Mid-term results of minimally invasive deltoid-split versus standard open deltopectoral approach for PHILOS™ (proximal humeral internal locking system) osteosynthesis in proximal humeral fractures.

PURPOSE: Only a few reports compare the mid- and long-term outcome of the minimally invasive deltoid split (MIDS) with the classic anterior deltopectoral (DP) approach for osteosynthesis in proximal humeral fractures. This study compared the mid-term functional and the radiological results in patients with proximal humeral fractures undergoing osteosynthesis with the proximal humeral internal locking system (PHILOS™). METHODS: All patients undergoing osteosynthesis between 2008 and 2015 were clinically and radiologically examined with a minimal follow-up period of 1 year. Functional outcomes were analyzed using the DASH- and Constant Shoulder Scores (CSS). Radiological results were analyzed using a newly developed score. RESULTS: Thirty-nine patients underwent PHILOS™ osteosynthesis with the MIDS and twenty-three with the DP approach. Follow-up time was 41 months in the MIDS group and 62 months in the DP group, respectively. The median CSS was similar with 79 points in the MIDS group and 82 points in the DP group (p = 0.17). The MIDS group showed a significant lower power measurement in the CSS. In four-part fractures, a substantially lower CSS in absolute numbers in the MIDS group was detected. The median DASH score was 26.7 points in the MIDS group and 25.8 points in the DP group (p = 0.48). There was no difference in the radiological score. More patients with partial avascular necrosis (AVN) were found in the MIDS group, most with three- and four-part fractures. However, this was not statistically significant. Morbidity was similar between groups. CONCLUSION: The results of the two surgical approaches are statistically comparable. Some differences such as a lower power measurement in the MIDS group, a higher partial AVN frequency and more plate removals are observed. In four-part fractures, the CSS was lower in the MIDS compared to the DP cohort. The MIDS technique might not be a solution for all fracture types, and the surgeon should be careful to analyze the morphology of the fracture before deciding upon the approach. Four-part fractures might be better treated with a DP approach.

Effectivity of laparoscopic inguinal hernia repair (TAPP) in daily clinical practice: early and long-term result.

INTRODUCTION: The aim of the study was to investigate the effectiveness of laparoscopic inguinal hernia repair in daily clinical practice. PATIENTS AND METHODS: All patients admitted to the hospital for surgery of an inguinal hernia during a 1-year period were prospectively documented and included in a follow-up study. The follow-up was performed at least 5 years after surgery and consisted of a clinical examination, ultrasound investigation and a questionnaire. RESULTS: From January 2000 to January 2001 a total of 1208 inguinal hernias in 952 patients were consecutively operated by a total of 11 general surgeons in daily clinical routine. Of the patients, 98.02 % were operated on laparoscopically with the transabdominal preperitoneal patch plasty technique (TAPP) and 1.98 % had an open repair. The frequency of intraoperative and early postoperative complications was 2.8 %. The complication rate in the patients presenting a complex hernia was not higher than in patients with uncomplicated unilateral hernias. Life-threatening complications were seen in four patients (bowel lesion-0.4 %), but all four patients presented extensive adhesions in the abdominal cavity after previous abdominal surgery. The follow-up rate after 5 years was 85.3 %. After 5 years the recurrence rate was 0.4 % and the rate of severe chronic pain 0.59 %. None of the patients took analgesics or had to change his occupation. CONCLUSION: Laparoscopic repair can be applied to all types of inguinal hernia as a daily routine procedure with low rates of recurrences and chronic pain. Limiting factor may be extensive adhesions after previous major surgery in the lower abdomen.

Teaching and training in laparoscopic inguinal hernia repair (TAPP): impact of the learning curve on patient outcome.

