Incisional hernia treatment with polypropylene graft: results of 10 years.

PURPOSE: To report herein our results of tension-free repair of large incisional hernia with polypropylene mesh using a modification of the method that was described by Usher. METHOD: Two hundred ninety-one patients who were operated on between January 1994 and December 2004 were studied. Two hundred thirty-two patients were female (79.7%), and 59 were male (20.3%). The average follow-up period was 55 months. The patients were evaluated for infection, recurrences, hematoma and seroma formation, sinuses and enterocutaneous fistula formation. RESULTS: Infection was observed in eight patients (2.7%). Graft removal due to infection was encountered only in two patients (0.6%). Recurrence was observed in six patients (2.1%). Two patients (0.6%) developed hematoma while another two developed seroma. No patient developed enterocutaneous fistula. CONCLUSION: By using our modified technique we can decrease the expected complications after tension-free repair of large incisional hernias.

Spigelian hernias: a prospective analysis of baseline parameters and surgical outcome of 34 consecutive patients.

Most of the papers published on spigelian hernia are either case reports or small retrospective series. In this prospective multicenter study, we aimed to outline the specific features of spigelian hernias and patients' characteristics more clearly. Surgeons enrolled patients to be entered into the database as they diagnosed and treated the hernias at will. The baseline and surgical outcome parameters were noted in each patient. A painful mass was the main presenting complaint in half of 34 patients. Accurate preoperative diagnosis was possible in 31 patients. Open intraperitoneal mesh repair was the preferred technique. The mean hospital stay and time until return to normal daily activities were 4.1 and 15.6 days. Although a rare condition, diagnosis of a spigelian hernia is not difficult once remembered. Its surgical repair seems to cause few complications and is very well tolerated by the patient.

Preoperative use of selective COX-II inhibitors for pain management in laparoscopic nissen fundoplication.

BACKGROUND: This randomized, double-blind, prospective, placebo controlled study was planned to determine the effectiveness of selective COX-II inhibitors used preoperatively to alleviate pain after Nissen fundoplication surgery. METHODS: For this study, 60 patients were allocated to four groups at random: group C (celecoxib, 200 mg by mouth), group R (rofecoxib, 50 mg by mouth), group P (placebo, pill), or group D (diclophenac sodium, 75 mg intramuscularly). Postoperative abdominal and shoulder pain experienced by the patient at rest, with motion, and with coughing were assessed. Side effects and postoperative analgesic requirement (tramadol, intramuscular) also were recorded. RESULTS: The median tramadol requirement in the 1st h and total tramadol requirement at the 24th h were higher in group P than in the other study groups (p < 0.01). The pain scores in the first postoperative hour were higher in group P (p < 0.05). CONCLUSIONS: The preoperative use of celecoxib, rofecoxib, or diclophenac in laparoscopic Nissen fundoplication surgery decreases pain intensity and tramadol requirement in the first postoperative hour and has a trarnadol sparing effect in the first 24 h.

Effect of single-dose prophylactic ampicillin and sulbactam on wound infection after tension-free inguinal hernia repair with polypropylene mesh: the randomized, double-blind, prospective trial.

OBJECTIVE: To assess the value of single-dose, intravenous, prophylactic ampicillin and sulbactam (AS) in the prevention of wound infections during open prosthetic inguinal hernia repair by a double-blind, prospective, randomized trial. SUMMARY BACKGROUND DATA: The use of antibiotic prophylaxis during open prosthetic inguinal hernia surgery is controversial, and no prospective trial has been conducted to examine this issue. METHODS: Patients undergoing unilateral, primary inguinal hernia repair electively with the Lichtenstein technique using polypropylene mesh were randomized to receive 1.5 g intravenous AS before the incision or an equal volume of placebo according to a predetermined code of which the surgeons were unaware. Patients with recurrent, femoral, bilateral, giant, or incarcerated hernias or any systemic diseases were excluded. Age, sex, body mass index, American Society of Anesthesiologists score, type of hernia, type of anesthesia, duration of surgery, and use of drains were recorded. Infection was defined according to the criteria of Centers for Disease Control. Patients were evaluated 1 week, 1 month, 6 months, and 1 year after surgery by an independent surgeon. All complications were recorded. Results were assessed using chi-square, Fisher's exact, and Student t tests as appropriate. RESULTS: Between September 1996 and July 1998, 280 patients (140 AS, 140 placebo group) entered the protocol. Four patients from the AS group and seven from the placebo group were excluded because of inadvertent antibiotic administration or follow-up problems. Groups were well matched for all the variables studied and postoperative complications, excluding wound infections, which occurred at a rate of 0.7% in the AS group and 9% in the placebo group (P =.00153). Twelve patients in the placebo group developed wound infections, requiring five repeat hospital admissions in three patients. These three patients suffered deep infections reaching the graft, which resulted in graft loss in two. The single infected patient in the AS group had his graft removed as well because of deep persistent infection. CONCLUSIONS: This study documented a significant (10-fold) decrease in overall wound infections when single-dose, intravenous AS was used during Lichtenstein hernia repair. Deep infections and wound infection-related readmissions were also reduced by the use of AS. Proponents of mesh repairs may therefore be advised to use prophylactic single-dose intravenous antibiotic coverage in the light of the results of this trial. AS proved to be an effective antimicrobial agent.

