The European hernia society groin hernia classification: simple and easy to remember.

After reviewing the available classifications for groin hernias, the European Hernia Society (EHS) proposes an easy and simple classification based on the Aachen classification. The EHS will promote the general and systematic use of this classification for intraoperative description of the type of hernia and to increase the comparison of results in the literature.

Cure of inguinal hernias with large preperitoneal prosthesis: Experience of 2,312 cases.

It is clear that the recurrence rates after nonprosthetic methods for the repair of inguinal hernias, like McVay, Bassini or Shouldice techniques, are high (6-10%). Since 20 years, we are convinced, in the GREPA-EHS group, about the advantages of the use of a prosthetic mesh in majority of patients for repairs of primary or recurrent inguinal hernias and incisional hernias. We describe our typical technique for the cure of all inguinal hernias. We place a large supple mesh, by open inguinal route, posterior to the transversalis fascia and anterior to the peritoneum. We have made a double modification in the initial technique of Rives - the use of a very large unsplit prosthesis (15 × 17 cm) and the parietalization of the spermatic cord helped by a wide opening of the Fruchaud's orifice by diversion of the epigastric vessels. The positioning of the mesh is about the same as in the TEP technique but with the advantages of reduction in the vital laparoscopic risks and reinforcement of the wall by a short tension-free McVay technique.For this prospective study, we repaired 2,312 consecutive hernias in 1,828 patients, 284 of which were recurrent. We present our results in terms of quality of repairs, recurrence rates (0.4%), morbidity rate (8%), and mortality rate (0.8%).This technique involves the placement by an open incisional route of a large preperitoneal sheet of mesh for initial treatment of all inguinal hernias - including scrotal, giant or femoral - to ensure a definitive solid muscular wall, even for recurrent hernias.

Stented hepaticojejunostomies after resection for cholangiocarcinoma allow access for subsequent diagnosis and therapy.

A method is described for stenting hepaticojejunostomies after resection for hilar carcinomas. The small size of the catheters allows the intubation of all biliary anastomoses, in order to decrease the morbidity rate and allow postoperative internal radiotherapy.

Early histological changes in acute necrotizing hemorrhagic pancreatitis. A retrospective pathological study of 20 total pancreatectomy specimens.

Settled lesions of acute necrotizing hemorrhagic pancreatitis have been commonly reported. Early alterations remained unknown. In a retrospective pathological study of 20 total pancreatectomy specimens, early changes have been evidenced in "grossly unmodified" areas of pancreas: acinar cells homogenization, ductal dilatation with epithelial degeneration, diffuse interstitial edema and fibroblastic reaction, necrotic angeitis . These alterations were identical to the changes described in experimental studies.

[Risk factors in surgery of obstructive jaundice. Retrospective studies apropos of 176 patients]. / Facteurs de risque de la chirurgie des ictères obstructifs. Etude rétrospective à propos de 176 patients.

With the help of 28 criteria, the authors analyze the factors influencing mortality and morbidity related to surgery in jaundiced patients. The results differed according to whether the patients were examined as a whole or whether patients with benign and malignant lesions were considered separately; there was a significant difference in mortality between these two groups. Five factors were noted to predict an unfavorable outcome in patients with malignant lesions: the duration of symptoms, the presence of preoperative diabetes, renal failure, hypoalbuminemia and the type of surgical procedure. In patients with benign lesions, five factors were also significant: previous biliary surgery, decreased prothrombin level, leucocytosis, renal failure and an age greater than 80 years. It is thus possible to isolate a population "at risk" for whom surgery should be preceded by the correction of disorders due to cholestasis, and particularly the renal consequences.

[Peroperative echography in 14 cases of pancreatic insulinoma and gastrinoma]. / Echographie per-opératoire au cours de 14 cas d'insulinomes et de gastrinomes pancréatiques.

Fourteen cases of endocrine tumors (10 insulinomas and 4 gastrinomas) were to studied by intraoperative ultrasonography (IOU). Localization was established by preoperative ultrasonography in 1/14, by CT scan in 1/11, by arteriography in 6/12 and by pancreatic venous sampling in 7/8. Tumor size ranged from 0.5 cm to 2.5 cm. Manual palpation was positive in 10/14. The tumor was accurately and completely localized by IOU in 9/10 insulinomas: the one false negative was probably due to micro-adenoma. The intrapancreatic tumor was localized only in 1/14 gastrinomas. Intraoperative sonography localized lymph nodes in all cases. One distal pancreatectomy was improperly performed because of an accessory spleen. After reviewing 59 other cases in the literature, we propose: a) to abandon venous sampling in insulinomas because of adequate performance of IOU; b) to use IOU as a complementary investigative method along with other preoperative methods of localization in gastrinoma.

