Pure tissue inguinal hernia repair with the use of biological mesh: a 10-year follows up. A prospective study.

PURPOSE: The long-term results for inguinal hernia repair (IH) with the use of biological mesh (BM) are not known. A prospective study was started in 2003-2004 to evaluate the results of pure tissue (IH) repair with the use of biological mesh with a 10-year follow-up. METHODS: From March 2003 to December 2004, all patients with IH who presented to the office, including incarcerated and recurrent IH, not excluding any, underwent pure tissue IH repair reinforced with a BM. During this period, 101 patients (87/male, 14/female) underwent 104 IH repair with a continuous suture of transversalis to transversalis fascia repair reinforced with BM of porcine intestinal submucosal origin (Surgisis, Cook) and were followed up for 10 years. RESULTS: There were 104 IH, 90 electives (86%), 2 incarcerated (1.9%), and 12 recurrent (11%). Follow-up was scheduled at 1 week, 1 month, 1 year, 3 years, 7 years and 10 years., in 100%, 100%, 99%, 93%, 89% and 85% of the patients, respectively. Recurrence was observed in 2/104 (1.9%): one recurrence at 1 week in a patient with bilateral IH and one at 7 years. The mean recovery time was 1.2 days (range 1-5 days). Mortality was 0(0%). COMPLICATIONS: six hematic infiltration to the scrotum and one to the vulva, all resolved spontaneously; wound infection 0(0%); urinary retention 11/104 (10.5%); inguinal scrotal hypoesthesia 7/104(6.7%), improved after 4-6months; asymptomatic fever of 39°C, 2/104 patients (1.9%), responded to a single dose of 4 mg betamethasone. No long-term inguinal pain complaint was found except for one patient with a recurrent IH. CONCLUSIONS: The use of BM to reinforce a pure tissue IH repair is safe and effective. The recurrence rate is comparable to short- and long-term synthetic mesh IH repair with less complications and pain than the use of synthetic mesh as reported in the literature.

Reinterventions after complicated or failed stapled hemorrhoidopexy.

BACKGROUND: Stapled hemorrhoidopexy has become increasingly popular over the past five years, mainly because of the assumption that it is associated with less pain. However, persistent tags and recurrence might represent a problem, because piles are not excised and severe complications requiring surgery have been occasionally reported. The aim of the present study is to analyze the causes for and the outcome of reintervention following either severely complicated or failed stapled hemorrhoidopexy. METHODS: A total of 232 primary stapled hemorrhoidopexies and 65 reinterventions after stapled hemorrhoidopexy were performed by the authors in five centers devoted to colorectal surgery. Twelve patients of the latter group had the stapled hemorrhoidopexy performed in one of these centers. Thirty-five were males and 30 were females. The mean age was 50 (range, 29-81) years. In all cases the primary indication for stapled hemorrhoidopexy was either third-degree or fourth-degree symptomatic hemorrhoids. In all patients submitted to reoperation the diagnosis of either severely complicated or failed stapled hemorrhoidopexy was made. The clinical history of all of these patients was carefully studied and all underwent inspection, digital exploration, and proctoscopy. After the reintervention, proctoscopy was performed in 61 patients (92 percent) after a median follow-up of 5.5 (range, 1-36) months. RESULTS: Our reoperation rate after stapled hemorrhoidopexy was 11 percent. The most frequent indications for reintervention were persistent, severe anal pain (visual analog pain score higher than 7) in 29 patients (45 percent), severe postoperative bleeding in 20 (31 percent), anal fissure in 16 (21 percent), prolapsing piles in 12 (18 percent), rectal polyp in 11 (16 percent), anorectal sepsis in 11 (16 percent), and fecal incontinence in 7 (11 percent). Thirteen different types of reintervention were needed. Excisional hemorrhoidectomy, removal of staples, and fissurectomy and/or internal sphincterotomy were the most frequent operation (n = 41). A decrease in anal pain, as measured by visual analog pain score, was observed one month after reintervention, compared with that measured preoperatively (from 5.6 +/- 3.6 to 3.0 +/- 2.9) (P < 0.001). Bleeding requiring treatment occurred in six cases (10 percent), anal stricture requiring dilation occurred in three (5 percent), and fecal incontinence in three (5 percent). Proctoscopy showed no recurrences in 52 cases (80 percent) after the reintervention. CONCLUSION: Pain and bleeding mostly caused by piles, fissures, and retained staples were the most frequent causes for reoperation after stapled hemorrhoidopexy. Reintervention was associated with a high bleeding and soiling rate, but was effective in treating pain and other symptoms in the majority of patients. Because of the wide spectrum of different interventions required, a failed or complicated stapled hemorrhoidopexy might be better treated by an experienced colorectal surgeon.

