Prospective comparison between laparoscopic preperitoneal herniorrhaphy and open mesh herniorrhaphy.

Controversy persists regarding the most effective inguinal hernia repair. The purpose of this study is to compare the complications, charges, patient satisfaction, and recovery time between laparoscopic (LH) and open mesh herniorrhaphy (OH). A nonrandomized prospective analysis of 233 consecutive inguinal hernia repairs was performed over a 12-month period by 27 surgeons. The type of repair was determined by surgeon preference. Cost analysis was performed using anesthesia records and hospital cost. Patient satisfaction and recovery time were evaluated by third-party interview. A total of 113 OHs and 120 LHs were performed; 11 OHs and 42 LHs were bilateral. Patient demographics were equivalent for the two groups. No statistical difference was noted when comparing anesthesia/operating room time between the two groups. The LHs accrued an additional charge of $2254 per case. Complication rates were 4.4 per cent for the OHs and 8.3 per cent for the LHs. All complications were considered minor. No infectious complications or recurrences were noted in either group. Satisfaction rates and pain indices were nearly identical for both OHs and LHs. The LHs had a shorter recovery time by 5.5 days. We conclude that LH is associated with a higher complication rate and cost than OH. Pain indices are similar, but LH has a shorter recovery time.

Laparoscopic management of gallbladder duplication: a case report and review of literature.

Gallbladder duplication is an unusual congenital biliary anomaly, and its laparoscopic management has rarely been described. This is a report of a gallbladder duplication successfully treated with laparoscopic cholecystectomies. Previous cases are summarized, and recommendations for optimal laparoscopic management are presented.

Surgical management of hepatoma.

For the majority patients with HCC, the prognosis is poor. Only a fraction of patients will be resectable at the time of their diagnosis. For the oncologic surgeon caring for such patients, the challenges are multifaceted. First, he or she must have a familiarity with current imaging techniques and reliable support from a radiologist to determine whether a given patient can be technically resectable. We rely most heavily upon the initial diagnostic CT scan followed by the staging CTAP in order to define the resectable patient as clearly as possible. Additionally, the risk of postoperative hepatic failure must be assessed. Careful physical exam, blood chemistries, and volumetric analysis of CT scans demand much judgment on the part of the surgeon. While some patients are clearly capable of undergoing a resection, and others are clearly inoperable due to poor hepatic function, a large group of patients exist in a "gray area" where resection can be entertained but the risk of hepatic failure looms large. In this group the use of the ICG retention test or the 14C-aminopyrine breath test are occasionally useful. Further research into better assessment of hepatic reserve is clearly needed. Once a laparotomy is undertaken, IOUS is a key component of intraoperative staging and the final determinant of resectability. Resection itself must be performed with three goals: Resection of all disease with negative surgical margins, retention of as much hepatic parenchyma as possible in keeping with oncologic principles, and maintenance of hemodynamic stability with minimal transfusion requirements in an effort to minimize the stress of surgery. The combination of vascular control and the porta hepatis (and IVC where necessary), segmental hepatic resection where appropriate, and ultrasonic dissection can accomplish these goals. Intrahepatic recurrence, despite adequate resection, can be expected in many patients, and few will be candidates for a second resection. For this reason, and because most patients are unresectable at presentation, the oncologic surgeon must be familiar with palliative options available for his patients, as well as the surgical management of operable tumors. Close collaboration with one's colleagues in medical oncology, invasive radiology, and gastroenterology are critical to the optimal care of this difficult patient population.

Inferior vena cava leiomyosarcoma.

Leiomyosarcoma of the inferior vena cava is a rare malignancy, and radical resection with negative margins remains the only hope for cure. In this report we cite four cases of this tumor treated at The University of Texas M.D. Anderson Cancer Center with particular emphasis on the use of preoperative chemotherapy. In our patients, preoperative chemotherapy did not adversely affect operative outcomes or survival. The potential benefits of preoperative chemotherapy include control of micrometastases, reduction in tumor size before resection, and in situ evaluation of tumor response to chemotherapy for postoperative adjuvant therapy.

Current strategies for the treatment of hepatocellular carcinoma.

Although hepatic resection for hepatocellular carcinoma is the only known modality that offers an opportunity for cure, the practicing oncologist must be aware of alternative modes of therapy. A multidisciplinary approach between surgeon, medical oncologist, and invasive radiologist is necessary in exploring all potential therapeutic options. The oncologist must not only consider the stage of the tumor, but must also take into account the functional reserve of the nontumor-bearing liver in selecting appropriate therapy. More recently, hepatic transplantation has been recognized as a potential curative modality for specific tumor types and stages. Percutaneous ethanol injection and chemoembolization are excellent palliative measures. However, it remains clear that new and innovative techniques are necessary in the therapeutic, adjuvant, and palliative settings in the comprehensive care of the patient with hepatocellular carcinoma.

Pancreatic cystocholedochostomy. First report of a case.

The treatment of choice for most persistent, mature pseudocysts of the pancreas is internal drainage. Cystogastrostomy, cystojejunostomy with a Roux-en-Y loop, and, less frequently, cystoduodenostomy are the surgical techniques most commonly employed to attain effective internal drainage. We present the case of a patient with a pseudocyst arising from the cephalic portion of the pancreatic head and extending into the porta hepatis, causing obstructive jaundice, who was treated by cystocholedochostomy. This simple procedure was performed after an intraoperative cholangiogram showed no ductal obstruction distal to the pseudocyst. A cholecystectomy was also done, and the common bile duct was drained with a T tube. This expeditious procedure, rather than a Roux-en-Y cystojejunostomy, was elected because of the firm adherence of the posterior wall of the common bile duct to the anterior surface of the pseudocyst. The patient had an uncomplicated recovery and has been completely asymptomatic for 2 years. We believe this is the first report of a pancreatic cystocholedochostomy for a pancreatic pseudocyst.

An alternate method for determining the proliferative status of transplantable murine stem cells.

A simple method for determining the fraction of transplantable hematopoietic stem cells (CFUS) in the S-phase of cell cycle is described and evaluated. The method involves the administration of hydroxyurea to the lethally-irradiated assay animal concomitantly with the cell transplant. With this method, S-phase estimates are equivalent to those obtained with other, more traditional, methods. In addition, the method may prove advantageous in situations where the cell yield is too low for in vitro incubation with 3H-TdR or when ex vivo cell manipulations must be avoided.