Laparoscopic hernioplasty: why does it work?

BACKGROUND: To understand how laparoscopic hernioplasty prevents early recurrence of hernia, we reviewed our first 1,000 patients. We analyzed the patients by age, sex, and hernia type and by whether their hernia was primary or recurrent. METHODS: The 1,000 patients had 1,336 hernias repaired by the transabdominal preperitoneal or the totally extraperitoneal approach. One thousand one hundred seventy-three hernias were primary and 163 were recurrent. The type of hernia found varied with the patient's age (p < 0.001), and with whether the hernia was primary or recurrent (p < 0.001); 14% of primary and 27% of recurrent hernias were complex, a surprisingly high incidence compared to historical controls. RESULTS: With a median follow-up of 2 years, five hernias have recurred and all were due to technical errors. CONCLUSIONS: The laparoscopic repair's success may partially be due to its unique ability to diagnose previously overlooked complex elements. The defects are repaired without creating tension and the groin is reinforced with mesh, eliminating inherent weakness.

Laparoscopic repair of recurrent hernia.

BACKGROUND: Failure rates for recurrent hernioplasties vary from 3% to 30%. To help explain this high incidence of recurrence, we reviewed our 4-year experience using a laparoscopic approach and analyzed the characteristics of the recurrent hernias repaired. METHOD: One hundred fifty-two patients with 173 recurrent hernias and 942 patients with 1,230 primary hernias were laparoscopically repaired using either a transabdominal preperitoneal or a totally extraperitoneal laparoscopic approach. RESULTS: With a median follow-up of 24 months, one recurrence developed in the recurrent and four in the primary group. The incidence of bilateral disease (80% versus 46%), and the complexity of the hernias repaired (28% versus 14%) were significantly increased in the recurrent patients. CONCLUSION: The importance of intrinsic weakness and missed hernias as factors that contribute to the failure of recurrent hernioplasties was supported by our findings. The low early failure rate of our laparoscopic approach suggested that this technique may help in eliminating these causes of failure.

Laparoscopic hernioplasty. TAPP vs TEP.

This study compares the results of two laparoscopic hernioplasties: the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP). Over a 43-month period 1,115 laparoscopic hernioplasties, 733 TAPP and 382 TEP, were performed in 866 patients. There were 11 major complications in the TAPP group (2 recurrences, 6 trocar hernias, 1 small-bowel obstruction, 1 trocar, and 1 dissection injury of the small bowel) compared to 1 recurrence and no intraperitoneal complications in the TEP group. Five TEP procedures required conversion to the TAPP approach, resulting in one umbilical hernia. The median time to return to work did not vary with the approach, but was prolonged in patients compensated for time off, 16 vs 8 days for noncompensated patients. Results suggested that both techniques shortened recovery and eliminated most early failures, but the totally extraperitoneal approach reduced the potential for intraperitoneal complications and may be the procedure of choice in most situations.

Laparoscopic repair of recurrent hernias.

The purpose of this study was to evaluate the results of a laparoscopic approach to recurrent inguinal hernia repair which dissected the entire inguinal floor and repaired all potential areas of recurrence without producing tension. Both a transabdominal preperitoneal and a totally extraperitoneal laparoscopic approach were utilized. Ninety recurrent hernias were repaired in 81 patients. The patients had 26 indirect, 36 direct, and 26 pantaloon recurrent hernias of which eight had a femoral component. In all but one patient the primary operations were open anterior repairs. The median follow-up was 14 months, ranging from 1 to 28 months. Patients returned to normal activities in an average of 1 week. The only recurrence observed was in the one patient whose primary repair was laparoscopic. When the entire inguinal floor of the recurrent hernia was redissected and buttressed with mesh, early recurrence was eliminated and recovery was shortened.

Laparoscopic herniorrhaphy. Transabdominal preperitoneal floor repair.

The purpose of this study was to evaluate the results of a laparoscopic transabdominal preperitoneal (TAPP) approach to inguinal hernia repair which dissected the entire inguinal floor and repaired the indirect, direct, and femoral areas in all patients without tension. In our series, 183 patients had 205 hernia repairs and were followed for more than 6 months. Of this group, 128 hernias were indirect, 55 direct, 22 pantaloon, 26 recurrent, and 22 bilateral. All 12 females and the first 11 males had a single-buttress repair with polypropylene mesh. The other 160 male patients had a double-buttress repair. With median follow-up of 12 months, ranging from 6 to 21 months, no recurrences were found. Patients returned to normal activity in an average of 1 week. Dissection and buttressing of the entire inguinal floor with mesh appeared to solve the problem of early recurrence first seen in laparoscopic herniorrhaphy.

A rare case of 'coccidioidoma' of the breast.

Coccidioidomycosis has been reported in almost every tissue of the human body. The gastrointestinal tract and breast have been uniquely spared from this fungal infection. Despite the exceedingly large number of screening mammographies that are performed every year, to our knowledge subcutaneous breast tissue involvement as the sole presentation or of secondary spread of coccidioidomycosis has not been reported. We describe a patient who showed an unusual manifestation of a coccidioidal breast nodule simulating a neoplasm. The patient had been transiently immunosuppressed by prednisone therapy for presumptive temporal arteritis.