Direct trocar insertion versus Veress needle insertion in laparoscopic cholecystectomy.

BACKGROUND: Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. The safety of direct disposable shielded trocar insertion for the creation of pneumoperitoneum was assessed by comparing with Veress needle insertion during laparoscopic cholecystectomy (LC). METHODS: One thousand five hundred patients undergoing LC with pneumoperitoneum were included in this study. In 470 patients the Veress needle insertion technique was used, and in 1,030 patients direct trocar insertion technique was used. Patients having indications for open trocar insertion were excluded from the study. RESULTS: Complication rate was significantly higher in the Veress needle group (14% versus 0.9%; P <0.01), and the two major complications, gastric perforation and iliac artery laceration, were also encountered in this group. CONCLUSIONS: Our results suggest that with a lower complication rate, direct insertion of the disposable trocar is a safe alternative to Veress needle insertion technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost/instrumentation and rapid creation of pneumoperitoneum.

The adverse effects of octreotide on the healing of colonic anastomoses in rats.

Octreotide, a long-acting somatostatin analogue, is widely used in gastrointestinal hypersecretory states and also for endocrine tumors in an attempt to inhibit the paracrine hormones. Although it is well known that octreotide inhibits trophic and anabolic hormones, no research has been conducted on its adverse effects on wound healing. In the present study, groups of rats were given 20 mcg/kg/day octreotide and 100 mg/kg/day hydrocortisone, the latter being the negative control group, starting 5 days preoperatively. The colonic anastomoses were assessed for healing on postoperative days (PODs) 5 and 8 by determining the bursting pressure of the anastomoses, performing histopathological analysis, and measuring the hydroxyproline content of the anastomotic tissues. Octreotide was found to affect anastomotic healing negatively on both PODs 5 and 8, but the negative effect of hydrocortisone was significant only on POD 8. No significant difference was found between the adverse effects of the two agents on POD 8. These findings indicated that octreotide has an adverse effect on the healing of colonic anastomoses in rats.

Repair of midline incisional hernias using polypropylene grafts.

We report herein our results of routinely performing tension-free repair for midline incisional hernias larger than 3 cm using a woven polypropylene graft between January 1990 and December 1995. Included in this study were 45 patients, 34 (73.1%) of whom had previously undergone a primary repair which had failed. The follow-up period ranged from 3 to 56 months with a mean of 36 months. Only one patient (2.2%) suffered a recurrence of the hernia. Although three (6.6%) developed a wound infection, one (2.2%) developed a wound sinus, and two (4.4%) developed wound seroma, none of these complications required removal of the graft. The findings of this study led us to conclude that Prolene grafts could be used as routine prosthetic material in the repair of incisional hernias. Moreover, during the follow-up period we observed that the modifications we made in the operative technique had a significantly positive effect on the outcome of the patients.

Effect of haemodynamic variables on surgically created arteriovenous fistula flow.

BACKGROUND: The immediate success and flow rate of a newly constructed arteriovenous fistula is dependent on several haemodynamic factors affecting the inflow and outflow of the fistula. METHODS: In this study we evaluated the effect of preoperative arterial blood pressure, arterial inflow, subclavian venous flow, and operative venous outflow resistance on the immediate success, with special reference to the quantity of the fistula flow in 32 patients undergoing internal arteriovenous fistula operations. Flow measurements were done by utilizing colour flow duplex imaging and measurement of venous resistance of the fistula vein was accomplished indirectly by a newly developed simple system. RESULTS: A preoperative subclavian venous flow rate of less than 400 ml/min was associated with higher rate of immediate failures (P < 0.05) with a negative predictive value of 100% with 100% sensitivity. Regarding immediate failures, no other haemodynamic measurement was found to affect the success of a newly constructed fistula significantly. A linear correlation between the measured haemodynamic values and the quantity of postoperative fistula flow was not found. However, an arterial inflow value of > or = 40 ml/min was associated with higher fistula flow rates (P < 0.05). CONCLUSIONS: The immediate success and flow of a newly constructed arteriovenous fistula is mainly dependent on arterial inflow and subclavian venous flow. An arterial inflow rate of 40 ml/min or more and subclavian venous flow rate of 400 ml/min or more measured by colour flow duplex imaging prior to the operation will be associated with better outcomes, and therefore the use of colour flow duplex imaging is warranted during the evaluation of patients who are candidates for an arteriovenous fistula operation.

