[Classic and endoscopic surgical anatomy of the groin]. / Anatomie chirurgicale de l'aine: classique et endoscopique.

Knowledge of the groin's anatomy is indispensable to understanding the pathological anatomy of hernias and their surgical treatment. Although classical anatomy provides an understanding of the techniques of open surgery, learning celioscopic techniques requires a new mental representation and specific training. The objective of this focus was to describe the anatomic approaches to inguinal hernias and compare them to those described during the celioscopic approach.

[Epidemiology and delays in the management of 355 patients with lung cancer]. / Epidémiologie et délais de prise en charge de 355 patients atteints de cancer bronchique.

BACKGROUND: The epidemiology of patients with lung cancer in a Seine-Saint-Denis hospital are reported, as well as causes of diagnostic and therapeutic delays in their management. MATERIAL AND METHODS: Retrospective analysis of cases diagnosed from January 1, 1997 to December 31, 2003. RESULTS: Of 355 cases, 15.8% were women; the average age was 62 +/- 11. Mean smoking history was 50 +/- 24 pack years. Women were more likely to be non-smokers than men (16% and 1% respectively, p < 0.01) and were more likely to present at a young age (under the age of 50: 26.8% and 13.7% respectively, p < 0.05). Among women, adenocarcinoma was more frequent (41% vs. 25%, p < 0.05), and often presented with stage IV disease (74%). Squamous cell carcinoma occurred more frequently with increasing age (18.7% vs. 32.2% before and after the age of 60, p < 0.01). The median pre hospital, diagnostic and treatment delays were respectively 30, 10 and 9 days, the global delay from first symptom to treatment was 62 days. Surgery increased therapeutic delay by 20 days. CONCLUSION: Our results are complementary to those found in KBP-2000-CPHG study. Young women are diagnosed at a late stage. Influence of delays on prognosis is not proved and require others studies.

Infraperitoneal colorectal anastomosis: hand-sewn versus circular staples. A controlled clinical trial. French Associations for Surgical Research.

BACKGROUND: Disagreement continues among several studies as to the relative advantages and disadvantages of stapled versus sutured colorectal anastomoses. METHODS: One hundred and thirteen consecutive patients (48 men and 65 women, mean age: 67 +/- 12 years) were randomized to either hand-sewn (n = 59) or stapled (n = 54) infraperitoneal colorectal anastomosis. Both groups had similar patient demographics except that fewer patients (4 versus 15) had chronic disease (p < 0.02) and were undergoing side-to-end (11 versus 39) and more patients were undergoing end-to-end (37 versus 20) anastomosis in the stapled group (p < 0.001). RESULTS: Overall mortality was 6% (7 of 113 patients), with no difference found between the two types of anastomosis. Fewer anastomotic leaks occurred in the stapled group (11 versus 7), with an a posteriori gamma error of 11%, whereas the other early postoperative complications occurred with similar frequency in the two groups. Nine mishaps occurred in the stapled group. Stapled anastomoses took less time (median, 42 versus 30 minutes) to perform (p < 0.02). At 8 months, two strictures occurred in the hand-sewn group (n = 52) compared with eight strictures in the stapled group (n = 50) (p < 0.001). CONCLUSIONS: It was not possible to prove that lower anastomosis can be achieved with the stapling device. Routine or regular use of stapling instruments for infraperitoneal colorectal anastomosis cannot be advocated because of higher incidence of mishaps and strictures, even though the operation takes less time to perform and anastomotic leakage occurs less often.

Manual versus mechanical esophagogastric anastomosis after resection for carcinoma: a controlled trial. French Associations for Surgical Research.

