Impact of Mesh and Fixation on Chronic Inguinal Pain in Lichtenstein Hernia Repair: 5-Year Outcomes from the Finn Mesh Study.

OBJECTIVE: To find out the mesh fixation technique that minimises chronic pain in Lichtenstein hernioplasty. Mesh fixation may affect chronic pain and recurrence after inguinal hernia surgery, but long-term results of comparative trials are lacking. METHODS: Lichtenstein hernioplasty was performed under local anaesthesia on 625 patients in day care units. The patients were randomised to receive either a cyanoacrylate glue (n = 216), self-gripping mesh (n = 202) or non-absorbable 3-0 polypropylene sutures (n = 216) for the fixation of mesh. A standardised telephone interview or postal questionnaire was conducted 5 years after the index operation. The patients with complaints suggesting recurrence or chronic pain (visual analogue scale ≥ 3, 0-10) were examined clinically. The rate of occasional pain, chronic severe pain, recurrence, re-operations, daily use of analgesics, overall patient satisfaction and sensation of a foreign object were recorded. RESULTS: A total of 82% of patients (n = 514) completed the 5-year audit including 177, 167 and 170 patients in the glue, self-fixation and suture groups, respectively. There were no significant differences in the incidence of pain (7-8%), operated recurrences (2-4%), overall re-operations (4-5%), need for analgesics (1-2%), patient's satisfaction (93-97%) or in the feeling of a foreign object (11-18%) between the study groups. CONCLUSION: The choice of the mesh or fixation method had no effect on the overall long-term outcome, pain or recurrence of hernia. Less penetrating fixation (glue or self-gripping mesh) is a safe option for the fixation of mesh in Lichtenstein hernia repair.

Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman's hernia.

BACKGROUND: Sportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair. METHODS: A randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year. RESULTS: A total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70-80 to 10-20 in both groups (P < 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408). CONCLUSION: Totally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).

Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial).

BACKGROUND: Based on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70-80%) or complicated (20-30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis. METHODS: APPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients. Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin. DISCUSSION: To our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis. TRIAL REGISTRATION: Clinicaltrials.gov , NCT03236961, retrospectively registered on the 2nd of August 2017.

Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial.

BACKGROUND: An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial. METHODS: The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012. RESULTS: Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models. CONCLUSION: Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery.

Long-term mortality and causes of death in endoscopically verified upper gastrointestinal bleeding: comparison of bleeding patients and population controls.

OBJECTIVE: Upper gastrointestinal bleeding (UGIB) is a common emergency, with in-hospital mortality between 3 and 14%. However, the long-term mortality and causes of death are unknown. We investigated the long-term mortality and causes of death in UGIB patients in a retrospective single-centre case-control study design. METHODS: A total of 569 consecutive patients, aged ≥18 years, admitted to Kuopio University Hospital for their first endoscopically verified UGIB during the years 2009-2011 were identified from hospital records. For each UGIB patient, an age, sex and hospital district matched control patient was identified from the Statistics Finland database. Data on endoscopy procedures, laboratory values, comorbidities and medication were obtained from patient records. Data on deaths and causes of death were obtained from Statistics Finland. RESULTS: In-hospital mortality of UGIB patients was low at 3.3%. The long-term (mean follow-up 32 months) mortality of UGIB patients was significantly higher than controls (34.1 versus 12.1%, p < .001). During the 6 months following UGIB, the risk of death compared to controls was highest (HR 19.2, 95% CI 7.0-52.4, p < .001) and remained higher up to 3 years after the bleeding. Beyond 3 years' follow-up, there was no difference in mortality between the groups (HR 0.7, 95% CI 0.4-1.6, p = .436). During the first 3 months after the UGIB episode, mortality was related to gastrointestinal diseases; after 3 months, the causes of death were related to comorbidities and did not differ from causes of death in controls. CONCLUSIONS: UGIB patients have three times higher long-term mortality than population controls.

Randomized Clinical Trial Comparing Cyanoacrylate Glue Versus Suture Fixation in Lichtenstein Hernia Repair: 7-Year Outcome Analysis.

