Bilateral giant inguinoscrotal hernia. Presentation of a novel combined two-stage repair approach.

Giant inguinoscrotal hernia is typically defined as hernia extending below the midpoint of the inner thigh, in the standing position. These hernias can be a demanding surgical problem as replacing bowel contents into the abdomen that can cause a life-threatening increase in intra-abdominal pressures. Various techniques such as preoperative progressive pneumoperitoneum (PPP), debulking of abdominal contents with visceral resections with or without omentectomy and phrenectomy have been suggested. We report the case of a 65-year-old patient with giant bilateral inguinal hernia. We applied a novel two-stage combined approach consisting of PPP with simultaneous single shot injection of botulinum toxin Type A into the anterior abdominal wall, and a second stage laparotomy with hernia repair (Stoppa technique). This technique makes possible the successful treatment of giant inguinal hernias without the need for visceral resection. To our knowledge, this is the first presented case of this combined treatment modality.

Olfactory and Gustatory Function After Bariatric Surgery.

BACKGROUND: Neither hormone levels nor malabsorption alone fully explains the distinct weight loss after bariatric surgery in morbidly obese patients. Postoperatively, patients regularly report a change in the sense of taste and the development of food aversions. Hedonic and sensory components like olfactory and gustatory stimuli significantly affect appetite and flavour. METHODS: We prospectively analysed the orthonasal olfactory and gustatory function with psychophysical testing in 44 patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) or adjustable gastric banding (AGB) and in 23 healthy controls. RESULTS: About 22.7 % of morbidly obese patients were hyposmic, showing significantly lower threshold-discrimination-identification (TDI) scores (p = 0.009) with decreased discrimination and identification ability. In addition, 22.7 % of patients were tested to be limited in gustatory function, with significantly lower taste strip test (TST) scores (p = 0.003). Six months after surgery, olfactory and gustatory function was not different when compared to healthy controls. CONCLUSIONS: Due to obesity, patients frequently show impaired olfactory and gustatory function. Six months after laparoscopic bariatric surgery, both chemosensory functions improve. The TDI test is an appropriate tool to measure olfactory function in obese patients.

Quality of life in patients after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: is it worth the risk?

OBJECTIVE: To investigate the course of health-related quality of life (HQL) over time in patients with peritoneal carcinomatosis (PC) after complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Prospective, single-center, nonrandomized cohort study using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. RESULTS: Ninety patients who underwent CRS and HIPEC for PC in our institution were enrolled in the study. Mean age was 56 years (range 27-77 years) (61% female). Primary tumor was colorectal in 21%, ovarian in 19%, pseudomyxoma peritonei in 16%, an appendix tumor in 16%, gastric cancer in 10%, and peritoneal mesothelioma in 13% of cases. Mean peritoneal carcinomatosis index was 22 (range 2-39). Mean global health status score was 69±25 preoperatively and 55±20, 66±22, 66±23, 71±23, and 78±21 at months 1, 6, 12, 24, and 36, respectively. Physical and role function recovered significantly at 6 months and were close to baseline at the 24-month measurement. Emotional function starting from a low baseline recovered to baseline by month 12. Cognitive and social function had slow recovery on follow-up. Fatigue, diarrhea, dyspnea, and sleep disturbance were symptoms persistent at 6-month follow-up, improving later on in survivors. CONCLUSIONS: Survivors after CRS and HIPEC have postoperative quality of life similar to preoperatively, with most of the reduced elements recovering after 6-12 months. We conclude that reduced quality of life of patients after CRS and HIPEC should not be used as an argument to deny surgical therapy to these patients.

Clinical experiences derived from implementation of an easy to use concept for treatment of wound healing by secondary intention and guidance in selection of appropriate dressings.