BACKGROUND: On the basis of lower incidence of postoperative pain and faster recovery compared with open techniques, the laparoscopic transabdominal preperitoneal patch plastic (TAPP) technique was established as a leading mode of inguinal hernia repair. In contrast to open hernia repairs, which are well integrated in the training of young surgeons, TAPP is still considered a more difficult surgical procedure, raising the questions of how to include this technique in trainee programs and how to provide appropriate training. METHODS: Out of 15,101 TAPP procedures performed in our department between 1993 and 2007, we analyzed 254 operations that occurred from April 2004 to February 2007 by young trainees (between the second and fourth years of surgical training). The analysis compared the trainees' TAPP operations with 3,200 TAPP procedures performed by experienced surgeons in the same time period, and with the first 254 TAPP operations in our department performed by pioneers who introduced this technique in 1993. RESULTS: In the 254 operations performed by young trainees, the mean operation time was 59 min, the morbidity rate was 3.2 %, and the recurrence rate was 0.4 %. Compared to experienced surgeons, we found no significant difference in recurrence rate and morbidity. For operation time, however, the young trainees demonstrated a learning curve with continuous improvement until the end of the study period approaching expert level. Pioneers also demonstrated a clear learning curve in operation time and additionally also regarding morbidity and recurrence rate. CONCLUSIONS: Our study demonstrates that the TAPP learning curve of young trainees is only related to operation time. Therefore, TAPP is a safe and reproducible technique when performed by young trainees under the supervision of experienced laparoscopic surgeons. With an adequate program, the technique can be learned quickly, skillfully, and safely when a standardized technique is used. It should be included as a fundamental part of state-of-the-art trainee programs.

Lightweight mesh and noninvasive fixation: an effective concept for prevention of chronic pain with laparoscopic hernia repair (TAPP).

BACKGROUND: This prospective study aimed to evaluate the impact of transabdominal preperitoneal patch plasty (TAPP) with implantation of a lightweight mesh (<50 g/m²) fixed by fibrin glue on the occurrence of chronic pain and sexual dysfunction in hernia patients. METHODS: Patients were examined before TAPP, early and late postoperatively. The primary end point of the study was pain-related functional impairment 6 months after the operation as assessed by the validated assessment scale (AAS). For the first time, patients without any pain before surgery were compared with patients experiencing preoperative pain. Furthermore, the patients were asked about the frequency and extent of impairment in their sexual activities. A secondary end point was chronic pain in relation to the type of mesh fixation (glue vs clip). RESULTS: The study criteria was met by 276 patients. The dropout rate after 6 months was 2.9%. Mesh fixation was performed with glue for 212 patients and with clip for 64 patients. Chronic pain with significant impairment of daily activities was experienced by 42% of patients before the operation, which decreased to 8.3% after TAPP. The mean level of impairment, assessed by AAS, decreased from 11.2 preoperatively to 2 postoperatively (p < 0.001). The clip patients had more pain on days 4 and 7 postoperatively (p < 0.05) but not later. A majority of the patients (78%) experiencing pain before the operation were pain free 6 months after TAPP. New pain was seen in 7.4% of the patients but was only mild (numeric analog scale [NAS], 1-3; 78% of patients) or moderate (NAS, 4-6; 11% of patients). The only patient with severe pain (NAS, 8) had a clip fixation. Frequency of sexual dysfunction decreased after TAPP (p < 0.05). CONCLUSION: The TAPP procedure with implantation of a lightweight mesh fixed by glue is a highly effective option for preventing chronic pain in inguinal hernia repair. Fibrin fixation seems superior to clip fixation during the early postoperative period. However, for confirmation of results, a randomized study is recommended.

Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature.