BACKGROUND: Mechanical anastomosis has been claimed to reduce the rate of leakage compared with manual anastomosis. No randomized trials have been performed to date to prove this specifically in esophagogastric anastomosis. METHODS: One hundred fifty-four patients, 139 men and 15 women ranging in age from 36 to 83 years (mean, 50 +/- 10 years) and undergoing elective resection of esophageal or cardial carcinoma, were included in this multiinstitutional (14 centers) randomized study comparing the rate of anastomotic leakage after esophagogastric anastomosis performed manually or mechanically. Eligible for this study were patients with esophageal or cardial carcinoma located between the esophagogastric junction (included) and the upper border of the aortic arch. The choice between resection with or without thoracotomy was left to the discretion of the operating surgeon. Proximal resection of the fundus was mandatory. Intestinal tract continuity was reestablished in a one-stage procedure by an esophagogastric anastomosis without interposition of either the jejunum or the colon. The site of the anastomosis could be either intrathoracic or cervical. The principal end point was anastomotic leakage as judged by (1) egress of intestinal fluids or orally ingested methylene blue through drains, (2) sodium diatrozate swallow prescribed either routinely for all patients between postoperative days 3 and 8 or because of signs of leakage, or (3) reoperation or autopsy. RESULTS: After two patients were withdrawn for protocol violation, 152 patients, 74 in the manual group and 78 in the mechanical group, were studied. The number of anastomotic leakages was identical in both groups (n = 12, 16% and 15%, respectively). Overall 30-day mortality was 11%. Fewer deaths occurred in the manual group (7%), which had three anastomotic leakages, than in the mechanical group (15%), which had five anastomotic leakages, and fewer repeat operations were done in the manual group (n = 9) than in the mechanical group (n = 13), but both of these differences were not statistically significant. The duration of anastomosis and of operation was similar in both groups. In the mechanical group 16 anastomoses (20%) gave rise to technical mishaps (either in the fashioning of the purse-string, dilation of the esophagus, or in stapling). Among the factors recognized as potentially preventing leakage, only testing for airtightness was significantly correlated with less postoperative leakage (p < 0.05). Eight postoperative strictures were recorded at 3 months in 62 (13%) patients in the manual group, whereas seven strictures occurred in 53 (13%) patients in the mechanical group. CONCLUSIONS: When mechanical staples rather than manual sutures are chosen, the disadvantages (technical mishaps and higher costs) are not counterbalanced by a gain of time or a decrease in the rate or severity of anastomotic leakage.

Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research.

BACKGROUND: Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates. METHODS: One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8 +/- 12.1 years) were randomized to undergo hand-sewn (n = 74) or circular stapled (n = 85) supraperitoneal colorectal anastomosis after left colectomy. RESULTS: Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n = 10) and hemorrhage (n = 5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p < 0.001), but this time gain did not significantly influence the overall duration of operation (identical median times). The median duration of hospitalization was 13 and 14 days, respectively (NS). At 8 months there were 2 of 74 strictures in the hand-sewn group and 4 of 85 strictures in the stapled group (NS). CONCLUSIONS: According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.

Spigelian hernia long considered as diverticulitis: CT scan diagnosis and laparoscopic treatment. Computed tomography.

Spigelian hernia (SH) develops in the spigelian aponeurosis. In some cases, its clinical symptoms may mimic those infrequently the diagnosis of sigmoid diverticulitis. Herein we report the case of a patient who for 12 years experienced a pain and a mass in the left lower quadrant that appeared after straining and then disappeared again after rest. A diagnosis of sigmoid diverticulitis was made. She was admitted to hospital for the acute onset of an intense abdominal pain in the left lower quadrant associated with fever. Physical exam showed a 10 x 15 cm mass in the left lower quadrant. Computed tomography (CT) scan showed a left-sided SH containing a small bowel loop and a sigmoid loop. The SH was reduced easily with bed rest and external pressure. Under laparoscopy, a Gore-Tex mesh was stapled on the posterior side of the anterolateral abdominal wall so that it widely covered the abdominal wall defect. The reducible SH, the incarcerated SH, and the strangulated SH represent the majority of the clinical aspects of SH. Although many differential diagnoses are proposed, but the diagnosis of sigmoid diverticulitis is an infrequent one. Ultrasound (US) scan or a CT scan that shows the defect in the abdominal wall, the hernial sac, and its contents is an easy means of confirming the diagnosis of SH. SH can be treated through a direct approach or through a midline laparotomy. Laparoscopy is advisable for a tension-free treatment with an intraperitoneal mesh. It is important to make the diagnosis of SH before its strangulation. For that reason, CT scan and US scan are highly recommended. Laparoscopic treatment, which is effective and safe, is advisable in such cases.