The main objective of this case-cohort-type observational study conducted at different Surgical Departments of the Charité-Universitätsmedizin in Berlin was to evaluate the sequential use concept first described by Systagenix Wound Management in 2007. Fifty-two patients with different wound healing by secondary intention were treated for 7 weeks at the Charité-Universitätsmedizin in Berlin. A multidisciplinary team worked together to reach consensus in wound assessment; in classification of infection status according to the criteria described by European Wound Management Association (EWMA); in treatment protocol and on dressings to be used to 'cover' wounds. Before dressing application, all wounds were cleaned from debris. Following the sequential use concept, wounds classified as stages 2 and 3 were dressed with SILVERCEL(®) and TIELLE(®) or TIELLE PLUS(®) to 'clean' the wounds. After 2-3 weeks, treatment was changed to PROMOGRAN PRISMA(®) and TIELLE(®) to 'close and cover' wounds, thus providing optimal wound healing. Wounds classified as non infected were dressed with PROMOGRAN PRISMA(®) and TIELLE(®) during the complete treatment period. Patients were asked to evaluate the treatment using a simplified questionnaire developed at the Charité-Universitätsmedizin in Berlin. Wounds comprised 37 surgical procedures, 8 chronic mixed ulcer, 4 pressure sores, 1 diabetic foot ulcer, 1 venous leg ulcer, and 1 mixed arterial/venous ulcer. At baseline, 12 wounds were classified as stage 3, 38 wounds as stage 2 and 2 wounds as stage 1. After 7 weeks of treatment, all patients showed a positive clinical response to the sequential use treatment. Results of wound size showed a high significant progression of wound healing expressed with a profound reduction of wound area (P in all measurements <0·001, chi-square test) and improved granulation. This study summarises the clinical experiences derived from the evaluation of the sequential use concept in the daily clinical practice of wound treatment. On the basis of the wound healing results, patients' evaluation of treatment and the clinicians' and staff experiences, this concept was implemented at different Surgical Departments of the Charité-Universitätsmedizin in Berlin.

Transvaginal-hybrid vs. single-port-access vs. 'conventional' laparoscopic cholecystectomy: a prospective observational study.

PURPOSE: In the recent past, access to the peritoneal cavity has involved primarily 'natural orifice transluminal' and 'single-port access' techniques, which are based on laparoscopy. The most frequently performed procedure using these new developments is cholecystectomy. Few studies compare more than one 'new' method with the 'golden standard' of laparoscopic cholecystectomy. Here we present the results of the first prospective observational study comparing standard laparoscopic cholecystectomy with single-port cholecystectomy as well as transvaginal-hybrid cholecystectomy. METHODS: Fifty-one patients were included in a prospective observational study (20 four-trocar laparoscopic, 15 transvaginal-hybrid, 16 single-port cholecystectomies). Endpoints of the study were operative time, length of hospital stay and postoperative level of pain (numeric analogue score, while coughing). Conversion rates and complications are reported as well. RESULTS: Median operating times did not differ among all three access methods [55 (35-135) min vs. 65 (35-95) min vs. 68 (35-98) min]. Hospital stay was significantly shorter in the transvaginal-hybrid group [3 (3-12) days] and in the single-port group [3 (1-9) days], compared to the four-trocar laparoscopic group [4 (2-17) days]. Pain score was significantly diminished in the transvaginal-hybrid group during the early postoperative course. CONCLUSIONS: Concerning the length of hospital stay, transvaginal-hybrid cholecystectomy and single-port cholecystectomy appear to be superior to 'conventional' laparoscopic cholecystectomy. Additionally, transvaginal-hybrid access is associated with significantly less pain in the early postoperative course.

Thoracoscopic resection of a combined esophageal leiomyoma and diverticulum: a case report.

We report the case of a 66-year-old male patient with a combined esophageal leiomyoma and diverticulum. On account of the low incidence, there is little literature available with regard to the management of those conditions. Our patient underwent a simultaneous thoracoscopic enucleation of the leiomyoma and resection of the diverticulum. Though endoscopic enucleations of myoma and resections of diverticula have been described earlier, to our knowledge, we are the first, who performed those procedures in a single operation, which seems to be feasible and safe.

Evaluation of postoperative long-term quality of life after laparoscopic anterior partial fundoplication in the treatment of gastroesophageal reflux disease.

BACKGROUND: In the treatment of gastroesophageal reflux disease (GERD), anterior fundoplications are emphasized for their lower risk of complications compared to the posterior approach. AIM: The aim of this study was to evaluate the long-term results of laparoscopic anterior 180 degrees fundoplication in consideration of quality of life and reflux control. METHODS: One hundred and twenty-four patients suffering from GERD underwent laparoscopic anterior 180 degrees fundoplication and were enrolled in this observational trial. After a mean follow-up of 52 months, 95 patients remained in the study. The success of reflux control and the quality of life were assessed using standardized questionnaires (Gastrointestinal Quality of Life Index and Reflux Activity Index scores). RESULTS: Seventy-one patients (75%) reported that the operation was fully successful. Three patients (2%) had no clear opinion, while 21 patients (22%) reported they were poorly or not satisfied. Statistical evaluation of the questionnaires showed a clear difference (p < 0.001) in quality of life scores of patients who needed a continuous postoperative treatment for GERD compared to completely satisfied patients. CONCLUSION: The laparoscopic anterior 180 degrees partial fundoplication for the treatment of GERD can result in satisfying reflux control in long-term outcome, but the postoperative quality of life is severely affected by the success of the treatment.

