MRI­based neoadjuvant therapy indication in middle and low rectal cancer.

OBJECTIVE: The aim of this study was to evaluate the indication of neoadjuvant therapy in patients with middle and low rectal cancer based on MRI examination. BACKGROUND: In spite of noticeable advances in the diagnosis of rectal cancer, the optimal treatment remains highly debated. Current guidelines advise the use of neoadjuvant therapy in UICC stage II patients or higher. However, in clinical praxis, there is gradual implementation of new criterions and variables used in rectal cancer stage evaluation, the fact of which influences the treatment choice. The most important emerging variables taken currently into account are the distance from mesorectal fascia, circumferential resection margin, extramural venous invasion and intersphincteric plane, all of which can be evaluated using the MRI examination. METHODS: The accuracy of MRI staging was compared with definite histopathological results from resected tumors. Patient data were prospectively collected between the years 2013 and 2018 at 3rd Surgical Clinic, Faculty of Medicine, Comenius University in Bratislava, Slovakia. Data from 101 patients were gathered and divided into two groups, according to the localization of tumor within rectum, while 9 patients were excluded from the study because of benign lesion diagnosis based upon final histopathologic evaluation. RESULTS: In 92 evaluated patients, no significant change was noted between MRI and histopathological T-staging. However, in N-staging, significant differences were noted between preoperative MRI staging and postoperative histopathological staging. CONCLUSION: The results of this study demonstrate inefficient preoperative lymph node staging, suggesting overtreatment of rectal cancer patients. Although the use of neoadjuvant therapy has led to great advances in modern cancer treatment, it is connected with a number of side effects and therefore should be indicated only for patients who can benefit from this treatment (Tab. 1, Fig. 3, Ref. 16).

Significance of MRI in rectal carcinoma therapy optimization - correlation of preoperative T- and N-staging with definitive histopathological findings.

In past decades, both prognosis and therapy of rectal cancer patients showed significant improvement, on the other hand, the incidence of rectal carcinoma continues to have a rising tendency. According to current UICC classification, patients in stage II rectal cancer or higher are indicated for neoadjuvant chemoradiotherapy (nCRT). Magnetic resonance imaging (MRI) is currently the most common diagnostic method used for preoperative staging of rectal cancer. Several studies already pointed out the inaccuracy of preoperative lymph node staging in patients with rectal cancer. The present study analyzed overall accuracy of MRI staging of rectal cancer and thus its accuracy in neoadjuvant therapy indication, by comparing preoperative MRI staging with definitive histopathologic results from resected tumors. This study evaluated cases of 92 patients with rectal tumor that underwent MRI examination followed by surgical resection. Tumors included in the analysis were ranging from T1 to T3b according to TNM staging, with free circumferential resection margin (CRM), distance form mesorectal fascia more than 5 mm, negative intersphincteric plane and also negative extramural venous invasion (EMVI), while the N stage was not decisive. In all cases both N-staging and T-staging were evaluated histologically and compared with preoperative MRI results. Significant difference in preoperative and postoperative N-staging was shown in 51 patients (61.45%). In majority of cases MRI lead to overstaging, which was observed in 44 cases (53.1 %), with complete negativity of lymph nodes proven by histological examination in 34 cases. On the other hand, understaging of lymph nodes was observed only in 7 cases (7.4 %). The T-staging did not show significant differences. Results from this study confirm that MRI plays an important role in T-staging of rectal tumors, however, there are admittedly issues in N-staging of tumors, which should lead to reevaluation of neoadjuvant therapy indication in patients with positive lymph nodes according to MRI examination. Based on the results of this study, we see the future of preoperative staging of rectal tumors in precise T-staging together with accurate assessment of CRM and distance of tumor from mesorectal fascia as well as evaluation of intersphinteric plane and EMVI.

Early versus delayed laparoscopic cholecystectomy in treatment of acute cholecystitis.

