Transinguinal preperitoneal repair with the Polysoft patch: prospective evaluation of recurrence and chronic pain.

OBJECTIVE: The Polysoft patch was conceived to facilitate performance of the transinguinal preperitoneal patch method and combine the advantages of patch placement in the preperitoneal space and the open inguinal approach. The aim of this prospective study was to evaluate the rate of recurrence and chronic pain at midterm follow-up. METHODS: In a cohort of 200 hernia repairs involved in a prospective evaluation, midterm results of 171 cases operated on from 1 July 2004 to 31 December 2005 were assessed. The anesthesia was spinal in 136 (79.5%) cases, local in 26 (15.2%), and general in nine (5.3%). A questionnaire was sent to patients on 30 November 2006 asking about recurrence, chronic groin pain, and satisfaction. RESULTS: With a median follow-up of 21.9 months (11.6-29.4), 167 (97.7%) patients were evaluated, two were dead, and two were lost to follow-up. There were two (1.2%) recurrences that were reoperated on; both consisted of an indirect sac that protruded between the branches of the split patch. Eleven (6.6%) patients alleged the feeling of a foreign body, and 12 (7.2%) reported pain that occurred occasionally or upon effort but did not prevent activity. In one case, the pain present before operation was unchanged, and in three cases, the pain could clearly be attributed to an origin other than the hernia repair. No case of pain that impaired activity was observed. With regard to results, 98.2% of patients were satisfied and 97.6% declared that they would adopt the same method in case they had to be operated on for another hernia. CONCLUSION: These results suggest that the technique provides a low rate of recurrence and a low percentage of chronic pain that did not impair activity.

The Polysoft patch: prospective evaluation of feasibility, postoperative pain and recovery.

INTRODUCTION: The Polysoft patch was conceived to associate the advantages of placement of the patch in the preperitoneal space (PPS) and easiness of the inguinal incision. The aim of this study was to evaluate prospectively the feasibility and postoperative outcome of this method. METHODS: Two hundred Polysoft repairs were performed in 191 consecutive patients with Nyhus types III and IV hernias. The anesthesia was spinal in 146 patients (76.4%), local in 36 (18.8%) and general in 9 (4.7%). The patch was placed in the PPS through the hernial orifice in the fascia in direct hernias and through the internal orifice in indirect ones. The technical points and postoperative course data were prospectively recorded and postoperative pain was assessed daily by visual analogue scale (VAS) in 25 patients. RESULTS: The method was achieved in all the cases. The type of the hernias was as follows: 59 direct, 129 indirect (including 28 pantaloon and 16 sliding), 3 inguino-femoral and 9 recurrent. The size of the patch used was medium in 152 cases (76%) and large in 48 (24%). The large patch was used more in pantaloon, sliding and inguino-femoral hernias. In direct hernias the patch was not split; in indirect hernias the patch was split (so the wings recreate a new internal orifice around the spermatic cord) in 79 cases (61.2%) and not split (with the cord parietalized) in 50 cases (38.8%). The length of operation, postoperative hospital stay, return to daily activity, to work and analgesics consumption were [median +/- SD (extremes)]: 35 min +/- 9.1 (20-60), 1 day +/- 0.4 (0-5), 3 days +/- 1.8 (0-8), 15 days +/- 9.7 (1-30) and 3 days +/- 2.3 (0-10), respectively. The median number of analgesics units was 8 +/- 5.9 (0-32). The values of pain assessed daily by VAS (on 100) varied from 20.4 +/- 19.7 (0-60) at day 0, 25.0 +/- 24.5 (0-80) at day 1 to 7.5 +/- 13.7 (0-50) at day 7; the mean value for the week was 16.7 +/- 16.7 (0-57). There were 14 (7%) benign postoperative complications. CONCLUSION: This study permitted the definition of some technical points and showed that the Polysoft patch can be used for all types of hernias with a weak posterior wall, including complex cases (big scrotal, pantaloon, sliding and recurrent), with a low risk of postoperative complications, a low level of postoperative pain and a short recovery time.

Inguinal hernia: preperitoneal placement of a memory-ring patch by anterior approach. Preliminary experience.

