Acute appendagitis of the ligamentum teres hepatis: clinical, ultrasound, and computed tomographic findings.

PURPOSE: To describe the clinical, ultrasound (US), and CT findings in three patients with acute appendagitis of the ligamentum teres hepatis. METHODS: A retrospective search of cases over a 4-year period was performed and yielded three patients with acute appendagitis of the ligamentum teres hepatis. The diagnosis was confirmed by US, CT, and clinical follow-up in all three cases. We retrospectively noted the laboratory data, clinical findings, and presumptive clinical diagnosis and describe the US and CT findings. RESULTS: All three patients presented with severe, circumscribed epigastric pain without other symptoms. The complex reactive protein was not elevated or only mildly elevated. At the spot of maximum pain, US and CT showed all signs of an acute appendagitis; however, the pain was not close to colon, but close to the teres ligament. Symptoms resolved within 1 to 2 weeks without therapy. CONCLUSIONS: Acute appendagitis of the teres ligament is not as rare as previously assumed. Familiarity with the US and CT features enables a reliable diagnosis and prevents unnecessary medical or operative treatment.

The pattern of restenosis and vascular remodelling after cold-end radioactive stent implantation.

BACKGROUND: Edge restenosis is a major problem after radioactive stenting. The cold-end stent has a radioactive mid-segment (15.9 mm) and non-radioactive proximal and distal 5.7 mm segments. Conceptually this may negate the impact of negative vascular remodelling at the edge of the radiation. METHOD AND RESULTS: ECG-gated intravascular ultrasound with three-dimensional reconstruction was performed post-stent implantation and at the 6-month follow-up to assess restenosis within the margins of the stent and at the stent edges in 16 patients. Angiographic restenosis was witnessed in four patients, all in the proximal in-stent position. By intravascular ultrasound in-stent neointimal hyperplasia, with a >50% stented cross-sectional area, was seen in eight patients. This was witnessed proximally (n=2), distally (n=2) and in both segments (n=4). Echolucent tissue, dubbed the 'black hole' was seen as a significant component of neointimal hyperplasia in six out of the eight cases of restenosis. Neointimal hyperplasia was inhibited in the area of radiation: Delta neointimal hyperplasia=3.72 mm3 (8.6%); in-stent at the edges of radiation proximally and distally Delta neointimal hyperplasia was 7.9 mm3 (19.0%) and 11.4 mm3 (25.6%), respectively (P=0.017). At the stent edges there was no significant change in lumen volume. CONCLUSIONS: Cold-end stenting results in increased neointimal hyperplasia in in-stent non-radioactive segments.

Impact of randomized trials on the application of endoscopic techniques for inguinal hernia repair in The Netherlands.

BACKGROUND: One year after publication of a Dutch prospective trial randomizing patients with inguinal hernias to either endoscopic or open repair, a questionnaire was sent to all Dutch surgeons to evaluate the impact of this trial on the application of endoscopic inguinal hernia repair in the Netherlands. METHODS: All 780 registered Dutch surgeons were surveyed. The performance of endoscopic inguinal hernia repair, the technique and the indications, the involvement of surgical residents, the motives for use of conventional techniques, and the type of open repair were documented. RESULTS: The response rate was 100%. Endoscopic inguinal hernia repair was performed by 16% of Dutch surgeons. For 81% of the surgeons, the total extraperitoneal approach was the preferred endoscopic technique. Primary inguinal hernias were approached endoscopically by only 54% of these surgeons, and recurrent hernias by 92%. The technique of choice for open repair of primary hernias was the Shouldice repair. The predominant repair for recurrent inguinal hernias was the Lichtenstein technique. CONCLUSIONS: Although randomized clinical trials have provided evidence that the endoscopic approach to inguinal hernias is preferable, only 1 of 6 Dutch surgeons has adopted endoscopic inguinal hernia repair. Improvement in training of both surgical residents and surgeons and increasing awareness among medical doctors and patients about the benefits of endoscopic inguinal hernia repair are necessary to enhance the acceptance of this valuable technique for inguinal hernia repair.

