The comparison of laparoscopic and open ventral hernia repairs: a prospective randomized study.

BACKGROUND: The laparoscopic approach has emerged in the search for a surgical technique to decrease the morbidity associated with conventional repair of ventral hernias. In this study we aimed to compare the results of our open and laparoscopic ventral hernia repairs prospectively. METHODS: Between January 2001 and October 2005, a total of 46 patients diagnosed with ventral hernias (primary and incisional) who were admitted to our surgical unit and accepted to be included in this study group were examined. All patients were divided into laparoscopic repair (n = 23) and open repair (n = 23) subgroups in a randomized fashion. The patients' demographic characteristics, operation times, body mass indices, sizes of fascial defects, hernia locations, durations of hospital stay, presence and degrees of postoperative pain, and postoperative minor and major complications were analysed and compared. All the data were expressed as means +/- SDs. Chi-square and Wilcoxon tests were used for statistical analysis, and P < 0.05 was accepted as a significant statistical value (SPSS 11.0 for Windows). RESULTS: The demographic characteristics of both groups were similar. Women predominated, especially in the laparoscopy group (P < 0.05). The comparison of the results revealed that the major advantage of laparoscopy was the shortened postoperative hospital stay and the reduced incidence of mesh infection (P < 0.05, P < 0.05). On the other hand, operation time was significantly longer in the laparoscopy group (P < 0.05). The major complications encountered in the laparoscopy group were ileus and a missed enterotomy. The most frequent minor complication was seroma, which was significantly more frequent in the laparoscopy group (P < 0.05). Postoperative pain assessment revealed similar results in both groups (P > 0.05). CONCLUSIONS: The laparoscopic approach appears to be as effective as open repairs in the treatment of ventral hernias. Advanced surgical skill, laparoscopic experience and high technology are mandatory factors for successful ventral hernia repair.

Appendicitis in incarcerated femoral hernia.

BACKGROUND: Femoral hernia can rarely present with the content of appendicitis. We report on an elderly female who was admitted to our emergency department with a painful groin mass. METHODS: An 85-year-old woman presented with a 7-day history of right groin pain and swelling. She also had complaints of nausea, vomiting, and right lower quadrant abdominal pain. Physical examination revealed a right groin mass in the femoral region, which was painful on examination. Abdominal examination ended with normal findings except bilateral lower quadrant tenderness. Ultrasonographic examination revealed a hernia sac containing suspected aperistaltic bowel segment with edematous wall. RESULTS: The patient underwent surgery. During exploration of the right groin region, a strangulated femoral hernia sac containing appendicitis was detected. CONCLUSION: Surgeons should be aware of the existence of this kind of atypical presentation of appendicitis.

Thyroid status and leptin in Basedow-Graves and multinodular goiter patients.

In this study it was of interest to investigate the relationship between plasma leptin levels and thyroid function in recently diagnosed 27 Basedow-Graves patients and 22 multinodular goiter patients brought to euthyroid state with 1 mo of propylthiouracil (PTU) treatment. A group of 15 control subjects matched for age, gender, and body mass index were also studied. In Basedow-Graves patients there were significantly higher T4 and T3 levels accompanied by a marked fall in plasma thyroid-stimulating hormone (TSH). In multinodular goiter patients with PTU, the plasma T3 and T4 levels were significantly lower than in Basedow-Graves and TSH was markedly higher. However, TSH values in multinodular goiter patients were signifcantly lower than the control Plasma leptin levels were unchanged in all groups. These data suggest that leptin levels are not affected by thyroid dysfunction.

Influence of propylthiouracil treatment on oxidative stress and nitric oxide in Basedow disease patients.

