A novel approach for the treatment of Morgagni hernias: robotic transabdominal preperitoneal diaphragmatic hernia repair.

PURPOSE: We introduce a novel approach to the surgical repair of Morgagni hernias (MHs) utilizing the robotic transabdominal preperitoneal repair (rTAPP) approach. Borrowed from our previous and robust experience with rTAPP repairs for hernias of the anterior abdominal wall, this technique boasts the benefits of hernia sac reduction, the use of an uncoated mesh in an extraperitoneal plane, and minimal fixation leading to lower postoperative pain relative to other approaches. METHODS: To evaluate the effectiveness of this novel approach, five consecutive symptomatic Morgagni hernias (MHs) were repaired with the rTAPP approach. The size of the defect, mesh size, length of stay, follow-up imaging, and follow-up complications were documented for comparison. RESULTS: The size of the MH defects ranged from 4 × 6 cm to 5 × 10 cm. LOS was an average of 1.2 days. Two out of the five patients underwent concomitant repair of a lower abdominal hernias (one Spigelian hernia, and one indirect inguinal hernia). Outpatient follow-up from surgery ranged anywhere from 6 months to 4 years, with most patients receiving follow-up after 1 year. Four out of the five patients received follow-up CT scans to confirm the absence of hernia recurrence. One patient experienced an incisional hernia from the midline 12-mm port site which was repaired 1 year after. CONCLUSION: We propose a new technique for a minimally invasive strategy to treat these complex hernias utilizing an rTAPP technique resulting in minimal length of stay and a durable result in long-term follow-up. The benefits of repair, which include minimal postoperative pain, minimal length of stay, and cost-effective prosthetic mesh hidden from the visceral contents, are consistent with the author's experience for rTAPP repairs for hernias of the anterior abdominal wall.

Luminorefrigeration: vibrational cooling of NaCs.

We demonstrate the use of optical pumping of kinetically ultracold NaCs to cool an initial vibrational distribution of electronic ground state molecules X(1)Σ(+)(v ≥ 4) into the vibrational ground state X(1)Σ(+)(v=0). Our approach is based on the use of simple, commercially available multimode diode lasers selected to optically pump population into X(1)Σ(+)(v=0). We investigate the impact of the cooling process on the rotational state distribution of the vibrational ground state, and observe that an initial distribution, J(initial)=0-2 is only moderately affected resulting in J(final)=0-4. This method provides an inexpensive approach to creation of vibrational ground state ultracold polar molecules.

Photoassociation studies of ultracold NaCs from the Cs 6(2)P(3/2) asymptote.

A combination of pulsed depletion spectroscopy and photoassociation spectroscopy is utilized to assign photoassociation spectra of NaCs. These methods investigate the ab initio Ω = 2 potential energy curve and indicate a previously unknown avoided crossing between the (3)Ω = 1 and (4)Ω = 1 electronic states. We present rotational assignments of deeply bound singlet ground state molecules, an improved C(6) coefficient for the (4)Ω = 1 and assignments for all twenty-three photoassociation resonances detuned from the Cs 6(2)P(3/2) asymptote.

Evaluation of the bony pelvis in classic bladder exstrophy by using 3D-CT: further insights.

OBJECTIVES: To provide a complete look at the bony pelvis in children with classic bladder exstrophy: dimensions, orientation, and relationships. METHODS: Three-dimensional computed tomography was used in 6 boys and 1 girl, 5 of whom underwent primary closure and 2 who underwent reclosure at 4 and 8 months. These exstrophy pelves (intrapelvic angles and osseous dimensions) were compared with 26 age and sex-matched controls. RESULTS: The iliac wing angle was 11.4 degrees larger in the classic bladder exstrophy cases. The sacroiliac joint angle was 9.9 degrees more externally rotated in the exstrophy cases. The pelvis was rotated 14.7 degrees in the superoinferior plane in the exstrophy cases. The mean pubic diastasis was 4.2 cm (0.6 cm in controls). The inter-triradiate distance in the patients with classic bladder exstrophy averaged 6.0 cm (4.2 cm in controls). CONCLUSIONS: These new findings provide a better understanding of the bony pelvis, especially its posterior portion, in patients with classic bladder exstrophy. The results of this study revealed the orientation of the sacroiliac joints to be more externally oriented than previously thought and the pelvis to be rotated inferiorly, a previously unknown observation. Both of these factors will be important in the planning of newer osteotomies and pelvic reconstruction.

