Trocar umbilical hernia repair by open suture repair and open suture-mesh repair in an ambulatory setting in comparison to recurrent and primary umbilical hernia repair.

Reports on the ambulatory open repair of umbilical trocal hernias are missing. Patients with trocar, primary and recurrent umbilical hernia open suture and open suture-mesh repair with prospective follow-up were retrospectively evaluated. Patients received perioperative antibiotic prophylaxis, preemptive analgesia and modified anesthesia. In total, 171 patients with umbilical hernia (51 years, female 14%; male 86%) were treated with open suture (n = 29; 17%) and suture-mesh (n = 142; 83%) repair. In total, 10% of patients were treated for trocar hernia (late onset), 5% for recurrent hernia and 85% for a primary umbilical hernia. In total, 29% of trocar hernia repairs had minor complications associated with obesity (40%) and comorbidity (80%). Age, suture and suture-mesh repair were not associated with complications. According to guidelines for umbilical hernia repair open flat mesh may be useful in the treatment of trocar hernia.

Calf pain in runners may be caused by venous insufficiency.

UNLABELLED: Sportsman complaints in the legs are most often associated with diseases and/or trauma of the musculoskeletal system. More rarely disturbances of the vascular system, e.g., popliteal artery entrapment have been reported in sportsman. Venous entrapment or venous claudication is mainly observed in cases of deep venous thrombosis. We report a case of venous claudication in the right leg of a sportsman (long distance runner) without any history of venous thrombosis who presented himself to the Praxisklinik Sauerlach. After running one to two km the man had to stop running due to increasing numbness in the lower leg, aching muscles in the calf and finally pain. An orthopaedic evaluation including magnetic resonance imaging of the leg by two orthopaedic specialists did not reveal any disturbance in the musculoskeletal system being responsible for the pain. - At the first clinical evaluation in ambulatory surgery clinic in Sauerlach there were no visible signs of varicose veins in the legs. B-mode and duplex-sonographic investigation of the right leg revealed an enlarged (0.63 cm) insufficient sapheno-popliteal junction with reflux in the right leg, the investigation of the venous system in the left leg was normal. A popliteal artery entrapment was excluded by colour duplex sonography. The operative procedure, ligation of the sapheno-popliteal junction with segemental saphenous vein stripping, has been well tolerated. 2-3 weeks after ligation of the sapheno-popliteal junction and segmental saphenous vein stripping the patient resumed his running program and could run without any painful disturbances. CONCLUSION: Athletes, e.g., runners with complaints in the leg should be investigated for musculoskeletal defect but also for vascular disease,e.g., small saphenous vein insufficiency. The choice of treatment is ligation of the sapheno-popliteal junction with segmental saphenous vein resection which gives the patient optimal results and allows practicing long-distance running shortly after the operation.

Inguinal Hernia: classification, diagnosis and treatment--classic, traumatic and Sportsman's hernia.