Oxidative stress parameters and nitric oxide (NO) values were determined in 27 newly diagnosed Basedow patients before and after 1 mo of propylthiouracil (PTU) therapy and in 15 healthy controls. Basedow patients exhibited increased triiodothyronine (T3) and thyroxine (T4) and decreased thyroid-stimulating hormone (TSH) values compared to controls. Significantly higher thiobarbituric acid-reactive substances (TBARS), NO and glutathione (GSH) levels, and CuZn superoxide dismutase (CuZn SOD) activity were found in Basedow patients in comparison to controls, regardless of sex. Treatment with PTU (3 x 100 mg/d for 30 d) was effective in decreasing T1 and T4 and increasing TSH levels. Significantly decreased NO and TBARS and increased GSH and CuZn SOD levels were observed in PTU-treated Basedow patients compared to pre-PTU administration. PTU-treated patients compared to controls still exhibited significantly higher T3 and lower TSH values and higher NO, TBARS, GSH, and CuZn SOD levels. The induced antioxidant defense and decrease in NO) values in response to PTU therapy emphasizes the role of PTU as an antithyroid drug, where the ability to diminish hyperthyroidism results in decreased catabolism and lower oxidant generation.

Laparoscopic treatment of hepatic hydatid cysts.

BACKGROUND: Because of limited experience worldwide, controversies about the laparoscopic treatment of liver hydatid cysts have not been resolved. The aim of this study was to describe the technical details of a laparoscopic method we developed in 1992 and report the initial results from an endemic area. METHODS: Of the 30 consecutive patients with 33 liver hydatid cysts considered for laparoscopic treatment during a 6-year period at a university hospital in Turkey, conversion to an open procedure was required in 7 patients (23%) while 23 patients with 25 cysts were able to be treated laparoscopically. RESULTS: By using a special trocar to suspend the cyst against the abdominal wall, laparoscopic simple drainage was performed in 16 patients (70%) and unroofing and drainage in 6 patients (26%). Pericystectomy was performed in 1 patient (4%). Complications were observed in 1 patient (4%) perioperatively and 4 patients (17%) postoperatively. Eleven patients (48%) were followed-up for a mean of 17 months (range, 3-72 months) and 1 recurrence (9%) was detected. CONCLUSIONS: This report is a very large experience with the laparoscopic treatment of liver hydatid cysts in the literature. We have established a technique yielding a comparable morbidity and recurrence rate to open series in early follow-up. We advocate that it is a safe and simple technique with potentially a decreased risk of intra-abdominal spillage compared with the other laparoscopic methods described.

The effects of sodium deoxycholate, lactulose and glutamine on bacterial translocation in common bile duct ligated rats.

BACKGROUND/AIMS: Sepsis is a major cause of post-operative morbidity and mortality in obstructive jaundice as a result of bacterial translocation from the gut. This study was conducted to investigate the effects of glutamine, lactulose, and the bile salt Na deoxycholate in preventing bacterial translocation in an animal model where obstructive jaundice was developed by common bile duct ligation. METHODOLOGY: Fifty Wistar albino rats were divided into 5 groups of 10 animals each. The animals in groups I-IV underwent common bile duct ligation and received, respectively, either saline, Na deoxycholate, lactulose or glutamine, orally. Group V had sham ligation and received saline orally. The animals were sacrificed at the end of the 7th day, and serum concentrations of bilirubin, aspartate aminotransferase (ALT), alanine aminotransferase (ALT), and alkaline phosphatase (AP) were measured. In addition, mesenteric lymph nodes were removed and cultured together with cecal content. Histopathologic examination of terminal ileum specimens was made. RESULTS: Na deoxycholate, lactulose and glutamine all reduced bacterial translocation rates to mesenteric lymph nodes (p<0.05), with glutamine causing the greatest effect. Na deoxycholate and lactulose prevented bacterial translocation by causing a decrease in cecal intraluminal bacterial content (p<0.001), while glutamine exerted its effect by preserving intestinal mucosal integrity. CONCLUSIONS: The integrity of the intestinal mucosal barrier is of paramount importance in preventing bacterial translocation, and the measures taken to protect mucosal integrity reduce bacterial translocation to a greater extent than those taken to decrease the number of bacteria in the gut.

Lipid peroxidation and antioxidant state after laparoscopic and open cholecystectomy.

