Midline versus nonmidline laparoscopic incisional hernioplasty: a comparative study.

BACKGROUND: Nonmidline incisional hernia is a surgical problem of major interest, but to date, little information on this problem is available. This study aimed to analyze the results of nonmidline laparoscopic incisional hernioplasty in a multidisciplinary abdominal wall unit over the past 10 years. METHODS: This prospective study examined a series of 199 patients undergoing surgery for incisional hernia via the laparoscopic approach: 146 midline and 53 nonmidline. A comparative analysis compared midline and nonmidline defects, and a descriptive analysis compared four nonmidline types: 18 lumbar, 11 subcostal, 14 inguinal, and 10 lateral. Clinical and follow-up parameters were assessed during a mean follow-up period of 64 months (range, 12-120 months). RESULTS: The nonmidline incisional hernias were significantly larger, involved more preoperative pain, and required a longer hospital stay than the midline incisional hernias (p < 0.001). Also, the intraoperative complications and the consumption of analgesics were more frequent in the nonmidline group (p < 0.05). The postoperative morbidity and recurrence rates were similar in the two groups. No statistical differences were noted between the four types of nonmidline incisional hernias. The most common nonmidline type was lumbar hernia (34%). Hematomas (17%) predominated in the inguinal types, and pain predominated in the lumbar types. Two early recurrences were diagnosed for poor mesh placement: one subcostal and one lumbar. CONCLUSIONS: Laparoscopic incisional hernioplasty can be applied to nonmidline defects with the same rates of morbidity and recurrence as for patients with midline defects. The four types of nonmidline defects seem to have their own evolutionary characteristics.

Ambulatory laparoscopic repair of inferior lumbar or Petit hernia: a case report.

Lumbar hernias are an uncommon variety of abdominal wall defect. Diagnosis depends largely on the capacity for clinical suspicion, and confirmation is based on imaging tests. Surgical treatment is controversial due to difficulty in defining the borders of the lumbar defect and the involvement of a bone margin. We present a case of traumatic lumbar hernia in the Petit triangle, diagnosed by computed tomography (CT) and repaired laparoscopically as a major ambulatory surgery procedure. The laparoscopic approach enabled us to identify the whole of the lumbar area and effect a profound reconstruction on the same side as the defect.

Treatment of spigelian hernia using totally extraperitoneal laparoscopy ambulatory surgery.

Spigelian hernia is an uncommon hernia of the abdominal wall. Diagnosis and treatment are controversial because it is frequently an emergency pathology. We report two patients with preoperative diagnosis and treatment using totally extraperitoneal laparoscopy under regional anesthesia in a day surgery department.

Day surgery for laparoscopic repair of abdominal wall hernias. Our experience in 300 patients.

Laparoscopic repair of abdominal wall hernias is still a controversial and nongeneralized therapeutic option. The aim of this paper is to evaluate the results of laparoscopic surgery on abdominal wall hernias at a day-surgery unit and to describe our procedure protocol. Prospective analysis of 300 patients undergoing laparoscopic surgery for abdominal wall hernias was conducted: 260 preperitoneal and 40 intraperitoneal. The patients' clinical features, hernia type, intraoperative and postoperative complications, and follow-up are studied for both types of surgery. All the patients receiving surgery with extraperitoneal laparoscopy were completed as a day-surgical procedure with a rate of conversion to open surgery of 2.3%. Twelve (30%) of the 40 patients operated on for ventral hernias using intraperitoneal laparoscopy required hospitalization: five for perioperative complications and seven for pain (16%). There was no case of infection or mesh rejection. The recurrence rates were 0.78% (two cases) for the inguinal hernias and 2.5% (one case) for the ventral hernias. In conclusion, laparoscopic repair of abdominal wall hernias in a day-surgery setting is an efficient alternative to open surgery.

Spigelian hernia: bibliographical study and presentation of a series of 28 patients.

Spigelian hernias are rare defects of the abdominal wall. Our aim is to analyse the bibliography and present a series of 28 patients. A Medline bibliographical study was performed between 1970 and 2000 with analysis of the number of cases, series, ratio of cases to year and type of journal. We also present a personal study and analyse epidemiological, diagnostic, and treatment factors. There are 159 articles, 479 cases, and 19 series of more than five patients published in 85 journals (42.3% medical). Our diagnosis was preoperative in 75%, and programmed surgery was 3.6 times more common than emergency surgery. We found a significant relationship between hospital stay and type of surgery (P < 0.02) and surgical technique used (P < 0.001). We found that spigelian hernias have a multidisciplinary interest; they are given almost equal treatment in medical and surgical journals; preoperative diagnosis can be established in 75% of cases; and the best results are offered by the extraperitoneal laparoscopic approach.