The aim of this prospective study was to set up and evaluate a technique allowing, by the mean of a memory ring, easy placement of the patch in the preperitoneal space (PPS), directly via the hernia orifice, so as to associate the advantages of the preperitoneal patch, anterior approach and minimally invasive surgery. The memory-ring patch was made by basting a PDS cord around a 14 x 7.5 cm oval shaped polypropylene mesh. The hernia sac was dissected, blunt dissection of the PPS was carried out through the hernia orifice and the patch was introduced in the PPS via the orifice. Spreading of the patch in the PPS was facilitated by the memory-ring. One hundred and twenty nine hernias, classified as Nyhus Type IIIa, IIIb and IV, were operated on 126 patients; 11 were big pantaloon or sliding hernias. The anesthesia was spinal in 116 cases and local in 10 cases. There were three benign postoperative complications (2.3%) related to the hernia repair. Ninety six percent of the patients were evaluated with a mean follow up of 24.5 months (12-42). Two recurrences (1.6%) occurred, 7 patients (5.6%) felt some degree of light pain, but not any case of disabling pain was observed. This technique offers many advantages. It is tension-free and almost sutureless. The patch is placed in the PPS through the hernia orifice without any remote opening in the abdominal wall. The patch applied directly to the deep surface of the fascia reinforces the weak inguinal area by restoring the normal anatomic disposition. The good preliminary results are encouraging and justify further randomized evaluation.

[Subperitoneal inguinal hernioplasty by anterior approach, using a memory-ring patch. Preliminary results]. / Hernioplastie inguinale sous-péritonéale par voie antérieure, à l'aide d'une prothèse à mémoire de forme. Résultats préliminaires.

OBJECTIVE: Incidence of chronic pain is lower following laparoscopic hernioplasty than open surgery, probably due to the location of the patch in the preperitoneal space. But since laparoscopy is more demanding, the rates of complications and recurrences are higher. The aim of this study was to evaluate the results of a procedure consisting of placement of a patch, endowed with some memory of shape, provided by a thin peripheral memory ring, in the preperitoneal space, by inguinal incision, through the hernia orifice, under spinal or local anesthesia. METHODS: The study was carried out in two stages. The first study consisted of evaluating the results of a prosthesis made of a polypropylene mesh endowed with a memory-ring made of a PDS cord (Ethicon SAS, 92787 Issy-les-Moulineaux). The second study evaluated the results of the Polysoft patch manufactured by Bard C degrees (Bard France, 78960 Voisins-le-Bretonneux), according to this concept. RESULTS: The first study involved 129 hernias operated on 126 patients of mean age 60 years (27-84). There were 3 (2.3%) benign complications. With a median follow-up of 24.5 months (12-42), 124 hernias (96%) were evaluated. There were 2 recurrences (1.6%) and 7 cases (5.6%) of chronic pain. The second series involved 150 hernias operated on 139 patients of mean age 60 years (21-94). Four (2.7%) benign complications occurred. The median length of surgery was 36 min (20-60), the median postoperative hospital stay was 1 day (0-5), the median time to return to normal activity was 3 days (0-8) and the median time off work was 18 days (1(30). The patients took paracetamol for 3 days (0-10) and the total units number was 8 (0-28). CONCLUSION: These results suggest that the method, easily reproducible, provides a low rate of complications and recurrences, as well as a low level of postoperative and chronic pain. They are worth being confirmed by a randomised comparison to the laparoscopic and Lichtenstein techniques.

Preoperative radiochemotherapy in rectal cancer: long-term results of a phase II trial.