BACKGROUND: Acute cholecystitis is one of the most frequent diseases occurring in the developed countries of the world. Since the advent of laparoscopic cholecystectomy there has been a lack of agreement regarding the timing of the operation in the treatment of acute cholecystitis. METHODS: From September 2012 to January 2015 we carried out a prospective randomized trial at the IIIrd Surgical Department of University Hospital Milosrdní bratia in Bratislava. The aim of the trial was to compare the two basic approaches of the treatment of acute cholecystitis. During our trial, 62 patients with acute cholecystitis were admitted to the surgery department and 31 patients were treated with an early laparoscopic cholecystectomy within 72 hours after the appearance of the symptoms. Other 31 patients were primarily treated with antibiotics and subsequently underwent a delayed cholecystectomy after 6-8 weeks. RESULTS: Our results suggest several advantages of the early laparoscopic cholecystectomy such as shorter operation time, lower conversion rate, shorter length of hospital stay, shorter postoperative convalescence and lower cost of hospitalization. CONCLUSION: According to these results we believe that immediate laparoscopic cholecystectomy (within 24 hours from the patient's admission to hospital) should become a preferred method of treatment of the patients with acute cholecystitis (Tab. 1, Fig. 2, Ref. 17).

Importance of thymectomy and prognostic factors in the complex treatment of myasthenia gravis.

BACKGROUND: Thymectomy is indicated in patients with seropositive myasthenia gravis (SPMG) in patients under the age of 50 and in patient with myasthenia gravis (MG) associated with thymoma. METHODS: 345 patients with MG who underwent an extended thymectomy from April 1990 to December 2010. Patients were separated into the 4 groups: group with a complete stable remission, pharmacological remission group, group of patients with significant improvement and the group with mild improvement of symptoms. RESULTS: In our study, we observed 345 patients with MG and thymectomy. 137 patients (39.71 %) attained the complete stable remission (CSR) and 92 patients (26.67 %) the pharmacological remission (PR). The significant improvement of MG symptomatology was achieved in 95 patients (27.54 %). The rest of 21 patients from total 345 (6.08 %) have reached only a mild improvement. Patients after thymectomy with CSR were in the clinical stage I and IIA, in accordance to the modified Osserman classification and most benefited from the thymectomy. CONCLUSIONS: The extended thymectomy combined with immunotherapy is the preferred treatment with an expected satisfactory long-term remission rate. Despite the recent improvements in MG medical therapy, thymectomy plays an important role in the otherwise complex treatment of the disease. Because of early diagnosis with thymectomy performed without a delay, patients can achieve significantly more often favorable outcomes and even stable remissions (Tab. 4, Fig. 7, Ref. 17).

[Optimal timing of laparoscopic cholecystectomy in treatment of acute cholecystitis]. / Optimálne nacasovanie laparoskopickej cholecystektómie v liecbe akútnej cholecystitídy.

INTRODUCTION: Acute cholecystitis is one of the most frequent diseases occurring in developed countries of the world. Laparoscopic cholecystectomy is a treatment option for acute cholecystitis. Since the advent of laparoscopic cholecystectomy there has been a lack of agreement regarding the timing of the operation in the treatment of acute cholecystitis. METHOD: From September 2012 to August 2015 we carried out a prospective randomized trial at the IIIrd Surgical Department of University Hospital Milosrdní bratia in Bratislava. We compared two basic approaches to the treatment of acute cholecystitis. During the trial, 64 patients with acute cholecystitis were admitted to the surgery department. 32 patients were treated with early laparoscopic cholecystectomy within 72 hours from the appearance of the symptoms. The other 32 patients were primarily treated with antibiotics and subsequently underwent delayed cholecystectomy after 68 weeks. RESULTS: Our results suggest several advantages of early laparoscopic cholecystectomy such as shorter operation time, lower conversion rate, shorter length of hospital stay, shorter postoperative convalescence and lower cost of hospitalisation. CONCLUSION: Based on these results we believe that immediate laparoscopic cholecystectomy (within 24 hours from the patients admission to hospital) should become a preferred method of treatment of patients with acute cholecystitis. KEY WORDS: acute cholecystectomy early and delayed laparoscopic cholecystectomy prospective randomized trial.

Laparoscopic versus open appendectomy in treatment of acute appendicitis.

INTRODUCTION: The authors present the results of a retrospective study comparing the laparoscopic and open procedures of appendectomy for the diagnosis of acute appendicitis.Material and methods. Retrospective analysis of the results of both methods on a set of 161 patients in period 2006-2010. RESULTS: Regarding the intraabdominal complications and hospitalization periods, results confirm the equivalence of both methods. A significantly lower incidence of wound complications as well as shorter hospital stay were experienced in the laparoscopy-treated group of patients. CONCLUSION: Based on the results of this study, the laparotomic appendectomy would be reserved for appendicitis with diffuse peritonitis. The laparoscopy is positively preferred in obese patients (Tab. 3, Ref. 16).