The AP diameter of the pelvis: a new criterion for continence in the exstrophy complex?

OBJECTIVE: Reconstructive surgery of bladder exstrophy remains a challenge. By using CT of the pelvis, we suggest a new pre- and post-operative investigative procedure to define the AP diameter (APD) as a predictive criterion for continence in this anomaly. PATIENTS AND METHODS: Three axial CT slices were selected in nine children with exstrophy who had undergone neonatal reconstructive surgery. The three levels selected were the first sacral plate, the mid acetabular plane and the superior pubic spine. We used combined slices to measure: APD = distance between the first sacral vertebra and the pubic symphysis. Pubic diastasis (PD). Three angles defined on the transverse plane of the first sacral vertebra--iliac wing angle, sacropubic angle and acetabular version. RESULTS: In exstrophy, the angles demonstrate opening of the iliac wings and the pubic ramus, and acetabular retroversion compared to controls. Comparisons between controls, continent and incontinent patients reveal that in continent patients, APD increases with growth and seems to be a predictive criterion for continence, independent of diastasis of the pubic symphysis. CONCLUSIONS: We believe that CT of the pelvis with measurements of the APD should be performed in all neonates with bladder exstrophy before reconstructive surgery and for better understanding of the malformation. The APD seems to be predictive and may be a major criterion for continence, independent of PD.

Is there an interchromosomal effect in reciprocal translocation carriers? Sperm FISH studies.

Chromosome translocations have been known to affect disjunction of chromosomes unrelated to the translocation in the mouse and in Drosophila. However, in humans, an interchromosomal effect in chromosome translocations has not been demonstrated. The availability of techniques that allow the study of nondisjunction in sperm cells has permitted us to evaluate the possibility of an interchromosomal effect in male translocation heterozygotes. In this study, multicolor fluorescence in situ hybridization was used to determine levels of disomy for the clinically relevant chromosomes X, Y, 13, 18, and 21 in 332,858 spermatozoa from nine reciprocal translocation heterozygotes and nine controls with normal karyotypes. The specific translocations studied were as follows: t(10;12)(p26.1;p13.3), t(2;18)(p21;q11.2), t(3;19)(p25;q12), t(5;8)(q33;q13), t(11;22)(q23;q11), t(3;4)(p25;p16), t(8;9) (q24.2;q32), t(10;18)(q24.1;p11.2), and t(4;10)(q33;p12.2). Comparisons of disomy rates between carriers and controls were performed by using the Mann-Whitney test. Our results showed that the rates of sex chromosome hyperhaploidy were similar in controls (0.21%) and in translocation carriers (0.19%). Similarly, the frequencies of disomy for chromosomes 13, 18, and 21 did not differ significantly between controls and carriers (0.05% versus 0.08%, 0.07% versus 0.03%, and 0.14% versus 0.20%, respectively). Sex chromosome nondisjunction was more common than nondisjunction of chromosomes 13 and 18 both in controls (P=0.0057) and in carriers (P=0.0008). Similarly, the rates of chromosome disomy for chromosome 21 were higher than those for chromosomes 13 and 18 in both controls (P=0.0031) and translocation carriers (P=0.0057). In our study, the excess of chromosome 21 disomy versus disomy of the other autosomes was more pronounced in carriers than in controls. Thus, although the difference of disomy 21 between controls and carriers was not statistically significant, it is worthy of attention.

Osteotomy and distraction of the anterior segment of the pelvic ring in epispadias repair: case report.