[Diagnosis and treatment of spleen rupture during pancreatitis].

A 31-year old man was admitted for acute pancreatitis. His condition deteriorated progressively and he developed an acute anemia followed five days after admission by an hemorrhagic shock consecutive to splenic rupture. A 45-year old woman was admitted because of an acute episode of chronic pancreatitis. She improved progressively but developed eleven days after admission an hemorrhagic shock consecutive to the rupture of a subcapsular haematoma of the spleen. Splenic rupture, an infrequent complication of acute or chronic pancreatitis, is responsible for anemia and hemorrhagic shock. Abdominal ultrasonography and CT scan are necessary to make the diagnosis of splenic rupture and to look for risk factors of splenic rupture, i.e. necrosis in the spleen hilium, left pancreatic pseudocyst, splenic vein thrombosis, segmental portal hypertension, splenomegaly and intrasplenic collection. When possible, embolization of the splenic artery can stop bleeding. Splenectomy with distal pancreatectomy seems to be the appropriate treatment of splenic rupture.

[Indications for laparoscopic treatment of incisional hernias]. / Indicazioni al trattamento laparoscopica dei laparoceli.

OBJECTIVE: The aim of this article is to describe the technique used in the treatment of ventral hernia using the laparoscopic method and at the same time to evaluate the possible advantages of this surgical approach. METHODS: The clinical case we present regards a case of a patient who had undergone a double eventration treated with an application of a new type of prosthesis Parietex Composite of the Sofradim, using the laparoscopic method, we can be applied in intraperitoneal in contact with the intestinal loops. RESULTS: The method we used in the laparoscopic treatment of ventral hernias has highlighted, in a short time, the solidity of the abdominal wall, a noticeable reduction of infections and a reduction of hospitalization. There developed no long term recurrence in our patients treated with this technique. CONCLUSIONS: Laparoscopic ventral hernia treatment is currently used in a limited amount even though this pathology could be approached using the laparoscopic method. Our laparoscopic method, using the Composite prosthesis could represent a very valid method for primary and recurrent ventral hernia. This technique gives the opportunity to repair the eventration applying a prosthesis without any muscular tension, consenting, furthermore a reduction of any complications (infections, seroma, pain) that could arise and of any recurrence after the operation. Furthermore the surgical access is minimum and as we know this is of noticeable importance in aesthetics today.

[Actinomycosis of the appendix. Report of two cases]. / Actinomycose de l'appendice. Présentation de deux observations.

INTRODUCTION: We report two patients with actinomycosis of the appendix extending to the caecum and the ileum, and diagnosed postoperatively on histological analysis, the authors reviewed the literature. EXEGESIS: Actinomycosis of the appendix can be acute or chronic. Diagnosis may be obtained preoperatively on the analysis of aspiration or biopsy material under CT scan control. It is frequently done postoperatively on the analysis of surgical specimen. Actinomycosis can be treated with antibiotics only during six months if the diagnosis is made preoperative, by surgery followed by antibiotics during 6-12 months, according to the extension of the actinomycosis, if the diagnosis is made after surgery, and by a combination of a surgery and antibiotics in complex forms. CONCLUSION: Actinomycosis of the appendix is an infrequent pathology that merits to be known. With antibiotic therapy, we can avoid surgery or wide resections.

[Traumatic rupture of an accessory spleen]. / Rupture traumatique d'une rate accessoire.

A cyclist knocked over by a car was admitted with pain in the left upper quadrant that progressively worsened with haemorrhagic shock. Ultrasound showed a heterogenous spleen and perisplenic haematoma. Emergency laparotomy was performed and revealed rupture of an accessory spleen located on the splenocolic ligament.