BACKGROUND: Lichtenstein hernioplasty has relatively low recurrence rate, but chronic inguinal pain may cause harm to the patient. The aim of our study was to compare long-term results of cyanoacrylate glue versus absorbable sutures for mesh fixation in Lichtenstein hernioplasty. METHODS: Lichtenstein hernioplasty (n = 302) was performed under local anesthesia in three hospitals. The patients were randomized to receive either 1 ml of butyl-2-cyanoacrylate tissue glue (Glubran®; 151 hernias) or absorbable polyglycolic acid sutures (Dexon®; 151 hernias) for mesh fixation (Optilene® mesh). Short-term results were published previously. Chronic groin pain, foreign body sensation, use of analgesics, recurrence and re-operations were analyzed 7 years after surgery. RESULTS: We reached 236 patients (78%) to present study. In the glue group (n = 115), there were five (4.3%) and in the suture group (n = 121) three (2.5%) recurrent hernias (p = 0.491). The prevalence of chronic pain (NRS ≥ 3) in the patients without re-operations was similar in two groups: 15/118 (13%) and 13/111 (12%), respectively (p = 0.843). There were no significant differences in the foreign body sensation (8/14, p = 0.267) or in the need of analgesics (2/2, p = 1.00) between the two study groups. CONCLUSION: Both cyanoacrylate glue and mesh fixation with absorbable sutures were equal in terms of chronic pain and rate of recurrences in Lichtenstein hernioplasty after 7-year follow-up. TRIAL REGISTRATION NUMBER: NCT00659542.

Effect of pubic bone marrow edema on recovery from endoscopic surgery for athletic pubalgia.

Athletic pubalgia (sportsman's hernia) is often repaired by surgery. The presence of pubic bone marrow edema (BME) in magnetic resonance imaging (MRI) may effect on the outcome of surgery. Surgical treatment of 30 patients with athletic pubalgia was performed by placement of totally extraperitoneal endoscopic mesh behind the painful groin area. The presence of pre-operative BME was graded from 0 to 3 using MRI and correlated to post-operative pain scores and recovery to sports activity 2 years after operation. The operated athletes participated in our previous prospective randomized study. The athletes with (n = 21) or without (n = 9) pubic BME had similar patients' characteristics and pain scores before surgery. Periostic and intraosseous edema at symphysis pubis was related to increase of post-operative pain scores only at 3 months after surgery (P = 0.03) but not to long-term recovery. Two years after surgery, three athletes in the BME group and three in the normal MRI group needed occasionally pain medication for chronic groin pain, and 87% were playing at the same level as before surgery. This study indicates that the presence of pubic BME had no remarkable long-term effect on recovery from endoscopic surgical treatment of athletic pubalgia.

Bleeding complications in cholecystectomy: a register study of over 22,000 cholecystectomies in Finland.

BACKGROUND: Major bleeding is rare but among the most serious complications of laparoscopic surgery. Still very little is known on bleeding complications and related blood component use in laparoscopic cholecystectomy (LC). The aim of this study is to compare bleeding complications, transfusion rates and related costs between LC and open cholecystectomy (OC). METHODS: Data concerning LCs and OCs and related blood component use between 2002 and 2007 were collected from existing computerized medical records (Finnish Red Cross Register) of ten Finnish hospital districts. RESULTS: Register data included 17175 LCs and 4942 OCs. In the LC group, 1.3% of the patients received red blood cell (RBC) transfusion compared to 13% of the patients in the OC group (p < 0.001). Similarly, the proportions of patients with platelet (0.1% vs. 1.2%, p < 0.001) and fresh frozen plasma (FFP) products (0.5% vs. 5.8%) transfusions were respectively higher in the OC group than in the LC group. The mean transfused dose of RBCs, PTLs and FFP product Octaplas or the mean cost of the transfused blood components did not differ significantly between the LC and OC groups. CONCLUSIONS: Laparoscopic cholecystectomy was associated with lower transfusion rates of blood components compared to open surgery. The severity of bleeding complications may not differ substantially between LC and OC.

'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference.

