[Incisional hernia of the abdominal wall. Pathophysiology, etiology and prosthetic repair techniques]. / Eventrations de la paroi abdominale. Physiopathologie, étiologies et techniques de cure avec prothèse pariétale.

Postoperative incisional hernia is defined by 3 essential criteria, based on a perfect clinico-pathological knowledge of the abdominal wall: the site, dimensions, and defect. Two main elements predispose to incisional hernia: infection and mechanical factors. Local and systemic complications, accentuated in large incisional hernias, are respectively defined by two concepts: "incisional hernia lesion" and "incisional hernia disease". Precise assessment of these elements can guide the surgeon's operative strategy. Incisional hernias remain a relatively frequent complication of abdominal surgery. All of these patients generally require surgical repair of the abdominal wall. A French national survey showed that most surgeons now use prosthetic materials in 60% of primary repairs, and in 85% of recurrent cases. After reviewing the biomechanical characteristics and the in vivo behaviour of commercially available prostheses, the technical principles of prosthetic abdominal wall surgery will be considered together with the various implantation sites: retromuscular, intraperitoneal and premuscular. Based on their personal experience of 110 cases of large incisional hernias, treated between 1989 and 1998, the authors recommend the intraperitoneal position using expanded polytetrafluoroethylene, a reliable material which is well tolerated in contact with the viscera.

Foreign material in postoperative adhesions.

OBJECTIVE: The authors determined the prevalence of foreign body granulomas in intra-abdominal adhesions in patients with a history of abdominal surgery. PATIENTS AND METHODS: In a cross-sectional, multicenter, multinational study, adult patients with a history of one or more previous abdominal operations and scheduled for laparotomy between 1991 and 1993 were examined during surgery. Patients in whom adhesions were present were selected for study. Quantity, distribution, and quality of adhesions were scored, and adhesion samples were taken for histologic examination. RESULTS: In 448 studied patients, the adhesions were most frequently attached to the omentum (68%) and the small bowel (67%). The amount of adhesions was significantly smaller in patients with a history of only one minor operation or one major operation, compared with those with multiple laparotomies (p < 0.001). Significantly more adhesions were found in patients with a history of adhesions at previous laparotomy (p < 0.001), with presence of abdominal abscess, hematoma, and intestinal leakage as complications after former surgery (p = 0.01, p = 0.002, and p < 0.001, respectively), and with a history of an unoperated inflammatory process (p = 0.04). Granulomas were found in 26% of all patients. Suture granulomas were found in 25% of the patients. Starch granulomas were present in 5% of the operated patients whose surgeons wore starch-containing gloves. When suture granulomas were present, the median interval between the present and the most recent previous laparotomy was 13 months. When suture granulomas were absent, this interval was significantly longer--i.e., 30 months (p = 0.002). The percentage of patients with suture granulomas decreased gradually from 37% if the previous laparotomy had occurred up to 6 months before the present operation, to 18% if the previous laparotomy had occurred more than 2 years ago (p < 0.001). CONCLUSIONS: The number of adhesions found at laparotomy was significantly larger in patients with a history of multiple laparotomies, unoperated intra-abdominal inflammatory disease, and previous postoperative intra-abdominal complications, and when adhesions were already present at previous laparotomy. In recent adhesions, suture granulomas occurred in a large percentage. This suggests that the intra-abdominal presence of foreign material is an important cause of adhesion formation. Therefore intra-abdominal contamination with foreign material should be minimized.

[Treatment of bilateral inguinal hernia by subperitoneal prosthetic parietoplasty. Value of PTFE]. / Cure de hernie inguinale bilatérale par pariétoplastie prothétique sous péritonéale. Intérêt du PTFE.

This retrospective study reviews 211 patients having sustained a bilateral groin hernia repair during a 3 year period. The procedure was the same for all the patients: via a Pfannensteil approach, a pre peritoneal prosthetic repair is performed, using two ePTFE patches, after resection of the hernial sacs and closure of the parietal gaps. The mean follow up was 2 years. During the post operative course, thirty seven of 211 patients sustained 10 local complications, 9 urethral catheter related complications and 11 residual pain. No prostheses infection or testicular atrophy was observed. Nine patients had recurrences (2.2% of 422 repairs). All the recurrences were due to incorrect technique, eight were successfully re operated on--Expanded PTFE is a reliable prosthetic material, easy to handle and well adapted to preperitioneal hernia repair.

[Humanitarian surgical missions]. / Missions chirurgicales humanitaires.

Humanitarian surgical missions are one of the most promoted aspects of french humanitarian action in the third world through the media. This action, previously limited, is now well-organised and its actors have become real professionals. The working conditions of this kind of surgery, are characterised by its lack of means and insecurity. Logistic, technical and ethic constraints have led to propose specific training suitable for these special conditions.