Effect of lactulose on bacterial translocation.

OBJECTIVE: To find out if lactulose can prevent the bacterial translocation that is induced by obstructive jaundice in rats. DESIGN: Laboratory experiment. SETTING: Teaching hospital, Turkey. MATERIAL: 50 male Wistar-albino rats. INTERVENTIONS: 10 rats were not operated on and used as controls; 20 rats underwent laparotomy and sham ligation of the common bile duct (CBD); 20 had the CBD ligated alone; and 20 had the CBD ligated and were given oral lactulose 2 ml/day until death. All rats were killed after 14 days. MAIN OUTCOME MEASURES: Presence of Escherichia coli in mesenteric lymph nodes (MLN), and bacterial overgrowth as indicated by counts of E coli in the caecum. RESULTS: There was significantly less bacterial translocation to MLN in the group that had been given lactulose compared with CBD-ligated and lactulose not given (2/20 compared with 8/20, p = 0.06). There was also a significant reduction in the number of Gram negative bacteria in that group (p = < 0.01). CONCLUSION: Lactulose seems to reduce the incidence of translocation from the gut to MLN in rats with obstructive jaundice.

The fate of intraperitoneally retained gallstones with different morphologic and microbiologic characteristics: an experimental study.

Management of intraperitoneally retained gallstones after laparoscopic cholecystectomy (LC) is controversial, as their natural course is not known. This study was undertaken to assess the probable effects of stone morphology and clinically obvious infection on the outcome of retained gallstones in a mouse model. Forty albino mice were divided into four groups. Group I served as the control group (simple laparotomy, n = 10). Groups II, III, and IV (n = 10 in each group) were study groups. "Intact-sterile-cholesterol" (group II), "crushed-sterile-cholesterol" (group III), and "intact" (n = 5) [group IVa] and "crushed" (n = 5) [group IVb] "infected-cholesterol" gallstones aseptically retrieved from three different human patients were implanted to the peritoneal cavity of the animals. Group IV animals were implanted with stones retrieved from an acutely inflamed gallbladder with proven infection. Animals were sacrificed 6 and 12 weeks after the operations. Cultures and tissue samples were obtained. No animal was lost, no microscopic or macroscopic abnormality was observed in groups I and II, and cultures remained negative. In group III, adhesions surrounding the fragmented stones were evident at the 12th week, and no mortality was encountered. The histopathology revealed a fibroblastic reaction, and cultures remained negative in group III. In group IV, three animals from group IVb and one animal from group IVa died because of intra-abdominal sepsis before their sacrifice. All remaining mice showed severe adhesions with localized abscesses at the 12th week. In conclusion, intraperitoneally retained cholesterol gallstones remain inert and do not cause serious peritoneal reaction unless they are crushed into fragments or are from an acutely inflamed gallbladder. It is for this group of patients that laparotomy for total stone clearance is probably not justifiable. Better stone retrieval techniques or even laparotomy may be worthwhile considering in patients with crushed and particularly infected retained stones.

Surgical treatment of hepatic hydatidosis combined with perioperative treatment with albendazole.

OBJECTIVE: To evaluate the effect of albendazole combined with surgery on the incidence of recurrent hydatid disease. DESIGN: Prospective open study. SETTING: Teaching hospital, Turkey. SUBJECTS: 25 patients who presented with hepatic hydatid disease between December 1992 and October 1995. INTERVENTIONS: Albendazole 10 mg/kg/day for a month before ultrasonography and then excision, and then albendazole for a further two months. RESULTS: 2 patients were excluded because the albendazole caused disturbance of liver enzyme activities. Of the remaining 23 patients only 7 had viable cysts on ultrasonography. In 15 patients (65%) the germinal layer was partially or totally destroyed, and in 15 the fluid was either cloudy or stained with bile. During a mean follow up period of 29 months only one patient developed recurrent disease. CONCLUSION: Perioperative treatment with albendazole resulted in fewer recurrences than expected. A longer preoperative period of treatment may increase the success rate; this requires further study.

The safety of total hepatic vascular occlusion in rabbits with acute extrahepatic cholestasis.

