Groin hernia surgery: a systematic review.

BACKGROUND: An extensive volume of clinical research has been undertaken on the use of surgery for groin hernias. For many years there has been a large number of different methods of repairing hernias and, with the introduction of laparoscopic surgery, this has increased further. It is uncertain which method is the best in terms of safety and effectiveness. OBJECTIVES: This review was undertaken to compare the outcomes following different surgical procedures to treat groin hernias in adults. It sought answers to six questions: 1)Which method of surgery (including open procedures and laparoscopic surgery) is the safest and most effective for inguinal hernia repair? 2) Is local anaesthesia a safe and effective alternative to general anaesthesia? 3) Is there a difference in outcome between specialist and non-specialist surgeons? 4) Is day-case as safe and effective as inpatient surgery? 5) Is synchronous bilateral hernia repair as safe and effective as delayed repair? 6) Which method of surgery is the safest and most effective for femoral hernia repair? METHODS: The primary measure of effectiveness used was the proportion of hernia repairs in which there was a recurrence. Secondary outcome measures included complications, post-operative pain, wound infection, time to return to normal activities and/or return to work. A systematic search of the literature (up to February 1996) was undertaken using a variety of approaches. the methodological quality of all prospective comparative studies (45 randomised trials and 26 non-randomised trials/prospective cohort studies) was assessed using a standard checklist. RESULTS: Some of the variation in findings from different studies is likely to be due to methodological differences rather than differences in the effectiveness of the surgical procedures. The main methodological shortcomings of the studies that have been performed are: lack of agreed method for assessing severity of hernias; failure to take confounding into account in non-randomised studies; variation in length of follow-up; poor external validity; lack of objective measures of outcome; and inadequate statistical power. These problems severely limit the conclusions that can be drawn from the literature.

Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas.

Intraperitoneal free gas seen radiologically as air under the diaphragm nearly always indicates a perforated abdominal viscus that requires surgical intervention. Rarely, however, the presence of a pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. Such a situation is termed spontaneous or nonsurgical pneumoperitoneum. In this review, we explore the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. An appreciation of the condition and its likely aetiological factors should improve awareness and possibly reduce the imperative to perform an emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.

A negative herniogram does not exclude the presence of a hernia.

A retrospective review of 63 consecutive herniograms over a 3-year period was performed to assess the reliability in diagnosis of occult hernias. In all, 26 hernias were diagnosed in 23 patients, of which 13 were confirmed at operation. However, there were three false-positive results. Of the 38 negative herniograms, four proceeded to surgery with three positive hernia findings. We therefore found false-positive and false-negative rates of 18.7% and 7.9%, respectively. All of the false-positive results were in patients with a history of pain as the presenting complaint, while all of the patients with false-negative results had presented with a history of both pain and jump but no clinically detectable hernia. Our experience of this investigation is not as encouraging as others have reported.

Provision of a day case abscess service.

We have established a day case service for the surgical treatment of superficial abscesses and present the results of our first 100 patients. We feel that this is an efficient and safe service with 92% treated within 6 h of arrival in hospital and no complications in this series of patients. It has important implications for the management of this common surgical problem.

Use of laparoscopic instruments in conventional mobilisation of the rectum.

The use of conventional instruments for dissection within confined operating fields such as the pelvis may obscure the surgeon's view, and limit his reach. The long, narrow instruments used during laparoscopic surgery, particularly the diathermy scissors can facilitate bloodless dissection under direct vision during conventional surgery, improving the accuracy of procedures such as mobilisation of the rectum.

Rapid-bolus contrast-enhanced dynamic computed tomography in acute pancreatitis: a prospective study.

The purpose of this prospective study was to determine the clinicopathological significance of necrotic areas demonstrated by rapid-bolus contrast-enhanced computed tomography (CT) in patients with biochemically predicted severe pancreatitis. Although CT necrosis occurred significantly more frequently in patients with clinically severe (ten of 12) compared with mild (seven of 20) pancreatitis (P less than 0.025), seven of 17 (41 per cent) patients with CT necrosis developed clinically mild pancreatitis and six of ten (60 per cent) patients with clinically severe pancreatitis and CT necrosis recovered with conservative management. The site and extent of CT necrosis did not correlate with disease severity. Fine-needle aspiration cytology, operative and post-mortem findings and endoscopic retrograde cholangiopancreatography examinations all strongly suggested that CT necrosis represents true pancreatic necrosis. We conclude that the finding of CT necrosis is not in itself an indication for operative intervention, but that rapid-bolus contrast-enhanced dynamic CT greatly facilitates the planning and execution of surgical therapy.

