Cine magnetic resonance imaging vs high-resolution ultrasonography for detection of adhesions after laparoscopic and open incisional hernia repair: a matched pair pilot analysis

Background Intraabdominal adhesions represent nonspecific complications before or after laparoscopic or open incisional hernia repair. The objective of this matched control pilot study was to display long-term adhesions noninvasively by applying functional cine magnetic resonance (MR) imaging, as compared with applying high-resolution ultrasonography (US). Methods The study group, composed of 17 consecutive patients (12 men and 5 women; mean age, 52 years), underwent laparoscopic intraperitoneal onlay mesh repair using expanded polytetrafluoroethylene (ePTFE) mesh. Their mean body mass index was 30 kg/m², and the size of the hernia was 95 cm². Another group, matched for age, gender, and type of hernia, was subjected to open abdominal wall repair using the preperitoneal sublay technique with a large-pore, low-weight polypropylene mesh. For cine MR imaging (1.5 T), section-by-section dynamic depiction of induced visceral slide throughout the entire abdomen was achieved by applying transverse or sagittal true fast imaging with steady-state precession sequences. The location and type of adhesions were compared with high-resolution ultrasonography using nine segments of the abdominal map. Results The patients subjected to laparoscopic and open incisional hernia repair were examined 16 and 28 months after surgery. The findings showed functional cine MR imaging as superior to high-resolution ultrasonography for assessing the amount of intraabdominal adhesions (n = 53 vs n = 3; p < 0.01). Most frequently, adhesions were seen between small bowel loops and the abdominal wall (n = 22), followed by bowel-to-bowel adhesions (n = 19; p < 0.05). However, adhesions between small bowel loops and the abdominal wall occurred more frequently after open mesh repair (p < 0.05). Furthermore, a strong correlation was observed between patient complaints and findings with cine MR imaging (p < 0.05). Maximum pain correlated significantly with the region of the most distinctive adhesions (p < 0.05). Conclusions Functional cine MR imaging represents a reliable noninvasive technique for detecting long-term adhesions after open and laparoscopic incisional hernia repair. The study results suggest that this approach has distinct advantages over high-resolution ultrasonography.     

Mesh fixation with human fibrin glue (Tissucol) in open tension-free inguinal hernia repair: a preliminary report

Background: The Lichtenstein technique for inguinal hernia repair is easy to learn and associated with few complications. However, recent studies have suggested that this technique is inferior to some ‘sutureless’ repair systems in terms of perceived difficulty, operating time, surgeon satisfaction, etc. Methods: We employed a sutureless Lichtenstein technique in 80 consecutive patients with primary unilateral inguinal hernia, to assess patient and trainee surgeon outcomes. Human fibrin glue was used in place of conventional sutures. Results: The mean operating time was 36 min and all patients were discharged 5–6 h after the operation. On a 100-point visual analogue scale, the surgeons rated the difficulty of the operation as low (mean score, 31), and perceived satisfaction as high (mean score, 84). No complications were observed at 12-month follow-up. Conclusion: This study confirms the efficacy of mesh fixation with human fibrin glue, and supports the viability of a sutureless Lichtenstein procedure.     

Inguinal hernia repair in Hospital Authority hospitals: The role of laparoscopic hernioplasty

Objective: Two major changes have occurred in inguinal hernia repair during the last two decades: (i) the use of tension‐free mesh repair; and (ii) the application of laparoscopic technique for repair. The aims of the present study were to study: (i) how inguinal hernia repair was carried out; and (ii) the outcome of inguinal hernia repair in Hospital Authority (HA) hospitals. Methodology: This was a retrospective analysis on 8311 elective inguinal hernia repairs performed in 16 HA hospitals from January 2001 to December 2003. The mean age was 63.9 ± 14.2 years, and the male to female ratio was 22.0 : 1.0. Among these, 869 (10.5%) repairs were performed with the laparoscopic approach and 7442 (89.5%) repairs with the open approach. The proportion of laparoscopic hernia repair increased from 8.7% to 12.6%. Results: For open repair, 39% of cases were carried out with regional anaesthesia, 32% with general anaesthesia and 29% with local anaesthesia (LA). Furthermore, mesh repair was used in 88% of the patients. For laparosocpic repair, 98.4% of cases were carried out under general anaesthesia, and all patients had mesh repair using the totally extraperitoneal approach. A significantly higher proportion of bilateral repair and recurrent hernia repair was performed with the laparoscopic approach (P = 0.000). For primary unilateral repair, there was no significant difference in the postoperative length of stay (LOS) and the total LOS between the laparoscopic and the open surgery groups. No difference in LOS was found in recurrent hernia repair between the two groups. With respect to bilateral repair, both the preoperative LOS (P = 0.036) and total LOS (P = 0.039) were shorter in the laparoscopic group. Furthermore, a significantly higher proportion of day‐surgery patients was observed in the laparoscopic group than the open surgery group (21.3%vs 16.9%, P = 0.001). Nevertheless, when only the results of 2003 were analyzed, the postoperative LOS (P = 0.000) and total LOS (P = 0.000) were significantly shorter in the laparoscopic group than the open surgery group. The LOS parameters were significantly shorter in the open surgery LA subgroup compared with the non‐LA subgroup (P = 0.000), and they were not different from those in the laparoscopic group. Conclusions: The open mesh repair is the predominant approach for inguinal hernia repair in HA hospitals. The originally described local anaesthetic approach was under utilized, although it resulted in good outcome. The use of laparoscopic hernia repair is increasing and a learning curve was recently observed with improved outcome.     

