The European hernia society groin hernia classification: simple and easy to remember.

After reviewing the available classifications for groin hernias, the European Hernia Society (EHS) proposes an easy and simple classification based on the Aachen classification. The EHS will promote the general and systematic use of this classification for intraoperative description of the type of hernia and to increase the comparison of results in the literature.

[Functional anatomy of the abdominal wall]. / Funktionelle Anatomie der Bauchwand.

The anterolateral abdominal wall covers a region defined cranially by the xiphoid process and ribs, laterally by the medial axillary line, and caudally by the anterior ilium and pubic bone. Knowledge of the various parts of the abdominal wall is essential to the surgeon for effective laparotomy and primary and secondary hernia care. The abdominal musculature, aponeuroses, vascularity, and innervation are examined in detail along with the according vascular and neural structures of the dermis.

Intraperitoneal treatment of incisional and umbilical hernias using an innovative composite mesh: four-year results of a prospective multicenter clinical trial.

Intraperitoneal positioning of conventional parietal mesh provides efficient reconstruction but causes visceral adhesion formation in 80-100% of the cases. The purpose of this clinical trial was to assess the performance and tolerance of a new generation of polyester mesh protected by a hydrophilic resorbable film. Eighty patients were included in a prospective multicenter clinical trial. Patients were treated for ventral hernia via an open approach (64%) or laparoscopically (36%). All meshes were implanted in a midline intraperitoneal location. The main objective was to evaluate the anti-adhesive capability of the mesh in relation to the viscera. In order to assess the absence of visceral adhesion objectively, an ultrasound (US) specific examination was initially validated (pre-operative prediction vs. per-operative findings) and then used during the follow-up. The usual clinical parameters were also collected to follow the patients on a period up to 4 years. Pre-operative US prediction vs. per-operative macroscopic findings: sensitivity 79%, overall accuracy 76%, negative predictive value 85%. After 12 months, 86% of the patients were ultrasonically adhesion free. Early post-operative complications were: seroma/hematoma (16%), subcutaneous infection (4%), cutaneous necrosis (1%) and occlusions (outside the mesh) (2.5%). No mortality was reported. Clinically, after 12-month follow-up, no complication related to post-operative adhesions to the mesh was noted: (occlusion 0%, fistula 0%). Late complications were: mesh sepsis (1%), new defects (4%) and recurrence (2.5%). Finally, 56 patients (75.7%) were clinically evaluated with a mean follow-up of 48+/-6 months. One direct recurrence was noted while six patients experienced new defect outside the mesh. No long-term severe complication such as occlusion or enterocutaneous fistula was observed. Based on a mean clinical follow-up of 4 years, the results of this prospective multicenter clinical trial demonstrate the safety and the efficiency of this composite mesh in the intraperitoneal treatment of incisional and umbilical hernia. In particular there was no early or long-term main complication due to the intraperitoneal location of the mesh.

Intraoperative radionuclear 125I-labeled metaiodobenzylguanidine scanning of pheochromocytomas and metastases.

We developed a technique to assess the feasibility of intraoperative radionuclear detection of pheochromocytomas and their metastases. Thirteen patients were entered into the study: five control subjects with nonchromaffin adrenal tumors, eight with pheochromocytomas, and one of these patients showing bone metastasis. Each subject received thyroid blockade and an intravenous injection of 500 microCi (37 megabecquerels) 125I-labeled metaiodobenzylguanidine (MIBG) 3 days before surgery. In the five control subjects, adrenal tumor uptake never exceeded the liver or spleen uptake. One patient with a negative preoperative MIBG scan demonstrated no intraoperative uptake. Five patients with pheochromocytoma had positive preoperative scans and in one other patient preoperative scanning was not done. In each of these six patients intraoperative count ratio of pheochromocytoma/liver from 14:2 to 250:16 and pheochromocytoma/contralateral adrenal ratio from 60:1.5 to 60:16 was demonstrated. An intraoperative scan in one of these patients detected two small metastatic tumor deposits previously overlooked by the surgeon after removing a larger mass that had been localized by a preoperative 131I-MIBG scan. A negative preoperative scan in one patient was followed by an intraoperative scan demonstrating a bone metastasis with a ratio of metastasis/normal bone of 10:0.5. Specimen studies demonstrated a significant MIBG uptake ratio of tumor/plasma ranging from 95 to 667 (average 404 +/- 242) greater than in control subjects (average 25 +/- 41); in the patient with metastasis the uptake ratio of metastasis/normal bone reached 98.4. We conclude that intraoperative 125I-MIBG scanning might detect pheochromocytoma deposits overlooked by preoperative 131I-MIBG scans.