BACKGROUND: Advantages and disadvantages of open and endoscopic hernia surgery are still being discussed. Until now there has been no study that evaluated the advantages and disadvantages of bilateral hernia repair in a large number of patients. METHODS: Our prospectively collected database was analyzed to compare the results of laparoscopic bilateral with laparoscopic unilateral hernia repair. We then compared these results with the results of a literature review regarding open and laparoscopic bilateral hernia repair. RESULTS: From April 1993 to December 2007 there were 7240 patients with unilateral primary hernia (PH) and 2880 patients with bilateral hernia (5760 hernias) who underwent laparoscopic transabdominal preperitoneal patch plastic (TAPP). Of the 10,120 patients, 28.5% had bilateral hernias. Adjusted for the number of patients operated on, the mean duration of surgery for unilateral hernia repair was shorter than that for bilateral repair (45 vs. 70 min), but period of disability (14 vs. 14 days) was the same. Adjusted for the number of hernias repaired, morbidity (1.9 vs. 1.4%), reoperation (0.5 vs. 0.43%), and recurrence rate (0.63 vs. 0.42%) were similar for unilateral versus bilateral repair, respectively. The review of the literature shows a significantly shorter time out of work after laparoscopic bilateral repair than after the bilateral open approach. CONCLUSIONS: Simultaneous laparoscopic repair of bilateral inguinal hernias does not increase the risk for the patient and has an equal length of down time compared with unilateral repair. According to literature, recovery after laparoscopic repair is faster than after open simultaneous repair. Laparoscopic/endoscopic inguinal hernia repair of bilateral hernias should be recommended as the gold standard.

Predictive risk factors for persistent postherniotomy pain.

BACKGROUND: Persistent postherniotomy pain (PPP) affects everyday activities in 5-10% of patients. Identification of predisposing factors may help to identify the risk groups and guide anesthetic or surgical procedures in reducing risk for PPP. METHODS: A prospective study was conducted in 464 patients undergoing open or laparoscopic transabdominal preperitoneal elective groin hernia repair. Primary outcome was identification of risk factors for substantial pain-related functional impairment at 6 months postoperatively assessed by the validated Activity Assessment Scale (AAS). Data on potential risk factors for PPP were collected preoperatively (pain from the groin hernia, preoperative AAS score, pain from other body regions, and psychometric assessment). Pain scores were collected on days 7 and 30 postoperatively. Sensory functions including pain response to tonic heat stimulation were assessed by quantitative sensory testing preoperatively and 6 months postoperatively to assess nerve damage. RESULTS: Four hundred sixty-four patients were included, whereof 442 were examined at 6 months (95.3% follow-up). Fifty-five patients (12.4%) had "moderate/severe" PPP at 6 months. Logistic regression analysis identified four risk factors for PPP: preoperative AAS score, preoperative pain to tonic heat stimulation, 30-day postoperative pain intensity, and sensory dysfunction in the groin at 6 months (nerve damage) (all P < 0.03). A risk prediction model of only preoperative factors and choice of surgical technique revealed increased preoperative AAS score, increased preoperative pain to heat stimulation, and open surgery to increase the risk for PPP (all P < 0.02). CONCLUSION: PPP is related to both patient and surgical factors. Patients with a high preoperative AAS score and high pain response to a standardized heat stimulus may preferably be treated using an operative technique with lowest risk for nerve damage.

Image quality in conventional chest radiography. Evaluation using the postprocessing tool Diamond View.

The objective of this work was to evaluate the influence of the postprocessing tool Diamond View (Siemens AG Medical Solutions, Germany) on image quality in conventional chest radiography. Evaluation of image quality remains a challenge in conventional radiography. Based on the European Commission quality criteria we evaluated the improvement of image quality when applying the new postprocessing tool Diamond View (Siemens AG Medical solutions, Germany) to conventional chest radiographs. Three different readers prospectively evaluated 102 digital image pairs of chest radiographs. Statistical analysis was performed with a p value <0.05 considered as significant. Images were evaluated on basis of the modified imaging Quality Criteria by the Commission of the European Communities. Each of the 11 image quality criteria was evaluated separately using a five point classification. Statistical analysis showed an overall tendency for improved image quality for Diamond View (DV) for all criteria. Significant differences could be found in most of the criteria. In conclusion DV improves image quality in conventional chest radiographs.

Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively collected data of more than 200 cases.