Cervical intraepithelial neoplasia and squamous cell carcinoma of the anus in sexually active women.

Twenty-five patients with squamous cell carcinoma (SCC) of the anus have presented over an 8 year period; 18 were female. Six of 9 patients aged under 50 years were female. Five of these women had been treated for a previous cervical malignancy (2 invasive) and 4 practised anal intercourse; human papillomavirus (HPV) type 16 DNAs were isolated from their arcival anal/cervical paraffin sections. Signals were confined to the nuclei of the invasive anal SCC cells and the transformation zone of the cervix. HPV 6, 11 and 18 DNAs were not identified. Young women with cervical intraepithelial (CIN) III or invasive cervical SCC found in association with HPV infection are at risk of developing anal SCC (P less than 0.001; Fisher's exact).

Electrosurgical skin incision versus conventional scalpel: a prospective trial.

A controlled clinical study comparing skin incision by conventional scalpel with electrosurgical needle incision has shown the latter technique to be highly effective, consistently quicker, and to give better cosmetic results with minimal complications. It is a convenient technique and well tolerated by the patients with no added discomfort. Skin diathermy burns and wound haematomas were only seen after conventional scalpel incision. Fears of delayed wound healing, keloid formation and high infection rates are unfounded.

Changes in emergency surgery between 1973 and 1982: audit of the workload of one surgical team.

The emergency surgical workload of a consultant in general surgery has been studied by comparing two prospectively collected audits of 6-month periods 9 years apart. There have been a number of changes in the pattern and intensity of general surgical admissions (excluding trauma) with a decline in the total number per day from 14.1 to 12.4 and a reduction in the number of days on call for general surgery from 30 to 14 over the 6-month period. There was a similar fall in days on call for trauma from 60 to 23 days and a decline in total emergency surgical operations from 6.6 to 5.2 operations per night on call. These changes have mainly been produced by an increase in the number of consultants in the hospital from five to eight and specialisation with the establishment of an area urology unit. The results of this study suggest that as consultant numbers increase in a particular area there will be diminished exposure of surgical trainees to emergency cases both in quantity and in quality, and this loss of experience will prove deleterious to the trainee surgeon.

Ingrowing toenails: is there a nail abnormality? A prospective study.

Ingrowing of the nail of the hallux has been ascribed to an abnormality of the shape of the nail; our prospective study was planned to test this association. Twenty-three consecutive patients and 23 age-matched controls were assessed by caliper measurement and standard photographs, before a first operation for ingrowing toenail. We found no differences in shape between the toenails of the patients and those of the controls, both groups showing great variation. Our results suggest that the ingrowth is not commonly associated with an abnormal shape of the nail.

What does a house-surgeon on call for the wards do?

This survey shows that the number and type of out-of-hours calls arising from general surgical inpatients in a service of 181 beds can be satisfactorily handled by an on-call house-surgeon, covering all the firms. The house-surgeon must have readily available support from the registrar on duty for the few difficult problems, and the firms must all do service ward-rounds on Saturdays and Sundays. This method of staffing at night and at weekends is economical but the work involved in the weekend rounds should be recognised.

Prolonged bandaging is not required following sclerotherapy of varicose veins.

Following sclerotherapy of varicose veins, 158 limbs of 154 patients were randomized to be bandaged with either crepe or Coban for 6 weeks each, or with Coban for 3 days only. Objective assessment of vein eradication and subjective evaluation of symptoms 3 months after completion of treatment showed no clear differences between these regimens. Significantly more discomfort was experienced with Coban than crepe when used for 6 weeks. It is suggested that, following sclerotherapy, 3 days is an adequate period of bandaging when using Coban. Such a policy would considerably reduce the inconvenience to patients during treatment.