Laparoscopic inguinal hernia repair.

Open hernia repair is associated with significant postoperative pain and disability resulting in delayed return to full activity. Laparoscopic hernia repair has been advocated as the procedure that combines the benefit of tension-free repair with the preservation of the basic anatomy of the inguinal area. We present our experience with 803 laparoscopic hernia repairs in 517 patients over a period of 66 months (August 92 to February 98). The effects of the learning curve and the refinement of the technique had their impact on earlier results and complications. However, with more experience we found that the laparoscopic preperitoneal approach is safe and efficacious. There was no mortality. Most patients (85%) were discharged home within 24 h of the procedure and returned to full activity within 10 days. Patient satisfaction was excellent. The complication rate decreased and operative time was reduced with experience. This procedure is clearly indicated in patients who have recurrent or bilateral hernias. It is associated with shorter convalescence and a quick return to work.

Laparoscopic transverse rectus abdominus flap delay for autogenous breast reconstruction.

Laparoscopic ligation of the deep and superficial inferior epigastric vessels was done for ten mastectomized patients who elected to have autogenous reconstruction of their breast. All these patients had at least one indication for the delay which included obesity, smoking, or requirement of a large volume of tissue for their reconstruction. The procedure did not add any morbidity or mortality to our patients and was found to be comparable to the "open" delay in preventing partial tissue loss in all but two patients. We describe the use of a minimally invasive procedure to augment the deep superior epigastric pedicled blood supply for the future transverse rectus abdominus flap. We have found in laparoscopic delay a safe, short procedure that is useful in high risk patients who choose the option of autologous breast reconstruction.

Axillopopliteal & aortopopliteal bypass--two case reports.

Two cases of aortopopliteal and axillopopliteal bypass grafts done for limb salvage are reported. These extra-anatomical bypass grafts are valuable in patients who cannot otherwise undergo anatomical bypass grafts.

Carotid endarterectomy. Where do we stand?

The small number of carotid endarterectomies performed in our country is a cause for concern, since we fear that a good number of excellent candidates are denied this operation based on fears from previous experience. The world literature as well as our recent experience over the last 18 months lead us to believe that carotid endarterectomy is a very safe procedure with excellent short and long term results, and is associated with a very low morbidity and mortality.

Vascular trauma to the lower extremity: the Lebanese war experience.

The authors' experience with 386 patients who were operated on for vascular injuries to the lower extremities is reviewed. Of these, 118 had popliteal injuries, 252 had femoral injuries and 16 had tibial injuries. The overall mortality rate was 2.33% with no mortality in the popliteal and tibial injuries group whereas there were nine deaths in the femoral injuries group. The overall amputation rate was 5.95%, with 3.17% amputation rate for the femoral injuries group versus 11.86% for the popliteal injuries group and 6.25% for the tibial injuries group. Delay in repair (more than 6 h from injury), associated femoral fractures and shocked condition on admission led to increased amputation rate. Prompt surgical repair, arterial as well as venous repair for popliteal and femoral injuries especially if femoral fracture is present, external skeletal fixation and/or traction, and fasciotomy when necessary led to improved limb salvage.

Injury to the femoral vessels--the Lebanese War experience.

Over a 10-year-period extending from January 1976 to September 1986, 800 peripheral vascular injuries were surgically treated at the American University of Beirut Medical Centre. Of these, 150 were operated on because of injury to the femoral vessels. Bullets were the commonest wounding agents (60% of cases). Thirty-seven patients had a femoral artery injury, 27 a femoral vein injury and 86 combined femoral artery and vein damage. Twenty-three per cent of the patients had an associated fracture of the femur. Patients with fractures had an 11% amputation rate compared with 1% for those without fractures. Our data reveals the importance of venous reconstruction in the presence of an arterial injury instead of its ligation (P less than 0.05), particularly when there is an associated fracture of the femur. Thirty-seven per cent of patients were in shock on admission (systolic BP 90 mmHg). The amputation rate in these patients was 6.8% in contrast to 1% in the haemodynamically stable group (P less than 0.05). The overall amputation rate was 3.3%. Complications occurred in 36.6% of patients and the mortality was 4.0%.

Injury to the popliteal vessels: the Lebanese war experience.

Our experience with 118 patients who underwent surgery for a total of 178 popliteal vessels injuries is reported. Forty-nine per cent had injury to both artery and vein and 44% had associated bony fractures. Fourteen patients subsequently needed amputation for a rate of 11.9%. There were no deaths. Delay in repair (> 6 hours from injury), associated fractures, and a shocked condition resulted in increased limb loss. Arterial as well as venous repair, external skeletal fixation, and fasciotomy when necessary lead to improved limb salvage.