Open tension-free Cooper ligament repair for femoral hernia.

Many techniques have been described for the repair of femoral hernia. The technique applying the principles of the tension-free method of McVay's Cooper ligament repair by covering all potential hernia sites in the myopectineal orifice with a mesh has also been described, but no report has yet been published with large number of cases and long follow-up period. We used this technique in 28 patients (19 females and 9 males) with femoral hernia. The average operating time was 40 min (range 25-75) and average follow-up period was 40 months (range 6-75). No postoperative infection or seroma was recorded. There was no recurrence at the time of writing. This technique seems to be a good alternative for the repair of femoral hernia and also for concurrent femoral hernia with inguinal hernia.

Comparison of local and general anesthesia in tension-free (Lichtenstein) hernioplasty: a prospective randomized trial.

To compare pulmonary effects, postoperative pain and fatigue, morbidity, patient satisfaction, and cost of different anesthetic techniques for inguinal hernia repair, 50 patients were randomized to local and general anesthesia groups (LA and GA). All patients received the same premedications and the same postoperative analgesic regimen. The standardized postoperative analgesic, intramuscular pyroxicam 20 mg, was given to all patients in the recovery room and an additional 20 mg on the same day was given as requested by each patient. Pulmonary function studies and arterial blood gas analysis were performed 1 h prior to the operation and at the postoperative 8th and 24th hours. All patients underwent Lichtenstein's tension-free hernioplasty. Postoperative pain and fatigue were registered 8 h and 24 h after the operation. A questionnaire was filled out by the patients, and they were asked to give grades for the general comfort of the anesthesia and the surgical procedure (1 = worst, 10 = best). Postoperative pulmonary function tests were significantly poorer in the GA group both on 8th- and 24th-hour measurements (P < 0.05). Patients who underwent LA had significantly lower PCO2 and higher PO2 at the postoperative 8th hour (P<0.05). Mean postoperative pain and fatigue scores revealed a significant difference in favor of local anesthesia at only the 8th hour (P<0.05). There were two complications, one in each group (a hematoma in LA and a urinary retention in GA). Patient satisfaction grades were not different in the two groups. We conclude that LA in inguinal hernia repair does not adversely affect pulmonary functions, patients feel less pain, and patient satisfaction is comparable to that with GA.

Imprint cytology in the endoscopic diagnosis of gastrointestinal malignancies.

BACKGROUND/AIMS: To compare imprint cytology with histopathology regarding diagnostic accuracies and quickness in the diagnosis of gastrointestinal malignancies. METHODOLOGY: Multiple endoscopic biopsies were taken from 146 patients having various lesions without a prior histopathological diagnosis. Imprint smears were prepared, using all biopsied tissues, on 3-5 slides. Tissues were fixed in 10% formalin. Time from the materials were received at the pathology laboratory to when the results were available was recorded. Cytopathologists and histopathologists, blinded to each other's diagnosis, examined the imprint smears and tissues. RESULTS: Average time to get imprint cytology results was shorter than that of histopathology (55 minutes vs. 8 days). Fifty-eight patients had a final diagnosis of malignancy. Histopathology and imprint were positive in 56 and 54, respectively. Eighty-eight patients had benign histopathology, all of these had negative imprint results. False-negative and false-positive rates for imprint were 6.8%, 0% and for histopathology were 3.4%, 0%, respectively. CONCLUSIONS: Imprint cytology is an easy, reliable method that can be used as an adjunctive measure with histopathology. It gives the earliest information about the nature of the lesion with a minimum misdiagnosis risk. Imprint cytology lets the surgeon plan a therapeutic strategy approximately 1 week earlier.

Post-traumatic combined transdiaphragmatic intercostal and lumbar hernia.

Traumatic rupture of the diaphragm following blunt trauma is rare. Lumbar hernia in association with blunt trauma is even rarer. To our knowledge, the combination of these two entities has not previously been reported. We describe such a case and review the literature.

Lack of evidence that obesity is a cause of pilonidal sinus disease.

OBJECTIVE: To find out whether pilonidal sinus is more common among obese people. DESIGN: Retrospective study from hospital records. SETTING: Two university hospitals, Turkey. SUBJECTS: 419 patients who were operated on for pilonidal sinus disease; and 213 age and sex matched patients with benign diseases other than pilonidal sinus disease and who were not morbidly obese acted as controls. MAIN OUTCOME MEASURES: Comparison of body mass index (BMI) in the two groups. RESULTS: Patients with BMI of 25-30 were classified as overweight (61/419, 15% compared with 28/213, 13%), and those with BMI of 30 or more as obese (7/419 compared with 4/213, 2% in each group). Mean (SD) BMI of patients with pilonidal sinus disease was 26.0 (3.9) compared with 25.6 (3.9) in the control group (p = 0.4). CONCLUSION: Obesity alone is not an important factor in the aetiology of pilonidal sinus disease.

