Factors influencing development of subcutaneous carbon dioxide emphysema in laparoscopic totally extraperitoneal inguinal hernia repair

BACKGROUND: There is a paucity of published data on the incidence of subcutaneous emphysema and the causative factors responsible for its occurrence during laparoscopic procedures. This study was undertaken to evaluate the incidence and factors associated with the occurrence of subcutaneous emphysema in patients undergoing a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. MATERIALS AND METHODS: The prospective study included 100 patients who presented with a primary inguinal hernia and underwent an elective laparoscopic TEP hernia repair from November 2003 to May 2005. Various factors, including age, body mass index (BMI), type of hernia (i.e., unilateral or bilateral, indirect or direct), duration of surgery, and end-tidal carbon-dioxide tension (start and peak), were evaluated. A grading system was evolved to document clinically apparent subcutaneous emphysema immediately and at 6 and 24 hours after the surgical procedure. RESULTS: A BMI <25, longer operating time (especially >1 hour), and higher end-tidal carbon-dioxide tension (start, peak, and difference) were found to be significantly associated with the development of subcutaneous emphysema. Age and type of hernia -- unilateral versus bilateral, direct versus indirect -- were not found to be statistically significant factors. CONCLUSIONS: The incidence of subcutaneous emphysema in laparoscopic extraperitoneal hernia repairs is high and largely under-reported. Once it is noted, the progression of the surgical emphysema during this type of surgery can have serious complications (e.g., cardiovascular and hemodynamic disturbances) unless timely, appropriate measures are taken. Etiology of subcutaneous emphysema is multifactorial, with no single factor having a prominent association.     

Laparoscopic totally extraperitoneal repair of inguinal hernia: a policy of selective mesh fixation over a 10-year period

INTRODUCTION: The issue of mesh fixation in laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia repairs remains unresolved. The need for fixing the mesh arises from the fear of increasing recurrence rates. However, specific complications have emerged as a result of mesh fixation. MATERIALS AND METHODS: A retrospective analysis of 822 laparoscopic TEP hernia repairs in 634 patients over a 10-year period in a single surgical unit was performed. A policy of selective mesh fixation was followed and guidelines regarding indications of mesh fixation formulated. Recurrence rates and complications specific to mesh fixation were evaluated. RESULTS: Mesh was fixed in only 28 of 822 repairs. There were 6 (0.7%) recurrences. No neuropathic or mesh-fixation-related complications were noted in a follow-up period ranging from 10 to 82 months. CONCLUSIONS: Avoiding routine fixation of the mesh helps in decreasing complications and operative costs with acceptable recurrence rates. However, a policy of selective mesh fixation is advocated, based on specific indications.     

Ligand-dependent activation of the hedgehog pathway in glioma progenitor cells

The hedgehog (Hh) signaling pathway regulates progenitor cells during embryogenesis and tumorigenesis in multiple organ systems. We have investigated the activity of this pathway in adult gliomas, and demonstrate that the Hh pathway is operational and activated within grade II and III gliomas, but not grade IV de novo glioblastoma multiforme. Furthermore, our studies reveal that pathway activity and responsiveness is confined to progenitor cells within these tumors. Additionally, we demonstrate that Hh signaling in glioma progenitor cells is ligand-dependent and provide evidence documenting the in vivo source of Sonic hedgehog protein. These findings suggest a regulatory role for the Hh pathway in progenitor cells within grade II and III gliomas, and the potential clinical utility of monitoring and targeting this pathway in these primary brain tumors.     

RNA interference blocks gene expression and RNA synthesis from hepatitis C replicons propagated in human liver cells

RNA interference represents an exciting new technology that could have therapeutic applications for the treatment of viral infections. Hepatitis C virus (HCV) is a major cause of chronic liver disease and affects >270 million individuals worldwide. The HCV genome is a single-stranded RNA that functions as both a messenger RNA and replication template, making it an attractive target for the study of RNA interference. Double-stranded small interfering RNA (siRNA) molecules designed to target the HCV genome were introduced through electroporation into a human hepatoma cell line (Huh-7) that contained an HCV subgenomic replicon. Two siRNAs dramatically reduced virus-specific protein expression and RNA synthesis to levels that were 90% less than those seen in cells treated with negative control siRNAs. These same siRNAs protected naive Huh-7 cells from challenge with HCV replicon RNA. Treatment of cells with synthetic siRNA was effective >72 h, but the duration of RNA interference could be extended beyond 3 weeks through stable expression of complementary strands of the interfering RNA by using a bicistronic expression vector. These results suggest that a gene-therapeutic approach with siRNA could ultimately be used to treat HCV.     

Structural and functional alterations in microtubule protein from Chinese hamster ovary cell mutants.

We have examined mutant lines of Chinese hamster ovary cells that have increased resistance to the antimicrotubule drug Colcemid. Analysis of the functional properties of purified microtubule protein indicates that increased tolerance to the drug in vivo is reflected in altered properties of microtubules and tubulin in vitro. In this study, we have examined one series of related mutants and have found different microtubule alterations associated with each selection step. These changes include decreased Colcemid-binding affinity, an altered electrophoretic pattern of tubulin subcomponents, increased resistance to Colcemid inhibition of polymerization in vitro and, in one case, a decreased critical concentration for microtubule assembly. Characterized mutants of the class described here will be useful for probing the regulation of microtubule assembly in vivo.     

Occult hernias and bilateral endoscopic total extraperitoneal inguinal hernia repair: is there a need for prophylactic repair?

BACKGROUND: An advantage of the endoscopic total extraperitoneal approach over the conventional hernia repair is detection of an unsuspected, asymptomatic hernia on the contralateral side. A high incidence of occult contralateral hernias has been reported in the literature. However, few studies have examined the incidence of development of a hernia on the healthy side evaluated previously during an endoscopic unilateral hernia repair. This study aims to evaluate the incidence of development of a contralateral hernia after a previous bilateral exploration. The need for a prophylactic contralateral repair is also addressed. PATIENTS AND METHODS: We retrospectively reviewed the results of 822 endoscopic total extraperitoneal inguinal hernia repairs done in 634 patients over a period of 10 years from May 1993 to 2003. Incidence of hernia undetected clinically and during previous contralateral repair was assessed over a follow up period ranging from 10 to 82 months. RESULTS: About 7.97% of bilateral hernias were clinically occult hernias. Only 1.12% of unilateral hernia repairs (who had undergone a contralateral evaluation at surgery) subsequently developed a hernia on the other side. CONCLUSIONS: The endoscopic approach to inguinal hernia repair is an excellent tool to detect and treat occult contralateral hernias. The incidence of hernia occurring at the contralateral side after a previous bilateral exploration is low, hence a prophylactic repair on the contralateral side is not recommended on a routine basis.     

Chromobacterium violaceum: a case report of an unusual bacterium causing puerperal sepsis

Human infections by Chromobacterium violaceum are rare. Till date 6 cases have been reported from southern and eastern parts of India. We report here a case of puerperal sepsis by C. violaceum, probably the first case from Eastern part of Orissa. The patient was successfully treated with amikacin and gatifloxacin.