[Retroperitoneoscopy in tension-free repair of lumbar hernia in adults]. / Cure sans tension d'une hernie lombaire de l'adulte sous rétropéritonéoscopie.

A 65 year-old-patient who had a right-side 10 x 15 cm wide lumbar hernia, with a 3 x 4 cm wide parietal defect was operated in a left lateral position, under retroperitoneoscopy. The procedure consisted in dissection of the retroperitoneal fat, reduction of the hernia and insertion of a polypropylene mesh stapled on the lumbar wall. This approach provided a good postoperative comfort, a short hospital stay and an early recovery of autonomy and activities.

[Small bowel obstruction by a congenital band in 16 adults]. / Occlusion de l'intestin grêle sur bride congénitale chez 16 adultes.

UNLABELLED: During embryogenesis, abnormal adhesion of the peritoneal folds induces a congenital band which can cause small bowel obstruction. PATIENTS AND METHODS: From 1987 to 2001, 16 adult patients underwent surgery for small bowel obstruction due to a congenital band. There were 8 men and 8 women with a mean age of 59 years (range 23-90). None presented previous abdominal surgery. RESULTS: Six patients presented acute abdominal pain the month before hospitalization. Among the 16 patients, 9 were operated at admission, and 7 after initial surveillance. Suspected diagnosis before operation was small bowel obstruction in 8 cases (with a diagnosis of congenital band in 3); perforated duodenal ulcer (n = 2); appendicitis (n = 2); mesenteric infarction (n = 1); diverticultis (n = 1); cholecystitis (n = 1); and strangulated hernia (n = 1). During operation performed through laparotomy or laparoscopy, a congenital band was noted in 100% of the cases, associated with intestinal necrosis in 5. One patient died postoperatively. CONCLUSION: Because small bowel obstruction by congenital band is a rare condition, it represents a frequent problem of diagnosis. In this situation, the possibility of intestinal necrosis expose the patient to a possible fatal outcome.

[Complications of misdiagnosed Bochdalek hernia in adults. Literature review]. / Complications de la hernie de Bochdalek méconnue de l'adulte. Revue de la littérature.

AIM OF THE STUDY: To report 3 new cases of complicated Bochdalek hernia (BH) in adulthood and to review the literature about this rare condition. CASE REPORT: Three adult patients were operated on for a BH undiagnosed until occurrence of acute complication. The first patient, 27 years-old, had small bowel obstruction and the diagnosis of BH, unrecognized on chest X-ray, was established on barium meal and CT scan. The second patient, 38 years-old, had epigastric pain and gastric obstruction: diagnosis of BH, unrecognized at a previous laparotomy, was established on CT scan and barium enema. The third patient, 88 years-old, had respiratory failure and gastric obstruction: diagnosis of BH, unrecognized on chest X-ray, was established on CT scan. The 3 patients were operated on through laparotomy (n = 2) ou thoracotomy (n = 1) with one post-operative death. DISCUSSION: In adulthood, BH can remain asymptomatic for a long time before occurrence of a acute digestive or respiratory complication. Chest X-ray can be normal or misinterpreted. CT scan seems to be the most reliable examination to diagnose BH. CONCLUSION: In adulthood, diagnosis of BH should be evocated in case of respiratory or upper digestive symptoms.

[Value of celioscopy in treatment of isolated torsion of the Fallopian tube. Review of the literature. Apropos of 3 cases]. / Apport de la coelioscopie dans le traitement de la torsion isolée de la trompe de Fallope. Revue de la littérature. A propos de trois observations.

