Follow-up after laparoscopic inguinal hernia repair, can it be done by phone? A prospective study in 300 patients, the PINQ-PHONE.

BACKGROUND: The most important long-term complications after inguinal hernia repair are chronic pain and recurrence. Previous follow-up studies showed that physical examination is the only reliable method of follow-up to detect recurrences. However, physical examination is laborious and time consuming. We designed a telephone questionnaire as a method of follow-up after laparoscopic inguinal hernia surgery; the PINQ-PHONE (Post-INguinal-repair-Questionnaire by telePHONE). The aim of this study is to validate the PINQ-PHONE for detecting both asymptomatic and symptomatic recurrences. METHODS: This prospective study contained 300 randomly selected patients after laparoscopic inguinal hernia repair. All patients were contacted by telephone and the PINQ-PHONE was carried out. The PINQ-PHONE contains four elements; three questions and a do-it-yourself Valsalva maneuvre. Subsequently, all patients were seen in clinic and physical examination (gold standard) was done. RESULTS: The majority (96 %) was male and the mean age was 66 (range 26-93) years old. The mean interval between surgery and study inclusion was 58 (range 6-141) months. In five (1.7 %) patients, a recurrence was found. All of them replied positively to one or more elements of the PINQ-PHONE. Two-hundred-fifty-two (84 %) patients replied negatively to all elements and none of them had a recurrence. The overall sensitivity was 1.00 and the overall specificity was 0.86. CONCLUSION: This study validated the PINQ-PHONE. It is a reliable, practical, and simple method of follow-up after laparoscopic inguinal hernia repair to detect both symptomatic and asymptomatic recurrences.

Patient-reported outcomes after incisional hernia repair.

PURPOSE: Patient-reported outcomes (PROs) are pivotal to evaluate the efficacy of surgical management. Debate persists on the optimal surgical technique to repair incisional hernias. Assessment of PROs can guide the selection of the best management of patients with incisional hernias. The objective of this cohort study was to present the PROs after incisional hernia repair at long term follow-up. METHODS: Patients with a history of incisional hernia repair were seen at the out-patient clinic to collect PROs. Patients were asked about the preoperative indication for repair and postoperative symptoms, such as pain, feelings of discomfort, and bulging of the abdominal wall. Additionally, degree of satisfaction was asked and Carolina Comfort Scales were completed. RESULTS: Two hundred and ten patients after incisional hernia repair were included with a median follow-up of 3.2 years. The main indication for incisional hernia repair was the presence of a bulge (60%). Other main reasons for repair were pain (19%) or discomfort (5%). One hundred and thirty-two patients (63%) reported that the overall status of their abdominal wall had improved after the operation. Postoperative symptoms were reported by 133 patients (63%), such as feelings of discomfort, pain and bulging. Twenty percent of patients reported that the overall status of their abdominal wall was the same, and 17% reported a worse status, compared to before the operation. Ten percent of the patients would not opt for operation in hindsight. CONCLUSION: This study showed that a majority of the patients after incisional hernia repair still report pain or symptoms such as feelings of discomfort, pain, and bulging of the abdominal wall 3 years after surgery. Embedding patients' expectations and PROs in the preoperative counseling discussion is needed to improve decision-making in incisional hernia surgery.

A rare case of a groin hernia: the Hesselbach's hernia.

A 61-year-old woman presented with pain in the left groin. The pain radiated from the groin to the knee. At physical examination, a non-reducible swelling was found lateral to the femoral vessels. A CT-scan showed herniation of fatty tissue through the lacuna musculorum. A laparoscopic repair was carried out. A large adipose structure was found herniating through the lacuna musculorum and originating from the Bogros area. It ran along the iliopsoas muscle, suppressing the femoral cutaneous nerve. The tissue was reduced and excised, and a polypropylene mesh was placed to cover the defect. Inguinal hernias are categorized as medial, lateral or femoral hernias. We describe a case in which a hernia through the lacuna musculorum was found, which is very rare and referred to as a Hesselbach's hernia.

Spontaneous subclavian vein thrombosis: a successful combined approach of local thrombolytic therapy followed by first-rib resection.

In 17% to 74% of patients with subclavian vein thrombosis, conservative treatment or venous thrombectomy led to residual symptoms. To improve these results, a prospective study was started in patients with subclavian vein thrombosis who were treated with a combined approach of local thrombolytic therapy followed by a first-rib resection. From 1983 to 1987 five patients entered the protocol. Total lysis was achieved in all cases. In the follow-up period, phlebography and strain-gauge plethysmography according to Whitney showed no recurrent thrombosis. All patients were able to resume their normal activities.

A new model for posttraumatic osteomyelitis in rabbits.