Portal and peripheral vein concentrations of insulin and glucagon after arginine infusion in morbidly obese subjects.

Five morbidity obese subjects with fasting normoglycemia underwent catheterization of portal and peripheral veins immediately prior to jejunoileal bypass surgery. Levels of immunoreactive insulin (IRI), immunoreactive glucagon (IRG), and glucose were determined in simultaneously obtained serum samples before and after infusion of arginine. Portal levels exceeded peripheral levels by at least 50% with IRI and by 30%-40% with IRG. These results were similar to those reported in nonobese subjects and show that in morbid obesity as well as in nonobese states, peripheral insulin to glucagon molar ratios (I/G) underestimate portal I/G. Although hepatic extraction was not specifically measured, the data suggest that the peripheral levels of insulin and glucagon reported in morbid obesity result from alterations in secretion and not altered extraction.

Massive spontaneous hemoperitoneum due to rupture of visceral branches of the abdominal aorta.

Review of 153 cases of massive spontaneous hemoperitoneum following visceral arterial rupture showed that 94% of all young women and 100% of all pregnant women had ruptured congenital splenic artery aneurysms at the time of hemorrhage, whereas young males bled from a variety of sources. Individuals who were 45 years old or older bled either from lesions of the celiac axis or its branches (66%) or from arterial mesenteric system lesions (34%). Only 22% of the older individuals of either sex bled from splenic artery sources. Arterial hypertension was present in 40% and previous or simultaneous intracranial hemorrhage occurred in 9% of the older patients. There were no survivors among those in whom the bleeding source was not operatively controlled. With operation, 79% of the younger patients and 57% of the older ones survived. Results emphasize the high mortality of visceral artery rupture with intraperitoneal bleeding. Prophylactic excision is advised for all complicated aneurysms regardless of age and all uncomplicated aneurysms in healthy individuals, especially in fertile or pregnent women.

Pancreatic pseudocyst: management in fifty-four patients.

The management of pancreatic pseudocyst was reassessed in fifty-four patients: only sixteen (30 per cent) regressed with nonoperative management; six (11 per cent) died of septic complications; and thirty-two (64 per cent) eventually required operation. Most pseudocysts did not regress with nonoperative therapy, thus emphasizing the need of serial clinical and ultrasonic examination at frequent intervals to detect nonresolution or complications requiring earlier operation than previously advocated.

Heparin pretreatment suppresses norepinephrine concentrations in dogs in endotoxic shock.

Mongrel dogs were treated intravenously with either 1000 units of beef-lung heparin per kilogram of body weight or with isotonic saline, before intravenous administration of E. coli endotoxin. We found significant differences in circulating norepinephrine concentrations between a heparin-pretreatment group (1.89 +/- 0.39 microgram/liter) and the control group (9.83 +/- 4.64 microgram/liter), but none with respect to epinephrine. Systolic blood pressures at 360 min were also significantly (P less than 0.05) different, 148 +/- 6 mmHg as compared with 118 +/- 13.4 mmHg. Evidently heparin pretreatment can decrease circulating norepinephrine concentrations in the endotoxic state and changes in circulating catecholamine concentrations can affect physiological variables.

Endoscopic removal of submucosal colonic lipomas.

Although lipomas of the colon are second only to adenomatous polyps in frequency of benign lesions of the large bowel, they occur relatively rarely. These lesions are reported to be symptomatic in 15% to 91% of cases. Endoscopically, the lipoma is soft and pliable and appears globular and covered by pale "normal" tunica mucosa. The treatment of choice is colonoscopy and snare excision because of the potential hazards of bleeding and bowel obstruction and because the diagnosis can be confirmed only by histologic examination.

Antiperistaltic ileal segment in the prevention of ileostomy diarrhea.

Diarrhea, often profuse, accompanied by skin excoriation and nutritional and electrolyte depletion is a major complication of ileostomy. In an attempt to improve the course of these patients, an experimental study using dogs was undertaken to investigate an antiperistaltic ileal segment for the prevention of ileostomy diarrhea. Ileostomies were created in dogs. All the dogs with ileostomies died within nine days of weight loss and massive electrolyte and water depletion. A second group of animals underwent creation of an ileostomy simultaneously, with an antiperistaltic ileal segment placed 30.5 cm proximal to the ileostomy. These dogs maintained their weight and electrolyte and water balance. The stools in the group with the reversed ileal segment became semisolid to solid, compared to the watery diarrhea of dogs with ileostomies only.

Meckel's diverticulum: should it be excised incidentally at operation?

Meckel's diverticulum is the most common congenital abnormality of the small intestine, occurring in about 2 per cent of the population. Complications of a Meckel's diverticulum, including hemorrhage, inflammation, bowel obstruction, and neoplasms, occur in 15 to 33 per cent of cases and invariably demand operative treatment. When signs or symptoms arise from a Meckel's diverticulum, morbidity and mortality are high. Incidental Meckel's diverticulectomy should be performed at any age when the morbidity and mortality of the primary procedure will not be increased substantially.