Inguinal hernia repair is performed in more than 600,000 cases every year in the United States. However, the true prevalence may be even higher. Many groin hernias are not diagnosed, e.g., Sportmans' hernia, or are asymptomatic. The etiology of classic inguinal hernia, Sportsman's hernia or traumatic hernia may be different. The hernia repair is performed in agreement with a classification of the hernia, e.g., Nyhus classification. According to recent randomized controlled trials and meta-analyses open-mesh repair demonstrates several advantages in comparison to laparoscopic procedures. Laparoscopic procedures require more time and cost more, show a potential for serious complications and may be followed by an increased rate of recurrence. There may be a faster reconvalescence after laparoscopic procedures. However, there may be also a selection bias. Laparoscopic procedures are associated with specific complications, e.g., pneumomediastinum, pneumothorax, gas extravasation, trocar injuries, intraabdominal adhesions, bowel obstruction, which are rarely or never seen in open-mesh repair. In the United States we could observe an uncoupling of hernia repair from classification. In more than 90% of cases the treatment was open-mesh. In many hernia studies the hernias were classified as direct or indirect, primary or recurrent. The existing classifications are based on anatomical findings in relation to the development of the hernia: posterior floor integrity, enlarged interior ring and size of the hernia. However, the size of the hernia may not always be associated with the severity of the hernia and it may be difficult to estimate. The outcome of hernia repair may be influenced by other factors. There may be differences in the presentation of the hernia to the surgeon based on the damage done to the surrounding tissue in the inguinal canal, e.g., external ring, aponeurosis of the external oblique, inguinal ligament, which is most often accompanied by severe adhesions. Further factors influencing outcome of hernia repair may be patient-related factors, e.g., constipation, ASA classification, diabetes, smoking. A classification should be simple to use and easy to remember: (A) indirect hernia, (B) direct hernia, (C) scrotal or giant hernia, (D) femoral hernia. A and B can be classified as (0) uncomplicated, (1) posterior floor defect, (2) posterior floor defect plus defect in the anterior part of the inguinal canal. All four types (A-D) may be either primary or recurrent. In this classification combined femoral, indirect and/or direct hernias can be categorized by using the types A, B, C, or D as in a modular construction system. The category "other" is reserved for rare types of hernia, e.g., obturator hernia, Spieghelian hernia. Aggravating factors are included: Diabetes, obesity, age above 65, constipation, ASA III or more and cigarette smoking. This classification may be helpful to evaluate outcome of hernia repair with regard to patient related factors and the increased demands for the surgeon and the staff. In some health care systems the general belief is that all hernias are equal and be managed equally. However, groin hernias may be complex and need individual treatment.

Adverse events of sutures: possible interactions of biomaterials?

Absorbable sutures are in use for more than 30 years. Tissue reactions which might be associated with suture material have rarely been reported in the past. After a long period without complications caused by suture material we observed 12 cases of unexpected tissue reactions after clean operations. Our patients 3-8 weeks after uneventful elective clean operations (varicose vein, hernia, benign soft tissue tumor) had unexpected tissue reactions (inflammation, granuloma, extrusion, fistula, abscess) in the vicinity of Vicryl, suture material (8 cases with Vicryl, 4 cases with Vicryl plus. After removal of the suture material and the granulomatous tissue wounds healed without any further disturbance. These tissue reactions have been observed in patients with subcuticular sutures as well as in patients with deeper located vein ligatures. It is well known that next to patient-associated and surgeon-related factors biomaterials might have an impact on postoperative inflammatory process and healing. We use Vicryl, suture material for ambulatory surgery since 1999 and did not see complications for a long period up to now. 11 of the patients were observed within several weeks in summer 2005, whereas only one patient has been observed in the year 2004. All 11 patients observed in 2005 had a combination of Vicryl/ Vicryl plus suture material in deep/subcutaneous and Dermabond glue for skin closure. We do not know the cause for this change. For clarification evaluation of the tissue reactions of these biomaterials including possible interactions or combined reactions should be done.

Circadian rhythm of cytokine secretion following thermal injury in mice: implications for burn and trauma research.

Although there are many reports of circadian variation in hormone secretion, there are only a few reports on the relationship between circadian rhythm and cytokine production. The aim of the present studies was to investigate whether there is a circadian effect on cytokine production of splenic lymphocytes and adherent splenocytes in mice after burn or sham injury. We selected day 7 after injury for our determinations because we have previously shown day 7 is the time of maximal suppression of T cell IL-2 and IFNgamma production and maximal increase in adherent cell proinflammatory cytokine secretion in this model. IL-2 and TNFalpha were chosen as reference cytokines since the former is known to be produced by T cells and the latter by adherent cells of the innate immune system. The results showed that seven days after sham or thermal injury both T cell IL-2 and adherent cell TNFalpha production were altered by time of injury or time of cell harvest. IL-2 secretion was significantly decreased in burn compared to sham animals when splenocytes were harvested in the morning; the decrease was non-significant when splenocytes were harvested in the afternoon. TNFalpha secretion was significantly increased in burn vs. sham adherent cells only when injury took place in the morning. The observed circadian variations in cytokine production could have a significant effect on cytokine levels measured in clinical and animal studies of injury and may explain some of the reported discrepancies among these studies.