Thymic tumours associated with Myasthenia gravis: a long term observation study of operated patients.

Primary tumours of thymus, thymoma and thymic carcinoma, are very rare, they represent less than 1 % of all neoplasms. The most common manifestation of thymoma with appearance of 40 to 50 % of the neuromuscular autoimmune disease is myasthenia gravis (MG). The performance of a complete resection is the most predictive indicator for long-term survival of patients with thymic tumour, also important prognostic factors are the histological type of thymic tumour and its invasiveness. The aim of our study is to study the long-term survival of patients after the resection of the tumour, as well as enhanced efficiency of radical thymectomy in the complex treatment of myasthenia gravis. From 1989 to 2010 we operated on 369 patients with MG. Out of 49 patients (13.7 %) 38 cases (76.6 %) were thymomas and 11 cases (23.4 %) thymic carcinomas. Complete removal of tumours (stage I, II, and III) were performed in 45 (92 %) cases. Of the 41 living patients (83.7 %), three (7.3 %) were diagnosed with metastatic thymic carcinoma or thymoma, and treated with adjuvant therapy. In one case, the patient died due to generalization of the thymic carcinoma. Statistical analysis with Kaplan-Meier method showed better overall survival of patients with thymoma than patients with thymic carcinoma. The difference in survival curves was not significant. (Mantel-Cox p = 0.479, Generalized Wilcoxon p = 0.326). In terms of treatment of Myasthenia gravis associated with thymoma, we achieved 70 % successful clinical and pharmacological remission. On the other hand, paraneoplastic MGAT has the worst prognosis of all the other forms of MG. The difference between MGAT to every other form of MG was statistically significant (Tab. 6, Fig. 1,Ref. 28).

[Laparoscopic repair of incisional hernias - our first experience]. / Laparoskopická plastika hernií v jazve po laparotómii - nase prvé skúsenosti.

INTRODUCTION: The authors present their first experience with the laparscopic hernioplasty of the incisional hernias appearing after laparotomy. MATERIAL AND METHODS: In the period from January 2008 to June 2012, 29 patients underwent hernioplasty by the IPOM technique (Intra Peritoneal Onlay Mesh) using Teflon mesh. The patients were followed up prospectively for the mean time of 29 months. The mean age of the patients was 57 years, the average size of the hernias was 6.5 cm, and the average time of the operation was 75 minutes. RESULTS: In the early postoperative period in 3 patients (11%) occurred pseudoperitonitis caused by the irritation of the peritoneum in the area of the attached mesh. In one patient (3%) severe paralytic ileus developed, and 22 patients experienced seroma in the left hernial sac. All seroma was absorbed except for one patient. In the mentioned case, seroma absorbed completely after repeated aspiration within 3 months. During the period of follow-up no patient showed any signs of recurrence. CONCLUSION: Since the first method of choice in the treament of incisional hernias after laparotomies is still unclear, laparoscopic repair seems to be a promising option. Results of laparoscopic repair are comparable with the conventional hernioplasty using mesh.

[Relapsing urinary tract infections as a single symptom of a foreign body within the GIT in a diverticulosis patient]. / Recidivujúce infekcie mocových ciest ako jediný príznak cudzieho telesa gatrointestinálneho traktu pri divertikulóze.

Recidiving urinary tract infections and pneumaturia are the cardinal symptoms of colovesical fistula. The authors present a case of rare complication of diverticulosis and gastrointestinal foreign body, that only had urological symptomatology.

Surgical treatment of pulmonary metastases in germ-cell testicular cancer patients--long-term results.

OBJECTIVES: The aim of this prospective clinical study is to evaluate our 20-year experience with surgical treatment of pulmonary metastases in germ-cell testicular cancer and discuss the optimal therapeutical approach. BACKGROUND: Authors presents 63 patients who were surgically treated in the period from 1988 to 2008 for pulmonary metastases in germ cell testicular cancer. All patients were allocated for surgical treatment after undergoing cisplatin-based combination chemotherapy. METHODS: In a group of 63 patients, 57 thoracotomias and 27 sternotomias were performed. In pulmonary procedures small atypical resections prevailed--84%. Postoperative mortality was 1.2%. Decision for follow-up treatment was made on basis of histological investigation of metastases. In some cases when viable tumor tissue was found (16% patients), further chemotherapy was administered. The rest of patients were monitored intensively. RESULTS: In a long-term follow-up, remission was achieved in almost 60% of patients. CONCLUSION: We suggest that lung metastasectomy as the secondary treatment in generalized germ cell testicular cancer should be fully warranted (Fig. 3, Ref. 16). Full Text (Free, PDF) www.bmj.sk.