Survival of severe congenital diaphragmatic hernia has morbid consequences

Background/Purpose

Fetal tracheal occlusion (TO) was developed in an attempt to enhance prenatal lung growth and improve survival in fetuses with severe congenital diaphragmatic hernia (CDH). We conducted a randomized, controlled clinical trial in 24 fetuses with severe left CDH (liver herniated into the thorax and low lung-to-head ratio) to compare survival after endoscopic fetal TO vs standard perinatal care (control) and prospectively followed up the 16 survivors (9 control, 7 TO) to compare neurodevelopmental, respiratory, surgical, growth, and nutritional outcomes.

Methods

At 1 and 2 years old, subjects underwent evaluation consisting of medical and neurological history and physical, developmental testing, nutritional assessment, oxygen saturation and pulmonary function testing, chest radiograph, and echocardiogram. Growth and developmental measures were corrected for prematurity. Data were analyzed by Mann-Whitney rank sum test, Fisher's Exact test, and logistic and linear regression.

Results

Infants with TO were significantly more premature at birth (control vs TO, 37.4 ± 1.0 vs 31.1 ± 1.7 weeks; P < .01). Growth failure (z score for weight <2 SDs below mean) was severe in both groups at 1 year of age (control vs TO, 56% vs 86%; P = .31). There was considerable catch-up growth by age 2 years (growth failure: control vs TO, 22% vs 33%; P = .19). There were no differences in other growth parameters. There were also no differences in neurodevelopmental outcome at 1 and 2 years. Supplemental oxygen at hospital discharge was a significant predictor of worse neurodevelopmental outcome at 1 and 2 years old (P = .05 and P = .02, respectively). Hearing loss requiring amplification has been diagnosed in 44% of the group (control vs TO, 44% vs 43%; P = 1.0).

Conclusions

In this group of infants with severe CDH, there were no differences in outcome at 2 years old despite significant prematurity in the TO group. Oxygen supplementation at hospital discharge identified the most vulnerable group with respect to neurodevelopmental outcome, but all infants had significant growth failure, and hearing impairment is a substantial problem in this population. Severe CDH carries significant risk of chronic morbidity.     

Femoral vein occlusion and spontaneous collateral ectasia presenting as recurrent hernia of the groin: a case report

Femoral vein occlusion is not a common complication even after repeated hernia repair. We describe a case of a 14-year-old boy with a visible and soft, yet irreducible, mass below the inguinal ligament after 3 previous inguinal hernia repairs and heart catheterization in infancy. Further examination showed dilated venous collaterals, bypassing an occluded common femoral vein via the testicular sheaths and across the pelvic floor. We discuss etiology, diagnostic pitfalls, therapeutic options, and possible future complications, with a literature review.     

Neonatal thoracoscopic repair of congenital diaphragmatic hernia: selection criteria for successful outcome

Background/Purpose

Complications of open conversion, hypercarbia, and intestinal injury have plagued minimally invasive approaches to congenital diaphragmatic hernia (CDH) repair in neonates. To safely begin using minimally invasive techniques for neonatal CDH repair, we formulated preoperative selection criteria and operative techniques that would enhance chances for successful thoracoscopic primary diaphragm repair and uncomplicated outcome.

Methods

During the period from January 2003 to October 2004, neonates were selected for thoracoscopic CDH repair using anatomic and physiologic criteria. Anatomically, all patients were required to have stomach in the abdomen by radiography. Physiologically, all patients were required to be on minimal ventilator support with preoperative ventilator peak inspiratory pressures in the low 20s mm Hg. No patient could have clinical evidence of pulmonary hypertension at the time of surgery. Thoracoscopic CDH repair was performed using 3 trocars (3 and 5 mm). The hernia contents were reduced into the abdomen using 5-mm Hg insufflation, and the diaphragms were repaired primarily using interrupted 3-0 Ethibond simple sutures (Ethicon, Inc, Piscataway, NJ). Posterolateral diaphragm stitches were passed around the posterolateral ribs and tied extracorporeally.