OBJECTIVE: To measure the amount of lipid peroxidation and erythrocyte antioxidation in patients undergoing laparoscopic and open cholecystectomy and healthy controls. DESIGN: Non-randomised study. SETTING: University hospital, Istanbul. SUBJECTS: 31 patients, of whom 14 underwent open and 17 laparoscopic cholecystectomy, and 15 healthy controls. INTERVENTIONS: Heparinised blood samples were taken from the patients immediately after operation and from the healthy controls. MAIN OUTCOME MEASURES: Lipid peroxidation index as expressed by thiobarbituric-acid-reactive substances (TBARS) and components of the erythrocyte antioxidant defence system, namely reduced glutathione, reduced glutathione peroxidase (glutathione-Px) and CuZn superoxide dismutase (CuZn SOD) in patients undergoing open or laparoscopic cholecystectomy and healthy controls. RESULTS: All 4 variables were significantly higher in the cholecystectomy groups than in controls (p < 0.001), and laparoscopic cholecystectomy caused significantly less oxidative stress than the open operation (p < 0.001). CONCLUSION: Both types of cholecystectomy cause oxidative stress and lead to an adaptive antioxidant response in the body. However; both oxidative stress and the antioxidant response are more pronounced after traditional open cholecystectomy.

A case of chordoma in association with rectal carcinoma.

A 74-year-old male patient presented with anal and sacral pain 18 months after abdomino-perineal resection for rectal cancer. Computerized tomography (CT) of the pelvis demonstrated a well defined mass anterior to the lower sacrum, posteriorly infiltrating and destroying the fourth and fifth sacral nerves and invading the right gluteal fossa. A 7.5 x 15 x 2 cm encapsulated mass was demonstrated during the operation using a posterior approach and the lower sacral segments together with the tumour were removed by amputation at S3 level. Histopathology revealed chordoma. This case is unique because of the rarity of chordoma in association with rectal tumour at the sacrococcygeal region.

The effect of intestinal transit time on bacterial translocation.

Increase in intraluminal bacterial count, disruption of the mucosal integrity, changes in intestinal immunity and transit time are the factors involved in bacterial translocation. The relationship between intestinal transit time, intra luminal bacterial count and translocation rate were investigated in 40 Wistar-albino rats. The study was conducted in 4 groups with 10 animals in each. Group I (controls): saline + laboratory chow, Group II: saline + oral total parenteral nutrition (TPN) solution, Group III: morphine sulfate (MS) + oral TPN solution, Group IV: neostigmine bromide (NB) + oral TPN solution. Intestinal transit time was measured by using Indium111-labeled diethylene triamine pentaacetic acid (DTPA). It was prolonged in the MS-treated group and shortened in the NB-treated group (p < 0.01). The frequency of bacterial translocation was 60% in the oral TPN solution group, 100% in the MS-treated group, 20% in the NB-treated group and 10% in controls. Bacterial counts in duodenum, jejunum, ileum and caecum were significantly increased (p < 0.001) in the MS-treated group and decreased (p < 0.05) in the NB-treated group in comparison with the control group. In conclusion, the prolongation of intestinal transit time increased the intraluminal bacterial count and augmented bacterial translocation. The decrease in intestinal transit time had a converse effect.

Breast cancer and benign breast disease patients evaluated in relation to oxidative stress.

In this study, breast cancer (n = 23) and benign breast disease (n = 15) patients were evaluated in relation to oxidative stress. The extent of lipid peroxidation was assessed by measuring thiobarbituric acid reactive substances (TBARS) in plasma. Erythrocyte glutathione peroxidase (GSH Px), CuZn speroxide dismutase (CuZn SOD), glutathione (GSH) and plasma vitamin E, cholesterol Fe, Zn, Cu levels were analysed in both groups GSH Px (p < 0.01), vitamin E (p < 0.001), Zn (p < 0.01), Cu (p < 0.05) and cholesterol (p < 0.01) concentrations were found to be significantly increased, TBARS level (p < 0.01) significantly decreased in breast cancer patients in comparison to benign breast disease group.