Optimal mesh size for endoscopic inguinal hernia repair: a study in a porcine model.

BACKGROUND: Although the recurrence rate for endoscopic herniorraphy is low (0-3%), it can still be improved. In addition to using an expert technique that will minimize the risk of recurrence, it is essential that the mesh be large enough to cover the hernial defect adequately. To gain an impression of the optimal mesh size for such repairs, we performed an experimental study in a porcine model. METHODS: To mimic inguinal hernial defects, circular holes of different diameters were cut in the pigs' abdominal walls after the peritoneum was lifted from the transverse fascia. The abdominal walls were positioned in a hermetically sealed chamber in which air pressure was applied to replicate intraabdominal pressure. Measurements were obtained to relate the protrusion of the mesh to the following three variables: intraabdominal pressure, defect size, and mesh overlap over the defect after positioning of the mesh between the abdominal wall and the peritoneum. RESULTS: Mesh protrusion increased as defect size and intraabdominal pressure increased. Mesh protrusion decreased as overlap of the mesh over the defect increased. Protrusion was found to level off when the mesh overlapped the defect by 3 cm and adequate positioning of the mesh was maintained. CONCLUSION: Recurrences after endoscopic inguinal hernia repair due to inadequate mesh size and mesh protrusion can be reduced by using a mesh that overlaps the defect by > or = 3 cm.

Applicability of laparoscopic surgery for colorectal disease.

BACKGROUND: The advantages of laparoscopic colorectal surgery for selected patients have been well established. However, the applicability of laparoscopic surgery in the whole population of patients with colorectal disease is not well known. METHODS: A single-institution medical records review of 269 patients subjected to colorectal surgery was made. Of these, 206 open colorectal procedures were performed, and data were reviewed retrospectively. In addition, 63 patients were subjected to laparoscopy, and their data were recorded prospectively. An analysis of the existence of factors that contraindicate laparoscopic colorectal surgery was done. These factors were of two types: absolute (urgent intervention, severe cardiopulmonary disease, advanced liver cirrhosis, tumor invasion into adjacent organs, simultaneous major surgery) and relative (midrectal tumors, tumors in the transverse colon, bulky tumors, more than two previous infraumbilical operations, previous intestinal surgery, and previous peritonitis). RESULTS: Factors that could contraindicate the laparoscopic approach were found in 118 patients (44%). The most common were urgent intervention (40%), midrectal tumors (19%), locally advanced cancer (13%), previous intestinal surgery (13%), and tumors >10 cm (6%). We considered 25% of the contraindications to be absolute and 19% relative. Taking these exclusion criteria into consideration when selecting patients for laparoscopic surgery, the conversion rate in our initial laparoscopic series (63 cases) was 13%. CONCLUSION: The indication for laparoscopic surgery for patients with colorectal disease is superior to 60% (absolute 56%, relative 81%). When using appropriate selection criteria, the conversion rate may be maintained below 10%. Preoperative selection of patients with colorectal disease allows optimal use of the advantages of laparoscopic surgery.

Laparoscopic surgery and surgical infection.

INTRODUCTION: It has been observed that the metabolic response to surgical injury is less after laparoscopic surgery than after open surgery. However, the effect of laparoscopic surgery on surgical infection has not been given much attention in the surgical literature, even though it may decrease the incidence of infectious complications. The objective of this study was to assess the influence that laparoscopic surgery has on surgical infection and to highlight certain controversial aspects. METHODS: A review of the literature was undertaken to examine the relationship between laparoscopic surgery and surgical infection. This was achieved primarily by using PubMed Medline as a source of material. RESULTS AND CONCLUSION: Laparoscopic surgery is associated with better preservation of the immune system than open surgery. This results in a decreased incidence of infectious complications. Although carbon dioxide pneumoperitoneum affects the peritoneal response to injury, it seems to have no harmful effect in terms of intra-abdominal infection. Nevertheless, at laparoscopic operation the virulence of intestinal micro-organisms should be recognized and, while knowing the advantages of minimally invasive surgery, the surgeon should consider the complexity of this technique. Furthermore, maintenance of laparoscopic instruments should be governed by the same norms as those used in open surgery; recommendations offered by the manufacturers should be respected.

