Should bilateral inguinal hernias be repaired during one operation?

BACKGROUND: We tested the hypothesis that performing an open tension-free bilateral inguinal hernia repair at one operation would have similar outcomes as performing an open tension-free unilateral repair. METHODS: In our prospective study of 243 patients who underwent inguinal hernia repair, 197 were unilateral (UL) and 46 were simultaneous bilateral (SBL). Prospectively the surgeon completed a standardized form during the first postoperative visit. Long-term follow-up was obtained by telephone interview. RESULTS: Respectively for UL versus SBL: age 56 +/- 16 years versus 60 +/- 12 years, regional anesthesia 93% versus 94%, operating room time 76 +/- 22 minutes versus 114 +/- 21 minutes (P < 0.05), and operating room costs $1,513 versus $1,793. Also observed were nonsignificant differences in overnight admissions 9.6% versus 4.3%, wound infection 0% versus 2.2%, number of days of narcotic pain pills taken 3.5 +/- 2.7 versus 3.3 +/- 2.2, postoperative day first left home 2.4 +/- 1.6 versus 2.8 +/- 1.7, postoperative day drove car 4.6 +/- 2.1 versus 5.0 +/- 2.3. Telephone contact was made in 62% after a follow-up period of 28 +/- 17 months. Recurrences were observed in 6 of 151 (4.0%): UL 4.2% and SBL 3.0%. CONCLUSIONS: We believe a tension-free technique allows bilateral inguinal hernias to be repaired during one operation with similar outcomes as a unilateral tension-free repair and less cost than a sequential bilateral repair.     

Acute abdomen: emergency laparoscopy or observation?

Acute abdomen accounts for 13-40% of all emergency surgical admissions. The aim of this prospective randomised controlled study was to examine the role of early laparoscopy in the management of acute abdomen compared with the more traditional active observation approach. From July 1993 to August 2004, 522 patients consecutively admitted with acute abdomen were randomised to either early laparoscopy (260 patients) (group 1) or active observation and non-invasive investigation (262 patients) (group 2). Baseline investigations included a full blood count, a pregnancy test in women of child-bearing age, and chest and/or abdominal radiography, if indicated clinically. Sixty-two patients in the laparoscopy group underwent a total of 116 radiological investigations compared with a total of 558 investigations in all patients in the observation group (p < 0.05). In the observation group, 34.7% of patients remained without a clear diagnosis compared with 4.2% of patients in the early laparoscopy group (p < 0.0001). The morbidity rate was 1.1% in group 1 and 27% in group 2 (p < 0.0001). The duration of hospital stay was significantly shorter in group 1 (3.1 vs 7.3 days) (p < 0.01). Eight patients in group 1 required readmission (total readmission: 46 days) compared with 58 patients in group 2 with a total readmission of 201 days (p < 0.05). Early laparoscopy is valuable in the management of acute abdomen. It affords significantly higher diagnostic accuracy and a greater improvement in quality of life than the more traditional observation approach.     

Appendiceal abscess: immediate operation or percutaneous drainage?

Conflicting evidence exists regarding the optimal treatment for abscess complicating acute appendicitis. The objective of this study is to compare immediate appendectomy (IMM APP) versus expectant management (EXP MAN) including percutaneous drainage with or without interval appendectomy to treat periappendiceal abscess. One hundred four patients with acute appendicitis complicated by periappendiceal abscess were identified. We compared 36 patients who underwent IMM APP with 68 patients who underwent EXP MAN. Outcome measures included morbidity and length of hospital stay. The groups were similar with regard to age (30.6 +/- 12.3 vs. 34.8 +/- 13.5 years), gender (61% vs. 62% males), admission WBC count (17.5 +/- 5.1 x 10(3) vs. 17.0 +/- 4.8 x 10(3) cells/dL), and admission temperature (37.9 +/- 1.2 vs. 37.8 +/- 0.9 degrees F). IMM APP patients had a higher rate of complications than EXP MAN patients at initial hospitalization (58% vs. 15%, P < 0.001) and for all hospitalizations (67% vs. 24%, P < 0.001). The IMM APP group also had a longer initial (14.8 +/- 16.1 vs. 9.0 +/- 4.8 days, P = 0.01) and overall hospital stay (15.3 +/- 16.2 vs. 10.7 +/- 5.4 days, P = 0.04). We conclude that percutaneous drainage and interval appendectomy is preferable to immediate appendectomy for treatment of appendiceal abscess because it leads to a lower complication rate and a shorter hospital stay.     