[Peroperative ultrasound scanning of the pancreas]. / Echotomographie per-opératoire du pancréas.

Intraoperative realtime high resolution ultrasound scanning of the pancreas seems to be a new and promising procedure. We have performed it in 28 patients: the normal ultrasound picture of pancreatic ducts and parenchyma was defined in 9 patients without pancreatic disease; in 19 patients with pancreatic disease, intraoperative ultrasound was compared with preoperative ultrasound examination. Seven of 8 patients with pancreatic carcinoma and 4 of 6 with calcifying chronic pancreatitis had positive findings, respectively. In 3 cancer patients, intraoperative ultrasound investigation avoided a long and unavailing dissection of the tumor by revealing extensive spread. In selected cases, intraoperative sonography allowed to characterize and to localize pancreatic carcinoma: portal vein invasion, relationship of the tumor to the duct of Wirsung and small hepatic metastases. In chronic pancreatitis, intraoperative ultrasound information concerning the dimensions of the pancreatic duct, the structure and the localization of pseudocysts was comparable to that obtained by radiological opacification. Furthermore, intraoperative ultrasound exploration guided proper incision and evacuation of pancreatic pseudocysts in two patients. Operative ultrasound seems to us to be mandatory during pancreatic surgery. Further experience with this technique is needed in a larger number of patients. However, we believe that it could replace intraoperative cholangiography and pancreaticography in the assessment of extension and complications of pancreatic disease.

[Intraoperative systematic cholangiography in celiopscopic cholecystectomy]. / Cholangiographie per-opératoire systématique au cours des cholécystectomies par coelioscopie.

OBJECTIVES: Laparoscopic cholecystectomy has become the therapeutic gold standard in uncomplicated cases of cholelithiasis. This study evaluated the feasibility and the results of intra-operative cholangiography during laparoscopic cholecystectomy. METHODS: Intra-operative cholangiography was attempted in 126 consecutive patients undergoing laparoscopic cholecystectomy. Common bile duct stones were detected according to the following criteria: a) clinically (history of jaundice or pancreatitis); b) biologically (aminotransferase > 2 N, alkaline phosphatase > 2 N, total bilirubin > 20 mumol/L); c) ultrasonographically (diameter of the common bile duct > 12 mm, presence of gallbladder stones < 10 mm); d) calculation of the multifactorial score of Huguier. RESULTS: An intraoperative cholangiography was performed in 116 patients (92%), for a mean duration of 16 minutes (range: 9-25 min). Two anomalies of the biliary tree were detected. Ten common bile duct stones were detected (8.6% with 50% success of laparoscopic extraction). One false positive case had justified a surgical exploration of the common bile duct. The sensitivity of preoperative criteria was 80%. No morbidity or postoperative biliary complications were related to the intraoperative cholangiography. CONCLUSIONS: Routine intraoperative cholangiography should be systematically performed during laparoscopic cholecystectomy, providing anatomical information of the biliary tree and detecting, in 1.7% of cases, unsuspected common bile duct stones which could be treated during the same operative procedure.

[Vital prognosis in acute pancreatitis. Study of 5 clinicobiological indices]. / Pronostic vital dans la pancréatite aiguë. Etude de 5 indices clinico-biologiques.

The values of the Acute Physiology and Chronic Health Enquiry (Apache II) and the Simplified Acute Physiology Scores (SAPS) were compared with Ranson and Imrie scores to predict death after acute pancreatitis. Fifty-five (ten deaths) patients were evaluated. Patients who died had a mean score greater than those who survived. The accuracy of all scores was similar after 48 hours. The ICU (Intensive Care Unit) available at the time of admission may facilitate the early selection of patients for appropriate management.

[Treatment of inguinal hernias. Value of the insertion of an unsplit dacron mesh with parietalization of the cord elements by inguinal approach. Apropos of 1017 cases]. / Traitment des hernies de l'aine. Intérêt de la mise en place par voie inguinale d'un tulle de Dacron non fendu avec pariétalisation des éléments du cordon. A propos de 1017 cas.

The authors describe an original technique for repair of groin hernia, using a large sheet of Dacron mesh placed by the inguinal route. Among 1613 procedures for hernia repair, this technique was used for 1017 repairs in 971 patients with a mean age of 63 years. The mortality rate was 0.1% and the morbidity 9%. The mesh had to be removed in one case because of infection. During follow-up, only 3 recurrences have been observed. This technique allows a solid and definitive repair thanks the procedure is correctly performed. The role of laparoscopic approach in the future is still debated.