An experimental study evaluating the effect of Mitomycin C on the prevention of postoperative intraabdominal adhesions.

BACKGROUND: Fibroblast proliferation is one of the well-known mechanisms for postoperative intraabdominal adhesion formation. Inhibition of fibroblast proliferation is an attractive field of investigation in the prevention of adhesions. Mitomycin C (MMC) is a cytotoxic agent that alkylates and crosslinks DNA and also inhibits fibroblast proliferation up to a few weeks. We aimed to determine the effect of MMC on the prevention of adhesions. MATERIALS AND METHODS: Generation of adhesions in rats by brushing a 1-cm(2) area of the cecum and the peritoneum on the right side of the abdominal wall was followed by intraperitoneal administration of saline, 1 mg/kg MMC, and 0.5 mg/kg MMC in saline. After 45 days, formation of adhesions was graded. RESULTS: The average adhesion scores of the control, and MMC (1 mg/kg), MMC (0.5 mg/kg) groups were 3.2 +/- 0.7, 0.8 +/- 0.6, and 0.7 +/- 0.8, respectively. Adhesion scores of the two MMC-treated groups were significantly lower than that of the control group (P < 0.001). There was no difference between the two MMC groups (P > 0.05). No side effect of MMC was observed. CONCLUSION: MMC was found to be very effective in the prevention of postoperative intraabdominal adhesions.

Management of sigmoid colon volvulus.

BACKGROUND/AIMS: Sigmoid colon is the most frequent site for a volvulus. The condition has been a formidable one, fraught with innumerable complications responsible for many deaths. In this report, we reviewed our experience with sigmoid colon volvulus. METHODOLOGY: We present our experience of 61 cases of sigmoid volvulus admitted to our department. Twenty-four patients were subjected to non-operative decompression and the others underwent emergency operation. RESULTS: Intestinal volvulus has quite a high morbidity and mortality. Mortality rate of elective resection following sigmoidoscopy was 7.6%. Mortality rate for emergency surgical detortion, primary resection and Hartman procedure were respectively 13%, 16.6% and 37.5%. Important factors such as the patient's features and frequent late diagnosis can influence the complicated outcome of the disease. Plain X-ray of the abdomen is helpful. CONCLUSIONS: Management with the conservative method of treatment in the form of detortion by sigmoidoscopy and rectal tube application is initially effective in most cases of volvulus of the sigmoid colon. On the other hand, elective or emergency sigmoid resection is the most effective treatment for the disease.

The role of obesity on the recurrence of pilonidal sinus disease in patients, who were treated by excision and Limberg flap transposition.

Recurrence of pilonidal sinus disease after surgical intervention is not a very rare problem although sophisticated reconstruction procedures have been developed. Recurrence is thought to be related to the anatomical status of the patients, i.e., depth of the intergluteal groove. Obese patients have deeper intergluteal grooves. The aim of this study was to use body mass index (BMI) as an objective indicator of obesity to determine whether there is a relationship between BMI and recurrence of pilonidal sinus disease. BMI was calculated preoperatively in 114 patients with pilonidal sinus disease who were treated by excision and Limberg flap transposition between 1996-1999 in general surgery departments of two university hospital clinics. Fifteen patients were referred to our clinics after surgical intervention carried out at other institutions. Their average BMI was calculated by using their hospital records. The mean follow-up period was 24 months (range 10-36). Six of the 114 patients (5%) had recurrence. The mean BMI of patients with and without recurrence was 29.35 and 27.415, respectively (P<0.05). The mean BMI of 15 patients referred to us because of recurrent disease was 29.41; however, that of patients with primary pilonidal sinus disease was 27.212 (P<0.05). Their BMI before their first operation was 29.30. This was also significantly higher than patients with primary disease (P<0.05). We conclude that obese patients with high BMI have a higher risk of recurrence of pilonidal sinus disease after surgical intervention.

Effects of experimental obstructive jaundice on contractile responses of dog isolated blood vessels: role of endothelium and duration of bile duct ligation.