The stenosed Brescia-Cimino fistula: operation or intervention?

INTRODUCTION: Stenosis of the vein close to the arteriovenous anastomosis is the most frequent cause for late failure of Brescia-Cimino fistulae (BCF). Although since decades proximal re-anastomosis has been regarded as the surgical standard treatment, success rates can hardly be deducted from the literature. Considering the increasing activities of interventional radiologists surgical position finding seems necessary. METHODS: Over three years 30 anastomotic BCF stenoses were treated in 28 patients. In 15 patients the stenosis had caused fistula thrombosis. In all cases the fistula vein was re-anastomosed to the proximal radial artery. All patients could be followed up (average 12 months). Each fistula functioning after 24 hours was classified as procedural success. For calculation of patency rates (life table analysis), however, usability of the needling segment of the access was assessed. RESULTS: Procedural success rate was 100%. One fistula thrombosed on the second postoperative day after a successful dialysis session due to an overlooked proximal stenosis of its feeding radial artery. In five fistulae stenoses developed after 4 to 13 months. In only one fistula this was a true re-stenosis of the newly created anastomosis (0.03 per patient-year). Two of the stenoses occurred in the needling segment of the access vein and within its central venous outflow, respectively. Overall re-intervention rate was 0.3 per patient-year, and primary (secondary) patency was 80% (95%) at one year and 67% (87%) at two years. CONCLUSION: In BCF proximal re-anastomosis is a simple and effective therapeutic option for anastomotic venous stenosis. Re-intervention rates are low and procedural success rates as well as primary and secondary patency rates at least equal those of interventional radiology.     

The etiology of indirect inguinal hernias: congenital and/or acquired?

The development of indirect inguinal hernias in infants is caused by a patent processus vaginalis (PPV). Consequently, this type of hernia is cured by simple herniotomy. In adults, however, herniotomy alone is accompanied by a high recurrence rate. This indicates that additional factors play a part in the development of indirect inguinal hernias in adults. The aim of this study was to determine the etiology of the development of an indirect hernia in adult life. Also, the prevalence of a PPV without clinical evidence of a hernia was determined and related to age. From November 1998 until February 2002, 599 patients from four different teaching hospitals, who underwent abdominal laparoscopy for various pathologies, were included. During laparoscopy, the deep inguinal ring was bilaterally inspected. Patients undergoing laparoscopy for inguinal hernia repair were excluded. Mean age was 45 years (range 8–89 years). Thirty-two percent (189/599) were male. Twelve percent (71/599) had PPV, all without clinical symptoms. Fifty-five percent (39/71) with PPV were male (P<0.0001). Fifty-nine percent (42/71) with PPV were right-sided, 29% (21/71) with PPV were left sided, and 12% (8/71) were bilateral (P=0.01). The prevalence of PPV in patients under 20 years was 22%. Of those between 20 and 30 years of age, 6% had PPV. Of those between 30 and 50 years, 24 patients (11%) had PPV. Of patients over 50 years, 33 (14%) had PPV. No significant differences between ages were observed. It is concluded that asymptomatic patent processus vaginalis frequently exists in adult life. The prevalence of PPV does not increase significantly with age. Assuming that indirect hernias start with asymptomatic peritoneal protrusion that can be observed laparoscopically, the incidence of PPV, like the incidence of adult indirect hernias, should increase in case of acquired etiology. Such an increase of incidence with age was not confirmed by our results. It is concluded that the etiology of indirect inguinal hernia in adults, as in infants, is congenital.     

Inguinal hernias: should we repair?

This review examines available data concerning the natural history of treated and untreated inguinal hernias. The incidence of complications with either treatment strategy is discussed using historical information from a time before herniorrhaphy became routine and contemporary data from two recently completed randomized controlled trials comparing routine repair using a tension-free technique with watchful waiting.     

Surgical therapy of complicated sigmoid diverticulitis: single stage or multi-stage operation?