Results

Thirty neonates with CDH were admitted to Children's Hospital Boston and Vanderbilt Children's Hospital during the study period. Eight patients (27%) met selection criteria and 7 underwent thoracoscopic CDH repair. Primary diaphragmatic repair was successfully accomplished thoracoscopically in all neonates without perioperative complication. Preoperative anatomic criteria correlated accurately with intact esophageal hiatus and primary diaphragm repair. Physiologically, each patient tolerated intrathoracic insufflation and CDH repair without clinical pulmonary hypertension or blood pressure lability. Three patients had intraoperative respiratory acidosis that was reversed with ventilator changes. Operative times averaged 152 minutes and ranged from 212 to 106 minutes. Postoperative mechanical ventilation ranged from 0 to 7 days, and the length of hospitalization ranged from 5 to 32 days. Longest follow-up has been 17 months. One patient required reoperation for recurrent CDH at 10 months after repair, but there have been no other long-term complications.

Conclusions

Neonatal thoracoscopic CDH repair is safe in selected patients who have good preoperative pulmonary function and anatomy amenable to primary diaphragmatic repair. A wider range of neonates may be acceptable for thoracoscopic CDH repair with increasing surgical experience.     

Primary omental liposarcoma presenting as an incarcerated inguinal hernia

Herein, we present a case of primary liposarcoma of the omentum found in an incarcerated inguinal hernia in a 52-year-old male patient. The patient was admitted to our hospital in June 2000 with sudden onset of left-sided abdominal and groin pain of 12 hours duration with a large, irreducible inguinal hernia. This was not associated with nausea or vomiting. An emergency operation was performed, and in the hernia sac the tumor, arising from the greater omentum, was found. After we opened the transversal fascia and peritoneum, the tumor was resected with a block of the greater omentum, and hernioplasty was performed using Shouldices method. The histopathological diagnosis of resected tumor showed myxoid type liposarcoma. In the English medical literature, omental liposarcoma has never before been reported as the content of a hernia sac.     

A review of incisional hernia repairs: preoperative weight loss and selective use of the mesh repair

At the Shouldice Clinic pre-operative weight loss is used prior to incisional hernia repairs. Mesh repair is selectively used, based on specific hernia characteristics. A series of 236 patients were reviewed and followed up for 36 months. Data were available on 188 patients (80%). There were 15 recurrences (8%). The number of obese patients was reduced from 67 (35.6%) to 25 (13.3%) through the weight loss program. The hernia diameter, gastrointestinal complications, and surgical site infection were significantly related to recurrence but not the type of repair, obesity, location, or previous recurrences. The risk factors of incisional hernias include size, intestinal complications and infections. A selective use has a comparable result to the exclusive use of mesh repair. Weight reduction has yet to be shown to affect the rate of recurrence, and further prospective studies are required.     

A comparative study of adhesion formation and abdominal wall ingrowth after laparoscopic ventral hernia repair in a porcine model using multiple types of mesh

Background The ideal mesh for laparoscopic ventral hernia repair is not yet identified.Methods We laparoscopically placed polypropylene (PPM), expanded polytetrafluoroethylene (ePTFE), and polyester with antiadhesive collagen layer (PCO) in eight pigs using sutures and tacks for fixation. After 28-day survival, we compared adhesion formation, fibrous ingrowth, and shrinkage among the types of mesh.Results Mean area of adhesions to PCO (8.25%) was less than that to ePTFE (57.14%, p < 0.001) or PPM (79.38%, p < 0.001). Adhesions peel strength was less for PCO (2.3 N) than for PPM (16.1 N, p < 0.001) or ePTFE (8.8 N, p = 0.02). Peel strength of mesh from the abdominal wall was less for ePTFE (1.3 N/cm of mesh width) than for PCO (2.8 N/cm, p = 0.001) or PPM (2.1 N/cm, p = 0.05). ePTFE area (94.4 cm²) was less than that for PCO (118.6 cm², p < 0.001) or PPM (140.7 cm², p < 0.02).Conclusion PCO had fewer and less severe adhesions than ePTFE or PPM while facilitating excellent ingrowth of the adjacent parietal tissue.     

微型腹腔镜治疗小儿腹股沟斜疝62例体会

目的:探讨微型腹腔镜治疗小儿腹股沟斜疝的可行性。方法:应用微型腹腔镜,采用自行设计的带线针和En-doc lose与操作钳配合,运用提插式缝合方法,高位荷包缝扎内环口周边腹膜,治疗小儿腹股沟斜疝62例。结果:62例手术均成功,手术时间10~15m in,住院2~3d。术后随诊1~28月无复发。结论:微型腹腔镜下高位荷包缝扎内环口治疗小儿腹股沟斜疝具有损伤小、恢复快、住院时间短、对侧再发率低的优点。