Titanium coating of a polypropylene mesh for hernia repair: effect on biocompatibilty.

Titanium and its alloys are used worldwide in surgery. The favorable characteristics that make this material desirable for implantation are corrosion resistance and biocompatibility. Concerning hernia repair, a mesh modification has been developed using titanium layering of a polypropylene mesh implant, which is said to lead to an improved biocompatibility compared to commercially available mesh materials. To analyze the pure effect of titanium coating, two different mesh structures were studied using a standardized animal model. The titanium-coated monofilamentous, large porous, and lightweight mesh made of polypropylene and coated with titanium (PP+T) was compared to a pure polypropylene mesh manufactured with a similar structure and amount of material serving as a control (PP). In Sprague-Dawley rats, mesh samples were placed in a subcutaneuous position. Then 56, 84, and 182 days after mesh implantation, three animals from each group were sacrificed for morphological observations (amount of inflammatory and connective tissue formation, percentages of proliferating and apoptotic cells, percentage of macrophages). Both mesh modifications investigated showed an overall good biocompatibility. Macroscopic clinical observation after implantation of up to 182 days was uneventful. The tissue response to the PP as well as to the PP+T mesh was characterized by a moderate inflammatory tissue reaction limited to the perifilamentary region as is known for low weight, large porous, and monofilamentous mesh structures. No significant improvement of biocompatibility was found when analyzing the effect of titanium coating compared to the pure polypropylene mesh structure.

[Ropivacain after inguinal hernia surgery. A prospective, randomised, double-blinded, controlled study]. / Ropivacain zur Leistenhernienoperation in Lokalanästhesie. Eine prospektiv randomisierte, doppelt blind kontrollierte Studie.

BACKGROUND: To optimise the satisfaction of patients after repair of primary inguinal hernias under local anaesthesia, we analysed the analgetic power of Ropivacain in the postoperative period. MATERIAL AND METHODS: One hundred consecutive patients underwent repair under local anaesthesia with the same volume of 0.75% Ropivacain or 1% Mepivacain in a randomised and blinded manner. Postoperative pain analysis was carried out in all patients. RESULTS: Subjective pain levels at rest and under stress as well as impairment by pain were found to be significantly lower in the Ropivacain group at the day of operation. Decrease in vital capacity and peak flow showed similar results. The postoperative amount of analgesics and time of mobilisation showed a positive influence by the use of Ropivacain. CONCLUSION: Ropivacain reduces postoperative pain levels after hernia repair. This leads to increased comfort for patients, without elevated perioperative risk.

Abdominal musculature and the transversalis fascia: an anatomical viewpoint.

This anatomical study investigated the connection of the muscles of the abdominal wall to the transversalis fascia in the groin. In six unfixed male corpses we prepared the single levels of the inguinal abdominal wall and examined their interrelationships. Of special interest were the direction of the force vectors determined by the direction of the muscular fibers in relation to the transversalis fascia. We found no confirmation of a direct connection between the muscles of the abdominal wall and the transversalis fascia in the inguinal region. No force vector of the different muscular layers points away from the triangle of Hesselbach. By contraction each muscle thus relaxes the transversalis fascia of the Hesselbach triangle.

Breaking strength and tissue elasticity after Shouldice repair.

There are few objective studies in the surgical literature on the strength of an inguinal hernia repair during the immediate postoperative period. To provide the relevant advice and recommendations on physical activities during the period of convalescence, a study on the strength of the Shouldice repair was carried out. Twenty-eight Shouldice repairs were performed on 17 fresh human cadavers (11 male, 17 female, mean age 79.9+/-6.2 years). Following the excision of the transversalis fascia, the breaking strength and tissue elasticity were measured using an automated test device. All tissue ruptures occurred outside the limits of the Shouldice repair. Mean breaking strength was 53.9+/-20.1 N, showing no significant differences between males and females. The measured overall elasticity of tissue samples was 4.6+/-2.3 N/cm. Again there was no marked difference between genders. However, breaking strength and elasticity were found to be significantly affected by age. The Shouldice repair demonstrated a higher tensile strength when compared to the surrounding tissue. Strength after a Shouldice repair of the floor of the inguinal canal was found to be several times higher than could be attained under physiologic conditions. Therefore, an early postoperative return to normal activity can be recommended.

Inguinal tensile strength and pain level after Shouldice repair.