PURPOSE: To assess toxicity and long-term results of preoperative chemoradiotherapy in rectal cancer. METHODS AND MATERIALS: Between 1989 and 1997, as a phase II study, 66 patients with T3 M0, rectal cancer received preoperatively a 45 Gy dose pelvic radiotherapy (XRT) combined with two 5-day chemotherapy courses (CT) of 5-Fluorouracil (5-FU) and Leucovorin (LV) delivered the first and fifth week of XRT. For each CT course, LV:20 mg/m2/d1-d5,. While the 5-FU dose was variable from 450 to 350 mg/m2/d first course and 370 to 350 mg/m2/d second course. Surgery was planned 3 weeks later. RESULTS: XRT-CT was stopped in 1 patient due to progressive disease. CT was stopped in 1 patient due to toxicity. Grades 2 and 3 diarrhea were observed in 8 and 3 patients, respectively. One patient died from acute diarrhea due to deviation from recommendations; 60 patients went to surgery. Among the 58 patients operated on for cure, 5 had an R1-resection. After a 4.5-year median follow-up, the 5-year pelvic disease-free survival was 92% for the whole group and 96% in the R0-resection group. CONCLUSION: Preoperative combined XRT-5-FU-LV is feasible if optimal XRT and patients are carefully managed. The recommended 5-FU daily dose is 350 mg/m2 for both CT courses. This approach is currently tested in a large EORTC phase III trial.

Stapled coloanal anastomosis with reservoir procedure.

A closed-lumen procedure of coloanal anastomosis with a reservoir, performed exclusively with staplers to reduce spillage, is described. This stapling procedure provides three advantages: simplicity, reduction of spillage, and the preservation of sphincteric structures. In 33 procedures performed, 2 (6%) anastomotic leakages and 5 (15%) dilatable stenoses occurred.

Inguinal hernia: the size of the mesh.

The size of the mesh used for surgical repair of groin hernias differs significantly from one technique to another. Such differences are not unimportant, since implantation of a large amount of prosthetic material can induce some drawbacks and may perhaps be avoided in many cases. The weak inguinal area, where inguinal hernias are exteriorized, is smaller than the myopectineal orifice, and a mesh 8-9 cm long and 5-6 cm wide is sufficient to cover this area. The results of methods using a small mesh are good, and large patches provide at best the same results with some real drawbacks. A large mesh spread in the preperitoneal space on the bladder and iliac vessels can induce some difficulties in case of further operation on these organs, and when we operate on a man 30 to 50 years old, we ignore whether he may need that kind of operation many years later. Consequently, in most cases a small patch covering only the weak inguinal area is preferable and a large preperitoneal patch should be used only in selected cases at high risk of recurrence.

Inguinal hernia: a patch covering only the myopectineal orifice is effective.

A large mesh in the preperitoneal space, spread on iliac vessels and bladder, can cause future difficulties in a case of urogenital or vascular disease. Since all recurrences are located in the area of the myopectineal orifice, a mesh covering only this area, as in the Rives procedure, is effective and avoids these drawbacks. However, the Rives procedure is demanding, which is why we tried to simplify the technique. A mesh 8-10 cm long and 6-7 cm wide was spread in the preperitoneal space using the inguinal approach, without any fixation or with only a few stitches; the fascia was then simply approximated over the mesh without tension. A total of 161 hernias (99% Nyhus type III and IV) were repaired using this technique. Only six benign complications (3.7%) occurred. With a median follow-up of 63 months (range, 18-94 months), only one recurrence occurred (0.7%), due to misplacement of the mesh, eight patients complained of mild pain, and no late complications were observed. In conclusion, placement of a small mesh covering only the myopectineal orifice using the inguinal approach is effective and is associated with a low risk of drawbacks and complications.

Cholecystectomy by minilaparotomy without muscle section: a short-stay procedure.

The aim of this prospective study was to assess the results of cholecystectomy performed by an incision characterized by its small size and absence of muscle section, to minimize postoperative discomfort, and shorten hospital stay. Surgical access was via a transverse division of the linea alba extending 1.5-2 cm on the rectus sheath, on both sides, without section of muscle. One hundred and ninety-one patients were operated on. Only 1 (0.5%) peroperative complication (injury of cystic artery) and 4 (2%) benign postoperative complications occurred. The mean postoperative hospital stay was 4.4 +/- 1.7 days (range 2 to 12); for the 90 patients operated on in 1989-1990 it was 3.3 +/- 1.7 days (range 2 to 12). Long-term results were assessed in 113 patients. Only 1 (0.6%) complication occurred, namely migration of a retained common duct stone. Neither incisional hernias nor a need for reoperation occurred. The cosmetic results were assessed by the patients themselves as very good in 95 (84.1%) cases and good in 16 (14.2%) cases.