Complications after stapled hemorrhoidectomy: can they be prevented?

Stapled hemorrhoidectomy (SH), a new approach to the treatment of hemorrhoids, removes a circumferential strip of mucosa about four centimeters above the dentate line. A review of 1,107 patients treated with SH from twelve Italian coloproctological centers has revealed a 15% (164/1,107) complication rate. Immediate complications (first week) were: severe pain in 5.0% of all patients, bleeding (4.2%), thrombosis (2.3%), urinary retention (1.5%), anastomotic dehiscence (0.5%), fissure (0.2%), perineal intramural hematoma (0.1%), and submucosal abscess (0.1%). Bleeding was treated surgically in 24%, with Foley insertion 15%; and by epinephrine infiltration in 2%; 53% of patients with bleeding received no treatment and 6% needed transfusion. One patient with anastomotic dehiscence needed pelvic drainage and colostomy formation. The most common complication after 1 week was recurrence of hemorrhoids in 2.3% of patients, severe pain (1.7%), stenosis (0.8%), fissure (0.6%), bleeding (0.5%), skin tag (0.5%), thrombosis (0.4%), papillary hypertrophy (0.3%) fecal urency (0.2%), staples problems (0.2%), gas flatus and fecal incontinence (0.2%), intramural abscess, partial dehiscence, mucosal septum and intussusception (each <0.1%). Recurrent hemorrhoids were treated by ligation in 40% and by Milligan-Morgan procedure in 32%. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. The most common complication in the first 25 cases of the surgeon's experience was bleeding (48%). Even though SH appears to be promising, we feel that a multicenter randomized study with a long-term follow-up comparing SH and banding is necessary before recommending the procedure. Most complications can be avoided by respecting the rectal wall anatomy in the execution of the procedure.

Combined laparoendoscopic colon resection and anastomosis using the "no touch technique" and fibrin glue. An experimental study.

BACKGROUND: Laparoscopic colon anastomosis are technically demanding. A new technique for colon resection and anastomosis using a combined laparoendoscopic approach is presented. METHODS: In 10 pigs, pneumoperitoneum was induced and 5 trocars were placed. A sigmoid segment was isolated; a vein stripper was inserted from the anus, and the head was secured with a tie; the segment was intussuscepted pulling the stripper out; 4 seromuscular sutures were placed at the anastomotic site and fibrin glue was spread all around; an electrical wire loop, introduced via a colonoscope, was used to resect the intussuscepted segment that was removed from the anus. RESULTS: All animals but one survived until sacrifice at 30, 60, 90, and 120 days. Macroscopically, the anastomosis appeared well healed; microscopically, after 90 days, there was a complete restitutio ad integrum of the intestinal wall. CONCLUSIONS: This technique is feasible and quick; it could be used clinically in small tumors not removable endoscopically.

Historical evolution of the surgical anatomy of the liver.

The authors report the history of the anatomy and surgical anatomy of the liver from the paleolithic age up to now. Particular emphasis has been reserved to the changing anatomical knowledge in these last decades which represents the basis of the modern surgery of the liver.

A new technique for indirect inguinal hernia repair.

This report concerns a preliminary study of a new technique for indirect herniorraphy, which was used in 242 patients from December 1988 through March 1991. Its main characteristics are the creation of a deep neo-inguinal ring in a more medial site, shortening of the inguinal canal by transposition of the superficial ring to the point where the inferior border of the internal oblique muscle is well represented, reinforcement of the inguinal canal by overlapping the external oblique aponeurosis in a double-breast fashion, and maintenance of the cremasteric muscle. Follow-up in our outpatient clinic was carried out at 1, 6, 12, and 24 months in 71% of our patients. There were no recurrences, except for one crural pseudo-recurrence, no mortality, and no testicular atrophy. Thirteen percent of patients had subcutaneous serous collection; 1% had hematomas; 2% temporary testicular edema; and 0.4% wound infection.

Modern operative thoracoscopy.

