Surgery of the abdominal aorta: experience of a university hospital in Thailand.

One hundred and thirty two patients who underwent aortic surgery at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 1991 to December 2000 were studied. Twenty three patients (17.4%) were aged less than 60 years, 102 (77.3%) aged 60-80 years, and 7 (5.3%) were older than 80 years. Ninety eight patients (74.2%) underwent elective operations and 34 (25.8%) underwent emergency operations. Elective abdominal aortic aneurysms (AAA) repair was the most common indication for abdominal aortic surgery (56.0%). Eighteen patients (13.6%) underwent surgery for infected AAA. The incidence of infected AAA was 16.1 per cent among patients with AAA. Fifteen patients (11.4%) had ruptured AAA and 19 patients (14.4%) had aortoiliac occlusive disease. The overall mortality rate was 15.2 per cent. The mortality of elective aortic surgery was 5.1 per cent and of emergency aortic surgery was 44.1 per cent. The mortality of elective AAA repair was 4 per cent. Multiple system organ failure was the most common cause of death (80%), followed by acute myocardial infarction (10%) and exsanguination (10%). The authors conclude that elective surgery on the abdominal aorta is safe and should be performed when indicated to prevent the development of complications requiring emergency surgery which carries a much higher risk.

Surgical treatment of perforated duodenal ulcer: a prospective trial between simple closure and definitive surgery.

Seventy-eight patients with perforated duodenal ulcer were prospectively studied between 1977 and 1982. Patients were alternately allocated to receive simple closure (Group I, 33 patients) and definitive surgery (Group II, 32 patients). High-risk patients and those whose conditions dictated a definitive operation were excluded. All patients in Group II had a truncal vagotomy and drainage except one who had a proximal gastric vagotomy. There was no death in Group I or Group II; the complication rate and postoperative course were similar. Twenty-seven patients in Group I and 26 patients in Group II were available for follow-up 12 to 80 months after operation, mean 39 months. Good/excellent results were achieved in 30 per cent of Group I compared with 81 per cent of Group II (P less than 0.01). Eighty-five per cent of Group I patients developed recurrent ulcer symptoms and 33 per cent had already had a second definitive operation. Two patients (8 per cent) in Group II were reoperated upon for recurrent ulcer due to an incomplete vagotomy. In a population of patients where long-term follow-up and medical treatment for duodenal ulcer is unsatisfactory, truncal vagotomy with drainage should be the treatment of choice for perforation. Simple closure should be reserved for high-risk patients or when the surgeon is inexperienced.

Laparoscopic vs open inguinal hernia repair. A randomized, controlled trial.

BACKGROUND: The role of laparoscopic inguinal hernia repair is controversial. The aim of this study was to find out whether it is justified to switch from the predominantly modified Bassini repair which the authors had been using to laparoscopic repair. METHODS: Randomized controlled trial in 120 eligible patients admitted for elective hernia repair in a university hospital. RESULTS: Sixty patients underwent laparoscopic transabdominal preperitoneal mesh repair; the other 60 patients had an open repair, mostly with the modified Bassini technique. Operative time for laparoscopic repair was significantly longer, mean (s.d.) 95 (28) min vs 67 (27) min (p < 0.001). The mean analogue pain score during the first 24 h after surgery was 36.2 (20.2) in the laparoscopic group and 49.3 (24.9) in the open group (p = 0.006). The requirement for narcotic injections and postoperative disability in walking 10 m and getting out of bed were also significantly less following laparoscopic repair. The postoperative hospital stay was not significantly different, mean 2.6 (1.2) days for laparoscopic repair and 3.0 (1.5) days for open repair (p = 0.1). Patients were able to perform light activities without pain or discomfort sooner after laparoscopic repair, median interquartile range 8 (5-14) days vs 14 (8-19) days (p = 0.013). Patients also resumed heavy activities sooner, but not significantly, after laparoscopic repair, median 28 (17-60) days vs 35 (20-56) days (p = 0.25). The return to work was not significantly different, median 14 (8-25) days after laparoscopic repair and 15 (11-21) days after open repair (p = 0.14). After a mean follow-up of 32 months one patient developed a recurrent hernia 3 months after a laparoscopic repair. Laparoscopic repair was more costly than open repair by approximately $400. CONCLUSIONS: Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair, but there were no benefits regarding postoperative hospital stay and return to work; laparoscopic repair was also more costly.