INTRODUCTION: The aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG). METHODS: Experts in the diagnosis and management of SG were invited to participate in a consensus conference held by the British Hernia Society in Manchester, U.K. on 11-12 October 2012. Experts included a physiotherapist, a musculoskeletal radiologist and surgeons with a proven track record of expertise in this field. Presentations detailing scientific as well as outcome data from their own experiences were given. Records were made of the presentations with specific areas debated openly. RESULTS: The term 'inguinal disruption' (ID) was agreed as the preferred nomenclature with the term 'Sportsman's hernia' or 'groin' rejected, as no true hernia exists. There was an overwhelming agreement of opinion that there was abnormal tension in the groin, particularly around the inguinal ligament attachment. Other common findings included the possibility of external oblique disruption with consequent small tears noted as well as some oedema of the tissues. A multidisciplinary approach with tailored physiotherapy as the initial treatment was recommended with any surgery involving releasing the tension in the inguinal canal by various techniques and reinforcing it with a mesh or suture repair. A national registry should be developed for all athletes undergoing surgery. CONCLUSIONS: ID is a common condition where no true hernia exists. It should be managed through a multidisciplinary approach to ensure consistent standards and outcomes are achieved.

Long-term outcome of patients with acute non-specific abdominal pain compared to acute appendicitis: prospective symptom audit after two decades.

BACKGROUND: Non-specific abdominal pain (NSAP) and acute appendicitis (AA) are the two most frequent diagnoses of acute abdomen in the emergency wards. The long-term morbidity, mortality and quality of life of the patients with NSAP compared to AA are unknown. METHODS: The study group consisted of 186 patients with acute NSAP compared to 147 patients with AA initially treated during 1985-1986. Medical history, social background, quality of life and abdominal symptoms were assessed with standardized questionnaires in both groups during 2006-2009. The patients who continued to have abdominal symptoms were invited to a check-up visit. RESULTS: During 1985-6, the NSAP group had more previous abdominal symptoms and operations than the AA group. Some 29% of patients with NSAP and 11% of patients with AA had still abdominal symptoms at long-term check-up (p < 0.0001). Chronic abdominal pain (38 vs 17) and peptic ulcer disease (18 vs 2) occurred more often in the NSAP group than in the controls, respectively (p = 0.001). After five years of follow-up, 11 patients in the NSAP group and 6 patients in the AA group had died (ns). During the twenty years of follow-up, mortality was higher (46/22, 25/15%) in the patients with NSAP than in controls (p = 0.013). Ischaemic heart disease was the leading cause of death in both groups (18 NSAP vs 5 AA, p = 0.017). The quality of life scores were comparable in both study groups. CONCLUSION: Over 70% of NSAP- and almost 90% of AA-patients were free of symptoms after 20 years of follow-up. Mortality was higher and various alimentary track diseases were more frequent in patients with NSAP than in AA.

The Sheen Paajanen grOin Recommended Treatment 'SPoRT' score for groin pain.

INTRODUCTION: Evaluating groin pain still evades many clinicians at times as they have difficulty determining the cause of pain when no true hernia exists. This study's aim was to evaluate a simple and novel scoring system which is reproducible, to help determine whether conservative measures or surgery is recommended for the management of groin pain attributable to inguinal disruption. MATERIAL & METHODS: A retrospective analysis of all patients from 2018 to 2020 that underwent surgery or conservative management for inguinal disruption with at least a 1-year follow-up were evaluated. The scoring system is based on MRI and ultrasound imaging as well as clinical findings, with scores given from - 2 to + 2 based on the defined findings listed. A maximum total of four points scored for each assessment was used. Sensitivity and specificity analysis was conducted for each potential score cut off point. RESULTS: A total of 172 patients were evaluated with 33 patients (19%) undergoing conservative management and 139 patients (81%) undergoing surgery. The median SPoRT score for the surgery group was 2.0 (1.0, 3.0), and - 1.0 (- 3.0, 0.0) in the physiotherapy group which was a significant difference (p < 0.001). An optimal cut off of ≤ 0 for physio and ≥ 1 for surgery was established, yielding a sensitivity of 90.9% (95% CI 75.7%-98.1%), a specificity of 89.2% (95% CI 82.8%-93.8%) and an area under the curve (AUC) of 0.936 (95% CI 0.874-0.997). DISCUSSION: SPoRT score of ≤ 0 can recommend a patient should undergo conservative measures or physiotherapy as a mainstay of treatment with a score of ≥ 1 recommending surgery. Further validation of the score is necessary.