A new animal model for posttraumatic osteomyelitis was designed. This model mimics the pathogenesis of the human disease more accurately than models presently available. Femora of New Zealand white rabbits were exposed at the greater trochanter and a stainless steel rod was inserted into the marrow cavity. A Staphylococcus aureus suspension was placed in and around a bone defect, which was drilled midshaft. The disease was evaluated by clinical observation and roentgenographic, hematologic, bacteriologic, and histologic parameters. Osteomyelitis developed in all 24 infected rabbits. None of the five rabbits receiving only an intramedullary rod developed an osteomyelitis. This model proves that an experimental posttraumatic osteomyelitis associated with a foreign body can be reliably induced, even when no infection-promoting chemical agents, small inoculum of bacteria, or minimal bone trauma is present.

Is surgical repair of an asymptomatic groin hernia appropriate? A review.

PURPOSE: Groin herniorrhaphy is the most common operation performed by general surgeons. Annually, more than 20 million groin hernias are repaired worldwide. The general approach towards groin hernias is surgical repair regardless of the presence of symptoms. The rationale to recommend surgery for asymptomatic groin hernias is prevention of visceral strangulation. The goal of this review is to evaluate the appropriateness of surgery in patients with asymptomatic groin hernias. METHODS: The review was based on an extensive literature search of Pubmed, Medline and the Cochrane Library. RESULTS: The risk of incarceration is approximately 4 per 1,000 patients with a groin hernia per year. Risk factors for incarceration are age above 60 years, femoral hernia site and duration of signs less than 3 months. Morbidity and mortality rates of emergency groin hernia repair are higher in patients who are older than 49 years, have a delay between onset of symptoms and surgery of more than 12 h, have a femoral hernia, have nonviable bowel and have an ASA-class of 3 or 4. The recurrence rate after tension-free mesh repair in the management of emergency groin hernias is comparable to that of elective repair. There is no difference in pain and quality of life after elective repair compared to watchful waiting. There is no advantage in cost-effectiveness of elective repair compared to watchful waiting. CONCLUSION: Watchful waiting for asymptomatic groin hernias is a safe and cost-effective modality in patients who are under 50 years old, have an ASA class of 1 or 2, an inguinal hernia, and a duration of signs of more than 3 months.

Surgical treatment of pathological fractures caused by bone metastases.

A survey of the surgical treatment of 31 patients with metastases in the long bones is presented. Early diagnosis is essential to prevent pathological fractures in patients with a malignancy. Localized bone pain and an abnormal isotope bone scan or X-ray are the most reliable clues to diagnosis. Should a pathological fracture occur, reduction and internal fixation are indicated to keep the patient active and reduce pain. This was performed in 29 of the cases reported here. Fixation prior to fracture was carried out in six patients. The advantage of this strategy is that it reduces both operative risks and duration of hospitalization. Furthermore, it creates a more favourable situation with regard to preoperative diagnostic appraisal and choice of approach to improve the mechanical qualities of the bone involved, thus preserving function and activity.

Scoring multitrauma patients: which scoring system?

Two methods of estimating the severity of injury and evaluating outcome, the Injury Severity Score (ISS) and the Polytrauma-Schlussel (PTS), were evaluated. The records of 37 victims of multiple injuries were assessed retrospectively by nine trauma surgeons using both methods of scoring. The agreement among the users was calculated by standard deviation. The standard deviation (SD) among users was smaller for the PTS (4.1) than for the ISS (6.2). Each method of scoring comprises six components contributing to the total score. The three highest scoring components of the ISS were first squared and then summated, the sum being the total ISS score. All the PTS categories were summated. Comparison of the SD for each of the components was not possible. However, the category or categories which mostly influenced the standard deviation could be indicated. For the ISS these were the circulation and central nervous system and for PTS, the limbs. We prefer the Polytrauma-Schlussel method because this takes account of age, needs revision of only one category and gives more consistent results among users.

Taurolin in the treatment of experimental post traumatic osteitis.

Post-traumatic osteitis (PTO) still constitutes a medical and surgical problem. Although different treatment regimes have been tested, controversial results have been obtained. Taurolin-gel® 4% and Taurolin®-collagen are broad spectrum synthetic antibacterial agents used for the local treatment of PTO. This study was designed to evaluate Taurolin under standardised conditions using an animal model for experimentally induced PTOIn 21 rabbits a PTO was induced in the left femur and they were assigned into three groups. Four weeks after this operation the second operation followed: in group A (n=5) the intramedullairy rod was removed and the marrow cavity flushed with Ringer lactate solution. In groups B and C (n=16) Taurolin®-gel 4% or Taurolin®-collagen was installed into the marrow cavity after the same debridement. The disease was monitored by hematologic, roentgenografic and bacteriological parameters.After 4 weeks all animals showed signs of an osteitis. At obduction the marrow flush and bone cultures of group A all consisted S. aureus. In group B three out of eight and in group C two out of eight cultures showed bacterial grows.Treatment of an animal PTO is more difficult than the human disease for thorough debridement is difficult. Even though we achieved a succespercentage of 69%. This is a number which is also described in clinical studies. Further investigations with Taurolin® are necessary to develop an optimal treatment regime and to determine to what extent it can be integrated in everyday clinical practise.

