Effect of tension induced by Shouldice repair on postoperative course and long-term outcome.

OBJECTIVE: To record intraoperative tension during Shouldice hernioplasty and correlate it with postoperative course and long-term outcome. DESIGN: Prospective clinical trial. SETTING: University clinic, Germany. SUBJECTS: 20 male patients undergoing elective primary inguinal hernia repair by Shouldice technique. INTERVENTION: Measurement of intraoperative tension during hernioplasty (low 0-2.0 N, moderate 2.1-4.0 N, high > 4.1 N). Main outcome measures: Postoperative pain measured by visual analogue scale (VAS) at rest and activity, pain-related change of ventilatory measurements (8, 24 and 48 hours after intervention), postoperative complications, length of stay in hospital, and recurrence rate at mean 46.7 (range 43-54) months after operation. Data are given as mean (SD). RESULTS: The results for 18 patients were analysed, 2 being lost to follow up. Mean pain score was 17.5 (15.6), 14.8 (15.6) and 12.3 (14.9) at rest 8 hours, 24 hours and 48 hours after operation, during activity 42.0 (16.5), 36.4 (18.5) and 33.7 (19.1) respectively. Most depression of ventilatory measurements was found 8 hours after operation (vital capacity 88.4 (12.5)%. peak flow 81.3 (17.2)%) compared with preoperative values. Complications comprised one seroma, one subcutaneous wound infection, and 3 haematomas. Mean length of stay in hospital was 4.3 (range 2-7) days. At follow up, no recurrences were found. No correlation with intraoperatively-induced tension was found. CONCLUSIONS: Postoperative pain and recurrences depend on many factors, but induced intraoperative tension can be excluded. The reported advantages of tension-free procedures are not based on the avoidance of tension. The Shouldice repair can therefore continued to be used as a routine technique in uncomplicated primary inguinal hernia repair.     

Spontaneous changes in left ventricular function between sequential studies

To evaluate day to day changes in left ventricular function, studies were performed in 17 patients in stable condition undergoing elective cardiac catheterizatlon and coronary arteriography on successive days. Seven patients had significant coronary artery disease, seven had significant valvular heart disease, two had both lesions, and one had no demonstrable heart disease.The group as a whole demonstrated no significant day to day changes in any measured parameter of left ventricular function …. The hematocrit decreased from 43.4 ± 4.3 to 41.5 ± 4.5 percent (P < 0.01). Individual patients showed rather marked day to day variation. The mean (± standard deviation) percent changes for paired determinations in individual patients were: mean arterial pressure ? 1.0 ± 19.4 percent; heart rate 3.4 ± 14.6 percent; cardiac index ? 1.2 + 19.4 percent; left ventricular end-diastolic pressure ?2 ± 37.2 percent; left ventricular stroke work index ?10.7 ± 34.6 percent; end-diastolic volume ?0.9 ± 23.1 percent; ejection fraction ?6.2 ± 15.7 percent; mean circumferential fiber shortening rate ?7.7 ± 24.8 percent. Left ventricular wall motion abnormalities present in five patients were unchanged in site. The extent of asynergy changed by an average of 2 percent (range ?2 to +4 percent).The range of these day to day changes in the parameters of left ventricular function without therapeutic intervention must be considered when evaluating the effects of therapy. Since wall motion abnormalities were constant in site and showed little variation in extent, the effects of medical and surgical treatment on left ventricular asynergy can be assessed by sequential studies.     

Laparoscopy and collagen metabolism

The collagens represent a vital component within the wound healing process and physiological scar formation. Therefore, analysing the influence of new operative procedures on collagen metabolism is of great surgical interest. As the endoscopic technique has, nowadays, become routinely applied for diverse abdominal diseases worldwide, we present a review of literature facing its impact on collagen biology.     

Modification of collagen formation using supplemented mesh materials

Background Formation of recurrent inguinal and incisional hernia shows an underlying defect in the wound healing process. Even following mesh repair an altered collagen formation and insufficient mesh integration has been found as main reason for recurrences. Therefore the development of bioactive mesh materials to achieve a local modification of the scar formation to improve patients outcome is advisable. Methods Thirty-six male Wistar rats were used within this study. A Mersilene ? mesh sample was implanted after midline skin incision and subcutaneous preparation. Before implantation mesh samples were incubated for 30 minutes with either one of the following agents: doxycycline, TGF-beta 3, zinc-hydrogeneaspartate, ascorbic acid, hyaluronic acid. Incubation with a physiologic 0.9 % NaCl solution served as control. Seven and 90 days after mesh implantation 3 animals from each group (n = 6) were sacrificed for morphological observations. Collagen quantity and quality was analyzed measuring the collagen/protein as well as the collagen type I/III ratio. Results Following an implantation interval of 90 days supplementation with doxycycline (39.3 ± 7.0 μg/mg) and hyaluronic acid (34.4 ± 5.8 μg/mg) were found to have a significantly increased collagen/protein ratio compared to implantation of the pure Mersilene ? mesh samples (28.3 ± 1.9 μg/mg). Furthermore, an overall increase of the collagen type I/III ratio was found in all groups indicating scar maturation over time. However, no significant differences were found after 7 and 90 days of implantation comparing collagen type I/III ratio of supplemented mesh samples and control group. Conclusions In summary, we found an influence of supplemented mesh materials on collagen deposition. However, the investigated bioactive agents with reported influence on wound healing were not associated with an improved quality in scar formation.     

Abdominelles Kompartmentsyndrom

Abdominal compartment syndrome (ACS) is characterized by a persistent pathologic increase in intra-abdominal pressure (IAP) exceeding 20 mmHg with consecutive dysfunction of multiple organ systems. The main causes of ACS are abdominal trauma, obstruction, infection, and sepsis, but it may also be initiated by extra-abdominal diseases. The gold standard for diagnosis is repeated assessment of the IAP measurements of bladder pressure. The incidence of ACS is up to 15% in operative ICUs and the therapy of choice for it is decompressive laparotomy. Nevertheless, mortality is high, up to 60%.     

Incisional intercostal hernia after a nephrectomy

The aim of the present case report is to present the diagnostic and therapeutic challenge of intercostal incisional hernia. We report on a female patient with leftsided intercostal incisional hernia between the eleventh and twelfth rib due to preceding lumbar incision for tumor nephrectomy. Because of its infrequence, diagnosis was established late although simple clinical examination and ultrasound investigation displayed the hernia. At laparotomy, a 5×5 cm² fascial defect with a colonic sliding hernia was found. Hernia repair using permanent mesh reinforcement in the retromuscular position is described. Abdominal incisional hernia in the intercostal region is rare and therefore easily overlooked. As with other incisional hernias, the hernia repair using mesh implantation in the retromuscular region is technically feasible and represents the treatment of choice.