Randomized clinical trial of tissue glue versus absorbable sutures for mesh fixation in local anaesthetic Lichtenstein hernia repair.

BACKGROUND: Chronic pain may be a long-term problem related to mesh fixation and operative trauma after Lichtenstein hernioplasty. The aim of this study was to compare the feasibility and safety of tissue cyanoacrylate glue versus absorbable sutures for mesh fixation in Lichtenstein hernioplasty. METHODS: Lichtenstein hernioplasty was performed under local anaesthesia as a day-case operation in one of three hospitals. The patients were randomized to receive either absorbable polyglycolic acid 3/0 sutures (Dexon(®); 151 hernias) or 1 ml butyl-2-cyanoacrylate tissue glue (Glubran(®); 151 hernias) for fixation of lightweight mesh (Optilene(®)). Wound complications, pain, discomfort and recurrence were identified at 1 and 7 days, 1 month and 1 year after surgery. RESULTS: A total of 302 patients were included in the study. The mean(s.d.) duration of operation was 34(12) min in the glue group and 36(13) min in the suture group (P = 0·113). The need for analgesics was similar during the first 24 h after surgery. Five wound infections (3·4 per cent) were detected in the glue group and two (1·4 per cent) in the suture group (P = 0·448). The recurrence rate at 1 year was 1·4 per cent in each group (P = 1·000). The rates of foreign body sensation, acute and chronic pain were similar in the two groups. Logistic regression analysis showed that the type of mesh fixation did not predict chronic pain 1 year after surgery. CONCLUSION: Mesh fixation without sutures in Lichtenstein hernioplasty was feasible without compromising postoperative outcome. REGISTRATION NUMBER: NCT00659542 (http://www.clinicaltrials.gov).

Factors predicting chronic pain after open inguinal hernia repair: a regression analysis of randomized trial comparing three different meshes with three fixation methods (FinnMesh Study).

BACKGROUND: Chronic pain after inguinal hernioplasty is the foremost side-effect up to 10-30% of patients. Mesh fixation may influence on the incidence of chronic pain after open anterior mesh repairs. METHODS: Some 625 patients who underwent open anterior mesh repairs were randomized to receive one of the three meshes and fixations: cyanoacrylate glue with low-weight polypropylene mesh (n = 216), non-absorbable sutures with partially absorbable mesh (n = 207) or self-gripping polyesther mesh (n = 202). Factors related to chronic pain (visual analogue scores; VAS ≥ 30, range 0-100) at 1 year postoperatively were analyzed using logistic regression method. A second analysis using telephone interview and patient records was performed 2 years after the index surgery. RESULTS: At index operation, all patient characteristics were similar in the three study groups. After 1 year, chronic inguinal pain was found in 52 patients and after 2 years in only 16 patients with no difference between the study groups. During 2 years' follow-up, three (0.48%) patients with recurrences and five (0.8%) patients with chronic pain were re-operated. Multivariate regression analysis indicated that only new recurrent hernias and high pain scores at day 7 were predictive factors for longstanding groin pain (p = 0.001). Type of mesh or fixation, gender, pre-operative VAS, age, body mass index or duration of operation did not predict chronic pain. CONCLUSION: Only the presence of recurrent hernia and early severe pain after index operation seemed to predict longstanding inguinal pain.

Correction to: Factors predicting chronic pain after open inguinal hernia repair: a regression analysis of randomized trial comparing three different meshes with three fixation methods (FinnMesh Study).

In the original publication, co-authors affiliations were incorrect.

The Accuracy of the Computed Tomography Diagnosis of Acute Appendicitis: Does the Experience of the Radiologist Matter?