BACKGROUND: Tension of the abdominal wall in the inguinal region induced by Shouldice repair of an inguinal hernia is said to be responsible for elevated postoperative pain levels. PATIENTS AND METHODS: In 20 patients we recorded the inguinal tensile strength during closure of the hernial gap using a wound retractor equipped with strain gauges. Postoperative pain levels were scaled using a visual analogous score, and correlated with the tensile strength of the inguinal abdominal wall together with peak flow and forced expiratory volume in 1 s (FEV1) 8, 24, and 48 h after the time of operation. RESULTS: Shouldice repair caused an average increase in inguinal tensile strength of 2.9 +/- 0.58 N (mean +/- SEM). The pain level expressed by active patients was twice the value obtained from resting patients (41.55 +/- 6.3% vs 20.81 +/- 7.1% 8 h after operation), but decreased slightly later on. Peak flow during forced expiration was depressed to about 80% of the control values, whereas the 1-s volume during forced expiration decreased only to 95% of the control value. We excluded any correlation between the recorded individual inguinal tensile strength or the changes in distance between the lateral edge of the rectus sheath and the base of the inguinal ligament and the postoperative pain level. CONCLUSION: We failed to see any evidence for the hypothesis that higher inguinal tensile strength induced by Shouldice repair leads to an elevated level of postoperative pain. If there is any effect, it may be masked by other factors with a stronger influence.

[Anastomotic ulcers after duodenopancreatectomy for carcinoma of the head of the pancreas]. / Anastomosenulzera nach Duodenopankreatektomie wegen Pankreaskopfkarzinoms.

Anastomotic ulceration following partial pancreatoduodenectomy carries a substantial risk of complications. More than 50% of patients have episodes of bleeding and up to 20% die as a direct consequence of peptic complications. In a retrospective study of 88 patients, frequency of ulcer was analysed comparing Whipple-Child reconstruction and partial pancreatoduodenectomy with a Roux-Y gastrojejunostomy. Indication was ductal carcinoma of the pancreas in 80 cases and periampullary carcinoma in eight patients. Roux-Y gastrojejunostomy was performed in 53 cases, Billroth-II anastomosis with enteroanastomosis in 35 patients. Perioperative mortality was 7% (n = 6). Nine cases of anastomotic ulceration were verified after Roux-Y gastrojejunostomy (18%). Three out of five Roux patients with a periampullary carcinoma developed ulcers. After Billroth-II reconstruction anastomotic ulceration was found in only one out of 33 cases (3%). Six ulcers presented with bleeding, anastomotic stenosis occurred in two cases. Three ulcer patients with curatively resected periampullary carcinoma were reoperated. After resection of the Roux limb and truncal vagotomy no recurrence was seen during a follow-up period of 19 to 46 months. Roux-Y gastrojejunostomy carries an increased risk of anastomotic ulceration. The lack of inactivation of pepsin by bile acids has to be discussed as an underlying mechanism.

Prophylactic urgent revascularization of the internal carotid artery in the symptomatic patient.

BACKGROUND: The symptomatic patient showing a string sign or ulcerative stenosis of the internal carotid artery (ICA) is subject to a high risk of arterial thrombosis or persisting intracranial embolization during the waiting period before operative revascularization. PATIENTS AND METHODS: During one year 186 operative revascularization procedures of the ICA were performed on the symptomatic patient. 26 of them fulfilled the prophylactic urgency criteria: symptoms of the cerebrovascular insufficiency and a string sign or ulcerative stenosis of the ICA with ulceration greater than 2 mm in depth. These results were compared to the control group of the 157 procedures under elective circumstances. RESULTS: Mean clamping time of the urgency and the elective patients were 23.8 min vs. 24.5 min and operation time 50.1 min vs. 54.3 min. None of our urgency patients presented new neurological defects in the postoperative phase, while this occurred in 3.8% in the elective group. Mortality rate in the elective group was 2.7% and 0% in the urgency group. Furthermore, there were fewer local complications in the urgency group. CONCLUSION: The urgent indication for the desobliteration of the ICA showing a symptomatic string sign or ulcerative stenosis can be recommended. Early thrombosis or neurological defects during the waiting period may be prevented without increasing complication rates.

[Value of subcutaneous drainage in repair of primary inguinal hernia. A prospective randomized study of 100 cases]. / Stellenwert der subcutanen Drainage bei der Reparation primärer Leistenhernien. Eine prospektive randomisierte Studie an 100 Fällen.