Surgical tactics for the teatment of complicated diverticulitis are in constant evolution and remain a subject of controversy. Amongst 53 patients operated on for complicated sigmoid diverticulits over a 10 year period in our hospital, 29 underwent a Hartmann's procedure (3 Hinchey's stage II, 19 stage III and 7 stage IV). Only 11 out of 20 having survived the operation underwent restoration of bowel continuity (55%). This experience is in line with the literature. Surgeons have become conscious that in reality the colostomy was permanent in a significant proportion of patients who were poor candidates for a second operation. Therefore there is a tendency to perform as far as possible a resection of the sigmoid and a colo-rectal anastomosis in a one-stage procedure. In the absence of prospective randomized studies and objective criteria, the decision to resect the sigmoid in a one-stage or in a multi-stage procedure is based on consensus and clinical judgement.     

Small acoustic neuroma: observation or treatment? A review of 207 cases

The management of small acoustic neuromas (AN) whether localized in an intracanalar position (stage I) or with a small extension of less then 2 cm into the cerebellopontine angle (stage II) remains under debate. Proposed strategies include surgery, stereotactic irradiation and observation. From 1987 to 1997, among 343 AN referred to our department, 207 were small (83 stage I and 124 stage II). Initially, 72 patients were treated conservatively mainly because of their age (over 60-65) and 132 were operated on. Three patients underwent irradiation because of their poor general condition. Significant tumor growth was observed in 15 cases in the conservative treatment group; 14 of these patients underwent secondary surgery and one irradiation. Among the 146 AN operated on (132 initially and 14 secondarily), 142 small AN were operated on via a transpetrosal approach (64% translabyrinthine, 21% middle-fossa and 15% retrosigmoid) and 4 AN, which became large tumors during the observation period, were treated through the translabyrinthine approach. No mortality was observed in our series. Postoperative complications included 11 CSF leakages necessitating reoperation (8%). In 93% of the cases, postoperative facial function at one year was good. Hearing preservation was attempted in 51 selected cases (pure tone average=50 dB, speech discrimination score 100%) with a 51% success rate (53% and 48% through middle-fossa and retrosigmoid approaches respectively). In our opinion, surgery with this risk-benefit ratio is indicated for small AN, except in the elderly for whom conservative management is preferred and in patients in poor clinical condition with a growing AN, for whom irradiation is recommended.     

Occult pneumothorax in the blunt trauma patient: Tube thoracostomy or observation?

Background

The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes.

Methods

A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status—dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures.

Results

In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p = 0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p = 0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces.

Conclusion

The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial.     

Atrial compartment operation for atrial fibrillation: to isolate the left atrium or not?

BACKGROUND: The atrial compartment operation was designed to convert atrial fibrillation (AF) to sinus rhythm with intentional preservation of the electrical connection between adjacent atrial compartments. However, incidental left atrial isolation was observed in some patients. This study compared the long-term clinical outcomes of left atrial isolation for AF with those with right and left atrial connection. METHODS: Twenty patients with mitral valve disease and chronic AF who underwent atrial compartment operation with successful sinus conversion were studied. Left atrial isolation was documented by local electrogram recording. When there were no signs of electrical connection between the left atrium and the rest of the heart, either during sinus rhythm or during stimulation from various atrial compartments, left atrial isolation was confirmed. All patients were followed by electrocardiogram and echocardiogram serial recordings. Clinical signs and symptoms of cardiac performance and thromboembolism were also examined. RESULTS: Seven patients showed an isolated left atrium and 13 patients had electrical connection between the right and left atria. The age, gender, AF duration, and underlying disease were not different between the two groups of patients. During a mean follow-up period of 66 +/- 15 months, none of the patients with left atrial isolation showed recurrence of AF, although one experienced paroxysmal atrial flutter. However, 8 of the 13 patients with right and left atrial connection experienced recurrent atrial flutter/fibrillation (6 atrial flutter and 5 AF) (p = 0.058). The propensity for recurrent atrial flutter/fibrillation in these patients may be related to the conduction delay between the two atrial compartments, measured at 142 +/- 48 ms. At the end of the follow-up period, all patients with left atrial isolation remained in normal sinus rhythm without antiarrhythmic drugs. Of the patients who had right and left atrial connection, 2 developed sustained AF and 1 developed atrial flutter. Patients with left atrial isolation showed a decreased transmitral "A" flow compared with those with right and left atrial connection. Postoperative left atrial diameter and clinical functional class did not differ between patients with and without left atrial isolation. The incidence of embolization observed in both treatment groups did not differ significantly: 14% (1/7) in patients with left atrial isolation and 8% (1/13) in patients with right and left atrial connection (p > 0.05 between the groups). CONCLUSIONS: Left atrial isolation confers a better arrhythmia outcome but at the expense of poorer mechanical performance as compared with preserved electrical connection between the two atria. Nonetheless, all patients remain at risk for systemic embolization. Therefore, modifications of current surgical incisions for AF are needed.     