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy.

BACKGROUND: Although the recurrence rate for endoscopic herniography is low (0-3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates. METHODS: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used. RESULTS: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. CONCLUSION: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy.

Endoscopic totally extraperitoneal repair of bilateral inguinal hernias.

BACKGROUND: Recurrence rates associated with bilateral inguinal hernia repair with a giant prosthesis (Stoppa procedure) are low. Endoscopic totally extraperitoneal bilateral inguinal hernia repair with a giant prosthesis combines the low recurrence rate of the Stoppa repair and the advantages of minimally invasive surgery. The aim of this retrospective study was to investigate whether extraperitoneal bilateral inguinal hernia repair could be performed by the minimally invasive, totally extraperitoneal approach. METHODS: From February 1993 to January 1998, 98 patients with bilateral inguinal hernias underwent surgery. A polypropylene 30 x 10 cm rectangular mesh or a 30 x 10/15 cm 'slipmesh' was used. Follow-up, including a physical examination, of 96 per cent of patients was performed. RESULTS: Median operative time was 60 min. Mostly minor intraoperative complications occurred. Conversion was required for two patients. Apart from one patient with a necrotic fasciitis who died from respiratory failure, only minor postoperative complications (10 per cent) occurred. Median hospital stay was 1 (range 1-21) days. Median recuperation time was 5 (range 1-22) days. Median follow-up (96 per cent) was 32 (range 7-57) months; there were six recurrences among 34 hernias in the group of 17 patients treated with 10 x 30 cm mesh and two (1 per cent) in the group that received 30 x 10/15 cm mesh (162 hernias in 81 patients). CONCLUSION: The endoscopic approach for the Stoppa procedure for bilateral inguinal hernia repair is a reliable method with minor complications. It ensures a short recuperation time and the recurrence rate is low owing to adequate overlap of the hernial defect when a 'slipmesh' is used.

Endoscopic total extraperitoneal repair of primary and recurrent inguinal hernias.

BACKGROUND: In most reports different techniques have been described for combinations of primary and recurrent hernias. The aim of this study was to investigate and compare the results of endoscopic total extraperitoneal repair (TEP) of primary and recurrent inguinal hernias. METHODS: From January 1993 to July 1995, 221 patients with an unilateral inguinal hernia (186 primary and 35 recurrent) underwent TEP repair. Follow-up, including physical examination, was performed at regular 3-month intervals. RESULTS: The mean operation time was 37.6 min. Minor perioperative complications occurred in 23 cases. Conversion was required for 16 patients (7.2%). Postoperative complications were reported for 11.7% of the patients. Hospital stay was short. Mean follow-up was 40.4 months. The recurrence rate was 3. 2% for primary hernias and 20% for recurrent hernias. CONCLUSIONS: This study confirms the preliminary success of TEP for primary inguinal hernia repair, as previously reported. The high recurrence rate after endoscopic repair of recurrent hernias needs to be studied further.

Cellular reaction on the intraperitoneal injection of four types of polylactide particulates.

Four types of polylactide particulates, P-L-LA 100, 250, 550 KD and a P-DL-LA 400 KD were injected into the peritoneal cavity of mice. The inflammatory reaction showed an increase in cell number (mainly neutrophilic granulocytes) up to 48 h after which the cell numbers decreased below the control (phosphate-buffered saline). All four polylactide particulates aggregated and intermingled with inflammatory cells. The aggregates remained throughout the investigation period of 6 months. Quantitative measurements showed that standardization of the particle form and size is essential. From this study and other experiments in which calcium phosphates and asbestos were injected intraperitoneally, it is concluded that the inflammatory response observed in the peritoneal cavity is related to the type of material injected and probably to form and size of the individual particles, but not to molecular weight.