[Long-term results of surgical treatment of pulmonary metastases in germ cell testicular cancer patients]. / Dlhodobé výsledky chirurgickej liecby pl'úcnych metastáz u pacientov s germinatívnymi nádormi testis.

BACKGROUND: Lung metastasectomy as a treatment option in pulmonary metastases has been discussed for a long time.Testicular cancer belongs to a group of tumours primarily treated with chemotherapy because of the high efficacy of anticancer chemotherapy. Surgical treatment plays only a secondary role in the removal of residual pulmonary metastases. Decision-making in the treatment of pulmonary metastases requires histological investigation.The aim of this prospective clinical study is to evaluate 20 years of experience with the surgical treatment of pulmonary metastases in germ-cell testicular cancer. PATIENTS AND METHODS: In the period 1988-2008, 63 patients were surgically treated for residual pulmonary metastases of testicular germ-cell tumours. All of the patients were indicated for surgery--pulmonary metastasectomy after the anticancer chemotherapy had been carried out.The survival rate of patients was evaluated according to the Kaplan-Meier method. RESULTS: In total, 57 thoracotomies and 27 sternotomies were performed. 9 patients underwent repeated thoracotomy due to recurrent metastases. In the case of primary resection of pulmonary metastases, minor procedures dominated--atypical partial resections were performed in 84% of all patients. Postoperative mortality was 1.2%. The histological result of metastasis determined a further procedure. Patients in whom vital tumorous tissue was detected (16% of patients) were subsequently treated by second-line chemotherapy, while the rest of the patients were strictly followed-up. In long-term survival, where the mean duration of follow-up was 8.9 years, an almost 60% remission rate was achieved. CONCLUSION: Based on the long-term results, the authors consider surgical treatment of pulmonary metastases of testicular germ-cell tumours as the treatment fully indicated.

[Ventral hernia associated with morbid obesity--when is surgery indicated?]. / Ventrálna hernia spojená s morbídnou obezitou--kedy operovat'?

The authors refer results of surgical treatment of incarcerated ventral hernias in patients with morbid obesity. In the 3rd Department of Surgery of the Comenius University Medical Faculty in Bratislava, 4 obese patients (BMI over 40) were operated for incarcerated ventral hernias in 2007. Based on a follow up analysis, the authors recommend a proactive approach to elective surgical therapy.

[Scar hernia repairs using a mesh--the sublay technique]. / Operácie hernií v jazve pomocou siet'ky--technikou sublay.

In this work, the authors evaluated a group of patients operated on the III. Surgery Clinic FNsP MB in 2004 to 2006 for incisional hernias using the sublay technique--he mesh is implanted preperitoneally and covered by the fascia. The evaluation was done using a questionnaire, with a return rate of 65.5%. After an average of 24.8 months, 8.3% of patients report recurrence. Based on this data we further use this technique, but put more emphasis on minimalizing postoperative complications. From today's perspective, we consider retromuscular hernia repair using a mesh to be a standard procedure in incisional hernia management with best results in preventing recurrences.

[Surgical treatment of pulmonary metastases--long-term results]. / Chirurgická liecba plucnych metastáz--dlhodobé výsledky.

A group of 103 patients operated for lung metastases in the Surgical clinic of the FNsP of L. Dérer and in the II Surgical clinic of L. Pasteur is assessed in this work. Minor operations of atypical resection prevailed among the resections. The postoperative mortality in the whole group was 1.9%. The best long-term survival rates were reached in tumors primarily treated by chemotherapy and followed by the lung metastasectomy. All patients in this group suffered from testical tumors and their long-term survival rate was 69%. In tumor cases, where the metastasis was primarily removed by surgery, the long-term survival rate correlated with the literature data of 30%. When the prognostic factors were considered, the number of removed metachrone metastases being less than 3, appeared statistically significant from the point of view of the patient survival. Based on the evaluated results, it can be concluded that surgical treatment of the lung metastases performed within the interdisciplinary oncological concept, currently remains a generally accepted therapeutic procedure.