[Recognition of predictive prognostic factors in recurrent colonic cancer. Apropos of a retrospective series of 178 cases]. / Reconnaissance des facteurs pronostiques prédictifs de récidive du cancer colique. A propos d'une série rétrospective de 178 cas.

Prognostic factors influencing the outcome of colon cancer were studied retrospectively in 178 patients who underwent curative resection between 1975 and 1985. Monovariate and multivariate analysis have been performed. Median follow-up was 8.7 years. Three factors increased the risk of recurrences: age when equal or greater than 70, poorly differentiated tumor and advanced Duke's stage. Two factors increased the risk of intra-abdominal recurrence: age when equal or greater than 70 and advanced Duke's stage. Two factors increased the risk of metastasis (including the liver): poorly differentiated tumor and advanced Duke's stage. Multivariate analysis showed that the risk of recurrences was correlated to Duke's stage, age and histological differentiation. Patterns of failure and prognostic factors reported in the literature are reviewed and implications of these prognostic factors on adjuvant treatment indications are discussed.

[Clinical target volume for preoperative radiotherapy of rectal cancers]. / Volume-cible anatomoclinique dans la radiothérapie préopératoire des cancers du rectum.

The total mesorectal excision allows the marked increase of the local control rate in rectal cancer. Therefore, the mesorectal space is the usual field for the spread of rectal cancer cells. It could therefore be considered as the clinical target volume in the preoperative plan by the radiation oncologist. We propose to identify the mesorectum on anatomical structures of a treatment-position CT scan.

[Gastroesophageal reflux. Comparison of clinical, pH-metric and manometric results of Nissen's and of Toupet's procedures]. / Reflux gastro-oesophagien. Comparaison des résultats cliniques, pH-métriques et manométriques des procédés de Nissen et de Toupet.

OBJECTIVES: The aim of this prospective study was to evaluate and to compare the results of the circular fundoplication (Nissen) and the posterior hemifundoplication (Toupet) for the treatment of gastro-oesophageal reflux. METHODS: For each of the 71 included patients (Nissen, n:43; Toupet, n:28) the following data were collected: surgical complications, clinical symptoms, pH-metric and manometric data, before and 4 and 28 months after operation. RESULTS: Rates of perioperative complications were 26% and 7% in the Nissen and Toupet groups respectively. The Nissen induced more late complications (14%) than the Toupet (0%). At early postoperative evaluation (mean follow-up: 4 months), the rates of clinical and pH-metric recurrences were 2% and 2.5% respectively in the Nissen group and 4% and 9% in the Toupet group (NS). Thirty-seven percent of the patients in the Nissen group and 38% in the Toupet group experienced dysphagia (NS). Disturbances in oesophageal motility, which were present in both groups before surgery, were not significantly modified. At the late evaluation (mean follow-up 28 months), some symptoms of reflux were present in 8% and 17% of patients of the Nissen and Toupet groups respectively (NS). The pH-metric recurrence rate was 10% versus 44% in the Nissen and Toupet groups respectively (P < 0.01). Dysphagia was present in 39% of patients in the Nissen group versus 13% in the Toupet group (P < 0.02). Oesophageal motility remained unchanged in the Nissen group whereas it was significantly improved in the Toupet group where the peristaltic velocity rose from 3.2 cm/s before surgery to 4.4 cm/s after (P < 0.05), giving a value comparable to that of controls (4.2 cm/s). CONCLUSIONS: These results suggest that the short term effectiveness of both procedures is comparable. The effectiveness of the Nissen is more durable, but its morbidity is higher than for the Toupet. Moreover, oesophageal motility is significantly improved by the latter.

[A technique of cholecystectomy by minilaparotomy without cutting muscles]. / Une technique de cholécystectomie par minilaparotomie sans section musculaire.

A surgical incision for cholecystectomy is described. It is characterized by its small size, to reduce peritoneal exposure and the resulting postoperative ileus, and the absence of muscular section, to minimize pain and parietal injury. The skin incision is transverse, symmetrical to the midline, 6 cm in length and located 8-10 cm from the xyphoid process. Then a transverse division of linea alba extending 1.5-2 cm on both sides of the two walls of the rectus sheath, without muscular section, is made. Cholecystectomy is commenced at the fundus and continued downwards.