Hemorrhoidectomy: indications and risks.

Hemorrhoids are a common cause of perianal complaints and affect 1-10 million people in North-America and with similar incidence in Europe. Symptomatic hemorrhoids are associated with nutrition, inherited predisposition, retention of feces with or without chronic abuse of laxatives or diarrhea. Increased pressure and shearing force in the anal canal may lead to severe changes in topography with detachment of the hemorrhoids from the internal sphincter and fibromuscular network resulting in bleeding, itching, pain and disordered anorectal function, even incontinence. The significance of hemorrhoids for anal continence (corpus cavernosum) is recognized. In most instances, hemorrhoids are treated conservatively; the surgeon is contacted when conservative measures have failed or complications, e.g., thrombosis, have occurred. 4 degrees prolapsed internal hemorrhoids are the main indication for hemorrhoidectomy: high (Parks) or low (Milligan-Morgan) ligation with excision, closed hemorrhoidectomy (Ferguson) or stapler hemorrhoidectomy. Thrombosed external hemorrhoids are primary treated by incision and secondary by excision. Complications after operative treatment of external thrombosed hemorrhoids are rare. After standard hemorrhoidectomy for internal hemorrhoids approximately 10% may have a complicated follow-up (bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, incontinence); there may be concomitant disease, e.g., perianal cryptoglandular infection, causing complex fistula/abscess, which is associated with an increased risk (30-80%) for complications, e.g., incontinence. Other treatment options, e.g., sphincterotomy, anal stretch, have been accused to cause more complications, e.g., incontinence in 30-50% of cases. However, incontinence is a complex phenomenon; it is evident that an isolated single injury is normally not a sufficient cause, e.g., injury of the internal sphincter. The majority of patients may present with prior obstetric injury, perianal infection or Crohn's disease and other comorbidity. Therefore all systemic and regional disorders, causing incontinence, should be excluded before starting manometric, neurophysiological and sonographic investigations. Variation and overlap in test results, patient-, instrument- or operator-dependent factors ask for cautious interpretation. There is vast evidence that the demonstration of muscle fibers in hemorrhoidectomy specimens is a normal feature. In conclusion, standard hemorrhoidectomy with proper indication is a safe procedure. If complications occur, it is in the interest of the patient and surgeon to perform a thorough investigation.

Prophylaxis of thrombosis with low-molecular-weight heparin (LMWH).

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are a major cause of morbidity and mortality, affecting approximately 4 million people each year in the United States. The identification of risk factors for the development of DVT and PE helped to develop a system for risk stratification. The risk to develop a deep vein thrombosis has been estimated to be up to 80% in some populations without prophylaxis. In multiple studies LMWHs demonstrated to be efficient and safe for reduction of DVT of patients in general and visceral surgery, orthopedic surgery, and trauma. Three compounds have been studied best, e.g., dalteparin, enoxaparin, nadroparin, which may help to decide which type of LMWH to use. There is clearly an expanding role for LMWHs in gynecology, cancer, intensive care, patients with acute medical illness and bedridden patients. In summary, LMWHs have chemical, physical, and clinical similarities. They have greater bioavailability, longer half-lifes, more predictable pharmacological response, possible improved safety, and similar or greater efficacy compared with UH. However, the evaluation of clinical trials does not allow the determination of therapeutic equivalence due to different diagnostic methods, drug administration times, dose equivalencies, and outcome measurements The scoring of the quality of clinical trials for meta-analysis is problematic and it has been recommended to assess the methodological aspects individually. Despite clear evidence of effectiveness, deep vein thrombosis prophylaxis is underused. This has been recognized by law firms as evidenced by internet advertisement where patients are informed on the prevention of venous thromboembolism or economy class syndrome. "If you or a family member has been injured, contact a personal injury attorney today. Just fill out Injury.Board.com's on-line questionnaire and have a personal injury lawyer review your potential personal injury claim -- free of charge.". The medico legal implications of antithrombotic prophylaxis and treatment are well recognized.