Delayed orchiectomy after chemotherapy in patients with advanced testicular cancer.

INTRODUCTION: The therapeutic procedures in the management of testicular cancer are determined by histological findings in the removed testis and by the extent of the disease at the time of diagnosis. However, all advanced tumors could be treated by primary chemotherapy regardless of the histological findings. The current imaging techniques (ultrasound of the testis, abdominal and chest CT examination) and laboratory tests (determination of serum tumor markers AFP and hCG) provide sufficient evidence for the presence of cancer. When the diagnosis of advanced tumor is evident, it is possible to start the treatment without orchiectomy. The aim of this study was to evaluate the advantages of neo-adjuvant chemotherapy with delayed orchiectomy in the management of advanced testicular cancer. MATERIAL AND METHODS: A total of 36 patients with advanced germ cell testicular cancer underwent primary PVB or BEP chemotherapy without previous orchiectomy. Mean age of patients was 32 years. Detailed medical, surgical and urological examination showed pulmonary metastases and/or extensive abdominal tumorous masses imitating acute abdominal crisis and impaired drainage of the kidney due to ureteral obstruction. Searching for the origin, testicular tumor was detected. Eleven patients had a bulky disease in the retroperitoneum (Stage IIC), two had enlarged retroperitoneal lymph nodes (Stage IIB), two had enlarged mediastinal lymph nodes (Stage III) and other 16 patients had also pulmonary metastases, and 5 pts had pulmonary metastases only. The patients were treated with cisplatin-containing combination chemotherapy. Following completion of chemotherapy, orchiectomy was performed alone or simultaneously with retroperitoneal lymph node dissection (RPLND) and/or lung metastasectomy in cases with persistent residual mass. Following orchiectomy the patients were regularly checked and in cases with viable malignant tumor found in the testis sequential chemotherapy was administered. Similarly when the relapse of the disease was detected, the patients were treated with sequential chemotherapy. RESULTS: Complete disappearance of metastases was observed in 12 patients following chemotherapy alone. The residual mass persisted in 24 patients (in 22 out of them in the retroperitoneum and in two patients also in the lungs) and was removed surgically. The viable tumor in the removed tissue was found in one patient. Delayed orchiectomy was performed simultaneously with surgical removal of residual mass in the retroperitoneum in 24 patients and as a separate procedure in 12 patients who have been considered to be complete responders following chemotherapy alone. Residual viable tumor in testicular specimen was found in three patients, necrotic or fibrotic tissue in 18, and mature teratoma in 15 patients. Overall survival of the patients was 26/36 (72.7%) at mean of 56.9 months (range 7-145 months, median 50 months) since the start of the treatment. CONCLUSIONS: In patients with advanced germ cell testicular cancer preference must be given to the early beginning of intensive chemotherapy without the need of tissue diagnosis of primary tumor that should be obtained by orchiectomy. Benefit of this therapeutic approach is the timely management of acute abdominal and/or pulmonary symptoms of life-threatening distant metastases.

[Delayed orchiectomy and surgery of metastases after primary chemotherapy in the treatment of advanced testicular tumors]. / Odlozená orchiektómia a metastazektómia po primárnej chemoterapii v liecbe nádoru testis v pokrocilom stádiu.