[Treatment of inguinal hernia in the adult: results of tension-free procedures]. / Traitement de la hernie inguinale de l'adulte: résultats des réparations sans tension.

OBJECTIVES: The aim of this study was to verify, by a prospective multicenter evaluation, if the results attributed to tension-free procedures were obtained in current practice. PATIENTS AND METHODS: From 1994 to 1997, 398 patients were operated on by three surgical teams. There were 357 men and 4 women (mean age: 58.5 years, range: 25-90). The hernia was bilateral in 37 patients and 435 hernias were treated by Perfix plug (n = 322), Gilbert plug (n = 76) or by Lichtenstein procedure (n = 37), according to the choice of the surgeon. In tension-free procedures, sutures under tension were replaced by a mesh or a plug without any approximation of the margins of the hernial orifice. The procedure was performed under local (n = 316), epidural (n = 94), or general (n = 25) anesthesia. RESULTS: There were no postoperative deaths. There were 19 postoperative benign complications (4.4%). The duration of analgesics consumption, postoperative hospital stay, cessation of normal activities and work (mean [SD] [range]) were 3.3 days ([3.9] [0-60]), 1.3 day ([1.1] [0-16]), 4.5 days ([3.1] [0-34]) and 15.4 days ([10.2] [0-60]) respectively. With a mean follow-up of 36 months ([14] [6-67]), 423 hernias (97.2%) were assessed. Two (0.5%) recurrences occurred. Twenty three patients had secondarily troubles (5.8%): 21 patients complained of chronic pain, one had testis atrophy and one plug had to be removed. CONCLUSION: These results confirm that tension-free procedures are minimally invasive, induce few benign postoperative complications and low pain, allow early return to normal activity, and are followed by few recurrences.

[Feasibility and short-term results of the "plug" technique in inguinal hernia. A prospective evaluation]. / Faisabilité et résultats à court terme de la technique du "plug" dans la hernie inguinale. Evaluation prospective.

The aim of this prospective study was to assess the feasibility and postoperative outcome of the "plug" technique in inguinal hernia. One hundred and forty-six consecutive patients were operated for 151 hernias. A plug was applied in 131 cases (86.8%). The Lichtenstein technique was used in 20 cases (13.2%) because of a wide weakness of the posterior wall. Eleven (7.3%) postoperative benign complications occurred. No severe complications were observed and no patient was reoperated. The mean duration of oral analgesia was 2.7 (0-10) days. Mean durations of postoperative hospital stay, time off work and cessation of normal activities were 1.2 (0-4) days, 18.1 (1-37) days and 5.8 (1-18) days, respectively. In conclusion, the "plug" technique is feasible in a wide range of hernias and allows a short hospital stay and an early return to normal activity.

[Concomitant preoperative radiochemotherapy for rectal cancers]. / Radio-chimiothérapie concomitante pré-opératoire des cancers rectaux.

In December 1994, The French Consensus Conference on the Treatment of Rectal Cancer stated that: "Preoperative irradiation improves local control in T3 and T4 resectable rectal cancer patients and is recommended". Recent data indicate that this approach not only reduces local failure but also increases overall survival. The therapeutic ratio depends on the total dose delivered and technical parameters. Inadequate radiotherapy techniques leeds to increased toxicity and masks the potential benefits of the treatment. Combined preoperative chemo-radiotherapy, a promising issue in rectal cancer patients, is now under evaluation in a large European phase III trial (EORTC 22921).

[How can pain of surgery be limited?]. / Comment limiter la douleur des gestes chirurgicaux?

Postoperative pain is due to direct stimulation of nociceptors by surgical trauma, and by algogenic substances produced by damaged tissues. Control of surgical pain can be obtained by limiting the extent of damage to tissues as well as the choice of incision. Endoscopic or video-assisted surgery is an effective mean to reduce pain caused by surgical approach. It is widely used in abdominal, thoracic, orthopaedic surgery, and urology. Many studies have shown a reduction of postoperative pain by laparoscopy for gynaecological surgery and cholecystectomy, but for other procedures the potential advantage of laparoscopic surgery has not yet been established. Conventional open surgery is still widely used. It has been suggested that transverse laparotomies are less painful than midline incisions, and that incision by electrocautery was less painful than with scalpel; but this has not been strictly established. Infiltration of wounds or nerves with local anaesthetic agents is a way of clinical research, which merits further investigation. Whether delicacy in surgery is capable of minimising pain by limiting tissue attrition remains to be demonstrated. Finally, drains and catheters, particularly the naso-gastric tube, which are responsible for pain, could be abandoned when not essential.