Isolated fallopian tube torsion (ITT) is infrequent and associated with morphologic and dynamic disturbances. Mr L, 31 years old, suffered from right lower quadrant pain which became worse during the following 48 hours. Laparoscopy revealed a right necrotic ITT which was resected by laparotomy. Mr L, 49 years old, suffered from by left lower quadrant pain with progressive onset. Laparoscopy revealed a left necrotic ITT which was resected. Mr P, 76 years old, suffered from left lower quadrant pain for 14 days. Ultrasonography revealed an adnexal mass. Laparotomy revealed a left necrotic ITT which was resected. On literature review, ITT (81 cases) was revealed by lower quadrant pain, acute onset, which quickly became worse. Pelvis examination revealed a lateral cul-de-sac pain. Ultrasonography identified tubal cystic mass with high-impedance arterial waveform on colour Doppler sonography. Diagnosis was easily established by laparoscopy. In case of clinical symptoms suggestive of ITT, pelvic and endovaginal ultrasonography and laparoscopy are indicated. Tubal preservation must be the rule.

[Hematemesis revealing chronic volvulus of a wandering spleen]. / Hématémèse révélatrice du volvulus chronique d'une rate baladeuse.

A 23 years old woman was admitted on emergency for an upper digestive tract bleeding and endoscopy found gastric varices. CT scan revealed a splenomegaly, a twisted aspect of the splenic pedicle and varices in the gastrosplenic ligament. Arteriography showed a narrow splenic artery and varices in the gastrosplenic ligament. After a recurrent bleeding, splenectomy was performed. There was a chronic volvulus of a wandering spleen; the splenic venous flow was passing through the left gastroepiploic vein and a gastrosplenic vein. Chronic volvulus of a wandering spleen with gastric varices is an unfrequent pathology, diagnosed by imaging and requiring splenectomy.

[Cost of appendectomy: laparoscopy versus laparotomy. A retrospective study of two series of 114 cases]. / Coût de l'appendicectomie: coelioscopie vs laparotomie. Etude rétrospective de deux séries de 114 patients.

This retrospective study was designed to compare the cost of laparoscopic appendicectomy (LA) in patients operated in 1991-92 and open appendicectomy (OA) in patients operated in 1989-90. Patients were matched for sex, ASA score and age into 2 homogeneous series: 114 LA and 114 OA. Costs of accommodation, operation and time off work were calculated by the observed costs method: daily cost of the inpatient unit, hourly cost of the operating room-recovery ward, and the patient's consumption. A mean specific cost was added in the case of LA. A significant difference was observed for operating time, time off work and for the cost of postoperative stay, the operation and time off work and the total cost of the disease. The excess cost of the operation in the case of LA was not compensated by the reduction of the accommodation costs A clinical benefit in terms of reduction of pain and local complications has been reported in the literature. The cost of hospitalisation is higher with LA, but the cost of time off work is decreased. LA provides a clinical comfort in all patients and an economic benefit in patients with a professional activity.

[Celioscopic treatment of inguinal hernias by intraperitoneal patch of ePTFE according to Spaw. Preliminary results of a prospective study of 162 hernioplasties in 135 patients. Groupe CHIC (Cure des hernies inquinocrurales sous coelioscopie)]. / Cure coelioscopique des hernies de l'aine par patch intraperitonéal de ePTFE selon Spaw. Résultats préliminaires d'une étude prospective de 162 hernioplasties chez 135 patients. Groupe CHIC (Cure des hernies inguinocrurales sous coelioscopie).

Spaw's (original and modified) was technique evaluated in a prospective, multicentre study: from november 1992 to september 1993, 162 intraperitoneal laparoscopic herniorraphies were carried out in 135 patients for recurrent hernias or for hernias associated with a high risk of recurrence. Three needed an open procedure. Three early complications (2 periprosthetic hematomas, 1 microscopic bladder injury) were treated by another laparoscopy; a bowel loop retained in a trocar orifice was reintegrated under local anesthesia; dysesthesias of the lateral cutaneous nerve of the thigh in 1 patient and nonspecific parietal pain in 2 patients resolved within three weeks. Three seromas resolved after only one percutaneous aspiration. The mean post operative pain, evaluated by a visual analogic scale graduated from 1 to 10 was 1.8 (0 to 6) at D1, 05 (0 to 2) at D2 and the mean duration of analgesic requirments was 1.7 (0 to 15) days. The mean hospital stay was 2 (1 to 17) days for unilateral herniorraphies and the mean time to return to work or normal activity was 10 (2 to 44) days, even in heavy workers (35 patients). All patients were reviewed. The mean follow-up was 4 (1 to 10) months. Two complications needed further laparoscopic treatment: 1 recurrence at the internal edge of the patch, easily restapled with a stronger stapler, 1 bowel adhesion between patch and bladder revealed by pain without obstruction. The recurrence rate was 0.6% (1/162). The conversion rate was 2% (3/162) and the overall morbidity was 7.5% (12/162), decreasing respectively to 0 and 4% after the learning curve. This study confirms that Spaw's technique and its variant are feasible, and allows us to continue this study, and suggest these techniques would be useful in the treatment of some recurrent inguinal hernias.