Taurolidine reduces the tumor stimulating cytokine interleukin-1beta in patients with resectable gastrointestinal cancer: a multicentre prospective randomized trial.

BACKGROUND: The effect of additional treatment strategies with antineoplastic agents on intraperitoneal tumor stimulating interleukin levels are unclear. Taurolidine and Povidone-iodine have been mainly used for abdominal lavage in Germany and Europe. METHODS: In the settings of a multicentre (three University Hospitals) prospective randomized controlled trial 120 patients were randomly allocated to receive either 0.5% taurolidine/2,500 IU heparin (TRD) or 0.25% povidone-iodine (control) intraperitoneally for resectable colorectal, gastric or pancreatic cancers. Due to the fact that IL-1beta (produced by macrophages) is preoperatively indifferent in various gastrointestinal cancer types our major outcome criterion was the perioperative (overall) level of IL-1beta in peritoneal fluid. RESULTS: Cytokine values were significantly lower after TRD lavage for IL-1beta, IL-6, and IL-10. Perioperative complications did not differ. The median follow-up was 50.0 months. The overall mortality rate (28 vs. 25, p = 0.36), the cancer-related death rate (17 vs. 19, p = .2), the local recurrence rate (7 vs. 12, p = .16), the distant metastasis rate (13 vs. 18, p = 0.2) as well as the time to relapse were not statistically significant different. CONCLUSION: Reduced cytokine levels might explain a short term antitumorigenic intraperitoneal effect of TRD. But, this study analyzed different types of cancer. Therefore, we set up a multicentre randomized trial in patients undergoing curative colorectal cancer resection. TRIAL REGISTRATION: ISRCTN66478538.

Long-term results of quality of life after standard laparoscopic vs. robot-assisted laparoscopic fundoplications for gastro-oesophageal reflux disease. A comparative clinical trial.

BACKGROUND: The role of telematic surgical approach in gastro-oesophageal reflux disease (GERD) is still unclear. METHODS: The aim of the study is to assess disease specific symptoms and quality of life in patients with GERD treated with either traditional laparoscopic (TL) or robot-assisted fundoplication using the Da Vinci system (DV) in long-term follow-up. RESULTS: Eighty patients underwent a fundoplication in 2003. Four years later all patients were given a standardized questionnaire and 59 (74%) replied. The TL group included 44 patients (18 male/26 female) and the DV group 15 patients (9 male/6 female); the mean operating time was 116 min for the TL group and 207 min for the DV group (p < 0.001). The mean GIQLI score was 106 points for TL and 107 points in the DV (p > 0.05). CONCLUSIONS: Although a safe and feasible procedure, high functional costs of the Da Vinci system and longer operating time prevent this operation from being the standard surgical procedure for GERD.

Heterotopic ileal pancreas with lipoma and coexisting fibromatosis associated with a rare case of gastrointestinal bleeding. A case report and review of the literature.

CONTEXT: The development of pancreatic tissue outside the confines of the main gland represents a congenital abnormality referred to as heterotopic pancreas. This is a rare pathological and surgical entity which remains mostly asymptomatic. CASE REPORT: We present the case of a 28-year-old male, who was admitted to hospital because of a history of blood in bowel movements. After a normal gastroscopy and colonoscopy, Tc99m-tagged red blood cells scintigraphy showed enrichment in the right lower abdomen. At double-balloon endoscopy, a intraluminal polypoid mass 8 cm in diameter was revealed 120 cm from the ileocecal valve. The initial macroscopic diagnosis was a gastrointestinal stromal tumor. During surgery, the diagnosis of heterotopic pancreas with lipoma and fibromatosis was made. To our knowledge this is the first case of ileal heterotopic pancreatic tissue and lipoma described to date in the literature. CONCLUSION: Ileal heterotopic pancreas is a rare entity with potentially life-threatening complications, local excision being the appropriate indicated treatment.

Application of a solid tumor model to evaluate tumor recurrence after an open or laparoscopic rectal resection in rats.