Low-molecular-weight heparin (LMWH) in the treatment of thrombosis.

Thromboembolic complications are a common and costly medical problem, associated with significant morbidity and mortality, especially in postoperative patients. There have been reports of death due to thromboembolic complications even after short procedures, e.g. arthroscopy. Low-molecular-weight heparins (LMWHs) (e.g., certoparin, dalteparin, enoxaparin, nadroparin, reviparin, tinzaparin) have been tested for treatment of deep vein thrombosis in comparison to unfractionated heparin (UFH) in many patients being effective and safe alternative for treatment of deep vein thrombosis (DVT) and venous thromboembolism (VTE). Fixed-dose subcutaneous LMWH once daily is in most cases of equivalent efficacy and safety compared to conventional UFH therapy. There may be less risk for bleeding, less platelet activation together with a control of markers of haemostatic system activation, and either no progression or regression of thrombus size in patients treated with LMWH. The handling of LMWH is more comfortable for patients and less time consuming for nurses and laboratories compared to UFH. The cost-effectiveness analysis showed that LMWH are more cost effective than UFH. It has been calculated that outpatient treatment with LMWH may save 1641 dollars per patient in comparison to hospital treatment. This economic benefit of outpatient treatment of DVT seems to be realized in different health systems. Women with antiphospholipid antibodies and a history of either prior thrombotic events or pregnancy loss are at high risk during pregnancy for either another fetal death or thrombosis and may benefit from treatment with LMWH. In patients with malignant tumors secondary prophylaxis or long-term treatment with LMWH is successful. Patients with a contraindication for oral anticoagulants may benefit from treatment with LMWH as do patients on chronic anticoagulation treatment scheduled for an operative intervention. In most instances LMWH (dalteparin, enoxaparin, nadroparin) treatment for DVT may be given once daily at a fixed dose without any harm, based on a prolonged antithrombin activity. Effectiveness and safety of LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin) in comparison to UFH treatment on outpatient basis has been demonstrated in several studies. In summary, LMWHs have an established role in the treatment of DVT and pulmonary embolism (PE), on an in- and outpatient basis and could realize substantial savings. Most studies were performed with dalteparin, enoxaparin and nadroparin. There is evidence that LMWHs may help to prolong survival in cancer patients and to avoid complications of the acute coronary syndrome.

First results of Lichtenstein hernia repair with Ultrapro-mesh as cost saving procedure--quality control combined with a modified quality of life questionnaire (SF-36) in a series of ambulatory operated patients.

There are about 200,000 hernia repairs per year in Germany and about 770,000 in the U.S. In the United States most hernia repairs (80-90%) are performed as day surgery procedure; 90% of operations are open herniorrhaphies with mesh. Quality control includes the registration of complications, recurrence, and quality of life. In a prospective study 50 consecutive patients with inguinal hernia eligible for open mesh repair (modified Lichtenstein hernia repair), mostly Nyhus III and IV classification, were operated using light-weight Ultrapro-mesh (monocryl-prolene-composite, Ethicon Products), and interviewed 10 days after the operation according to a modified SF-36 questionnaire. Patients were examined three months later. There were 29 direct hernias, 21 combined (direct and indirect) hernias, 8 indirect hernias; 8 patients had hernias on both sides. 8 patients (16%) presented with recurrent hernias, mostly suture or laparoscopic repairs before. There were no intra-operative complications. 2 patients suffered from a moderate haematoma, which did not necessitate a surgical repair, after accidental intake of aspirin preoperatively in one case and after preoperative low-molecular-weight heparin prophylaxis. There were no other complications. All 50 patients (100%) had returned the questionnaire. 38 patients (78%) reported no or mild pain; only one patient (2%) suffered from severe pain, none had very severe pain. 32 patients (64%) applied no pain medication or only for 48 hours; only one patient (2%) used pain medication for more than 14 days. 34 patients (68%) admitted that their health status improved after the operation; 11 patients (22%) with good or very good health status indicated no change in health. Follow-up examination of the patients three months after the operation did not detect any recurrence. 49 patients (98%) were free of pain or restriction; one patient (2%) continued to have chronic pain which developed after two laparoscopic herniotomies performed at a different clinic before. There was no sign of mesh-related complication. The Ultrapro-mesh has been well accepted by the patients. In conclusion, open mesh repair according to Lichtenstein is safely done in specialised ambulatory day surgery clinics. Most patients benefit from this form of treatment according to a quality of life audit. The new light-weight mesh Ultrapro contributes to the improvement of hernia repair. There is evidence that ambulatory open mesh repair should be the method of choice for primary inguinal hernia. If in Germany an equal proportion of hernia repair as in the United States would be done as ambulatory procedure (80-90%), there would be an annual cost saving of several hundred million Euro.