[Cost of the surgical treatment of inguinal hernias]. / Coût du traitement chirurgical des hernies de l'aine.

The hospital stay of 100 patients admitted to hospital in 1988 for surgical repair of inguinal and crural hernias was analysed. Fifty-three per cent of patients were over the age of 60 years and more than one half of them has a medical history. There was no mortality and only a single serious complication. The mean hospital stay was 7.6 days, influenced by the age of the patients. The complementary investigations only constituted a small proportion of the cost of the hospital stay. The authors conclude on the necessity for further reduce the length of hospital stay (principal cost factor) and even propose day admission, although this alternative can only be proposed to a minority of patients.

[Laparoscopy-assisted colonic surgery. Initial experience. Apropos of 49 cases]. / Chirurgie colique coelio-assistée. Expérience préliminaire. A propos de 49 cas.

From November 1993 to December 1995, 49 colonic operations were performed by a videolaparoscopic assisted approach. Indications were malignant conditions in 10 cases, benign diseases in 39 cases (diverticular disease: 28, benign tumour: 9, reversal of Hartmann's procedure: 1, volvulus: 1). Conversion to a classical procedure was necessary in 6 patients. There was no mortality and 6 postoperative complications (3 reoperations). Colonic surgery this type of (laparoscopic-assisted operations) is technically feasible. It reduces the rate of post-operative wound complications and decreases the post-operative stay. It can be recommended for the surgical treatment of benign colonic diseases.

[Celioscopic appendectomy. Results in 137 consecutive patients]. / Appendicectomie coelioscopique. Résultats chez 137 malades consécutifs.

Between September 1990 and August 1992, laparoscopic appendicectomy was attempted in 137 patients: 98 females and 39 males (sex-ratio: 2.5:1) with a mean age of 31 years (range: 15-85). The patients were operated on by 9 surgeons. Laparoscopic appendicectomy was possible in 120 patients (87.6%). In 19 patients the procedure was converted into open surgery. The main causes of unsuccessful laparoscopic procedures were: retrocaecal appendix (n = 5) and injury of appendiceal artery (n = 4). The rate of unsuccessful procedures was 31% in retrocaecal appendix and 9.4% in the other cases (P < 0.02). In exclusively laparoscopic procedures, the mean operating time was 63 (2.9) minutes. It was 49 (3) minutes for experienced surgeons and 69 (3.3) for other surgeons (P < 0.05). Histological examination of the appendix revealed inflammatory signs in 97 specimens (71%). There were no wound infections after successful laparoscopic appedicectomy. One female patient developed an abscess in the pouch of Douglas. The median postoperative hospital stay was 3 days (range: 1-16). These results suggest that laparoscopic appendicectomy is a safe technique, with low morbidity allowing short postoperative hospital stay.

[Hemorrhagic gastro-duodenal ulcers. In which cases should emergency surgery be performed?]. / Ulcères gastro-duodénaux hémorragiques. Lesquels faut-il opérer en urgence?

From January 1983 to December 1987, 127 patients with bleeding peptic ulcer were admitted to hospital. The mean age of the 85 males was 57 years and 72 years for 42 females. All but four of the patients were managed medically after emergency endoscopy. Twenty-seven patients required surgical operations (21.2%): seven for cataclysmic haemorrhage, eight for persistent haemorrhage, twelve for recurrent bleeding. An analysis of factors leading to the necessity of surgical haemostasis was undertaken by considering the clinical status, endoscopic findings and laboratory results. The size of the ulcer (greater than 2 cm) was the most significant parameter (less than 0.01). Five other criteria (rectal bleeding) shock, endoscopic signs of recent haemorrhage, gastric or duodenal posterior ulcer) were also significant (p less than 0.05). Considering the gravity of these patients (six deaths among twenty-seven), clinical trials in bleeding peptic ulcer disease should only include patients in the high risk group.

[Chylous ascites caused by retroperitoneal neoplastic obstruction of lymphatic vessels. Treatment by peritoneo-jugular shunt. A case]. / Ascite chyleuse par obstruction lymphatique néoplasique rétropéritonéale. Traitement par dérivation péritonéo-jugulaire. Une observation.

A case of chylous ascites due to retroperitoneal tumoral compression is reported. Following failure of a medical treatment which consisted of paracentesis and medium-chain triglyceride (MCT) diet, the ascites dried up after installation of a peritoneum-jugular vein shunt valve. This operation is seldom performed in patients with chylous ascites since the medical treatment with paracenteses, MCT diet or even total parenteral nutrition succeeds in drying the effusion in almost 50 percent of the cases, notably those with postoperative lesion.

