduced into the pleural cavity. The telescope is equipped with a wire electrode, a grasping forceps, and a suction coagulation probe for endoscopic electroresection of the sympathetic trunk. In 63 patients, 124 endoscopic sympathectomies were performed. All patients were relieved of sweating in the hands; 18.6% still had some perspiration of the axilla. Side effects of thoracic sympathectomy were compensatory and gustatory sweating that, in four patients, were more embarrassing than the original form of hyperhidrosis. Fifty-five patients were highly satisfied with the result of endoscopic sympathectomy, which is considered the appropriate minor procedure for the treatment of upper limb hyperhidrosis, causing minimal discomfort to the patient and almost invisible scars.