Stress response to ovariohysterectomy in rabbits: role of anaesthesia and surgery.

The aim of this study was to evaluate the neuroendocrine and inflammation response to laparoscopic total ovariohysterectomy (TOH) in rabbits, by comparing surgical stress markers of laparoscopic group with those of conventional open ovariohysterectomy and open ovariohysterectomy with pre-incisional local anaesthesia groups. Blood was sampled from 18 rabbits, of which six underwent laparoscopic TOH, six conventional open TOH and six conventional open TOH with pre-incisional local anaesthesia, 30 min before induction of anaesthesia (T0), immediately after skin incision (T1), 90 min postoperatively (T2), and 24 h postoperatively (T3). Cortisol and C-reactive protein serum, and adrenocorticothrophic hormone, tumour necrosis factor-a (TNF-a), adrenaline, noradrenaline and IL-6 plasma concentrations were evaluated. Laparoscopic TOH in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations immediately after skin incision (p = .04), as well as plasma adrenaline (p = .035) and TNF-a (p = .047) concentrations 24 h postoperatively. Impact statement What is already known on this subject? Hysterectomy is the second most common surgery performed on women after caesarean section. Research has focussed on methods to modify the stress response associated with surgery. Various studies both in humans and animals, have demonstrated the less systemic, immunological and neurohormonal response of the laparoscopic technique, which is expressed by less elevated serum enzymes' and proteins' concentrations. However, other studies have documented that the systemic stress response after open hysterectomy is similar to that following laparoscopic surgery. What do the results of this study add? Laparoscopic total ovariohysterectomy in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations, as well as plasma adrenaline and TNF-a concentrations during the first 24 h postoperatively. What are the implications are of these findings for clinical practice and/or further research? There were no significant differences between the groups in number of surgical stress markers (p > .05) perioperatively. We cannot exclude the possibility that a later increase of surgical stress response might take place after the first 24 h postoperatively.

The secondary external inguinal ring and associated fascial planes: surgical anatomy, embryology, applications.

Classically, two inguinal rings are defined: internal and external. We previously introduced a third one, the secondary internal inguinal ring, deep to the classic internal. Here, we present a fourth ring, the secondary external inguinal ring, initially described by McGregor (Surg Gynecol Obstet 49:273-307, 1929), but now forgotten. Embryologically, this ring may be formed by evagination of Scarpa's fascia during testicular descent. Anatomically, it is located 2 cm below the pubic tubercle. It is formed by Scarpa's fascia that covers the spermatic cord anteriorly; medial and lateral fascial reflections delineate the ring and form the spermatic cord canal. The cord is attached to the posterior wall of the canal. The canal ends at the entrance of the scrotum, where Colles' fascia fuses with coverings of the cord. Adjoining the secondary external ring, at the same surgical layer and communicating with the subcutaneous abdominal space, are four subcutaneous pouches: laterally, the superficial inguinal pouch; medially, the perineal, femoral, and pubic pouches. Surgically, an inguinoscrotal hernia passes though the secondary external ring and obtains an extra outer layer by entering the spermatic cord canal. Underdevelopment of the ring leads to incomplete testicular descent or ectopic testis. We recommend reconstruction of Scarpa's ring after orcheopexies and herniotomies in children. After urethral rupture distal to the urogenital diaphragm, urine may fill the subcutaneous abdominal space, pouches, and scrotum, due to their communication around the secondary external ring. In females, this ring was not found, possibly because of the non-descent of the ovaries through (and beyond) the inguinal canal.

Parental exposures and risk of nonsyndromic orofacial clefts in offspring: a case-control study in Greece.

OBJECTIVE: To investigate the association between cleft lip and/or palate and nongenetic factors in Greece. METHODS: We designed a case-control study including 35 patients with nonsyndromic cleft lip and/or palate, retrospectively selected, and 35 control patients matched for prefecture of residence, prospectively selected from pediatric population hospitalized for abdominal pain or injury. Parents were interviewed about drug uptake, diseases, habits, non-occupational exposure to pollutants, and occupation. Questions covered the period from one year before until three months after conception. RESULTS: High-risk paternal occupations (mostly farmers) were significantly more frequent in cleft lip and/or palate than in controls (p=0.039) and increased significantly the cleft lip and/or palate risk in offspring (OR: 3.00; 95% CI: 1.03-8.70). Maternal occupation did not correlate with cleft lip and/or palate. Parental disease, drugs uptake, hazardous habits, maternal folate supplementation and non-occupational exposure to pollutants did not correlate with cleft lip and/or palate. There was a suggestion of increased risk with maternal passive exposure to tobacco (OR: 1.81; 95% CI: 0.69-4.74) and with residential proximity to industries (OR: 1.70; 95% CI: 0.61-4.74). CONCLUSIONS: Paternal high-risk occupations probably exert a teratogenic effect on spermatogenesis or result in maternal contamination, and deserve specific preventive policies. The relation of smoking and residential proximity to industries with occurrence of cleft lip and/or palate deserves further study.

Serum beta-endorphin response to stress before and after operation under fentanyl anesthesia in neonates, infants and preschool children.

