Crura ultrastructural alterations in patients with hiatal hernia: a pilot study.

BACKGROUND: Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) and hiatal hernia has been validated worldwide in the past decade. However, hiatal hernia recurrence still represents the most frequent long-term complication after primary repair. Different techniques for hiatal closure have been recommended, but the problem remains unsolved. The authors theorized that ultrastructural alterations may be implicated in hiatal hernia. Thus, this study was undertaken to investigate the presence of these alterations in patients with or without hiatal hernia. METHODS: Samples from Laimer-Bertelli connective membrane and muscular crura at the esophageal hiatus were collected from 19 patients with GERD and hiatal hernia (HH group), and from 7 patients without hiatal hernia enrolled as the control group (NHH group). Specimens were processed and analyzed by transmission electron microscopy. RESULTS: Muscle and connective samples from the NHH group did not present any ultrastructural alteration that could be detected by transmission electron microscopy. Similarly, connective samples from the HH group showed no ultrastructural alterations. In contrast, all muscle samples from the HH group exhibited sarcolemmal alterations, subsarcolemmal vacuolar degeneration, extended disruption of sarcotubular complexes, increased intermyofibrillar spaces, and sarcomere splitting. CONCLUSION: The evidence of ultrastructural alterations in all the patients in the HH group raises the suspicion that the long-term outcomes of antireflux surgery depend not only on the surgical technique, but also on the underlying muscular diaphragmatic illness.

New devices for inguinal hernia repair in elderly patients.

A recent meta-analysis concluded that there was a lower incidence of recurrences after mesh hernioplasty, as opposed to non-mesh open methods. Inguinal mesh and plug hernioplasties have been performed using prostheses of different sizes and shapes, either sutured or not to the tissues. However, hernia repair using mesh is sometimes associated with postoperative pain, more or less severe and/or persistent. As a consequence it may interfere with the time required to return to work and to normal daily activities. Finally, concerning the postoperative complications and recurrences, the data presented in our study confirm the very low rate for both aspects; then, as regards the time to return to work, our good results are similar to those of other studies available in literature. In conclusion the tension-free hernia repair described, based upon the use of Prolene 3D patch, is a safe operation, simple to be acquired, it can be performed on an outpatient basis, with a low complication rate, a low level of pain, and an excellent quality of life thereafter. The new device seems to satisfy all requisites of a feasible, reliable and effective system for repairing primary inguinal hernia, at low cost, high patient comfort, and with low risk of recurrences.

Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results.

BACKGROUND: Thoracotomy represents the traditional surgical approach for the treatment of epiphrenic diverticula. A mini-invasive procedure has been reported in only few series. This article describes the authors experience with the laparoscopic approach for performing diverticulectomy, myotomy and Nissen-Rossetti fundoplication. METHODS: From 1994 to 2002, 13 patients (6 men and 7 women), mean age 57 years (range 45-71 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy, and Nissen-Rossetti fundoplication. RESULTS: The mean operative time was 145 min (range 110-180 min). No operative mortality was observed. The mean hospital stay was 13.9 days (range 7-25 years). The first three patients (23.1%) who underwent surgery experienced a partial disruption of the suture staple line. One patient (7.7%) died of a myocardial infarction. After a mean clinical follow-up period of 58 months (range 3-96 months), all the patients were symptom free. CONCLUSIONS: Laparoscopic management of epiphrenic diverticula seems to be as safe and effective as the traditional approach, although a longer follow-up period is necessary to confirm the study results.

Feasibility of primary inguinal hernia repair with a new mesh.

BACKGROUND: The purpose of this study was to evaluate the feasibility of primary inguinal repair with open tension-free and sutureless technique using a new polypropylene "patch and plug system" (Prolene 3D patch), and the quality of the treatment in terms of reduction of postoperative discomfort. METHODS: Fifty-six consecutive patients, mean age 54.5+/-11.2 years, with primary unilateral uncomplicated inguinal hernia, were treated in a day-surgery setting. Collected data included: pain scores at 24 hours, 72 hours, and 7, 15, and 30 days after operation, analgesic medications, return to work and to heavy house and/or moderate sporting activities, and quality of life as measured by Short Form 36 health survey questionnaire (SF-36) before the operation and at 6 months follow-up. RESULTS: Postoperative pain was low: the mean visual analog scale (VAS) scores were 2.8 at 24 h, 1.8 at 72 h, and 0.9, 0.3, and 0.04 at 7, 15, and 30 days, respectively. Analgesic drugs were not used by 66.0% (n=37) of the patients. The mean global time to return to work and to heavy activities was 9.9+/-4.6 and 14.6+/-7.0, days, respectively. Patient satisfaction showed a significant improvement in all SF-36 domain scores at 6 months follow-up (P<0.001). There were no major complications, recurrences, or mortality. CONCLUSIONS: The new mesh seems to satisfy all requirements of a feasible, reliable, and effective device for repairing primary inguinal hernia with high patient comfort.