The technique of normothermic total hepatic vascular occlusion (THVO) is achieved by concomitant clamping of the inferior vena cava above and below the liver in addition to portal inflow occlusion. In this study we investigated the use of THVO for 45 min in a rabbit model with acute cholestasis of 10 days' duration. In rabbits with normal preoperative liver functions (control group), serum total bilirubin, glutamic-pyruvic transaminase (SGPT), glutamic-oxaloacetic transaminase (SGOT), alkaline phosphate, and gamma-glutamyltranspeptidase levels returned to normal ranges within a week after THVO. In the group with persistent cholestasis THVO was performed 10 days after ligation of the extrahepatic bile duct. Total bilirubin and canalicular enzymes remained high while the SGOT and SGPT peaked and almost returned to the preoperative levels at 7 days following THVO in this group. A third group of animals also underwent THVO 10 days after ligation of their extrahepatic bile ducts with relief of the obstruction with a Teflon stent immediately after THVO. This group also showed the trend of normalization of liver canalicular and parenchymal enzymes and bilirubin by the end of 7 days. This study demonstrated the feasibility of THVO in rabbits with acute extrahepatic cholestasis whether the extrahepatic biliary obstruction persisted or not.

The effect of octreotid on bacterial translocation from the gut. An experimental study.

Octreotid (OC) is a somatostatin (ST) analog which is being increasingly used during the management of various gastrointestinal disorders. This study was undertaken to assess the probable effects of OC on intraintestinal microflora and bacterial translocation. To our knowledge, no previous work has addressed this issue. Ten rats forming the study group were injected 20 micrograms/kg of OC subcutaneously for seven days. A control group (n = 10) received an equal volume of isotonic saline for seven days. All animals were sacrificed on the eighth day and tissue cultures were obtained from the mesenteric lymph nodes, liver, and spleen. Cultures were also made from the caecal content and a piece of terminal ileum was removed for histopathological examination. For statistical analysis, Mann Whitney-U, and Fisher's exact tests were used. Caecal bacterial content, and bacterial translocation were found to be significantly increased in the study group in comparison to the control group (p < 0.05). Among the study group, there was also a statistically significant increase in the caecal bacterial content in rats with evidence of bacterial translocation (p < 0.05). Histopathological evaluation drew a great deal of attention to submucosal edema present in the study group. OC significantly increases bacterial overgrowth, and translocation in rats. Studies on humans are needed to demonstrate similar clinical effects of OC.

Predictive value of colour Doppler ultrasonography in detecting failure of vascular access grafts.

The predictive role of colour Doppler ultrasonography in determining the initial success and long-term patency of polytetrafluoroethylene (PTFE) vascular access grafts for haemodialysis was investigated. Two groups of patients were studied. The upper extremities of 21 patients in the control group were assessed by clinical examination only; those of 17 in a second group (Doppler group) were also assessed by ultrasonography before and after operation. Straight PTFE vascular access grafts were used between the brachial artery and axillary vein in all patients. The median preoperative brachial artery flow rate was significantly lower in patients who later developed graft thrombosis (66 versus 87 ml/min, P < 0.01), as was the median postoperative graft flow rate (480 versus 800 ml/min, P < 0.001). Routine preoperative and postoperative colour Doppler ultrasonography is recommended for every patient in whom a vascular access graft is planned.

The effectiveness of low molecular weight heparin on adhesion formation in experimental rat model.

In our experimental animal model, 50 Winstar-Albino rats were divided into five groups in a randomized manner. After all were anesthesized with ether, laparotomy was performed on each one and the caecum and terminal ileum were scrubbed with a toothbrush until serosal petechial bleedings were seen. In the first group, the abdomen was closed after this procedure. In the second group, the abdomen was closed after application of 0.9% NaCl solution intraperitoneally. In the third group, the abdomen was closed after LMWH (low molecular weight heparin) was given intraperitoneally. In the fourth group, LMWH was given in prophylactic dosage subcutaneously on the day of operation and for the following seven days. In the fifth group, abdomen was closed after heparin was given intraperitoneally. On the fourteenth postoperative day, the rats were sacrificed and intraperitoneal adhesions were scored according to the "Mazuji's Scale". There was a statistically significant difference between group I and group III. No statistically significant difference could be found between group I and group IV (p > 0.05). Between group I and V a statistically significant difference was found (p < 0.005). Again a statistically significant difference was found both between group III and IV (p < 0.05), and between group IV and V (p < 0.001). No such difference was observed between group IV and V (p < 0.05). As a result, in this animal model, LMWH given intraperitoneally to prevent adhesions was found to be more effective than subcutaneous and intraperitoneal heparin application.