[Two-year results of celioscopic hernioplasties using an intraperitoneal ePTFE patch. A prospective multicenter study of 184 cases. Groupe CHIC (Cure des hernies inguinocrurales sous coelioscopie)]. / Résultats à deux ans des hernioplasties coelioscopiques par patch intrapéritoneal de ePTFE. Etude prospective multicentrique de 184 cas. Groupe CHIC (Cure des hernies inguinocrurales sous coelioscopie).

Two hundred and four groin hernias in 173 patients were laparoscopicaly treated using an intraperitoneal ePTFE patch and prospectively studied. Two patients died for diseases unrelated to their hernia nor their hernioplasty. Eight patients were lost to follow up (5.2%), 163 were followed up for at least 1 year, without recurrence at their last examination, and 155 were followed up for at least 2 years. This study concerns these 155 patients accounting for 184 hernioplasties. Twelve recurrences (6.5%) were found in 11 patients, 10 of 12 occurred within the first year after operation. After each surgeon's 20th hernioplasty the recurrence rate was 3 of 113 hernioplasties (2.6%) (p < 0.05). Late local pain around the patch and its staples was found in 12 patients, slight in 10 cases, mild in 1 case and serious in 1 case. Local hypoesthesia of the upper internal part of the thigh was found in one patient. Not any testicular atrophy, nor intraperitoneal complications were observed. This study suggests that: 1) the 2-year recurrence rate of intraperitoneal ePTFE hernioplasties is not very different, after the learning phase, from those of many other procedures; 2) their expensive price lead to use these techniques only when other efficient procedures are not feasible, for example in the challenged treatment of recurrent hernia after failure of a preperitoneal prosthetic hernioplasty.

[Celioscopic treatment of recurrence of inguinal hernia after insertion of a prosthesis. Value of the intraperitoneal technique with ePTFE patch? Group CHIC (Cure des Hernies Inguino-Crurales sous Coelioscopie)]. / Cure coelioscopique des récidives sur prothèse des hernies de l'aine. Intérêt de la technique intra-péritonéale avec patch de ePTFE? Group CHIC (Cure des Hernies Inguino-Crurales sous Coelioscopie).

From April 1993 to December 1994, 14 failures of classic prosthetic herniorraphies in 13 patients (13 men) were treated by a laparoscopic intraperitoneal onlay mesh technique (IPOM) using an ePTFE patch. The mean age of these patients was 55.69 +/- 13.11 years (28 to 70). The mean operating time was 72.5 +/- 24 mn (40 to 120). The technique could not be performed in one case. The mean postoperative pain at D1, evaluated by a visual analog scale graduated from 0 to 10 was 2.36 (2 to 3). The mean hospital stay was 1.64 days (1 to 3). One inguinal hematoma occurred and resolved after a short incision. The mean time to return to work or normal activity was 12.14 +/- 7.25 days (3 to 30). All patients were reviewed. The mean follow-up was 13.37 +/- 2.87 months (6 to 25). No testicular atrophy was observed. One recurrence occurred at M6 treated at M9 by an open procedure. Our study suggests that this technique, avoiding extensive preperitoneal dissection, thus decreasing vascular and genital risks, would be useful in the treatment of failures of prosthetic herniorraphies.