Incisional herniorrhaphy with intraperitoneal composite mesh: a report of 95 cases.

Incisional herniorrhaphy remains a formidable challenge to the general surgeon. Recurrence rates after primary repair are reported between 31-54 per cent while tension-free repairs with prosthetic mesh have lowered this rate to 10 per cent. Repairs with composite mesh (polypropylene/ePTFE) have been gaining in popularity due to the ease of mesh placement in the intraperitoneal location. This paper reviews our experience with composite repairs at a teaching community hospital. A retrospective chart review was performed which evaluated all patients undergoing abdominal incisional hernia repairs over a 4(1/2)-year period. The data were analyzed for mortality, recurrence, infection, subsequent bowel obstruction, and fistula formation. Two hundred twenty-one incisional herniorrhaphies were identified in the resident database of which 95 were repaired with Composix mesh (Bard Surgical, Cranston, RI) in the intraperitoneal position. There were two (2%) recurrences and eight (8%) infections. Fistulization to the small bowel from exposed polypropylene occurred in one patient. There were no bowel obstructions. One postoperative death occurred secondary to pulmonary embolus. Mesh removal was required in all infected cases, and there was a high incidence (63%) of methicillin-resistant Staphylococcus aureus (MRSA). Our findings parallel the low recurrence rate following prosthetic repair. We have reported a higher than expected infection rate particularly with MRSA. Although repairs with Composix mesh are highly successful in regard to recurrence, the high infection rate and resulting morbidity needs to be further evaluated.

Current management of common bile duct stones in a teaching community hospital.

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.