We report a new therapeutic approach for bladder exstrophy and epispadias in one case of failed epispadias repair. The width of the pelvis was measured by what we defined as the anteroposterior diameter (APD) on combined transverse computed tomography (CT) scan cuts of the pelvis. The APD was half the normal value in an incontinent patient with failed epispadias repair. He underwent a supraacetabular osteotomy of the pelvis with progressive anterior distraction of the anterior segment of the pelvic ring. Four months later, hardware was removed, and the APD was near normal value. Within 9 months of follow-up, the patient was dry day and night. We believe that in patients with failed exstrophy and epispadias repair, APD seems to be a predictive criterion for continence, and results of the reconstructive surgery with osteotomy should be improved by distraction of the anterior segment of the pelvic ring.

Meiotic products of two reciprocal translocations studied by multicolor fluorescence in situ hybridization.

The sperm products of two male carriers of reciprocal translocations were studied by fluorescence in situ hybridization (FISH) using a combination of three probes for each translocation. One patient carried a t(2;18)(p21;q11.2), the other a t(8;9)(q24.2;q32). The probes selected included a centromeric marker for each chromosome involved in the translocation plus a third probe distal to the translocation breakpoint of one of the translocation chromosomes. This assay identifies alternate, adjacent 1, adjacent 2, and 3:1 types of meiotic products. It allows the identification of recombination events and also estimation of the frequency of diploidy. For the t(2;18), the frequency of normal and balanced sperm and of adjacent 1, adjacent 2, and 3:1 products was 43.6%, 29. 8%, 10.5%, and 12.8%, respectively. Similar segregation patterns had been reported for this donor by direct sperm karyotyping of sperm cells. For the t(8;9), the frequency of normal and balanced sperm and of adjacent 1, adjacent 2, and 3:1 products was 44.4%, 41%, 3.1%, and 9.4%, respectively. The frequency of complementary adjacent 1 products was statistically different in both the t(2;18) (P < 0. 0001) and the t(8;9) (P < 0.0001) carrier. When the number of adjacent 2 products with one translocation chromosome (regardless of normal or derivative) was compared to the number of adjacent 2 products with the second translocation chromosome (again, regardless of normal or derivative), no statistical difference was noted for either the t(2;18) (P = 0.32) or the t(8;9) (P = 0.69). Recombination events within the interstitial segment of chromosome 2 were statistically higher than those seen in chromosome 18 (P < 0. 0001), whereas in chromosomes 8 and 9, recombination in the interstitial segments was similar (P = 0.64). The rate of diploidy was similar in both the t(2;18) (0.5%) and the t(8;9) (0.6%). Thus, FISH provides chromosome information on the sperm products produced by translocation carriers, although it cannot provide an assessment of the full chromosome complement of the spermatozoon.

The pelvis of fetuses in the exstrophy complex.

By using a three-dimensional computed tomography (CT) scanner, we compared the anatomic features of the pelvis of three fetuses of same gestational age, one with a normal pelvis representing the reference model, one with classic bladder exstrophy, and one with cloacal exstrophy. The tomography slices were selected at the same levels for each case. Three angles expressing external opening of the pelvis were defined. Comparing normal and abnormal pelvises allowed definition of three criteria for the correction of the malformation: (a) the sum of the differential angles gives the amplitude of the correction needed; (b) a supraacetabular osteotomy appears to allow best closure of the pelvic ring; (c) only three slices of a CT scan are needed, which cannot be harmful, especially for neonates. Therefore, we believe that a CT scan of the pelvis should be performed whenever an osteotomy is planned in the surgical reconstruction of bladder and cloacal exstrophy.

Elevated liver function tests in a case of moderate ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome is a recognized complication of ovulation induction. Abnormalities in liver function have been considered to be a rare manifestation of the severe form of ovarian hyperstimulation syndrome (OHSS). A 28 year old woman with primary infertility underwent ovulation induction and intrauterine insemination. She was diagnosed with moderate OHSS and was followed as an outpatient. Early in her course of treatment she complained of upper right quadrant pain. Her work-up included an upper right quadrant ultrasound which showed only moderate ascites. Liver function tests at that time were elevated in a hepatocellular damage pattern. Liver function test elevations, as well as the ovarian hyperstimulation, resolved spontaneously in 10 days. Transient abnormalities in liver function do not appear to be limited to the most sever forms of OHSS.

Augmentation by thyroxine of human granulosa cell gonadotrophin-induced steroidogenesis.