OBJECTIVE: The therapeutic procedures in the management of testicular germ cell tumors (TGCT) are determined by histological findings in the removed testis and by the extent of the disease at the time of diagnosis. However, all advanced TGCT could be treated by primary chemotherapy (CHT) regardless of histological findings. The current imaging techniques (ultrasonography of the testis, abdominal and thoracic CT examination) and laboratory tests (determination of serum tumor markers AFP and hCG) provide sufficient evidence for the presence of TGCT. In cases of acute abdominal and/or pulmonary symptoms because of life-threatening distant metastases, when the diagnosis of advanced TGCT is evident, it is possible to start the treatment without primary orchiectomy (OE). The aim of this study was to evaluate the advantages of neo-adjuvant CHT with delayed OE in the management of advanced TGCT. MATERIAL AND METHODS: During last 12 years a total of 40 patients with advanced TGCT were treated by neo-adjuvant cisplatin-based combination CHT without previous OE. Eleven patients had bulky mass in the retroperitoneum (Stage IIC), three patients had enlarged retroperitoneal lymph nodes (Stage IIB), two patients had enlarged mediastinal lymph nodes (Stage III). Another 24 patients had pulmonary metastases (Stage IV), 15 of them had also bulky mass in the retroperitoneum and 6 of them in the mediastinum. Following the completion of CHT, OE was performed alone or simultaneously with retroperitoneal lymph node dissection (RPLND) and subsequent lung metastasectomy in cases with persistent residual mass. RESULTS: Complete disappearance of metastases was observed in 13 (32.5%) patients following PVB or BEP CHT alone. The residual mass in the retroperitoneum was removed surgically in 27 patients. In three of them residual tumorous mass was removed also from the lungs without finding of viable tumor. Viable malignant tumor in the removed retroperitoneal tissue was identified in two patients (7.4%). Residual viable malignant tumor in the testis was found in 5 patients (12.5%). Overall survival was 29/40 patients--72.5% (by mean of 55.2 months since the start of the therapy). CONCLUSIONS: The benefit of this therapeutic approach in the immediate management of acute abdominal and/or pulmonary symptoms of life-threatening distant metastases. Another advantage is the like hood of surgical treatment of residual metastatic masses simultaneously with delayed OE on the same day, under one anaesthesia.

[Simultaneous occurrence of acute myasthenia gravis and acute polymyositis in 3 patients and in 2 patients also associated with a thymoma]. / Kombinovaný výskyt akútnej myasténie gravis a akútnej polymyozitídy u troch pacientov, u dvoch v asociácii s tymómom.

In the Slovak Centre for Neuromuscular Diseases 768 patients with myasthenia gravis are on the records. 112 myasthenics (14.5%) have another associated autoimmune disease. Most frequently a combination with an autoimmune disease of the thyroid gland or rheumatoid arthritis is involved. Extremely rare is the concurrent manifestation of the acute form of mysthenia gravis and acute polymyositis, observed by the authors in three patients,incl. two associated with a thymoma. In all three patients the disease had a serious clinical picture which called for controlled ventilation and a nasogastric tube. From the prognostic aspect rapid and correct diagnosis and early adequate treatment--combined immunosuppressive treatment (prednisone, azathioprin) is most important, incl. large i.v. doses of methylprednisone, repeated plasmaphereses, i.v. administration of human immunoglobulin, 0.4 g/kg body weight for a period of five days and optimally timed thymectomy with removal of the thymoma.

[Thymectomy at the 2nd Surgical Clinic of the Comenius University Medical School Hospital]. / Tymektómia na II. chirurgickej klinike LF UKo a dnes.

Based on comparison of two groups of thymectomies (46 in 1955-1975 and 158 in 1990-1998) the authors found a marked improvement of the results of thymectomy. During the former period thymectomies had a severe postoperative course with a high lethality and low percentage of remissions. Due to the introduction of immunosuppressive treatment the lethality of thymectomies declined to almost zero and clinical and pharmacological remission resp. was recorded in 70% patients.

[Determination of prognostic factors in surgical treatment of myasthenia gravis]. / Stanovenie významu prognostických faktorov pri chirurgickej liecbe myasténia gravis.

The authors evaluated, using statistical analysis, the importance of prognostic factors in patients subjected to thymectomy on account of myasthenia gravis. The results revealed a better prognosis of the disease, if the history was less than 6 months, preoperative treatment less than 1.5 years, a histological finding of thymus hyperplasia, second clinical stage according to Ossermann and the patients age below 30 years. From the statistical analysis ensues that the prognosis of myasthenia gravis is more favourable when the case-history is shorter as a result of rapid diagnosis and when preoperative treatment is reduced to a minimum.

[Hernias in scars]. / Hernie v jazve.

The authors evaluated a group of patients operated at the Surgical Clinic in 1992-1996 on account of a hernia in a scar by the Mayo plastic operation. During a mean follow-up period of 33 months 44% patients were re-operated or had a relapse. The results confirmed data reported in the literature of 30-50% relapses of hernias in scars when synthetic nets are not used. With regard to the unfavourable results the authors use since November 1997 synthetic nets in plastic operations of hernias.