BACKGROUND: Feasibility of laparoscopic transperitoneal inguinal hernia repair (TAPP) in primary hernias has been well established, but can the TAPP also be recommended after radical prostatectomy? METHODS: Our prospectively collected patient database was reviewed from March 1996 until December 2006 in order to compare operative data and postoperative outcomes in 264 TAPPs after prostatectomy with 10,962 TAPPs because of primary hernias. Patients operated after prostatectomy were divided into two subgroups (year of surgery March 1996-July 2002 and August 2002-December 2006, with 132 TAPPs per group) to check for a possible learning curve. RESULTS: In the group operated after prostatectomy patients were older (70 vs. 59 years), duration of operation was longer (59 vs. 40 min) and morbidity was higher (5.7 vs. 2.8%), but recurrence rate was similar (0.8 vs. 0.7%) as was body mass index (BMI) (25 kg/m(2)). Subgroup analysis showed a clear learning curve with a decrease of morbidity (9.8-1.5%) and recurrence rate (1.5-0%) but similar results in operation time (60 and 58 min). CONCLUSIONS: Even if TAPP after radical prostatectomy is a difficult operation it can be performed efficiently and safely. However, for a definite decision regarding recurrence rate long-term results have to be waited for.

Comparison of CT angiography with MR angiography in the preoperative assessment of living kidney donors.

BACKGROUND: The aim of the study was to prospectively compare the diagnostic performance of CT angiography (CTA) with MR angiography (MRA) in the preoperative assessment of living renal donors. METHODS: Forty-eight potential living renal donors (mean 51 years, 29-67 years) underwent multislice CTA and gadolinium-enhanced MRA. Six potential donors were excluded. Forty-two donors underwent minimal invasive retroperitoneoscopic nephrectomy (left 36, right 6) and their datasets available for analysis independently performed by two blinded radiologists. The surgical status served as gold standard. RESULTS: In 42 donors (84 kidneys), CTA identified 63 kidneys with 1 artery (MRI 61), 19 with 2 arteries (MRI 20), one with three arteries (MRI 2), and one with four arteries (MRI 1). Considering only the side with the surgical status available for verification, both CT and MRI correctly characterized 35 of 36 donors with a single renal artery and five of six with one supernumerary artery. Two false positives were two arteries suggested as supernumerary both in CT and MRI not confirmed during surgery. CTA and MRA both correctly identified three accessory renal veins in two donors. CONCLUSION: CTA and MRA had the same accuracy for characterization of renal vasculature in the preoperative assessment of living renal donors.

Intraarterial contrast-enhanced MR aortography with and without parallel acquisition technique in patients with peripheral arterial occlusive disease.

OBJECTIVE: Repeated intraarterial gadolinium injections are necessary in endovascular MRI-guided interventions; therefore a low-dose protocol with a short acquisition time is preferable. The purpose of this study was to conduct a quantitative comparison of intraarterial MR aortograms obtained with and without high-speed parallel acquisition technique. SUBJECTS AND METHODS: Intraarterial MR aortography was performed at 1.5 T on nine patients with peripheral arterial occlusive disease and in an aortic phantom with pulsatile flow. A 3D fast low-angle shot MRI sequence was used for standard technique (acquisition time, 20 seconds) and for parallel acquisition technique (acquisition time, 14 seconds). In all patients, a pigtail catheter was left in the suprarenal position after digital subtraction angiography. Contrast-enhanced intraarterial MR aortography was performed after automated injection of 50 mmol/L gadoterate dimeglumine at an injection rate of 4 mL/s. Contrast-to-noise ratio (CNR) and image quality were evaluated in both imaging series at different locations. In an aortic phantom with pulsatile flow, CNR was determined 1, 30, and 60 cm distal to the catheter tip with standard and parallel acquisition techniques. RESULTS: In all patients, intraarterial MR aortography was feasible with both acquisition techniques. No significant difference in CNR or image quality was observed in the patient study. Similar results were calculated for the pulsatile aortic flow phantom at all locations. CONCLUSION: Intraarterial MR aortography is feasible with parallel acquisition technique without a significant loss of CNR. This technique reduces contrast agent consumption approximately 30% owing to an approximately 30% reduction in acquisition time.