PURPOSE: We used a solid tumor model to evaluate the influence of laparotomy versus laparoscopy on tumor growth after curative resection for rectal cancer in rats. METHODS: Colon tumor cells (DHD/K12/TRb) were administered intraperitoneally in 15 rats, which were used as solid tumor donors. Twenty-one days later, a 20-mg piece was then implanted in the rectal submucosa of the study rats (n=45). Animals were randomized into 3 groups for rectal resection either open or laparoscopic using either carbon dioxide (CO2) or helium for pneumoperitoneum. Autopsy took place 21 days after resection and tumor recurrence was evaluated. RESULTS: Port-site metastasis was observed after laparoscopy with CO2 (1 animal) and helium (1), whereas intraperitoneal tumor growth was detected in 2 and 3 animals of these groups. No tumor recurrence was observed after open surgery. CONCLUSIONS: Our solid tumor model is a novel neoplastic model that might simulate the clinical situation of an upper rectal carcinoma. It might be helpful to develop new protocols in studying solid tumor biology and different surgical procedures for cancer to address problematic issues in oncologic research.

Robotic-assisted laparoscopic and thoracoscopic surgery with the da Vinci system: a 4-year experience in a single institution.

PURPOSE: We set up a pilot study to evaluate the efficacy of telerobotic surgery using the da Vinci system for several procedures for which traditional laparoscopy (or thoracoscopy) is a standard approach in a single institution. METHODS: We performed fundoplications (hiatal hernia repair and antireflux surgery, n=112), upside-down stomach (14), cholecystectomy (16), gastric banding (3), colectomy (5), esophagectomy (4), sub/total gastrectomy (2), gastrojejunostomy (2), along with thymectomy (100), thoracic symatectomy (11), lobectomy (5), mediastinal parathyroidectomy (5), and left pancreatic resection (1). RESULTS: The median set up time for all procedures was reduced from 25.0 to 10.4 minutes. Conversion to traditional laparoscopy or thoracoscopy occurred in 12 cases and in open surgery in 11 cases. There was no morbidity related to the telerobotic system. CONCLUSIONS: Robotically assisted laparoscopic and thoracoscopic surgery is feasible and safe for a variety of procedures in general, visceral, and thoracic surgery.

Surgical treatment of gastroesophageal reflux disease and upside-down stomach using the Da Vinci robotic system. A prospective study.

So far, the impact of telematic surgical approach in Gastroesophageal Reflux Disease (GERD) is still obscure. In this prospective study, we analyzed the Da Vinci Intuitive Surgical robotic system for antireflux surgery. In April 2003, we set up a pilot study to evaluate the efficacy of laparoscopic telerobotic surgery using the three-arm Da Vinci system. Optimal trocar positions, operating and setup times, conversion rate, intraoperative complications, and perioperative morbidity, as well as mortality rate, were analyzed. The median age was 53 years (range 25-74) in 118 patients (52 female/66 male). In 17 patients, an upside-down stomach- and in 101 GERD was surgical indication. The median operating time has been reduced from 105 min to 91 min after 40 procedures and setup time from 24.5 min to 10.4 min after 10 procedures. The system is safe and it seems to be superior to traditional laparoscopy during dissection in the esophageal hiatus region. This compensates long setup- and operating times. Disadvantages are the high costs, the time to master the setup/system and the necessity of exact trocar positioning.

The tumor suppressive reagent taurolidine inhibits growth of malignant melanoma--a mouse model.

BACKGROUND: The tumor suppressive agent taurolidine (TRD) inhibits tumor growth of more than 30 cell lines in vitro and reduces tumor load in early and advanced stages of neoplastic disease in animals. TRD has been shown to induce apoptosis of melanoma cells in vitro. Therefore, the effects of TRD on disseminated melanoma were evaluated in a mice model. METHODS: After general anesthesia, a midline laparotomy was performed and 1.5 million malignant melanoma cells (B78-D14) were applied in the spleen and 1 million cells at the back (C57BL/6). Animals were randomized and either treated intraperitoneally (i.p., n = 40, 7 days, 12 hourly) or intravenously (i.v., n = 40, 2 days, 12 hourly) with 1%, 2%, or 3% TRD or with Ringer's solution (control group). On day 28, all animals were sacrificed and the total tumor weight and the number of metastatic lesions were determined by two investigators blinded for randomization. RESULTS: The i.p. therapy caused a dose-dependent inhibition of total tumor growth (P = 0.003) and i.p. tumor growth (P = < 0.001), whereas subcutaneous (s.c.) tumor growth was not affected (P = 0.132) compared with the i.p. control group. The i.v. therapy reduced the total tumor growth (P = 0.013) and the s.c. tumor growth (P = 0.016), whereas the i.p. tumor load was not reduced (P = 0.122) compared with the control group. Both i.p. and i.v. therapy with 3% TRD significantly decreased the total number of metastatic lesions. The animal weight was not affected. CONCLUSIONS: The i.p. and i.v. therapies reduce total tumor weight and number of metastatic lesions of disseminated malignant melanoma in a dose-dependent fashion in mice. Our encouraging findings should be further confirmed in clinical studies examining the influence of TRD in patients with disseminated malignant melanoma for whom prognosis still remains dismal.