[Mucosecreting tumors of the appendix. 3 cases]. / Les tumeurs mucosécrétantes de l'appendice. Trois observations.

The three cases reported here illustrate the diagnostic, therapeutic and prognostic problems raised by these tumours. These are rare lesions with little suggestive symptoms, which explains why they are exceptionally diagnosed before surgery. Mucosal hyperplasias and cystadenomas are benign formations with a 90-100% survival rate 5 years after appendicectomy, even when non-cellular mucoid effusion is present. Cystadenocarcinomas are malignant tumours with mucoid secretion containing epithelial cells; they have a tendency to recur despite repeated evacuations, and their 5-year survival rate is approximately 25%; death results from intestinal obstruction or compression of intra-abdominal viscera by the mucoid substance.

[Treatment of inguinal hernia with unsplit mersylene prosthesis. Significance of the parietalization of the spermatic cord and the ligation of epigastric vessels]. / Cure des hernies de l'aine par prothèse de mersylène "non fendue". Intérêt de la pariétalisation du cordon et de la ligature des vaisseaux épigastriques.

The authors describe their technique of "thorough" dissection of the spermatic cord by the inguinal route. After parietalization of the cord and ligature of the epigastric vessels, a wide prosthesis of unsplit mersylene can be inserted through the groin behind the muscular layer brought down to Cooper's ligament. From their experience of 120 patients operated upon and without relapse at follow-up, they feel able to recommend this method in cases of recurrent hernias with weak walls and large sac and of hernias occurring in elderly of obese subjects.

[Conservative surgical treatment of acute pancreatitis. Strategy and technic]. / Traitement chirurgical conservateur des pancréatites aiguës. Stratégie et technique.

Not all patients with acute pancreatitis can be cured by medical treatment alone; surgery is mandatory when signs of aggravation or complications are present. The authors propose a new strategy involving bilateral subcostal laparotomy, wide approach to the pancreas, evaluation of the lesions and therapeutic decision: either abstention or excision which may be performed according to rules or adapted to each case. The abdominal wall is then closed, often around a pre- and peripancreatic Mikulicz's drain. This method has substantial advantages: the dangers of hasty and inappropriate surgical procedures on ill-defined lesions are avoided, necrotic areas can be removed, drainage is facilitated and possible reoperations are restricted to the supramesocolic cavity.

[Biliary pancreatitis: when is surgery indicated?]. / Pancréatites biliaires: quand opérer?

Retrospective analysis of a homogeneous group of 48 patients admitted with acute pancreatitis of biliary origin showed that 60% were in a serious condition. A total of 41 patients were operated upon, 25 in the early stages, 13 within a month, and 3 at some time after the acute episode. Lithiasis of the common bile duct was detected in 48, 23 and 33% of cases respectively; 9 calculi were enclaved including 7 in the early operated group. Cholecystectomy was combined with external drainage in 24 cases, choledocho-duodenal anastomosis in 3 and sphincterectomy in one; surgery to pancreas was necessary 17 times (necrosectomy in 13 and pancreatectomy in 4). 3 patients received endoscopic treatment and 4 were not operated upon. Ten patients died, including 8 in the early operated group. A literature review suggests that operation should be deferred (10th day), reducing severity of immediate surgery and avoiding risk of short or long term recurrence. The place of endoscopic sphincterectomy, notably in severe forms, has not been established.

[Diverticular peritonitis. Clinical, prognosis and therapeutic aspects]. / Péritonites diverticulaires. Aspects cliniques, pronostiques, thérapeutiques.

The results of diagnosis and management of perforated sigmoid diverticulitis were studied retrospectively over a 10 years period. 23 patients underwent operation, 17 for generalized peritonitis and 6 for local peritonitis. The mean age of patients was 65.7 years. Diverticular disease were known previously in 5 patients (21%) and complicated (diverticulitis) in 2 patients (8.6%). Depending on the symptoms and the spreading of the peritonitis 4 types of the disease can be described: primary generalized peritonitis, secondary generalized peritonitis, progressive generalized peritonitis and local peritonitis. Hartman procedure was performed in 16 patients, and proximal colostomy with drainage in 6 patients, ideal resection in one. The over all mortality was 34.7%, 43% after resection, 16% after conservatrice procedure, depending on the clinical status, duration of symptoms, type of peritonitis, surgical procedure. Improved results will require early diagnosis, adapted surgical procedure, appropriate antibiotics therapy and extension of prophylactic segmentation colectomie after one acute diverticulitis.