Ret and trk proto-oncogene activation in thyroid papillary carcinomas in French patients from the Champagne-Ardenne region.

OBJECTIVES: To investigate the presence of ret and trk proto-oncogene rearrangements in thyroid tumors. DESIGN AND METHODS: High-molecular-weight DNA was extracted from 36 thyroid tumors (1 multinodular goiter, 14 follicular adenomas, 16 papillary carcinomas, 1 lymph node metastasis of a papillary carcinoma, 1 follicular carcinoma, and 3 medullary carcinomas) and 22 adjacent tissues. Southern blot analysis was performed after digestion with EcoR1 or BamH1, using specific probes for ret and trk. RESULTS: Only 2 ret rearrangements were found in 2 papillary carcinomas (overall frequency: 6%; papillary carcinoma frequency: 13%). All normal or tumor samples were negative for the presence of a trk rearrangement. CONCLUSIONS: The previous data from the literature are highly conflicting, ranging from 0 to 30% of activation. Our results could be, therefore, classified as medium between these extreme values. It seems, therefore, that genetic and/or geographical factors could play a role in ret and trk proto-oncogene activation.

The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications.

No significant difference has been found between early and new diagrams of the posterior anatomy of the inguinofemoral area from a laparoscopic standpoint because anatomy is unique to each individual. But new dangers can arise from new approaches, even if the anatomic structures are well known, so anatomic research is still useful. It provides, relative to new surgical techniques, new vision of structures known for centuries.

The inguinal rings.

The inguinofemoral area constitutes the frontier between the abdomen and the lower limb. Because of the human standing position, the inguinal region is a zone supporting the abdominal thrust, and is weakened by the orifice of the inguinal and femoral passages. Peritoneal diverticula may externalize into these orifices, leading to the formation of hernias. This article reviews the anatomic constituents of the inguinofemoral region and the anatomic basis for the treatment of hernias.

Ampulla of Vater. Anatomic, embryologic, and surgical aspects.

The region of the ampulla of Vater constitutes a complex anatomic and functional entity, the biliopancreaticoduodenal confluence, of which the essentials of this rapid review are the: Variation in site of implantation of the greater duodenal papilla, whereas the relations between the common bile duct and the main pancreatic duct are relatively constant Presence at this site of a weak point in the duodenal wall, commonly the site of mucosal diverticula Interdependence of the parietal duodenal mucosa and the sphincteric system of Oddi Existence of an extramural zone of this sphincter, which should be the only one involved in sphincterotomy Danger of wide excisions of the papilla, which, apart from the risk for hemorrhage, cause a breach of the digestive barrier The ampulla of Vater corresponds to the dilated junction of the common bile duct and main pancreatic duct, if present. The ampulla is an extensive anatomic and functional region that includes not only the choledochopancreatic junction but also the sphincter of Oddi, the whole traversing the duodenal wall to open at the greater duodenal papilla. The chief anatomic features of this biliopancreaticoduodenal junction have been reviewed, forming the basis of techniques of surgical or endoscopic sphincterotomies and localized excisions of vaterian tumors.

Anatomic basis of hepatic surgery.

Modern hepatic surgery is based on precise anatomic foundations. The importance of this information applies to all levels of the diagnostic and therapeutic chain. Modern methods of imaging--CT scanning, MR imaging, and preoperative sonography--help physicians to detect variations and plan surgical excision.

Functional anatomy of the gastroesophageal junction.