[Tension-free procedures: progress in the treatment of inguinal hernia]. / Les procédés sans tension: un progrès dans le traitement de la hernie inguinale.

OBJECTIVE: Tension-free procedures are aimed to minimize post-operative pain and rate of recurrence, by replacing sutures under tension by a mesh without any approximation of the margins of the hernial orifice. Moreover they offer the advantage of being performed under local or epidural anesthesia. The aim of this study was to verify, by a prospective multicentre evaluation, if the results attributed to these procedures are obtained in current practice. RESULTS: Evaluation involved 435 hernias, treated by Lichtenstein procedure, Gilbert plug and Perfix plug. There were 19 postoperative benign complications (4.4%). The durations of analgesics consumption, post-operative hospital stay, cessation of normal activities and time off work [mean, [(SD), (extremes)]] were 3.3 days [(3.9) (0-60)], 1.3 days [(1.1) (0-16)], 4.5 days [(3.1) (0-34)] and 15.4 days [(10.2) (0.60)] respectively. With a mean follow-up of 36 months [(14) (6-67)], 423 hernias (97.2%) were assessed. Two (0.5%) recurrences occurred. Twenty three patients had secondary troubles (5.8%): 21 patients complained of chronic pain, one had atrophy of the testis and one plug had to be removed. CONCLUSION: Our results confirm that tension-free procedures are minimally invasive, induce few benign postoperative complications, low pain and allow early return to normal activity.

[Inguinal hernia: what is the optimal size of prosthetic patch?]. / Hernies inguinales: quelle est la dimension optimale de la prothèse?

The use of prosthetic material for hernia repair is steadily increasing although some surgeons consider this excessive. This shift in surgical practice seems inevitable given the advantages of mesh prosthetic repair, but one may wonder about the amount of prosthetic material left in place which varies widely from one technique to another. While it may be impossible to determine the ideal size of a mesh, it is nevertheless useful to evaluate the relative advantages and drawbacks of techniques using meshes of different sizes. This study provides some elements of reflection based on anatomical, technical, and clinical data. The myo-pectineal orifice of Fruchaud is divided in two parts by the ilio-pubic tract. While the lower part is occupied by the femoral nerve and vessels and the lacunar ligament, the upper part contains the zone of weakness through which most groin hernias protrude. This area is small in size and can be covered by a mesh 8-9 cm long and 5-6 cm wide. There is no difference in the rate of recurrence of repairs using a wide preperitoneal mesh and those using a smaller onlay mesh. The theoretical advantage of a wide preperitoneal mesh is to prevent the possible occurrence of a femoral hernia. Given the rarity of femoral hernia, this advantage must be balanced against the drawbacks of this technique which include the need for general anesthesia, a higher incidence of early postoperative complications, and particularly a higher risk of late complications due to adhesion of the mesh to bladder and iliac vessels. Small onlay mesh prostheses are preferrable in most cases; the use of a wide preperitoneal mesh should be reserved for those cases of inguinal hernia at high risk of recurrence, particularly if bilateral.

[Progress in the treatment of inguinal hernia]. / Progrès dans le traitement de la hernie inguinale.

The aim of surgical treatment of inguinal hernia is to a) reduce post-operative pain and discomfort to a minimum allowing patients to return to the activities as rapidly as possible, and b) hold the recurrence rate under 1%. The Shouldice technique remains the gold standard; its real recurrence rate is about 5%. Applying a mesh in the retroperitoneal space by laparoscopy is a good approach and can theoretically reach both aims. In current practice however, laparoscopy is not always favorable: general anesthesia is mandatory, technical pitfalls lead to morbidity and later to recurrences. Tension-free procedures would provide the best compromise for achieving the two advantages of: a) reducing pain, discomfort and recurrence risks by eliminating tension and, b) local and or loco-regional anesthesia.