1. We examined the effects of experimental obstructive jaundice caused by bile duct ligation (BDL) on vascular smooth muscle function, as well as the underlying mechanisms involved, by recording responses to noradrenaline (NA), 5-hydroxytryptamine (5-HT) and acetylcholine (ACh) in canine isolated renal arteries and to NA in isolated mesenteric arteries in vitro. All studies were performed 7 days after the onset of BDL in renal arteries and 3, 7 and 15 days after the onset of BDL in mesenteric arteries. 2. The maximum contraction evoked by both NA and 5-HT was significantly attenuated with no change in agonist potency (pD2 value) in renal arteries with endothelium obtained from 7 day BDL dogs when compared with those from sham-operated controls (SO). However, the reduction almost disappeared when the endothelium was removed. In contrast, no change in the responsiveness of renal arteries to KCl could be detected at 7 day BDL. Endothelium-dependent relaxations produced by ACh were significantly increased in renal artery rings from 7 day BDL dogs, but the endothelium-independent relaxations produced by papaverine in BDL preparations were not changed when compared with SO controls. 3. At 7 and 15 days after BDL, the Emax values of the mesenteric ring of BDL dogs to NA were significantly lower than that of SO controls, whereas 3 days after surgery there was no significant difference. The pD2 values in arteries obtained from 15 day BDL animals were significantly lower than those obtained from SO control animals. However, no significant changes in pD2 values were seen 3 and 7 days after the onset of BDL. 4. In conclusion, it is suggested that enhanced production and/or release of nitric oxide, mainly of endothelial origin, is associated with reduced vascular responses to contractile agents in experimental obstructive jaundice and that this effect is related to the duration of obstructive jaundice. These results may explain, at least in part, a cause of hypotension that leads to renal failure in patients with obstructive jaundice.

Traumatic rupture of the diaphragm.

Diaphragmatic rupture following trauma is often an associated and missed injury. The diagnosis is difficult, so is usually made intraoperatively. Twenty-one patients with traumatic rupture of the diaphragm (TRD) who presented between 1995 and 1998 were retrospectively analysed: 12 had penetrating injuries and nine had blunt injuries. Right-sided defects exceeded left (12 vs 9). Only seven patients had signs and symptoms directly referrable to rupture of the diaphragm. All patients were operated on through a midline laparotomy. Diaphragmatic hernia was seen in six patients (28.5%); 20 (95%) patients had concomitant injuries. The liver was the most commonly injured organ (10 patients). The aim of this study was to report our experiences with TRD and review the literature. We conclude that correct preoperative diagnosis of TRD needs a high index of suspicion. It can be diagnosed intraoperatively by explorative laparotomy. Most ruptures can be repaired by the abdominal approach.

Imprint cytology in the diagnosis of Helicobacter pylori. Does imprinting damage the biopsy specimen?

OBJECTIVE: To investigate the efficacy of imprint cytology in the diagnosis of Helicobacter pylori infection and whether it damages the biopsy specimen for subsequent histologic examination. STUDY DESIGN: Two antral biopsies were taken from 76 patients with dyspeptic symptoms undergoing upper gastrointestinal endoscopy. Imprint cytology was made from the first specimen. This specimen was fixed in 10% formalin and sent for histopathologic examination. The second specimen was directly fixed in 10% formalin for routine histopathologic examination without being used for an imprint. The imprint smears were examined by cytopathologists. The biopsy specimens were examined by pathologists who did not know which specimens were used for the imprints. RESULTS: H pylori was seen in smears from 55 (72%) patients and in both biopsy specimens from the same patients. The pathologists could not recognize the biopsy specimens from which the imprints were made. Concordance between imprint cytology and histopathology was 100%. CONCLUSION: Imprint cytology is a suitable test for H pylori diagnosis, and imprints do not adversely affect the quality of the biopsy specimen.

Prevention of postherniorrhaphy urinary retention with prazosin.

Urinary retention that necessitates catheterization after herniorrhaphy is a well known, but usually ignored, situation. Increased sympathetic activity resulting from surgery may be the contributing factor. Blockade of alpha receptors in the bladder neck and urethral sphincter may prevent postoperative urinary retention. In this prospective placebo-controlled study, the efficacy of prazosin in preventing postoperative urinary retention after herniorrhaphy was investigated in 156 patients. Patients were randomized into two groups. Patients in Group I (control) were given placebo orally 12 hours before surgery, just before surgery, and 12 and 24 hours after surgery. In Group II, 1 mg of prazosin was given in the same manner of placebo. Nine of 84 patients (10.8%) in the prazosin group and 18 of 72 patients (25%) in the placebo group developed urinary retention. Catheterization was required in only 3 patients (3.5%) in the prazosin group compared to 10 patients (13.8%) in placebo-treated group (P < 0.05). In conclusion, prophylactic use of prazosin after herniorrhaphy significantly reduced the incidence of urinary retention and catheterization.