The study of the functional anatomy of the gastroesophageal junction allows for the demonstration of a double mechanism that combats the conflict of pressures that tends to lead to gastroesophageal reflux. On one hand, the LES, an intrinsic structure, is directly related to the muscle fibers of the organ and responds to a neurohormonal physiologic command. On the other hand is an anatomic entity, centered by the crura of the diaphragm, closely related to the movements of respiration. These structures constitute a second, extrinsic sphincter that gives rise to the zone of high pressure in the terminal esophagus. This role is difficult to assess, and its importance is underestimated. The proper functioning of these two mechanisms implies that the gastroesophageal junction remains in place within the diaphragmatic channel of the esophagus. Also important are the postural phenomena associated with the sloping position of the fundus. In patients with gastroesophageal reflux, the decrease of the pressure measured in the terminal esophagus accounts for the occurrence of reflux. Investigators concede that, under the influence of abdominal straining, the gastroesophageal junction tends to ascend into the diaphragmatic channel. The results are twofold: (1) the muscle fibers of the lower esophagus relax, explaining the incompetence of the intrinsic sphincter, and (2) the sphincteric zone is withdrawn from its muscular diaphragmatic environment. Physicians should consider these structures as a whole in approaching the surgical treatment of reflux. The construction of a periesophageal valve has no anatomophysiologic basis. A gastropexy procedure must be added to replace the gastroesophageal junction in its anatomic setting and keep it there. This procedure also allows retightening of the muscle fibers of the esophageal wall, which is essential in long-term surgical correction.

Surgical anatomy and embryology of the adrenal glands.

Gross anatomy explains the different surgical approaches to adrenalectomy and the difficulties encountered by surgeons during this procedure. Development of the adrenal glands explains the location of the ectopic sites and excess hormone production by adrenal tumors. The choice of a surgical approach is sometimes difficult and is dependent on (1) the morphology of the body; (2) the volume of the tumor, which necessitates immediate vascular control; and (3) the type of disease, which may necessitate a complete exploration of the abdominal cavity.

Laparoscopic antireflux surgery: comparative study of Nissen, Nissen-Rossetti, and Toupet fundoplication. Société Française de Chirurgie Laparoscopique.

BACKGROUND: The aim of this retrospective study was to compare the results of Nissen, Nissen-Rossetti, and Toupet laparoscopic fundoplication in terms of gastroesophageal reflux disease (GERD). METHODS: From 1992 to 1996, 1,470 laparoscopic fundoplications were performed using one of three procedures: Nissen (n = 655), Nissen-Rossetti (n = 423), and Toupet (n = 392). Preoperative checkup included esophagogastroduodenoscopy in 1,437 patients (97. 7%), esophageal manometry in 934 patients (63.5%), and 24-h pH-metry in 799 patients (54.3%). The results were estimated at 1 month, 3 months, and 2 years. Patients unable to visit the hospital center were contacted by telephone. RESULTS: The three groups were quite similar regarding demographic data such as age, gender, preoperative clinical symptoms, and duration of GERD. One death (0.07%) occurred. At 3 months, there were no differences among the three groups concerning conversion, morbidity, dysphagia, early reintervention, or postoperative length of stay. The length of surgery was more important in the Toupet procedure. In the Nissen group, there were fewer Visick grade I patients but more Visick grade III patients. At 2 years, the recurrence and reintervention rates were similar. The overall residual severe dysphagia rate was 0.35% (n = 5). In the Nissen group, there were fewer Visick grade I patients but more in Visick grade II patients. There was no difference in Visick grade III and IV among the groups. More than 90% of the patients were satisfied (Visick I + Visick II), with no significant difference among the three groups. CONCLUSIONS: The results of this study do not differ significantly from the data reported in the literature, suggesting such surgical techniques are effective and well tolerated, and that both can be properly used in the treatment of GERD.

Morbidity of laparoscopic fundoplication for gastroesophageal reflux: a retrospective study about 1470 patients.