Intraoperative and postoperative complications of totally extraperitoneal laparoscopic inguinal hernioplasty.

Inguinal hernioplasty using extraperitoneal laparoscopy is a new surgical option but still controversial because of the great technical difficulty involved. To analyze the clinical factors that could be related to intraoperative and postoperative morbidity, a prospective study was performed of 131 patients (153 repairs) undergoing totally extraperitoneal endoscopic surgery for inguinal hernia in an Outpatient Surgery Unit. Clinical parameters (age, sex, associated diseases, prior abdominal surgery, site and type), intraoperative complications (detachment of epigastric vessels, preperitoneal bleeding, rupture of the peritoneal sac, subcutaneous emphysema, problems with extending the mesh, visceral or deferential lesions, and rate of reconversion), postoperative complications (haematomas, urinary retention, transitory pain, neuralgias, and infections), and rate of recurrence were evaluated. Follow-up averaged 18 months (range, 1-3 years) and was complete in 100% of the patients. Intraoperative morbidity was 47%; postoperative, 16%; and the rate of reconversion, 4%. The rate of readmissions was 0%. One patient underwent reoperation for suspected early recurrence. The following statistically significant relations were shown: bleeding to recurrent hernias; presence of pain to hematomas; peritoneal rupture to female sex, diabetes, prior infraumbilical surgery and bilateral site; detachment of epigastric vessels to absence of prior surgery and hernia type 3a; and hematomas to age older than 50 years (P < 0.05). The preperitoneal laparoscopic technique is a difficult surgical operation, which often requires added interventions to resolve unexpected problems. The complications are acceptable, and the rate of recurrence is low (0.65%). We establish a standard for selecting patients during a program of apprenticeship.

Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience.

Ventral hernia repair is still a difficult problem for surgeons because of the high recurrence rate and possible postoperative complications. Repairs with a prosthesis have reduced the recurrence rate, but the anterior approach still involves high morbidity and a long hospital stay. The purpose of this article was to evaluate the results of laparoscopic surgery on ventral hernias using a new double-layer mesh in an intra-abdominal position. A retrospective analysis was performed of the first 20 patients undergoing laparoscopic surgery for ventral hernia (75% incisional and 25% umbilical) with intra-abdominal prosthetic repair using a double-layer mesh consisting of three-dimensional multifiber polyester on one side and a hydrophilic resorbable nonstick collagen membrane on the other (Parietex composite, Sofradim, Villefranche sur Saone, France). The procedure was done on an outpatient basis in 85% of the cases. There was no morbidity or mortality. During a mean follow-up period of 10 months we found no infections, rejections, fistulas, recurrences, or alterations in bowel function. Laparoscopic repair of ventral hernias is an efficient alternative to open repair, with a low morbidity rate and short hospital stay. The double-layer mesh is safe for intra-abdominal use.

[Barrett's esophagus does not revert after medical or surgical therapy for gastroesophageal reflux]. / El esófago de Barrett no revierte tras el tratamiento médico o quirúrgico del reflujo gastroesofágico.

An evaluation was made of 34 patients having Barrett's oesophagus. Medical therapy consisted of antacids, H2 blockers, orthopramides, and postural measures (20 cases, mean follow-up 2.9 years). A Nissen fundoplication was done in 14 cases (mean follow-up 2.5 years). Clinical, endoscopic and histologic evaluation was done in all patients and pH measurements also done in all operated cases. Clinical results have been excellent in 70% of medically treated patients and in 100% of surgically treated ones, pH measurements were between normal limits in all operated patients. However, recovery of the normal epithelium did not occur in any case, except for some partial improvement in one patient treated surgically.

[Role of the vagal system in changes in small intestinal motility induced by psychological stress. Experimental study on dogs]. / Participación del sistema vagal en las alteraciones de la motilidad del intestino delgado inducidas por el stress psíquico. Estudio experimental en perros.

The objectives of the present study were: 1) to describe the modifications in motility of the small intestine in response to situations of psychic stress during fasting and postprandial periods. 2) To analyse the possible involvement of the vagal system in these modifications. For this we used a total of 40 dogs. The motility of the small intestine was recorded using electromyography techniques (monopolar electrodes) and manometric techniques (submucous microballons). The stress stimulus consisted in the complete body immobilization of the animal in plaster. We show that stress induced a significant increase in the intestinal motility index (percentage of show waves followed by the action potential) in the three locations of the intestine studied (duodenum, angle of Treitz and proximal part of the jejunum) during the fasting (p less than 0.001) and postprandial periods (p less than 0.001). Finally, we demonstrate that vagotomy prevents the effect of hypermotility causes by the psychic stress. We can conclude that psychic stress does indeed modify the normal motility of the small intestine, both in the fasting and postprandial periods, and the vagus is implicated in this hypermotility response.