INTRODUCTION: The endogenous opioid beta-endorphin is a known indicator of stress and pain. Opioid anesthesia during operation may prevent postoperative beta-endorphin hypersecretion. We examine the effect on serum beta-endorphin of both preoperative stress and stress of operation under opioids in neonates, infants and preschool children. In order to eliminate the effect of hospitalization anxiety we compared with inpatients of similar age with non-surgical disease. MATERIAL AND METHODS: We included 74 surgical patients (25 neonates, 24 infants, 25 preschool children), and 44 non-surgical inpatients (14 neonates, 12 infants, 18 preschool children). Anesthesia comprised propofol and fentanyl. In presence of pain after extubation, supplementary morphine was administered. Sera were taken preoperatively and 2 h postoperatively in surgical patients, and once in non-surgical patients. Beta-endorphin was tested using ELISA (ng/ml). RESULTS: In all surgical patients beta-endorphin did not increase significantly after surgery. Neonates showed significantly elevated beta-endorphin preoperatively (mean+/-SD: 2.02+/-0.76) and postoperatively (2.07+/-0.90) compared to neonates with a non-surgical disease (1.05+/-0.34; p<0.005). In contrast, infants (preoperative values: 1.75+/-1.32, postoperative values: 2.00+/-1.83) did not differ from respective non-surgical inpatients (1.49+/-0.70). Before and after surgery, beta-endorphin was significantly elevated in preschool children (7.19+/-1.85, 6.42+/-1.31), as compared with neonates and infants (p<0.0005), and with preschool children with non-surgical disease (1.01+/-0.27; p<0.0005). CONCLUSIONS: Fentanyl/propofol anesthesia, supplemented by postoperative morphine where necessary, protects from surgical stress and postoperative pain, as denoted by no postoperative increase of beta-endorphin in all age groups. Preschool children, who exhibit increased emotional perception, have explicitly high serum beta-endorphin before and after surgery. Preoperative preparation programs might be worthy in this age group. Neonates show a moderate but still significantly high response of beta-endorphin to stress, retained after operation. In contrast, infants tolerated stress better (not increased beta-endorphin pre- and post-operatively).

Retroperitoneal perforation of a duodenal diverticulum with colonic necrosis -- report of a case.

Primary duodenal diverticula are usually asymptomatic. About 115 perforations have been reported, but none with right colon necrosis. We report a 45-year-old woman, with a five days history of high fever along with epigastric and periumbilical pain. Physical examination revealed right upper and lower quadrant tenderness with peritoneal signs. White blood cell count was 11 500/mm (3) while biochemical and hepatic biology tests were normal. Abdominal radiographs showed no pathologic findings. Ultrasound disclosed fluid in the lower pelvis. Computerized tomography revealed fluid collection in the right hepatorenal space. Intraoperative findings included purulent fluid in the lower pelvis, segmental necrotic changes of the right colon, and a perforated diverticulum on the antimesenteric border of the third part of the duodenum. Surgery consisted of right hemicolectomy and ileo-transverse anastomosis, diverticulectomy, and decompressive lateral duodenostomy at the second duodenal portion. The patient had an uneventful postoperative course. A contrast study from the duodenostomy tube on the 6 (th) postoperative day showed no leakage or obstruction. Duodenostomy tube was removed on the 14 (th) postoperative day. Histology confirmed the diagnosis of a primary duodenal diverticulum.

Not just an appendix: Sir Frederick Treves.

The history of the anatomy and surgery of the appendix is a beautiful chapter in medical education, and we appreciate the role of Sir Frederick Treves in its development.

Absence of antisperm surface antibodies in prepubertal boys with cryptorchidism and other anomalies of the inguinoscrotal region before and after surgery.

PURPOSE: Although the prepubertal immune system cannot recognize postmeiotic germ cell antigens, an overall 21 to 28% incidence of antisperm antibodies directed at these antigens has been reported preoperatively in prepubertal children with cryptorchidism and other inguinoscrotal anomalies. We investigated the prevalence of antisperm antibodies in these prepubertal patients before and after surgery. MATERIALS AND METHODS: We examined 82 prepubertal boys 0.6 to 13.2 years old, including 33 with unilateral cryptorchidism, 21 with inguinoscrotal anomalies and 28 who were normal. IgG, IgM and IgA antisperm antibodies were determined by the indirect Immunobead test. Serum testing was repeated 1 and 2 years postoperatively and annually for 2 more years in the normal children. Also sera from 183 infertile men 21 to 47 years old with a history of cryptorchidism and/or inguinal hernia operated on in childhood were similarly studied. RESULTS: Of the adults 70 (39%) tested IgG positive, including 12 (7%) who were also IgA positive, and all tested IgM negative. Repeat measurements were negative for all IgG, IgA and IgM isotypes in all children, patients and controls. CONCLUSIONS: We conclude that there are no antibodies to sperm surface antigens in prepubertal children with cryptorchidism and inguinoscrotal anomalies before and within 2 years after surgery. Autoimmunity against postmeiotic sperm membrane antigens is apparent in adults only.

Ovarian cavernous hemangioma in an 8-year-old girl.

The case of an ovarian cavernous hemangioma with torsion in an 8-year-old girl is described. Current literature records less than 50 cases of which only 8 are in children. The presenting symptoms of acute abdomen and the ultrasonographic study led to the preoperative diagnosis of torsion of an ovarian tumor. Salpingo-oophorectomy and appendicectomy were performed with an uneventful postoperative course. The histological pattern of the tumor was that of an entirely cavernous hemangioma. The case is reported in view of its rarity.