[Benign non-parasitic splenic cysts. 9 cases]. / Kystes spléniques bénins non parasitaires. 9 observations.

Benign non-parasitic splenic cysts are uncommon. Their diagnosis can benefit from ultrasounds and computed tomography. However, it may be difficult, before surgery, to distinguish between true cysts, which are congenital with epidermal lining, and false cysts, which are consecutive to a trauma, inflammatory or degenerative, without epidermal lining. We report nine cases of non-parasitic splenic cysts and try to determine the preoperative diagnostic approach. To prevent the overwhelming post-splenectomy infection syndrome, conservative surgical treatment is mandatory. Various surgical methods are discussed.

[Peritoneal puncture dialysis in the monitoring and treatment of hemoperitoneum of traumatic origin?]. / Ponction dialyse péritonéale dans la surveillance et le traitement des hémopéritoines d'origine traumatique?

The great diversity of injuries after abdominal wound, need an adapted treatment. When laparotomy is indicated in uncontrollable hemorrhage, peritoneal lavage associated with C.T. scan seems to be interesting in the management of hemoperitoneum with a moderate injury severity score and stable arterial and venous pressures. Three patients were recently managed non operatively with good results. The authors draw up these three cases with inclusion criterias and limits of the method.

[Value of investigation tests in thoracic goiters]. / Intérêt des examens complémentaires dans les goitres plongeants.

Two groups of substernal goiters should be considered fist; the "simples" ones localised in the anterior and superior part of the mediastin. They are most common and less dangerous. By opposition to the "complexes" ones which have relation with the vessels, the airways and the digestive tube. That surgeons would like to approach with security. The study of those retrosternal goiters requires two categories of complementary examinations. One for diagnosis: X Ray standard of the neck and the chest; Echography Biopsy and Radioactive Iodine scintigraphy. Others for localisations to prevent the risks, particularly vascular seeing in the surgery of the substernal goiters: TDM and IRM.

[Perineal anorectal wounds in war surgery]. / Plaies anorectales périnéales en pratique de guerre.

Wounds of perineal rectum represent an emergency by reason of immediate and secondary seriousness, their ultimate sequelas (15%). From their experience, review of the literature, the authors define a surgical attitude available for civilian injuries: terminal colostomy, large drainage, cautious surgical treatment of rectal injury.

[Surgical indications of hyperbaric oxygen therapy]. / Les indications chirurgicales de l'oxygénothérapie hyperbare.

Beside clostridial myonecrosis surgical utilization of hyperbaric oxygen remain unprecise. After review of literature, analysis of their experience, the authors define: principles and effects of hyperbaric oxygen, his position with regard to surgical intervention, its surgical utilizations: unquestionable (non clostridial and clostridial gas gangrene), relative (aerobic cellulitis, diabetic arterial disease), preventive.

[Physical and psychological traumatism. Dialectic of singular tragedy and biology]. / Traumatisme somatique et traumatisme psychique. La dialectique du tragique singulier et du biologique.

A good clinical assessment and a strict hospital's organization characterized essentially by the best climate of cooperation between the different departments permits now to control and to prevent some surgical sequelae. For a long time (approximately the 50's) generalists physicians, psychiatrists, behaviourists, have been limited in diagnosis and treatment afterwards. They could not take preventive measures, because the lack or insufficient acknowledge about this area. In fact, every surgical intervention implies psychic and existential, acute or long term disorders. A briefly summarized clinical case illustrate principles for the practice. The preventive approach of the post-surgical psychic troubles concern a lot of elements related to the patient's environement: social interactions, technic cares, types of drugs, style of relation between the specialized teams and patient, social and professional support and so on... The events, even the apparently minor, have to be enough mastered into the resuscitation's setting. The most important trouble is the "post-traumatic stress disorder" (cf D.S.M. III R), or (in the european traduction) a "névrose traumatique". It is a stress or illness of the whole existence, especially in the case of delayed subtype. The authors emphasize the notion of "second traumatism", often withdrived from social, familial and medical supports.

[Malignant pheochromocytoma]. / Phéochromocytome malin.

A case of metastatic malignant pheochromocytoma which was operated on is discussed. The benefits derived from the most recent localizing techniques such as CT scan and MIBG scintigraphic scanning are stressed. In the case presented these enabled the adrenal tumor to be detected but also demonstrated the presence of a costal metastasis and two metastases in the axial skeleton. A therapeutic trial with MIBG at doses of 100 mCi per treatment only enabled a survival of a little more than one year to be achieved.