The objective of this study was to investigate the influence of thyroid hormone on gonadotrophin-induced oestradiol and progesterone secretion by human granulosa cells maintained in vitro. Granulosa cells were obtained by aspiration of pre-ovulatory follicles from women undergoing assisted reproductive technology. Ovulation induction was performed with gonadotrophin-releasing hormone agonist, human menopausal gonadotrophin and human chorionic gonadotrophin. Granulosa cells were maintained in vitro in a defined medium with added insulin. Between 48 and 72 h after the initiation of cell culture, oestradiol and progesterone secretion into the medium was determined for granulosa cells growing in serum-free medium with follicle-stimulating hormone (FSH)/luteinizing hormone (LH) and in serum-free medium with FSH/LH and thyroxine added in a concentration range of 10(-10)-10(-7) M. All concentrations of thyroxine used produced a statistically significant increase in oestradiol (range 1.18-1.37 times the amount with FSH/LH alone) and progesterone (range 1.29-1.51 times the amount with FSH/LH alone) secretion.

Influence of thyroxine on human granulosa cell steroidogenesis in vitro.

PURPOSE: The objective of this study was to investigate the influence of thyroid hormone on estradiol and progesterone secretion of human granulosa cells maintained in vitro. METHODS: Granulosa cells were obtained by aspiration of preovulatory follicles of woman undergoing assisted reproductive technology. Ovulation induction was performed with GnRH agonist, hMG, and hCG. RESULTS: Granulosa cells were maintained in vitro in a defined medium with added insulin. Twenty-four-hour estradiol and progesterone secretion into the medium were determined for granulosa cells growing in serum-free medium and in serum-free medium with added T4 in a concentration range of 10(-7) to 10(-11) M. CONCLUSIONS: All concentrations of T4 used produced a statistically significant increase in progesterone secretion (range, 1.39 to 1.60 times the baseline amount). The increase in estradiol secretion reached statistical significance only at a T4 concentration of 10(-8) M (1.24 times the baseline amount).

Use of expanders for protection of viscera during irradiation of pelvic tumors in children.

The authors describe a new technique for radioprotection of pelvic viscera by placement of expanders in the subperitoneal area before irradiation of pelvic tumors. They use round shape sub-cutaneous expanders, the volume corresponding to children's weight. Seven patients were treated with excellent results, and minor complications: 2 rectitis due to unsatisfactory displacement of rectum by the balloon. There were no complications related to the device itself. The prosthesis was easy to withdraw. This method seems a safe and effective technique in protecting viscera.

Thyroid hormone receptor messenger ribonucleic acid in human granulosa and ovarian stromal cells.

OBJECTIVE: To examine whether mRNA for thyroid hormone receptors alpha and beta is present in human granulosa cells in nonstimulated ovaries. DESIGN: Paraffin-embedded sections of ovaries from normally cycling women were analyzed by in situ hybridization with oligonucleotide probes for thyroid hormone receptors alpha and beta. The sense strand oligonucleotide was used as a control for each of the probes. RESULTS: Granulosa cells from the preovulatory antral follicles examined showed positive staining for both the thyroid hormone receptor alpha and beta probes. Positive staining of ovarian stromal cells also was observed for both probes. CONCLUSION: Thyroid hormone receptor mRNAs are expressed in both granulosa cells and ovarian stromal cells found in nonstimulated ovaries. It is, therefore, conceivable that thyroid hormone may play a direct role in human ovarian physiology.

Thyroid hormones in human follicular fluid and thyroid hormone receptors in human granulosa cells.

