Diagnosis of esophageal carcinoma because of findings on transesophageal echocardiography.

A patient in whom transesophageal echocardiography was performed to evaluate a possible source of cerebral embolization. The fact that the probe could not be passed easily beyond 35 cm from the incisors suggested esophageal obstruction or compression. A mass was seen posterior to the left atrium that was heterogenous and contained blood vessels, suggesting a malignancy. There were no complications of the procedure. Esophageal adenocarcinoma was confirmed on biopsy. Transesophageal echocardiography may be diagnostic of paracardiac mediastinal masses, both benign and malignant. Great care must be taken if passage of the probe through the esophagus is met with resistance, to avoid serious complications.

Laparoscopic inguinal hernia repair: optimal technical variations and results in 1700 cases.

A follow-up series of 1700 laparoscopic inguinofemoral herniorrhaphies by a single surgical team is presented (1381 patients). Two standard techniques were used: transabdominal preperitoneal (1452 cases) and totally extraperitoneal (248 cases). Mean follow-up was 5.3 years. There were 348 patients with bilateral hernias, 121 with recurrent hernias, and 27 with incarcerated hernias. Numerous technical variations were used as the study progressed. A SurgiPro mesh (USSC, Norwalk, CT) with staple/tack fixation was used in all patients. Average operating time was 41 minutes for unilateral repairs, and 97.3 per cent of the procedures were outpatient procedures. Five recurrences were reported. The postoperative permanent neuropathy rate was found to be negligible, but a 5.1 per cent rate of uncomplicated ipsilateral postoperative seromas is reported. All patients were instructed to return to unrestricted physical activities on postoperative day one. Ninety per cent of the patients were able to do so within 5 days versus 93 per cent in 7 days. Ninety-six per cent of all patients felt minimal pain and discomfort after 72 hours. There was no significant difference in recovery or morbidity between the transabdominal preperitoneal and totally extraperitoneal repairs. To date laparoscopic inguinal herniorrhaphy continues to be a difficult procedure with a significant learning curve. The reported surgical performance data and the described optimal technical variations make this procedure a viable and competitive repair in the surgical management of inguinofemoral hernia.

Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy: results of 509 repairs.

A follow-up series of 509 transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs is presented. The technique used was an original TAPP approach using a SurgiPro Mesh with two technical variations. Age restrictions were removed after the first few cases; thereafter, all patients cleared for general anesthesia were entered into this study without restrictions. Our average operating time was 48 minutes for unilateral hernia repairs. All procedures were outpatient procedures with the exception of 11 overnight admissions for urinary retention. The procedure was well tolerated. Ninety-three per cent of all patients reported minimal pain or discomfort within 72 hours. All patients were instructed to resume unrestricted physical activities within 24 to 48 hours after the procedure; 89 per cent were able to resume activities within 5 days, 94 per cent within 7 days, and 97 per cent within 10 days. No significant morbidity nor mortality were reported, with the exception of two postoperative neuropathies. Nineteen patients developed postoperative seromas that were successfully aspirated. One recurrence has been reported to date. Due to the lack of long term follow-up, these results remain inadequate to establish an accurate recurrence rate. This procedure remains technically difficult and is subject to a learning curve, but the rate of recovery for these patients is significantly improved. In conclusion, the superiority of this procedure in comparison to its open counterpart cannot be proven until long term follow-up becomes available.

Laparoscopic inguinal hernia repair results: 131 cases.

Since its introduction, laparoscopic inguinal hernia has been plagued with multiple technical problems. A series of 131 laparoscopic inguino-femoral hernia repairs is presented. The technique used was an original transabdominal pre-peritoneal approach using a SurgiPro mesh with two technical variations. In the beginning, this procedure was only offered to patients less than 50 years of age. These guidelines were eliminated as the study progressed. For our first 10 cases, our average operating time was 1 hour and 39 minutes. For the last 40 cases, it averaged 63 minutes. All but four patients were discharged the same day. Ninety-six per cent of all patients felt minimal pain or discomfort within 72 hours. Four per cent felt pain or discomfort until the tenth post-operative day. All patients were ambulatory the day of surgery, and 94 per cent of all patients resumed regular activities before the tenth postoperative day. No significant morbidity and no mortality were identified with the exception of five postoperative inguinal seromas, which were successfully aspirated. No recurrence was demonstrated, but this series is clearly insufficient to establish a rate of recurrence. The cost of these procedures appeared to be higher than for a conventional repair; however, it has recently been reduced. The procedures remain difficult, but the rate of recovery for these patients is shown to be significantly improved. The superiority of this procedure over its open counterpart has not yet been proven.