Effect of resuscitation on bacterial translocation in haemorrhagic shocked rats.

The aim of this study was to investigate the resuscitative effects of various intravenous solutions on intestinal mucosal damage and bacterial translocation due to haemorrhagic shock. Seventy Sprague-Dawley rats were anaesthetised and subjected to thirty minutes of haemorrhagic shock (systolic blood pressure 40 mmHg). Resuscitation was established with either autologous-blood, three per cent hypertonic saline (HS), 7.5% HS, 0.9% NaCl and Ringer's lactate and Dextran 70 solution. Animals in sham shock group were only cannulated and not resuscitated. Bacterial translocation was evaluated by culture of mesenteric lymph nodes taken 24 hours after resuscitation. The rates of bacterial translocation observed were 50% in autologous blood group, 60% in Dextran 70 group, 40% in Ringer's lactate group, 10% each in 3% HS and 7.5% HS group and 20% in 0.9% NaCl group. A statistically significant difference was observed between the groups resuscitated with HS solution and the other solutions. No meaningful difference was noted between the various concentrations of hypertonic saline solution. The reduction in the rate bacterial translocation with hypertonic solution is assumed to be due to preservation of intestinal microcirculation and thus prevention of intestinal ischaemia.

Laparoscopic treatment of accessory splenic tissue.

A case of persistent thrombocytopenia after open splenectomy for immune thrombocytopenic purpura is presented. The accessory splenic tissue found by CT preoperatively was successfully treated using a laparoscopic technique. The management of this first case in the world literature of accessory splenic tissue is reviewed.

Endoscopic retroperitoneal adrenalectomy.

BACKGROUND: The anterior transabdominal approach for adrenalectomy is associated with a longer postoperative recovery period than a posterior extraperitoneal adrenalectomy. The posterior approach is useful for patients requiring bilateral adrenalectomy or in those undergoing unilateral adrenalectomy for benign adenomas smaller than 5 cm. Recently transabdominal laparoscopic adrenalectomy has been used in patients with adrenal tumors. Endoscopic retroperitoneal adrenalectomy (ERA) is an alternative method that provides excellent exposure and should be associated with less postoperative morbidity. METHODS: Between 1993 and 1994 11 ERAs were performed in eight patients in the Department of Surgery, Istanbul Faculty of Medicine. The patients were placed in the prone semijackknife position on the operating table. After the retroperitoneal space was expanded with a balloon trochar, four 10 mm trochars were placed to perform the procedure. RESULTS: Among the eight female patients 23 to 65 years of age (mean, 42 +/- 12.4 years), three had bilateral adrenal hyperplasia caused by Cushing's disease, three patients had functioning adenoma, one patient had nonfunctioning adenoma (three on right and one on left adrenal), and one patient had right adrenal cyst. The mean operation time was 150 minutes (range, 90 to 300 minutes). No changes in PCO2 values have been found during intraoperative blood gas analyses. No intraoperative or postoperative complications occurred. All patients were discharged on the third postoperative day. CONCLUSIONS: ERA is a new and safe method of adrenalectomy. It is less invasive than the posterior approach. Patients treated by ERA seem to experience less postoperative pain and discomfort and have a shorter postoperative hospitalization and recovery period.

Nucleolar organizing regions in the operated rat stomach: relationship to metaplasia, dysplasia and carcinoma.

This study investigated the role of duodenogastric reflux in rats after antecolic gastrojejunostomy. At the end of the study, adenocarcinoma was present in 43 per cent, dysplasia in 14 per cent and intestinal metaplasia in 43 per cent of animals. No such changes were found in control rats. A technique for silver staining nucleolar organizing regions (AgNORs) was applied to these lesions and to the control group. The AgNOR count gradually increased from normal gastric mucosa to carcinoma. This technique demonstrated differences in AgNOR count between normal mucosa and other lesions (adenocarcinoma, dysplasia, intestinal metaplasia) (P < 0.001). There was, however, considerable overlap among adenocarcinoma, dysplasia and metaplasia (P > 0.1).