Surgery and diagnostic imaging in abdominal Crohn's disease.

Surgery is well-established option for the treatment of Crohn's disease that is refractory to medical therapy and for complications of the disease, including strictures, fistulas, abscesses, bleeding that cannot be controlled endoscopically, and neoplastic degeneration. For a condition like Crohn's disease, where medical management is the rule, other indications for surgery are considered controversial, because the therapeutic effects of surgery are limited to the resolution of complications and the rate of recurrence is high, especially at sites of the surgical anastomosis. In the authors' opinion, however, surgery should not be considered a last-resort treatment: in a variety of situations, it should be regarded as an appropriate solution for managing this disease. Based on a review of the literature and their own experience, the authors examine some of the possibilities for surgical interventions in Crohn's disease and the roles played in these cases by diagnostic imaging modalities.

A modified Lichtenstein hernia repair using fibrin glue.

In recent years, general surgeons who perform inguinal hernia repair have paid attention to successful reduction in the recurrence rate. The Lichtenstein technique is widely used because it is easy to learn and is associated with a low rate of complication and recurrences. Today, the new objective in primary hernia surgery should be to reduce complications such as chronic pain. Chronic pain after hernia repair can be disabling, with considerable impact on quality of life and there is evidence to suggest increased use of health services by patients who have chronic pain. We have proposed an international randomized controlled trial with seven referenced European centers: The TI.ME.LI. trial. The aim of this study is to evaluate pain and further disabling complications in patients undergoing Lichtenstein technique for primary inguinal hernia repair by fixing the mesh with fibrin sealant versus sutures (control group).

Inguinal hernia recurrence: Classification and approach.

The authors reviewed the records of 2,468 operations of groin hernia in 2,350 patients, including 277 recurrent hernias updated to January 2005. The data obtained - evaluating technique, results and complications - were used to propose a simple anatomo-clinical classification into three types which could be used to plan the surgical strategy: Type R1: first recurrence 'high,' oblique external, reducible hernia with small (<2 cm) defect in non-obese patients, after pure tissue or mesh repairType R2: first recurrence 'low,' direct, reducible hernia with small (<2 cm) defect in non-obese patients, after pure tissue or mesh repairType R3: all the other recurrences - including femoral recurrences; recurrent groin hernia with big defect (inguinal eventration); multirecurrent hernias; nonreducible, linked with a controlateral primitive or recurrent hernia; and situations compromised from aggravating factors (for example obesity) or anyway not easily included in R1 or R2, after pure tissue or mesh repair.

Intestinal resection and multiple abdominal hernia mesh repair: is the combination safe and feasible?

In a highly advanced era from the point of view of instrumental diagnostic resolution it is, however, not always possible to obtain a precise preoperative diagnosis. Surgery is sometimes the only decisive solution. In April 2003, a 62-year-old male patient was referred to us for umbilical hernia, diastasis recti abdominis and left-sided inguinal hernia; he also complained of pain in the mesogastric-hypogastric region. This site presented with a hard, non-mobile, painful tumefaction at both superficial and deep palpation. The patient was submitted to various diagnostic examinations (pancolonoscopy, CT, X-ray of the digestive tract and angiography), but only surgery allowed us to establish the specific nature of the tumefaction. The operation consisted in the en-bloc removal of an abscess mass affecting intestinal loops, caecum and appendix and at the same time in the repair of the hernia components with the use of prosthesis in a potentially contaminated area. The tumefaction had originated following acute appendicitis episodes that had determined adherences between the appendix, caecum and ileal loops (histologically confirmed). There are situations that require surgery in order to be explicitly diagnosed and solved. Furthermore, although the use of prosthetic materials in the treatment of hernias in association with intestinal resection is an extreme case, it has also been reported in the international literature that nowadays there are no real contraindications to the implantation of a prosthesis in a potentially infected area.