Shoulder injury caused by electric shock.

Shoulder injury and more in particular bilateral dislocation of the shoulder joint after electric shock is rare. Three patients are presented with dislocation and fracture of the shoulder and serious muscle contraction. After an accident involving electric current potential shoulder injuries should be considered. Early diagnosis improves the functional results of adequate treatment.

A multivariate analysis of determinants of wound healing in patients after amputation for peripheral vascular disease.

In a prospective study 53 patients undergoing amputations of the lower limb were evaluated for clinical criteria, laboratory results, pulse volume recordings, Doppler pressures, Photoplethysmographic Skin Perfusion Pressures (PPG/SPP) and angiography. The purpose of the study was to analyse which of these techniques predicts wound healing adequately after amputation. Forty-five patients eventually completed all tests. With the exception of PPG/SPP none of these tests were able to predict skin healing. The technique of PPG/SPP proved very reliable in helping to select the level of amputation, if measured anteriorly (P = 0.0001, r = 0.83). Angiographic scoring also correlated significantly (P = 0.0016) with a successful result. This study suggests that surgeons should not rely on their clinical acumen for the selection of the amputation level. In the absence of a reliable non-invasive test, angiography may well be useful but PPG/SPP will enable the surgeon to amputate on an optimal level and thus reduce complications and improve rehabilitation.

Photoplethysmographic selection of amputation level in peripheral vascular disease.

In a prospective study 37 patients who required amputations of the leg were studied with a new technique: segmental photoplethysmographic skin perfusion pressures. The decision to amputate was made by a vascular surgeon in a traditional manner, with the aid of clinical criteria. The simple method of determining skin perfusion pressures with photoplethysmography is described; 273 measurements were performed. The technique proved to be highly correlated (r = 0.88) with wound healing after amputation, at a separating value of 21 mm Hg (p = 0.0001). The study suggests that the value of this noninvasive method will be to enable the surgeon to amputate at a lower level and to diminish complications and failure of rehabilitation.

Criteria for reliable selection of the lowest level of amputation in peripheral vascular disease.

To improve the chances for the amputee to become ambulatory the most distal level of amputation should be selected in patients with end-stage peripheral vascular disease. Physical examination alone provides insufficient information when amputation levels are closely related to areas with signs and symptoms of ischemia. In the present series of 85 lower extremity amputations the predictive values of clinical parameters and skin perfusion pressure measurements are assessed. The role of clinical judgment is clarified: the most distal level of amputation is to be selected by physical examination, but further information is required to assess the healing potential at the selected level. The presence of palpable pulses immediately above the selected level correlates well with primary wound healing (p less than 0.001, negative predictive value 100%). The absence of palpable pulses and angiographic patency scores are of no clinical value in amputation level selection. Skin perfusion pressure measurements were of excellent predictive value (p less than 0.001, positive predictive value 89%, negative predictive value 99%). According to these data a strategy is proposed for routine determination of the lowest level of amputation, where primary wound healing can be expected.

A modified scintigraphic technique for amputation level selection in diabetics.

A modified 123I-antipyrine cutaneous washout technique for the selection of amputation levels is described. The modifications imply a reduction of time needed for the examination by simultaneous recordings on different levels, and a better patient acceptance by reducing inconvenience. Furthermore, both skin perfusion pressure (SPP) and skin blood flow (SBF) are determined from each clearance curve. In a prospective study among 26 diabetic patients presenting with ulcers or gangrene of the foot, both SPP and SBF were determined preoperatively on the selected level of surgery and on adjacent amputation sites. These 26 patients underwent 12 minor foot amputations and 17 major lower limb amputations. Two of these amputations failed to heal. SBF values appeared indicative for the degree of peripheral vascular disease, as low SBF values were found with low SPP values. SPP determinations revealed good predictive values: all surgical procedures healed when SPP greater than 20 mmHg, but 2 out of 3 failed when SPP less than 20 mmHg. If SPP values would have been decisive, the amputation would have been converted to a lower level in 6 out of 17 cases. This modified scintigraphic technique provides accurate objective information for amputation level selection.