OBJECTIVE: To demonstrate the presence of thyroid hormone in human follicular fluid (FF) and the binding of antithyroid hormone antibodies in human granulosa cells (GCs). DESIGN: Follicular fluids and GCs collected from women undergoing oocyte retrieval after superovulation. SETTING: In Vitro Fertilization-America/Allegheny General Hospital and Reproductive Sciences Research Laboratories, the Department of Obstetrics and Gynecology, The Medical College of Pennsylvania/Allegheny Campus. MAIN OUTCOME MEASURES: Follicular fluid levels of triiodothyronine (T3) determined by a microparticle enzyme immunoassay and FF levels of thyroxine (T4) determined by a fluorescence polarization immunoassay. Three anti-thyroid receptor antibodies were used to determine the presence of thyroid receptor. The binding of these antibodies in GCs was assessed by fluorescent microscopy and flow cytometry. RESULTS: Both T3 and T4 were present in the FF of eight patients studied. A large majority of the samples of individual fluids fell within the normal range for serum. There was a positive correlation between serum T4 values and FF T4 values. The three antithyroid receptor antibodies showed positive nuclear staining of GCs by fluorescent microscopy. The antibody to all thyroid hormone receptors yielded 35% positive cells by flow cytometry, and the site specific antibody for either the alpha-1 or beta-1 receptors yielded 78% and 44% positive cells, respectively. CONCLUSION: These data demonstrated, for the first time, the presence of T3 and T4 in human FF and the presence of T3 binding sites in human GCs and suggest a role for thyroid hormone in the regulation of human GCs.

[Meconium peritonitis. The value of prenatal diagnosis]. / Péritonites méconiales. Intérêt du diagnostic prénatal.

Over an eight year period (1980-1987), fifteen cases of meconium peritonitis have been studied. As it has been reported, this pathology is still very rare. Ten pregnancies have been followed on by multiple échographies and the prenatal diagnosis of meconium peritonitis, suspected as early as 24 weeks of amenorrhea, has been established in ten cases. Among these, eight infants have been operated on before twelve hours of life, and for the ninth, surgical treatment was not advocated. The most frequent cause of the pathology is a perforation above a bowel obstruction. Two had cystic fibrosis. Of the 15 infants with meconium peritonitis, nine survived, and among these, one with cystic fibrosis and the one that has not been operated. Prenatal diagnosis in meconium peritonitis is of major interest in taking care early infants that will need an urgent surgical operation in most cases.

[The surgeon facing malignant non-Hodgkin's lymphoma of the abdomen in children]. / Le chirurgien face au lymphome abdominal malin non hodgkinien de l'enfant.

From February 1981 to December 1988, 30 children with Abdominal Malignant Non Hodgkin's Lymphoma (NHL) have been followed and treated in the Department of Pediatric Surgery of Saint Vincent de Paul's Hospital. The place of surgery in the Diagnosis, Evolution and Treatment of NHL is defined. In the diagnostic Stage, Surgery should be a fortuitous event, as in some cases of acute Intestinal Intussusception, or Appendicectomy, where lymphoma is an unexpected discovery. In all other cases, a cytologic study of ascites and/or pleural effusion that should be searched, can give a quick and reliable Diagnosis. Exceptionally, a complication of chemotherapy, as a peritonitis, with or without intestinal perforation, require an intervention. Most often in cases of already diagnosed and treated NHL, an abdominal residual mass have to be removed surgically and submitted to careful pathologic examination, to determine further treatment. If in some cases, initial Diagnosis is an unexpected discovery, the treatment of NHL is essentially medical. Surgery takes place in the Remission Evaluation after conventional chemotherapy.

[Esophageal atresia in newborn infants weighing less than 2,000 grams. Apropos of 37 case reports]. / Atrésie de l'oesophage chez les nouveau-nés de moins de 2,000 grammes. A propos de 37 observations.

In a consecutive series of 275 infants with esophageal atresia seen at Saint-Vincent-de-Paul's Hospital (Paris) between 1971 to 1987, the authors report the experience with 37 infants weighed under 2,000 g (13.45%). 19 had severe additional malformations (51.35%) and 10 (27%) had a respiratory distress syndrome. As Abrahamson in 1972 (3), Cozzi an Wilkinson in 1975 (4), Rickham in 1981 (5) reported, according to the criteria suggested in 1962 by Waterston (1), survival rate are related to additional congenital anomalies and initial respiratory distress (pulmonary dysmaturity or pneumonia) but seems more related to maturity (small-for-date babies) than to birth weight. The authors recommend to perform a primary division of the tracheo-esophageal fistula and end-to-end esophageal anastomosis whenever possible.