BACKGROUND AND AIMS: To assess the accuracy of computed tomography in diagnosing acute appendicitis with a special reference to radiologist experience. MATERIAL AND METHODS: Data were collected prospectively in our randomized controlled trial comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (APPAC trial, NCT01022567). We evaluated 1065 patients who underwent computed tomography for suspected appendicitis. The on-call radiologist preoperatively analyzed these computed tomography images. In this study, the radiologists were divided into experienced (consultants) and inexperienced (residents) ones, and the comparison of interpretations was made between these two radiologist groups. RESULTS: Out of the 1065 patients, 714 had acute appendicitis and 351 had other or no diagnosis on computed tomography. There were 700 true-positive, 327 true-negative, 14 false-positive, and 24 false-negative cases. The sensitivity and the specificity of computed tomography were 96.7% (95% confidence interval, 95.1-97.8) and 95.9% (95% confidence interval, 93.2-97.5), respectively. The rate of false computed tomography diagnosis was 4.2% for experienced consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis. CONCLUSION: The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings.

A single-surgeon randomized trial comparing three composite meshes on chronic pain after Lichtenstein hernia repair in local anesthesia.

BACKGROUND: Chronic pain may be a long-term problem related to operative trauma and mesh material in Lichtenstein hernioplasty. STUDY DESIGN: Inguinal hernioplasty was performed under local anesthesia in 228 patients (232 hernias) in day-case surgery by the same surgeon and exactly by the same surgical technique. The patients were randomized to receive either a partly absorbable polypropylene-polyglactin mesh (Vypro II(R) 50 g/m(2), 79 hernias), a lightweight polypropylene mesh (Premilene Mesh LP(R) 55 g/m(2), 75 hernias) or a conventional densely woven polypropylene mesh (Premilene(R) 82 g/m(2), 78 hernias). Pain, patients discomfort and recurrences of hernias were carefully followed at days 1, 7, 1 month, 1 and 2 years after surgery. RESULTS: The duration of operation (29-33 min) and the amount of local anesthetic (55-57 ml) were similar in the three groups. Two wound infections and four hematomas were detected with no difference between the meshes. Immediate pain reaction up to 1 month was statistically equal among the three meshes. After 2 years of follow-up, there were five recurrences (two in the Vypro group, one in the Premilene LP and two in the Premilene). A feeling of a foreign body, sensation of pain and patient's discomfort were similar with all meshes. CONCLUSION: There was no difference of pain and quality of life among a conventional polypropylene mesh, lightweight mesh or partly absorbable mesh in 2 years of follow-up, when the same surgeon operated on all patients with exactly the same technique.

Does laparoscopy used in open exploration alleviate pain associated with chronic intractable abdominal wall neuralgia?

BACKGROUND: This study aimed to assess the efficacy of diagnostic laparoscopy and open exploration of trigger points (scar revision and neurectomy) in the treatment of intractable chronic abdominal wall pain. METHODS: This prospective nonrandomized study enrolled 24 patients (21 women) with an average age of 59 +/- 11 years. Abdominal wall pain was diagnosed by excluding other causes of pain and using multiple injections of bupivacain. The patients' demographic data and long-term postoperative course (37 +/- 13 months) were carefully recorded. RESULTS: Using laparoscopy, intraabdominal adhesions close to trigger points were found and lysed in 15 patients (63%). Next, a subcutaneous nerve resection was performed. After 1 month, 33% of the patients were completely pain free, and 42% reported alleviation of pain. After 3 years, chronic abdominal pain was totally healed in 25%, diminished in 50%, and unchanged or increased in 25% of the patients. A total of 23 patients (96%) reported that surgery was beneficial for their intractable pain. CONCLUSIONS: Laparoscopy used in open exploration is beneficial for 75% of carefully selected patients with chronic abdominal wall pain.

Feasibility of axillary ultrasound in the quality assessment of sentinel node biopsy in breast cancer surgery.