BACKGROUND/AIMS: The aim of this retrospective study was to report and quantify the immediate and 3-year complications after laparoscopic anti-reflux surgery in order to understand the mechanism. METHODOLOGY: From 1992 to 1996, 1470 laparoscopic fundoplications were performed for symptomatic gastroesophageal reflux disease. Preoperative checkup included upper gastrointestinal tract endoscopy in 1437 patients (97.7%), esophageal manometry in 934 patients (63.5%), and 24-hour pHmetry in 799 patients (54.3%). Three procedures were performed: Nissen (n = 655), Nissen-Rossetti (n = 423), and Toupet (n = 392). The results were estimated at 1 and 3 months; thereafter they were evaluated at 3 years. Patients unable to return to the hospital center were contacted by telephone. RESULTS: Mean length of hospital stay was 4.6 days (range: 2-48 days). The preoperative complication rate was 2.1% (n = 31). The postoperative morbidity and mortality rates were 2.9% (43 patients) and 0.07% (1 patient), respectively. Conversion rate to laparotomy was 6.5% (96 patients). At 3 months, 87 patients (5.9%) had invalid dysphagia but there was no difference between the 3 procedures. Twelve patients have been reoperated (0.8%). At 3 years, 78 patients (5.6%) presented a clinical recurrence. The rate of dysphagia was 0.35%, and 38 patients were reoperated. CONCLUSIONS: Laparoscopic fundoplication is safe and effective with a low morbidity and mortality rate if junior surgeons commenced this procedure under the direct supervision of an experienced surgeon. Despite the advantage of this technique, we believe that indications for surgical management remain unchanged in the laparoscopic era.

[Subcutaneous seeding on the tract of percutaneous cytologic puncture with a fine needle of a hepatic metastasis from colonic adenocarcinoma]. / Essaimage sous-cutané sur le trajet d'une ponction cytologique percutanée à l'aiguille fine d'une métastase hépatique d'un adénocarcinome colique.

Subcutaneous seeding after percutaneous ultrasonically guided fine needle aspiration of liver tumours is a rare complication and only a few cases have been reported. We report a new case of cutaneous implantation following a fine needle (21.5 gauge of external diameter) aspiration biopsy of a superficial colonic liver metastasis, as shown by a subcutaneous nodule and increased serum carcinoembryonnary-antigen. We discuss the risk factors of this rare complication, especially the thickness of the liver parenchyma along the needle tract and precautions which can be taken for prevention.

[Rectal leiomyosarcoma. 4 new cases]. / Léiomyosarcome du rectum. Quatre nouvelles observations.

We report four cases of leiomyosarcoma of the rectum suspected by endoscopic ultrasonography. Three patients were treated by local excision and one by abdominoperineal resection. An excision of the mass via a Kraske's approach was used. Leiomyosarcoma confined to the rectum wall can be treated by local excision. Endosonography can provide exact estimation of the lesion and is of great value in selecting the appropriate treatment. The treatment is surgical excision with wide margins. The histological stage and the presence or absence of metastases determine the therapeutic. Two patients in our series underwent radiation therapy. Chemotherapeutic agents including doxorubicin have had beneficial effect on recurrence or survival, only for higher grade sarcomas.

[Retromuscular prosthetic repair: experience from France]. / Retromuskuläre Netzplastik: Erfahrungen aus Frankreich.

Large incisional hernias cannot be cured without prosthetic material. A large pore size prosthetic tissue seems to be the best alternative, since connective invasion of the mesh provides a very strong fixation of the prosthesis. In our view, the mesh should be placed in the rectus sheath, in a position we have described as "retromuscular prefascial". With this technique, a good result can be achieved in 98% of very large incisional hernias.

[Anatomo-clinical prognostic factors of papillary carcinoma of the thyroid. Multivariate analysis: report of a series of 52 cases]. / Facteurs pronostiques anatomo-cliniques des carcinomes papillaires de la thyroïde. Analyse multivariée: à propos d'une série de 52 cas.

A retrospective study about 52 cases of papillary thyroid carcinomas was carried out with emphasis on histopathological features. The mean follow up period was 10 years. The survival curves were estimated using the Kaplan-Meier method and compared using the log rank test. The multivariate analysis was performed using the Cox's regression model. In univariate analysis, age, Tp (histopathological extension of the tumor), histological differentiation, VAN score (Vascular invasion nuclear Atypia tumor Necrosis) of Akslen and the LeuM1 expression were significant prognostic factors. In multivariate analysis, the Tp and histological differentiation were associated with high risks of poor outcome.

[Percutaneous ultrasound-guided drainage in the surgical treatment of acute severe pancreatitis]. / Place du drainage percutané échoguidé dans le traitement chirurgical de la pancréatite aiguë grave.

