Surgical options in lumbar hernia: laparoscopic versus open repair. A long-term prospective study.

OBJECTIVE: To determine the safety and effectiveness of laparoscopic lumbar hernia repair. DESIGN: Prospective clinical study. SETTING: Abdominal wall unit, university hospital. PATIENTS: Between January 1995 and December 2008, data from 55 consecutive patients who had undergone laparoscopic (n = 35) or open (n = 20) lumbar hernia repair. MAIN OUTCOME MEASURES: The primary endpoint was recurrence; secondary endpoints were patient outcomes (morbidity, pain, and return to normal activity). RESULTS: Mean operating time (P = .01), hospital stay, return to normal activity, analgesic consumption, and pain at 1 month (P < .001) were significantly less in the laparoscopic group. Complications were similar in the 2 groups (37% vs 40%, respectively; P = .50). Traumatic hernias increased local complications versus incisional lumbar hernias (71.4% vs 29%; P = .007). Consumption of analgesics (6.8 ± 6.5 vs 18.1 ± 9.1; P < .001) and pain during the first month (no pain: 90% vs 54.3%; P = .015) were significantly less with a lightweight versus medium-weight mesh. The risk factors associated with recurrences development were localization (P = .01) and size (P = .008). Recurrence rates were 2.9% in the laparoscopic group and 15% in the open group (P = .13). CONCLUSIONS: Outcomes did not differ with respect to morbidity and recurrence rate after long-term follow-up; however, this study suggested that laparoscopic approach for lumbar hernia is safe, effective, and more efficient than open repair and can be considered the procedure of choice. Open surgery may be considered the best option in the diffuse hernias with size larger than 15 cm.

Non-invasive ventilation in patients with an altered level of consciousness. A clinical review and practical insights.

Non-invasive ventilation has gained an increasingly pivotal role in the treatment of acute hypoxemic and/or hypercapnic respira-tory failure and offers multiple advantages over invasive mechanical ventilation. Some of these advantages include the preserva-tion of airway defense mechanisms, a reduced need for sedation, and an avoidance of complications related to endotracheal intubation. Despite its advantages, non-invasive ventilation has some contraindications that include, among them, severe encephalopathy. In this review article, the rationale, evidence, and drawbacks of the use of noninvasive ventilation in the context of hypercapnic and non-hypercapnic patients with an altered level of consciousness are analyzed.