Retroperitoneal Castleman's tumor and paraneoplastic pemphigus: report of a case and review of the literature.

BACKGROUND: Castleman's disease is a rare lymphoproliferative syndrome. Its etiology and pathogenesis are unclear. The disease can be occasionally associated with a paraneoplastic pemphigus (PNP), an autoimmune mucocutaneous disorder commonly seen in neoplasms of lymphocytic origin. CASE PRESENTATION: We present a case of a 63-year old male patient who was referred for surgical treatment of a lately diagnosed retroperitoneal pelvic mass. The patient had been already treated for two years due to progressive diffuse cutaneous lesions histologically consistent with lichen ruber verucosus and pemphigus vulgaris. Intraoperatively a highly vascularized solid mass occupying the small pelvis was resected after meticulous vascular ligation and hemostasis. After surgery and following immunosuppressive treatment a clear remission of the skin lesions was observed. CONCLUSION: Castleman's tumor should be always suspected when a retroperitoneal mass is combined with PNP. In a review of the literature we found 37 additional cases. Complete surgical resection of the tumor can be curative in most of the cases.

Squamous cell carcinoma arising on a skin graft 64 years after primary injury.

Malignant degeneration of a chronic wound is often described by the term, Marjolin's ulcer. We present a case of a squamous cell carcinoma that developed in a patient 64 years after the initial injury during World War II. Tissue contusion and detachment required repeated surgery and full skin grafting in several hospitals. The patient had a persistent ulcer in the right popliteal region for the last 3 years. Excisional biopsy in our department showed a bifocal low-grade invasive squamous cell carcinoma of the skin. Because of extensive inflammation and previous scar formation it was difficult to determine the status of the surgical margins. Therefore, we proceeded with amputation at the right thigh. Some 6 months after surgery the general condition of the patient remains excellent.

Flank hernia and bulging after open nephrectomy: mesh repair by flank or median approach? Report of a novel technique.

Flank incisions may be associated with flank hernias, which may be complicated with incarceration and strangulation. Furthermore, they may cause a significant limitation of the patient's quality of life. In the period 1997-2006 we performed 15 flank hernia repairs with a prosthetic mesh implantation. From 1997 to 2001 hernias were managed with a standardized mesh implantation through the initial flank incision (seven cases, flank group). Since 2001 we have adopted a novel operative approach in eight patients. Through a median laparotomy and following a transabdominally reduction of the hernia sac, a prosthetic polypropylene mesh [Prolene, Vypro or UltraPro, Ethicon Endo-Surgery (Europe) GmbH, Norderstedt, Germany] overlapping the midline was placed in a sublay technique (median group). The perioperative complication rate was comparable and they consisted mostly of postoperative seromas. A patient from the flank group developed a hernia recurrence two months after surgery. Thirteen patients participated in the annual follow-up for a total follow-up time of five years. In this period we observed only one additional case of hernia recurrence: a patient of the flank group presented with a 3 cm hernia recurrence at the proximal end of the previous operative incision. No recurrence was observed in the median group. As a result the novel technique for open repair of flank incisional hernias we present permits a remodelling of the abdominal wall and is associated with excellent postoperative results.

Does an informative video before inguinal hernia surgical repair influence postoperative quality of life? Results of a prospective randomized study.

PURPOSE: Patients undergoing surgery can be impaired in several health-related quality of life areas. As a result, a modern and effective presentation of medical information before elective surgery is of great importance. Thorough preoperative education of the patient could possibly lead to an improvement of postoperative quality of life. MATERIALS AND METHODS: In a prospective randomized study we examined the influence of a preoperative informative video on the postoperative quality of life of patients undergoing elective surgery for inguinal hernia. Quality of life was assessed with a short form questionnaire (SF-36) preoperatively, on the first postoperative day and 3, 6, and 12 months after surgery. RESULTS: From January 2004 until January 2005, 100 patients were included in the study (video group n = 50 patients, control group n = 50 patients). Quality of life was measured higher in the video group soon after surgery and until 3 months afterwards. In the same group other aspects evaluated such as "global health" and "social role" showed higher values postoperatively and resumption of preoperative activities took place earlier. No difference was detectable 6 months after surgery. CONCLUSION: Informative video presents a modern and cost-effective method for the justified and detailed education of the patient about the several pre-, intra-, and postoperative steps of an elective groin hernia operation. The higher information level and the better conditions of surgical care, as the patients perceive these, lead to a better postoperative quality of life.