Management of mycoses in surgical patients -- review of the literature.

Fungal infections have been recognized as major cause of morbidity and mortality in neutropenic and non-neutropenic surgical intensive care patients. The incidence of Candida has increased: it is now the fourth most often isolated pathogen in bloodstream infections. The incidence of Aspergillus infection in transplant patients is highest in heart and lung transplants: 19-26%. Most invasive fungal infections in surgical patients are caused by Candida spp. and Aspergillus spp., less by Cryptococcus spp. and may be classified as local or organ-related, as (chronic) disseminated, and as fungemia. There is no highly specific and sensitive routine test for the diagnosis of Candida and Aspergillus infections available; clinical signs of fungal infections are rather unspecific. The significance of colonization remains undetermined. In non-neutropenic surgical patients central venous access and broad-spectrum antibiotics are independent risk factors for the development of fungal infection. Immunsuppression, e.g., transplantation, burn injury, can render patients susceptible to fungal infection. This has lead to the introduction of antifungal prophylaxis in transplant and burned patients which has reduced the mortality for Candida spp. infection significantly. There is no prophylaxis available against Aspergillus spp. and Cryptococcus spp. Treatment of fungal infections consists of surgical and medical treatment for most organ-related infections. Recommendations for the management of fungal infections exist mostly for neutropenic patients, only few reports address the fungal infection of the surgical intensive care patient. Amphotericin B has been recommended as first line treatment for most severe fungal infections with fluconazole as follow-up treatment. In case of the development of toxic side effects of amphotericin B, mostly fluconazole or lipid formulations of amphotericin were favored. However, a shift in Candida strains towards non-albicans spp. and more resistant species was observed during recent years. This has lead to treatment failures in severe Candida and Aspergillus infections. The prognosis for invasive Aspergillus infections remains poor despite amphotericin B treatment. Newer azoles, e.g. voriconazole, demonstrated stable activity against most of these strains and may offer an option in the treatment of refractory fungal infections.

Inguinal hernia and concomitant varicocele mimicking mesh complication.

In males inguinal hernia and varicocele are frequent diseases with a reported incidence of 1-2 % for hernia (Klinge 2000) and up to 20 % (Mickevicius et al. 2002) for varicocele. In 1997 approximately 220,000 inguinal herniotomies were performed in Germany (Horeyseck 1997). Leading symptoms in both diseases are complaints and dragging pain in the inguinal region radiating into the testis. Surgeons treat traditionally inguinal hernia whereas varicocele is the domain of urologists. Coincident appearance of inguinal hernia and varicocele is expected to be more frequent with regard to the pathogenesis (Friedman et al. 1993; Nakada et al. 1994; Rosch et al. 2002; Rovsing 1916; Santoro et al. 2000; Wagh and Read 1972). Therefore both surgeon and urologist should see patients with inguinal hernia or varicocele. If patients with hernia repair postoperatively suffer from similar complaints again, it should not be interpreted rashly as mesh complication (Conze et al. 2001). The need for an improved assessment has been recognized (Kehlet et al. 2002). It sounds reasonable to assume, that quite a number of patients with complaints after successful hernia repair may suffer from an undiagnosed varicocele. We present a case of inguinal hernia with mesh implantation and concomitant varicocele as an example for mesh-unrelated postherniorrhaphy pain.