Following Shouldice repair of a primary inguinal hernia 50 patients were given subcutaneous Redon drains, while another 50 patients underwent operations without drains in a prospective randomized trial. The amount of postoperative wound secretion in the drainage bottle was added to fluid retention established by sonographic volumetric analysis. The degree of personal impairment was estimated by a visual analogue score. Inflammation parameters were recorded as well as the rate of complications. The drain group showed significantly increased fluid production in comparison to the group without drains on the 1st postoperative day (36.0 vs. 2.5 ml). Wound sepsis was found in two patients in the drain group. Seven patients with drains and eight patients without underwent percutaneous seroma puncture. The drain only slightly affected personal impairment (25.6% vs 21.4%, visual analogue score). Body temperature was elevated in the drain group on the 3rd day after operation (37.2 vs. 36.7 degrees C). We believe there is no indication for the routine use of a Redon drain in the repair of a primary inguinal hernia. Instead, percutaneous puncture of subcutaneous fluid retentions should be performed.

[Pancreatoblastoma: a rare malignant neoplasm in early adulthood]. / Das Pankreatoblastom: Eine seltene maligne Neoplasie im jüngeren Erwachsenenalter.

INTRODUCTION: Here we report the ninth case of pancreatoblastoma in an adult. PATIENT AND METHOD: At the time of diagnosis the female patient was 22 years old. She had a tumor in the left upper abdomen, measuring 9 cm in diameter. Preoperatively the diagnosis of a pancreatoblastoma was suspected and an explorative laparotomy was performed followed by radical tumor extirpation and intraoperative radiotherapy. After the diagnosis of a pancreatoblastoma was confirmed by definitive histopathological examination, combined Radiochemotherapy was performed. DISCUSSION: Special features in histomorphological characterization of the tumor and problems concerning diagnosis and differential diagnosis as well as the lack of a definitive therapy regime are discussed.

[Tailgut cyst. Rare differential diagnosis of retrorectal tumors]. / Schwanzdarmzyste Seltene Differenzialdiagnose retrorektaler Tumoren.

Tumors of the retrorectal space are rare entities. The case report of a retrorectal tailgut cyst serves to illustrate the clinical and diagnostic findings, differential diagnosis, and therapy of retrorectal tumors. Tumors in this area can be identified by palpation. The subsequent investigations include ultrasound, endosonography, endoscopy, and by choice computed tomography or magnetic resonance imaging. Usually tailgut cysts are characterized as cystic tumors, well delineated with multicystic formation. The diagnosis has to differentiate between carcinomas of the colorectum, hamartomas, lymphomas, teratomas, chordomas, abscess formation, dermoid cysts, epidermoid cysts, and enteral cysts. An elevated level of CEA may point to malignancy. Complete surgical resection is the therapy of choice.

[Long-term results after Spitzy's umbilical hernia repair]. / Langzeitergebnisse der Nabelhernienreparation nach Spitzy.

A total of 140 patients presenting with umbilical hernia underwent Spitzy's operation and were included in a retrospective study to analyse the recurrence rate. The patients received a questionnaire and were invited for a physical examination including ultrasound. Participation included 108 patients (follow-up 77%). A total of seven patients (6.5%) developed postoperative wound infections. Prolonged postoperative impairment was mentioned by nine patients (8.3%). After a mean period of 16 days, the patients were able to continue their occupation, and after 27 days, they could manage their usual physical activity. The recurrence rate was 13.0%. The risk for a recurrence correlated with the relative bodyweight. In the group with a body-mass-index (BMI) of less than 30, the recurrence rate was 8.1 %, whereas 31.8% of the patients with a BMI of more than 30 developed a recurrent hernia. The size of the hernial orifice also had an influence on the postoperative result. In patients with a hernial gap smaller than 1 cm the recurrence rate was 6.3%, with hernia orifices from 1 to 2 cm the rate was 4.1%, from 2 to 3 cm 14.3%, from 3 to 4 cm 25.0% and in patients with hernial gaps greater than 4 cm the rate of recurrences was 54.5%. Considering these results,we recommend the use of alloplastic material for umbilical hernia repair for patients with a BMI greater than 30.0 and hernia orifice larger than 3 cm. The decision for use of a mesh in hernial gaps from 2 to 3 cm should depend on individual factors.

[Rare manifestation of actinomycosis as retroperitoneal space-occupying lesion]. / Seltene Manifestation einer Actinomykose als retroperitoneale Raumforderung.