Factors affecting surgical mortality and morbidity in patients with obstructive jaundice.

The importance of clinical and laboratory parameters which have an effect on postoperative mortality and morbidity was evaluated in 124 patients operated on because of obstructive jaundice. The causes of obstructive jaundice were a malign disease in 38 patients (30.6%) and a benign disease in 86 patients (69.4%). Biliary enteric anastomosis in 66 patients (53%), external drainage in 46 patients (37%), and cholecystectomy in 12 patients (10%) were the surgical techniques of choice for correction of obstructive jaundice. There were significantly high mortality rates in patients with weight loss, more than 10 kg during preoperative the month (p < 0.05); jaundice longer than 21 days, (p < 0.001); and malignancy caused jaundice (p < 0.002). Haematocrite less than 30% (p < 0.05), albumin level below 3 g/dl (p < 0.01), blood urea nitrogen level above 30 mg/dl (p < 0.001), and bilirubine above 10 mg/dl (p < 0.01) were determined as risk factors in mortality. Direct relationships between the number of risk factors, complications, and mortality ratios were determined. One or more complications were determined in patients with more than six risk factors. High mortality rate was also determined in patients who had five and more risk factors. The following factors were evaluated: respiratory, circulatory, renal functions, and infection, and metabolic concomitant diseases, and comorbid scores for each patient were calculated. High rate complications in patients with eight and more comorbid scores and high mortality rates in patients with six and more were also determined. Finally, all these parameters were important in demonstrating postoperative mortality in obstructive jaundice patients. We suggest that surgery after treatment of correctable risk factors decreases postoperative morbidity and mortality.

Vascular smooth muscle reactivity and endothelium derived relaxing factor in experimental obstructive jaundice.

Obstructive jaundice is associated with a predisposition to systemic hypotension and acute renal failure. Altered vascular reactivity may contribute to the development of hypotension. In this experimental study on dogs, alterations in vascular contractile responses to noradrenaline, serotonin and KCl were investigated. Contractile responses to noradrenaline, serotonin,,, KCL and relaxation responses to papaverin and acetylcholine were provoked in isolated femoral arteries of both control dogs and animals with obstructive jaundice. In this situation concentration-response curves of noradrenaline and serotonin were blunted when compared with controls. This blunting disappeared when endothelium was removed. In rings precontracted with phenylephrine, EDRF relaxation responses to acetylcholine were increased significantly as compared to controls: at lower concentrations maximal relaxation response occurred. Contractile responses to KCl and relaxation responses to papaverin did not differ between the groups, endothelium present or removed. These results indicate that obstructive jaundice induces a decrease in vascular contractile responses and an increased EDRF relaxation response. We suggest that an excess in the amount of released EDRF may be one of the causes inducing systemic hypotension in obstructive jaundice.

Postoperative retention of urine in general surgical patients.

OBJECTIVE: To find out the incidence of retention of urine after various general surgical operations, and to assess the effects of applying a bag filled with warm water (40-45 degrees C), and encouraging early mobilisation onreducing the necessity for catheterisation. DESIGN: Open study. SETTING: Cumhuriyet University Hospital, Sivas, Turkey. SUBJECTS: 577 consecutive patients who had no history of urinary problems and had not already been catheterised, and who underwent general surgical operations between April 1989 and December 1991. MAIN OUTCOME MEASURE: Ability to pass urine spontaneously. RESULTS: 64 of 272 men (24%) and 47 of 305 women (15%) developed retention of urine (p = 0.02), and 15 and 11, respectively, required catheterisation. Patients were most likely to develop retention after repair of incisional hernia (13/32, 38%), midline laparotomy (19/82, 23%), and subcostal incisions (30/142, 21%), but there were no significant differences among these. Significantly more patients whose operations had lasted 60 minutes or more, and who had opiate analgesia, required catheterisation (5/232 compared with 21/345, p = 0.04, and 11/120 compared with 15 out of 457, p = 0.01, respectively). 85 of the 111 patients who went into retention (77%) were able to pass urine spontaneously after application of a bag containing warm water to the suprapubic region, and walking about. The mean period of catheterisation was 12 hours (range 4-76), and all patients but one passed urine spontaneously when the catheter was removed. Only two of the 26 patients who were catheterised developed microbiologically confirmed urinary tract infections. CONCLUSION: Retention of urine is a common complication after general surgical operations, but the necessity for catheterisation can be kept to a minimum by simple and inexpensive measures.