Laparoscopic surgery has demonstrated advantages of less pain, early recovery, and cosmesis. Applying laparoscopic surgical techniques to thoracic procedures may allow for similar advantages. New instrumentation provides for greater versatility in treating thoracic conditions. Described herein is the use of thoracoscopy for a variety of thoracic procedures.

[Aseptic resection of the intraluminal colon in laparoscopy]. / Resezione di colon intraluminale asettica in laparoscopia.

Laparoscopic surgery is an "old" technique extending to new applications including colon surgery. Basically, even though surgical technique and indications do not differ from traditional surgery, it has the advantage to eliminate most of the complications associated with an abdominal incision. In order to improve also the outcome of intestinal anastomoses, an aseptic technique by intestinal intussusception previously described (3) has been modified and carried out laparoscopically in 3 pigs and 3 dogs successfully. The animals were sacrificed after 2 months. Anastomoses were evaluated endoscopically by barium enema and by gross and microscopic examination. Results indicated no mortality or complications except for a small area of mucosal peri-anastomotic necrosis in one dog, which spontaneously healed. Therefore, it seems that the aseptic resection of the colon is possible with laparoscopy obtaining at the same time a decreased morbidity related to the abdominal incision and colonic anastomosis.

The use of absorbable staples for construction of a bladder tube.

Stapling instruments have been widely used in general surgery but not in the surgical treatment of the urinary tract. The stapler Poly CS-57 (Auto Suture, U. S. S. C.) with absorbable staples has been evaluated in the construction of ten bladder tubes for ureteral substitution in three dogs and six pigs. The dogs and pigs were sacrificed at two, three and six months. There was no mortality rate, no infections, no suture leakages and no crystal or stone formation. There were three instances of ureterovesical anastomotic stenosis. It appears that the absorbable staple can be safely used in urologic operations and that the use of the Poly CS 57 stapler for the construction of a bladder tube makes the procedure safer, simpler and faster.

[Partial splenectomy using a stapler and the role of regeneration of the residual splenic stump]. / Splenectomie parziali con stapler e ruolo della rigenerazione del moncone splenico residuo.

Current evidence indicates that only complete or partial intact spleen can protect the organism against pneumococcal sepsis. What is not clear is the amount of minimal splenic tissue needed to protect the organism against such infection. This study has been carried out on 20 dogs which underwent partial or total splenectomy with stapler. Animals were divided into 8 groups according to the quantity of the remnant splenic tissue: 0% (4 dogs); 5% (4); 15% (1); 25% (1); 35% (2); 50% (2); 75% (2); 100% (4), and were followed up for 6 and 12 months. No mortality or bleeding was registered. Results showed a splenic regeneration, histologically demonstrated as an increased number of germinal follicles, in 12 out of 16 dogs, more evident in the animals sacrificed at one year. In conclusion, even a small amount (5%) of splenic tissue preserved with its blood supply can regenerate and acquire with time enough immunological function to protect the organism against post-splenectomy sepsis.

Insertion of the Coloshield through a colotomy after completion of a colonic anastomosis.

A modified technique of an intracolonic bypass procedure after an anastomosis has already been completed is described. Its use would be in place of those situations where the surgeon is contemplating protecting the completed anastomosis with a temporary colostomy/ileostomy.

Effect of fecal loading with/without peritonitis on the healing of a colonic anastomosis: an experimental study.

An experimental randomized prospective study was carried out in 64 dogs to evaluate the effect of intraluminal fecal matter at the anastomosis with/without peritonitis on the healing of a colonic anastomosis. The animals, none of whom had bowel preparation, were randomized in four groups: group I sigmoid resection and anastomosis, group II sigmoid resection and intraluminal fecal diversion from the anastomosis, group III induced fecal peritonitis, sigmoid resection and anastomosis and group IV induced fecal peritonitis, sigmoid resection and intraluminal fecal diversion from the anastomosis. Forty-eight hours before sacrifice at 5, 10 and 15 days, 10 microCi/kg C14 proline was given intravenously. Specimens were analyzed for hydroxyproline content, tissue counts and specific activity. The tissue counts and specific activity were analyzed by three-way analysis of variance. Overall, regardless of the groups, there was a statistically significant decrease in specific activity and tissue count from day 5 to day 15 and day 10 to day 15 at the anastomosis (p less than 0.05). When comparing groups II and IV to groups I and III, there was a significant increase in specific activity and tissue count at the anastomosis of group II and IV (p less than 0.05). This experimental study demonstrates that early anastomotic healing can occur even in presence of treated peritonitis as long as the fecal matter is diverted and prevented from coming in contact with the anastomotic site without disrupting the bowel continuity or function.