Pancreaticoduodenectomy due to cancer in the elderly.

The elderly have traditionally been excluded from pancreaticoduodenectomy due to the high morbimortality of this procedure. Six cases of pancreaticoduodenectomy) 5 cephalic and 1 total) for periampullary tumors in patients over 70 are reported. There was no mortality. We conclude that, in selected cases, pancreaticoduodenectomy can be performed safely in the elderly.

[Non-specific digestive ulcers and Behçet's disease]. / Ulceras digestivas inespecíficas y enfermedad de Behçet.

We present a 56-year-old patient with episodes of recurrent abdominal pain and constitutional syndrome, whose evolution was complicated by mucous ulcers in mouth, esophagus, anus and ileocecal valve, as well as occasional aphthae in scrotum. All these clinical signs are compatible with a Behçet's disease with relevant digestive manifestations.

[Impact of a clinical pathway for the diabetic foot in a general hospital]. / Impacto de una vía clínica para el pie diabético en un hospital general.

OBJECTIVE: The ulcers, infections and isquemia of the foot are the main causes of hospitalisation of the diabetic patient and, very frequently, they are reason for the amputation of the limb. The objective of this investigation consists of evaluating the results of a multidisciplinary clinical pathway designed by the set of specialists of different departments from our hospital, as well as of the associated personnel of infirmary, implied in the management of this pathology. PATIENTS AND METHODS: We have analysed the evolution of a series of clinical and socio-economic indicators comparing, in the patients admitted with diagnose of complicated diabetic foot, the previous period to the implantation of the clinical pathway years 1998, 1999 and 2000) with the later period to this implantation (years 2001 and 2002). It is evaluated in each group: the percentage of greater and smaller amputations, mortality, the average stay, the percentage of readmitances in 30 days, the percentage of arteriographies, the percentage of patients controlled by rehabilitation, and the economic cost of the individual processes, as well as the global cost. In the group including in the clinical pathway it was carried out, in addition, a satisfaction survey. The statistical comparison was made by means of the Chi square test. RESULTS: We did not find differences as far as the average stay, nor to intrahospitable mortality. If we found a clear increase in the percentage of arteriographies (of the 3.5% passage to 13%), and in the percentage of patients controlled by rehabilitation (of the 19.8% passage to the 84.3%). The rate of greater amputations of the patients not including in the clinical pathway change from 17.4% to 9.7% after the implantation of this route. The rate of readmitances to 30 days diminished from 9.3 to 6,5%. The global economic cost and the average cost by patient have been inferior after the implantation of the clinical route. The survey of satisfaction of this last group offered a global satisfaction of 95%. CONCLUSIONS: The results suggest that the approach to the diagnose and treatment on the complicated diabetic foot by means of this multidisciplinary clinical pathway improves the evolution of the hospitalised patient, diminishing the number of greater amputations, without extending the average stay and maintaining, or even diminishing, the global economic cost.

Evaluation of the magnitude of gastro-oesophageal reflux in Barrett's oesophagus.

A manometric study to determine the role of gastro-oesophageal reflux in Barrett's oesophagus was performed on 20 patients with Barrett's oesophagus and 53 patients with reflux oesophagitis without Barrett's oesophagus (25 with mild oesophagitis and 28 with severe oesophagitis). For the same reason, the 20 patients with Barrett's oesophagus also underwent 24 hour continuous oesophageal pH monitoring, and the results obtained were compared with those of 20 oesophagitis patients without Barrett's oesophagus (10 with mild oesophagitis and 10 with severe oesophagitis). The manometric results show that the motor changes found in the Barrett's group are specific but similar to the motor dysfunction associated with reflux oesophagitis. Motor anomalies are probably related more to the inflammatory process in the oesophageal wall than to the metaplastic changes themselves. The pH monitoring results show that while reflux in the Barrett's oesophagus patients was greater overall than in the oesophagitis group without Barrett's oesophagus, the changes are similar when the results are compared with the severe oesophagitis group. In conclusion there are other factors besides gastro-oesophageal reflux involved in the pathogenesis of Barrett's oesophagus.

Achalasia of the cardia: long-term results of oesophagomyotomy and posterior partial fundoplication.

Forty-eight patients with achalasia of the cardia were treated by Heller's myotomy with a posterior fundoplication of approximately 270 degrees, suturing the gastric fundus to the edges of the myotomy. The mean(s.d.) postoperative follow-up period was 5.4(2.8) years. The clinical results were good to excellent in 44 cases (92 per cent) and fair in four cases (8 per cent) (two with residual dysphagia and two with gastrooesophageal reflux). Barium studies showed a decrease in oesophageal diameter and disappearance of distal narrowing but normal oesophageal emptying did not occur. Postoperative manometric studies (29 patients) revealed a significant decrease in lower oesophageal sphincter pressure and a significant increase in the length of the infradiaphragmatic segment. In the oesophageal body a recovery of peristaltic waves in the proximal third was seen in ten of the patients (34 per cent). Twenty-four-hour pH monitoring showed pathological reflux in only three of 25 patients studied, and one of these was asymptomatic. This technique is effective, improving oesophageal symptoms and controlling long-term reflux.