Actinomycosis has to be included in the differential diagnosis of retroperitoneal masses especially when surrounding tissue is infiltrated. We present a 40 year old male patient with the rare manifestation of retroperitoneal actinomycosis. The definitive treatment consisted of surgical drainage and long-term penicillin therapy resulting in complete healing. Special features in clinical symptomatology and problems concerning diagnosis of actinomycosis are discussed.

[Primary angiosarcoma of the lung]. / Das primäre Angiosarkom der Lunge.

INTRODUCTION: Angiosarcomas are uncommon neoplasias, normally located in the skin, liver or heart. Primary angiosarcoma of the lung is rare. CASE REPORT: We report on a 41-year-old patient who presented increasing dyspnea. A 10-cm-angiosarcoma of the inferior lobe of the left lung was detected. After preoperative chemo- and radiotherapy the patient was referred to our clinic for surgical intervention. Resection of the inferior lobe of the lung, resection of part of the diaphragm, lymphadenectomy and replacement with a Vypro-II mesh was performed. Histological examination showed a mesenchymal neoplasia with myxoid tumor tissue, variable cell density and small proliferations of vessels. The immunohistochemical analysis confirmed the diagnosis of an angiosarcoma. The patient was discharged in a good general state for further ambulatory radiochemotherapy. DISCUSSION: Angiosarcoma of the lung must always be included in the differential diagnosis of lung nodules and diffuse infiltrates despite its rare occurrence. Success with neoadjuvant therapy has been reported, but radical resection is recommended due to the cumulative bad prognosis.

[Leiomyosarcoma of the hernial sac in inguinal hernia]. / Leiomyosarkom des Bruchsacks bei der Leistenhernie.

Malignant tumors associated with hernial sacs are rare entities. A review of literature offers only small groups of patients. The high incidence of inguinal hernia repair operations demands recognition of this morbidity. It should be suspected in cases of tight tissue in the hernial sac in differentiation to the unreduced inguinal and femoral hernia. Therapy of choice must be a resection in toto (R0), incomplete resection causes inguinal spreading or recurrence of the tumor. The exact evaluation of the surroundings should follow. There is no other standardized therapy besides operation. A case of leiomyosarcoma in inguinal hernia will present the entity of neoplastic disease in hernial sac.

[Intraoperative measurement of suture forces in Shouldice repair of primary inguinal hernias]. / Intraoperative Messung der Nahtkräfte bei der Shouldice-Reparation primärer Leistenhernien.

A special instrument was developed in order to quantify intraoperatively the traction forces which are employed during Shouldice repair of a primary inguinal hernia while adapting the lateral edge of the rectus sheath and the iliopubic tract. Further investigations were performed under the Valsalva manoeuvre and simultaneous measurement of the intra-abdominal pressure. In 25 patients an average increase in traction forces of 3.62 +/- 0.60 N was registered when the hernial gap was decreased to 0.3 cm. By applying the Valsalva manoeuvre with an average increase of 32 mm Hg in intra-abdominal pressure, traction was increased by a further 1.67 +/- 0.20 N on average. Hernia repair, tensing of the abdominal muscles and increasing the intra-abdominal pressure, however, have a small effect on the traction forces affecting the edges of the hernial gap. It may therefore be concluded that these factors, frequently believed causal for early hernia recurrence, are actually less influential as the force vector stressing the repair zone points in a different direction.

[Pro-Shouldice: primary tension-free hernia repair--conditio sine qua non?]. / Pro-Shouldice: Primär spannungsfreie Hernienreparation--Conditio sine qua non?

Protagonists of laparoscopic hernia repair with mesh emphasize the tension-free repair as a main advantage. Thus, conventional techniques of hernia repair with tissue approximation and suture lines are questioned. Postulated advantages of the tension-free repair are less postoperative pain, shorter labour disability, less recurrences and less complications. The results of our own patients (primary hernia n = 2025, recurrent hernias n = 897) operated with the Shouldice technique were evaluated with regard to the postulated advantages of the tension-free repair. 95% of our patients were operated under local anesthesia. The amount of analgetic drugs/patient decreased from 45% first postoperative day to 20% second postoperative day. The individual judgement of pain with a visual analogue scale decreased to zero at the second postoperative day. Chronic groin pain persisted in 1.4% after primary hernia repair and 2.6% after repair of recurrent hernias in our patients. Mobilizing the patient from the operating table the postoperative hospital stay is 3,7 days after primary hernia and 6,7 days after recurrent hernia. The length of labour disability correlated significantly with the occupation. 90% of self-employees are back at work 3 weeks postoperatively while, in the group of employers, it lasts 8 weeks. 5-year follow-up reveals a recurrence rate of 1.3% after primary hernia and 3.1% after recurrent hernia. With the Shouldice repair the modern goals of hernia surgery are feasible. Therefore, a primary tension-free repair is not a "conditio sine qua non".