The value of endoluminal ultrasonography and computed tomography in the staging of rectal cancer: a preliminary study.

A prospective study was carried out in 14 patients with rectal cancer. Tumors were staged preoperatively by endoluminal ultrasonography (EU) and computed tomography (CT). Patients were followed postoperatively for 2 years by the same modalities. Extramural spread was 100% (9/9), accurately assessed by EU and 77.8% (7/9) with CT. Lymph node sensitivity was 87.5% for EU and 37.5 for CT (P less than 0.05). Overall accuracy of lymph node metastases was 85.7% for EU and 57.1% for CT (P less than 0.1). In conclusion, the study shows EU to be statistically more accurate for nodal metastases than CT; therefore, its routine use can be recommended in the preoperative staging of rectal carcinoma in those patients for whom a sphincter-saving procedure is considered.

[A bladder tube construction using a stapler with absorbable stitches (Poly CS-57)]. / Tubulizzazione vescicale con suturatrice a punti riassorbibili (Poly CS-57).

A new technique for the construction of a bladder tube, using a Poly CS-57 stapler, has been tested on six pigs. With this procedure the operative time is shortened without complications. In fact, no crystal formation, dehiscence or infection was observed during a 3 month follow-up.

Colorectal neurovasculature and anal sphincter.

The varied blood supply of the colon and rectum has been described. It may be stated that the efficiency of any surgeon's hand is primarily dependent on the knowledge that guides it. Significant anatomic facts are described herein. An important blood supply to the terminal ileum comes from the generally unknown ileal artery, which, when absent, creates a critical, poorly vascularized area and thus an inappropriate area for an anastomosis. This right colic artery may be absent in 2 per cent. It may arise in common with the middle colic trunk (52 per cent). The middle colic artery is absent in 3 per cent. It occurs as a separate branch in 44 per cent and may be derived from celiac artery rarely. The inferior mesenteric artery divides into the left colic, which ascends to the splenic flexure, and a descending branch that continues downward as the superior rectal artery. The left colic artery may not reach the splenic flexure. The marginal artery may be interrupted or weakly represented at the splenic flexure. Therefore, one should perform a ligation of the left colic vessel before its bifurcation if the splenic flexure is to be preserved. The superior rectal artery is the main blood supply of the rectum. Its branching on the rectum is varied, but it has a rich anastomosis with the other rectal arteries, namely, the middle rectal and inferior rectal arteries. Sudeck's point is not critical. The middle rectal artery varies in number and origin and is not essential provided the inferior rectal artery is intact. The anatomy of the anal canal is described. The rectum is for a short distance surrounded by the anal canal with the external sphincter. The internal sphincter is the end of circular muscle of the rectum. The external sphincter can be thought of as one continuous muscle divided by longitudinal bands into three main parts: subcutaneous, superficial, and deep. Below the pectinate line in the anal canal, the nerve supply, lymphatic drainage, blood supply, and epithelium are different from that in the rectum.

Diagnostic anorectal functional studies. Manometry, sphincter electromyography, and defecography.

Anorectal manometric and electromyographic studies assess anorectal and pelvic floor neuromuscular disorders and can help in the diagnosis and management of incontinence, prolapse, megarectum, and other functional anorectal disorders. These studies can assess preoperative and postoperative anorectal function and help in the differential diagnosis of anorectal disorders, and thus they assist the surgeon in carrying out rational therapy.

Colorectal anastomotic healing and intracolonic bypass procedure.

Intestinal anastomoses continue to be complicated by leakages even in the best of hands despite the development of new surgical techniques, suture materials, devices, and stapling instruments. One may explain such persistence of anastomotic leakage on the basis of the dynamic effect that multiple factors have on the healing of an anastomosis. Awareness of these factors and proper precautions by the surgeon can make a high-risk anastomosis less prone to leakage. The intracolonic bypass procedure is an alternative to a temporary colostomy. It does not prevent an anastomotic dehiscence but can prevent anastomotic leakage with its associated complications in those situations where dehiscence is most likely to occur.