BACKGROUND AND AIMS: The purpose of this study was to evaluate the efficacy of high-resolution axillary ultrasound (AU) in detecting the rate of recurrence after a negative sentinel node (SN) biopsy in patients with breast cancer and without additional axillary dissection. MATERIALS AND METHODS: The operating oncologic surgeon performed 196 consequent sentinel node biopsies during surgery of breast cancer. The sentinel nodes were identified by using preoperative lymphoscintigraphy, intraoperative gamma probe and Patent Blue dye. A routine postoperative follow-up of the patients were performed every 3rd month including clinical examinations, blood chemistry and mammography. After 31 months (range 14-49 months), a high-resolution AU was performed for 107 patients with a negative sentinel node during surgery and without axillary dissection, to visualize any abnormal lymph nodes in the axilla. If necessary, large core biopsies were undertaken to obtain histology of abnormal axillary nodes. RESULTS: The SNs were visualized during preoperative lymphoscintigraphy in 167/196 (85%) and found during the surgery in 163/167 (98%) of patients. The mean number of removed SN were 1.7+/-0.8. The SN metastasis were found in 29% (56/196) of patients. During the follow-up, abnormal nodes were identified during AU in only 4/107 patients. Core biopsies confirmed benign histology in three patients and one case of lymphoma was detected. CONCLUSIONS: There were no axillary recurrences of breast cancer after a negative SN biopsy during the 2.6 year follow-up. Axillary ultrasound is a useful tool in the quality control of patients with negative SN biopsy and without diagnostic axillary dissection.

Operative treatment of massive ventral hernia using polypropylene mesh: a challenge for surgeon and anesthesiologist.

OBJECTS: Surgical repair of very large ventral hernias has become feasible after the introduction of synthetic meshes and developments in intensive-care treatment. In addition to the operative challenges, postoperative disorders in the cardiovascular system, tissue oxygenation, increased intra-abdominal pressure, and pulmonary embolism expose the patient to severe risks. METHODS: From 1997-2002 we operated on ten patients with giant ventral incisional or umbilical hernia (mean defect size 240 cm(2)) by using retromuscular polypropylene mesh. All patients were morbidly obese [mean Body Mass Index (BMI) 39+/-7.2 kg/m(2)]. Four of the operations were emergencies because of an acute intestinal occlusion, bowel gangrene, and skin complications. The patients were reinvestigated after the mean follow-up of 2.5 years to find out the frequency of recurrence and degree of disability. RESULTS AND CONCLUSION: There was no intraoperative mortality, but one patient died at home after 5 weeks because of myocardial infarct and prolonged wound infection. She had mild stable coronary heart disease preoperatively. Although minor wound complications were observed in three patients, there was no need to remove the meshes. One small recurrent hernia was observed in the follow-up, but it was too small to be repaired. The quality of life after surgery was good for all patients, and they were satisfied with the operation. Retromuscular mesh hernioplasty associated with careful patient monitoring in intensive care is safe and feasible in the selected patients with massive ventral hernia.

Role of orchiectomy in severe testicular pain after inguinal hernia surgery: audit of the Finnish Patient Insurance Centre.

PURPOSE: Testicular ischemia and necrosis are uncommon complications after inguinal hernioplasty. Our aim was to evaluate the incidence of severe urological complications related to adult inguinal hernia surgery in Finland with special reference to orchiectomy in relieving intractable chronic testicular pain. METHODS: All urological complications related to inguinal hernia surgery during 2003-2010 were analysed from the Finnish Patient Insurance Centre. The patients with intractable chronic scrotal or testicular pain that resulted in orchiectomy were re-evaluated after a median follow-up of 7 years (range 2-15 years). The operative factors related to chronic testicular pain and atrophy were analysed using multiple regression analysis. RESULTS: Altogether 62 urological complications (from 335 litigations) were recorded from 92,000 inguinal hernia operations. The distribution of claimed urological complications consisted of 34 testicular injuries, ten bladder perforations, seven massive scrotal haemorrhage or 11 miscellaneous injuries. Seventeen atrophic testes were left in situ and 17 (six early < 7 days, 11 late > 8 days) orchiectomies were performed due to necrosis or chronic testicular pain syndrome. In the conservative group of moderate scrotal or testicular pain (n = 17), all patients had late pain symptoms (>8 days), but pain was not so severe that orchiectomy was attempted. Using a multivariate analysis, postoperative infections were associated with chronic testicular or scrotal pain and atrophy, but hospital status, surgeon's training level, laparoscopic or open operation, type of hernia or use of mesh did not correlate with testicular injuries. During follow-up, 11/17 (65%) patients with orchiectomy were free of testicular pain. CONCLUSION: Urological injuries form one-fifth of the major complications after inguinal hernioplasty. Orchiectomy appears to help the majority of patients with severe testicular pain syndrome.