Impact of previous appendectomy on the outcomes of endoscopic totally extraperitoneal inguinal hernioplasty

Previous lower abdominal surgery presents a technical challenge during endoscopic totally extraperitoneal inguinal hernioplasty. Whether the presence of appendectomy scarring and adhesions will adversely influence the outcomes of totally extraperitoneal inguinal hernioplasty remains largely unknown. The objectives of the present study were to evaluate the safety of totally extraperitoneal inguinal hernioplasty in patients with a history of appendectomy and examine its impact on the perioperative outcomes. Between November 1999 and September 2003, patients who underwent totally extraperitoneal inguinal hernioplasty and had previous appendectomy were recruited as the appendectomy group. For each case patient, 3 age-matched cohorts were randomly selected during the same period. Perioperative data and postoperative outcomes were compared between the 2 groups of patients. A total of 92 patients, 23 cases and 69 controls, were recruited. There was no predominance of either direct or indirect inguinal hernia in the appendectomy group. One patient in the appendectomy group required conversion to transabdominal preperitoneal inguinal hernioplasty because of adhesions. The incidence of peritoneal tear and operative time was higher and longer in the appendectomy group respectively but the differences were not significant. Comparisons of the mean duration of hospitalization, postoperative morbidity rates, pain scores, and time taken to resume normal activities showed no significant difference between the 2 groups. Totally extraperitoneal inguinal hernioplasty in patients who had previous appendectomy was technically safe. A higher incidence of peritoneal tear was anticipated in the presence of appendectomy scarring and adhesions. Postoperative recovery and outcomes were equivalent to those who had no history of appendectomy.     

Atypical Down syndrome phenotype with severe developmental delay, hypertonia, and seizures in a child with translocation trisomy 21

An infant is reported who presented with a de novo 21;21 translocation trisomy 21 and an atypical phenotype for Down syndrome (DS). Findings included microcephaly, small stature, downslanting palpebral fissures, absent Brushfield spots, moderate micrognathia, left ptosis, left torticollis, severe developmental delay, seizures, and hypertonia. Further clinical evaluation using both the diagnostic criteria for DS and the Jackson checklist of 25 signs was inconsistent with the diagnosis for DS. Blood karyotype revealed: 46,XX,+21,dic(21;21) (p11.2;p11.2). Fluorescence in situ hybridization (FISH) analysis confirmed the trisomy 21 translocation. Both parents had normal karyotypes. Chromosome and FISH analyses were performed on skin fibroblasts. These studies revealed mosaicism for a translocation trisomy 21 cell line as wel as a second cell line consisting of one normal chromosome 21 and a ring chromosome 21 derived from translocation 21q21q which appeared to have a deletion of the critical region for DS involving the distal portion of the thelong arm of chromosome 21. The chromosome findings illustrate an atypical phenotype in the spectrum of mosaic DS and suggest possible mechanisms for the variability of the phenotype. It also emphasizes the importance of evaluating other tissues for mosaicism when presented with atypical clinical findings.     

Painless limp as a presentation of pelvic eosinophilic granuloma in a child

Painless limp in children continues to pose a diagnostic challenge. In the majority of the cases transient synovitis of the hip is the cause. However, bone tumours should be considered as a possibility and specifically looked for when a child continues to have ongoing symptoms. Failure to diagnose tumours at an early stage can lead to a poorer outcome. This case report describes a child with eosinophilic granuloma who presented with a progressive painless limp. It emphasises the need to look carefully at the pelvic bones when evaluating a hip radiograph.     

Reactivation of motility of demembranated hamster spermatozoa: role of protein tyrosine kinase and protein phosphatases

Demembranated cauda epididymidal spermatozoa of hamster, following reactivation with 1 mm ATP, exhibited either a loop or planar type of motility. The spermatozoa with planar motility exhibited increased progressive velocity (VSL), straightness (STR), linearity (LIN) and beat cross frequency (BCF) compared to the spermatozoa with loop type motility. cAMP was observed to have differential effects on the motility parameters of the demembranated spermatozoa depending on the type of motility. For instance, in the loop type, average path velocity (VAP), curvilinear velocity (VCL) and VSL were increased in the presence of cAMP unlike in the planar type. Furthermore, in an attempt to understand the role of protein kinases and protein phosphatases in regulation of sperm motility, the effects of various inhibitors of these enzymes on the motility and phosphorylation of proteins of reactivated demembranated spermatozoa were studied. Inhibitors of PTKase (protein tyrosine kinase) and protein phosphatases inhibited the motility of reactivated demembranated hamster spermatozoa. The activity of the respective enzymes associated with demembranated spermatozoa was concurrently inhibited, thus providing evidence that the effect of the inhibitors on motility was mediated through their inhibitory effects on the activities of the enzymes. The results also demonstrated that two phosphotyrosinylated proteins of molecular weight 65 and 80 kDa showed reduced phosphorylation in the presence of PTKase inhibitors, thus indicating their possible role in reactivation of motility of demembranated hamster spermatozoa.     

Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty

Background: Performance of endoscopic totally extraperitoneal inguinal hernioplasty (TEP) requires specialized anatomical knowledge and surgical dexterity. The present study was undertaken to evaluate the learning curve for a general surgeon to master the technique of TEP in the absence of an experienced supervisor. Methods: A retrospective analysis of the first 120 consecutive unilateral TEPs was performed. Medical records were reviewed to evaluate demographic features, perioperative outcome, and follow-up results. The study population was divided into six consecutive groups of 20 patients. Clinical data were compared among the groups to evaluate the impact of operative experience on perioperative outcome. Results: Operative time was the only clinical parameter that showed significant improvement with experience; it reached a plateau value of <1 h after the fourth group. Conversions to transabdominal and open approaches were required in only one patient in groups 1 and 6, respectively. Comparison of demographic features, hernia types, postoperative morbidity rates, length of hospital stay, and number of days to resume normal activities showed no significant differences among the groups. All complications were minor and resolved uneventfully. No recurrence was detected during follow-up. Conclusions: The learning curve for unilateral TEP by a general surgeon peaked after performing 80 procedures. In most cases, unilateral TEP can be accomplished safely within 1 h. Even during the learning process, TEP carries a low morbidity and conversion rate.