Scrotal hernias: a contraindication for an endoscopic procedure?

INTRODUCTION: Endoscopic repair was introduced for use with inguinal hernia therapy more than 10 years ago. The technique as well as the indications for this method are debated, however. As a borderline inguinal hernia situation, the scrotal hernia in particular evokes vehement objections to an endoscopic procedure because of the anticipated problems and complications in dissecting the extended hernia sac. The efficiency of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of scrotal hernia therefore is discussed in this article. METHODS: Laparoscopic hernia repair (TAPP) has been performed in our department since 1993. Data are collected by a prospective documentation of operative and follow-up results. For evaluation, a comparison of scrotal and normal hernia repair was performed. RESULTS: Between April 1993 and June 1998 the TAPP technique was used to treat 191 scrotal hernias, 42 (22%) of which were recurrent hernias. The median operating time for a normal inguinal hernia repair was 45 min, whereas scrotal hernias required a median of 65 min and irreducible scrotral hernias a median of 68.5 min. Major complications were observed in 1.6% of scrotal and 0.6% of normal inguinal hernia repairs. The most frequent scrotal hernia repair problem was the formation of a seroma, 10.5% of which had to be evacuated. During a follow-up period of 30 months, we found a total of two recurrences (1.05%). CONCLUSION: In scrotal hernia repair, TAPP is not associated with higher complication rates and can be performed with efficiency comparable with that in normal inguinal hernia repair.     

Does an infected peripancreatic fluid collection or abscess mandate operation?

OBJECTIVE: To assess the treatment of peripancreatic fluid collections or abscess with percutaneous catheter drainage (PCD). SUMMARY BACKGROUND DATA: Surgical intervention has been the mainstay of treatment for infected peripancreatic fluid collections and abscesses. Increasingly, PCD has been used, with mixed results reported in the literature. METHODS: A retrospective chart review of 1993 to 1997 was performed on 82 patients at a tertiary care public teaching hospital who had computed tomography-guided aspiration for suspected infected pancreatic fluid collection or abscess. Culture results, need for subsequent surgical intervention, length of stay, and death rate were assessed. RESULTS: One hundred thirty-five aspirations were performed in 82 patients (57 male patients, 25 female patients) with a mean age of 40 years (range 17-68). The etiologies were alcohol (41), gallstones (32), and other (9). The mean number of Ranson's criteria was four (range 0-9). All patients received antibiotics. Forty-eight patients had evidence of pancreatic necrosis on computed tomography scan. Cultures were negative in 40 patients and positive in 42. Twenty-five of the 42 culture-positive patients had PCD as primary therapy, and 6 required subsequent surgery. Eleven patients had primary surgical therapy, and five required subsequent surgery. Six patients were treated with only antibiotics. The death rates were 12% for culture-positive patients and 8% for the entire 82 patients. CONCLUSIONS: Historically, patients with positive peripancreatic aspirate culture have required operation. This series reports an evolving strategy of reliance on catheter drainage. PCD should be considered as the initial therapy for culture-positive patients, with surgical intervention reserved for patients in whom treatment fails.     

Klatskin unresectable tumour. Palliative treatment or no surgical operation?

The Klatskin tumor is a neoplasy of the proximate main biliary duet whose initial manifestation, and most of the time, the single one, consist in the appliance of an obstructive nature jaundice. This usually coincides with the spreading of the tumor beyond the walls of the tumors that have reached this state with a usually intraoperating made diagnosis, certain palliative technical surgery solutions could still exist. The author submits to your attention a retrospective survey on 85 tumors out of which only 3 were removable. For the remaining 82 he performed only exploratory laparotomy. Of these biopsy was made for 11 cases and palliative surgery for the other 71 (biliodigestive derivations on one or both liver lobes, or Huguet, Terblanche or Kehr tube surgery prosthesis operations). If the patient's living conditions are very good, his survival chances might be extended from 2 to 18 months, with no appearance of jaundice or pruritus. There is no doubt that if the pre-operations imagery testing results in the diagnosis "inoperable medical condition", the retrograde endoscopic transtumoral surgery prosthesis operation or the transparietal liver one, is recommended.