[Prospective randomized study of the comparison of the effectiveness of cefoxitin (triple dose) and cefuroxime (single shot) in preventive perioperative use of antibiotics in abdominal surgery]. / Prospektive randomisierte Studie zum Vergleich der Wirksamkeit von Cefoxitin (3fache Gabe) und Cefurexim (Single-Shot) in der perioperativen Antibiotikaprophylaxe in der Abdominalchirurgie.

In a prospective, randomized trial in 200 patients who underwent abdominal surgery, we compared the prophylactic effect of a single dose of 1.5 g Cefuroxime against three doses of 2 g Cefoxitin. The incidence of wound infections was 8.2% in both groups. No difference was found between the two groups in the incidence of other infections except for urinary tract infections, whose frequency was twice as high in the Cefuroxime-treated group. In all patients we swabbed material from the anastomosis for microbiological investigation. However, these results did not enable the prediction of a wound infection or the determination as to which specimen caused the infection. In our pharmacokinetic investigations we obtained better results in the Cefuroxime-treated group due to the drug's longer half-life. On the other hand, we found extreme interindividual variation in the results obtained in both groups. This not well known factor probably raises the incidence of wound infection.

Low-dose, single-shot perioperative antibiotic prophylaxis in colorectal surgery.

Reductions of frequency of administration and dosage of antibiotic agents used in colorectal surgery may lower costs and the occurrence of adverse side effects. In a prospective randomized trial we evaluated two single-short regimens, a low dose of 1 g cefotiam against a standard dose of 2 g cefotiam, both in combination with 500 mg metronidazole. The low-dose group had twice the number of patients with wound sepsis (4 of 30) than the group receiving the standard antibiotic regimen (2 of 30). Two hours after infusion, the antibiotic concentrations in samples of serum, subcutaneous fatty tissue, and colonic wall of those patients receiving 1 g cefotiam were < 1 mg/l. The concentrations after administration of 2 g cefotiam were higher, as expected, and without any adverse side effects. In conclusion, we prefer infection prophylaxis by the standard dose of 2 g cefotiam plus 500 mg metronidazole in colorectal surgery.

[Surgery of inguinal hernia with local anesthesia--technique and results of a minimal invasive procedure]. / Leistenhernienchirurgie in Lokalanaesthesie--Technik und Ergebnisse eines "minimal invasiven" Verfahrens.

In three prospective, randomized studies we analyzed the advantages of local anesthesia in patients with primary inguinal hernias. Each study consisted of 100 cooperative adults, using an open approach and the transinguinal procedure. Due to reduced postoperative complications, increased effectiveness of hospital resources, earlier discharges and a high acceptance by the patients, local anesthesia is the ideal treatment in adult hernia repair.

Ultrasound-based volumetric evaluation of fluid retention after inguinal hernia repair.

BACKGROUND: Daily routine has shown that there are differences between the aspirated volumes of subcutaneous liquid retention after inguinal hernia repair and the results of sonographic-based volumetry using the standard rotating ellipsoid formula. METHODS: In 83 patients, subcutaneous fluid retention after Shouldice repair was visualized by ultrasound and calculated as cuboid, cylinder, and rotating ellipsoid, respectively. The results were compared to the aspirated volume. Data were analyzed retrospectively. RESULTS: The volume obtained by percutaneous punction averaged 12.18 +/- 1.50 ml. The calculated volumes were distinctly less: cuboid, 11.98 +/- 1.59 ml; cylinder, 10.26 +/- 1.45 ml; rotating ellipsoid, 5.99 +/- 0.80 ml. We found different coefficients of regression for the aspirated and the calculated volumes (cuboid; 0.75; cylinder; 0.82; rotating ellipsoid; 1.50). The coefficients of correlation, however, were 0.79 for all modes of calculation. CONCLUSION: Because its results were closest to the aspirated volumes, we recommend the cuboid formula for the ultrasound-based calculation of liquid retention after inguinal hernia repair.