Value of 99mTc-MIBI scintimammography in women with impalpable breast lesions seen on mammography.

OBJECTIVE: To find out if 99mTc-methoxyisobutylisonitrile scintimammography (MIBI) is useful in the evaluation of impalpable breast lesions in women referred for biopsy after mammography screening. DESIGN: Observational and prospective study. SETTING: Radiological screening campaign in Spain. PATIENTS: 36 patients referred between September 1997 and June 1998 (37 biopsies) with impalpable breast lesions referred consecutively from a screening campaign. Ages ranged from 50 to 64 years. INTERVENTIONS: Mammography, ultrasound, MIBI, and wire-guided biopsy. MAIN OUTCOME MEASURES AND RESULTS: Mean values for sensitivity, specificity, positive predictive value, and negative predictive value for scintimammography were 78.9, 72.2, 75, and 76.5 respectively (p = 0.002). The logistic regression analysis showed that 99mTc-MIBI scintimammography result predicted (p = 0.003) the risk of breast cancer in this group of patients (odds ratio: 9.75), particularly infiltrating ductal carcinoma. CONCLUSIONS: MIBI scintimammography in patients referred for biopsy after mammography screening does not so much rule out cancer as confirm the diagnosis. Its practical benefit would be not so much avoiding biopsy for these patients as aiding in planning the radicality of their excision.

Influence of abdominal incision on the formation of postoperative peritoneal adhesions: an experimental study in rats.

OBJECTIVE: To see if the three most commonly used abdominal incisions were associated with the development of postoperative peritoneal adhesions. DESIGN: Prospective experimental study. SETTING: University hospital, Spain. SUBJECTS: 30 Wistar rats. INTERVENTIONS: Three groups each of 10 rats underwent suprainfraumbilical midline laparotomy, right subcostal laparotomy or infraumbilical right transrectal laparotomy. MAIN OUTCOME MEASURES: The animals were killed after 30 days and adhesions quantified according to a special designed score which assessed the number of adhesions, their site, vascularisation, thickness, and strength. RESULTS: The transrectal incision was associated with most adhesions (median: 9.3, interquartile 7-10), followed by subcostal laparotomy (5.5, 4-6.7), and midline laparotomy (2.0, 0-7). CONCLUSIONS: Infraumbilical incisions away from the midline are more traumatic, damage more of the peritoneum, and are more likely to come into contact with the omentum, peritoneal fat, bowel loops, and pelvic contents, thereby predisposing to the formation of peritoneal adhesions.

Long-term results of Nissen fundoplication in reflux esophagitis without strictures. Clinical, endoscopic, and pH-metric evaluation.

The present paper evaluates the efficiency of Nissen fundoplication as an antireflux technique in a series of 51 patients with different grades of esophagitis. Follow-up time averaged 6.6 years. The evaluation includes a clinical assessment, endoscopic study, and 24-hr pH monitoring. The results reveal an acceptable rate of recurrences, with clinical (9.8%) being less frequent than endoscopic (13.7%) or pH-metric (19.6%) recurrences. Side effects appeared in 37.3% of the patients (mainly inability to belch or vomit, and postprandial fullness), which were mild and transitory in most cases. Nissen fundoplication proved effective in controlling long-term gastroesophageal reflux, as over 80% of the patients presented an excellent-to-good clinical situation, without or with minimal digestive consequences.

Evolution of the need for operation for peptic pyloric stenosis over a period of 24 years (1976-1999).

OBJECTIVE: To analyse the need for operation for pyloric stenosis caused by duodenal ulcer over a period of 24 years (1976-1999). DESIGN: Retrospective study. SETTING: University hospital, Spain. SUBJECTS: 156 patients operated on for peptic pyloric stenosis. MAIN OUTCOME MEASURES: The number of patients operated on yearly were grouped into 4-year periods for statistical comparison. RESULTS: The number of cases operated on each year steadily decreased between 1976 and 1999. In the 1988-1991 period there was a significant reduction (p <0.05), which continued over the next two 4-year periods, particularly the last (p <0.01). CONCLUSION: Although we cannot use this study to establish a direct relation between the decrease in the indication for operations for peptic pyloric stenosis and the use of H2 antagonists, proton pump inhibitors, or treatment to eradicate Helicobacter pylori, we did find a significance difference between the years before and after the introduction of these drugs.