AIM OF THE STUDY: To report results of percutaneous ultrasound-guided drainage, performed by a surgeon, in the treatment of complications of acute pancreatitis (AP), and to determine the role of this technique in the therapeutic armamentarium of severe AP. PATIENTS AND METHODS: From 1986 to 2001, 59 patients were included in this retrospective study. All patients initially had severe necrotizing AP (mean Ranson score = 4.1 ; range : 2-7). Anatomical lesions included pancreatic abscess in 6 patients and necrosis in 53 (17 stage D and 36 stage E according to Balthazar's classification). Necrosis was infected in 42 and sterile in 11 respectively. Drainage was performed under ultrasound guidance and local anaesthesia using small-diameter drains (7-14 French). RESULTS: Drainage was performed on average 23 days after onset of AP. Infection was proven by fine-needle aspiration in 47 (80 %) patients (41 infected necrosis and 6 localized abscess). In one patient, culture of aspirated fluid was negative but necrosis was infected (one false negative). Culture of aspirated fluid was negative and necrosis was sterile in 11 patients. Nineteen (32%) patients healed without subsequent surgery: 7 (16%) in the infected necrosis group, 6(55%) in the sterile necrosis group, and 6 (100%) in the abscess group. Forty (68%) patients had subsequent necrosectomy including 8 (14%) who died. Twenty (34 %) digestive fistulas healed spontaneously, except one treated by diversion stomia. Of the 16 (27 %) pancreatic fistulas, 6 needed subsequent interventional treatment. CONCLUSION: In selected patients, percutaneous drainage can represent an alternative to surgery with a 14% mortality rate. The high rate of subsequent necrosectomy suggests that drains with larger diameter, possibly associated with continuous irrigation, should be used.

[Value and limitation of ultrasound-guided percutaneous drainage in acute lithiasic cholecystitis]. / Intérêt et limite du drainage per-cutané échoguidé dans la cholécystite aiguë lithiasique.

The aim of this study was to evaluate the results of ultrasound guided percutaneous cholecystostomy in the treatment of acute calculous cholecystitis. From July 1987 to December 1980, 32 patients (mean age = 80) were treated prospectively by this procedure. There was only one death (3%). Successful treatment was achieved in 70% of the patients and was related with mobilization of the gallstone impacted in the infundibulum of the gallbladder. When mobilization of the impacted stone cannot be obtained, surgery is indicated within one week, as later surgery is much more difficult. Twenty-three percent of the patients successfully cured later died from non biliary disease; this indicates the very poor condition of most of the patients. In our experience, percutaneous cholecystostomy is a safe and minimally invasive procedure in the treatment of elderly high-risk patients presenting with acute calculous cholecystitis.

[Is there still a place for surgery in the treatment of communicating pseudocyst in chronic pancreatitis?]. / Reste-t-il une place pour la chirurgie dans le traitement des pseudo-kystes communicants de la pancréatite chronique?

The purpose of this study was to evaluate the results of long term percutaneous catheter drainage in the treatment of chronic pancreatic pseudocysts communicating with pancreatic ducts. Since 1986, 13 consecutive patients with symptomatic pseudocysts were treated prospectively. All pseudocysts were associated with chronic pancreatitis. The location was head (n = 8), body (n = 3) or tail (n = 2). The procedure included fine needle aspiration under ultrasonic control, percutaneous drainage along a guide wire and closed suction aspiration. A radiological control was performed weekly and the catheter was left in place until total resolution of pseudocyst. Immediate relief of pain and resolution of pseudocyst were obtained in all 13 patients. The average length of hospital stay was 12.2 +/- 8 days (1 to 23). The average duration of drainage was 36 days. There was no mortality of morbidity related to the drainage. There were two asymptomatic recurrences, but long-term follow-up (mean 3 years) showed that all 13 patients were symptom-free. The clinical results of such a long-term catheter drainage seem better in our study than in other previous series. It is a simple and innocuous procedure, and could be carried out in an outpatient unit. Such drainage represents an efficient alternative to endoscopic or surgical treatment of chronic pancreatic pseudocyst with ductal communication. In our experience surgery is no longer indicated.