"Sports" hernia: treatment with biologic mesh (Surgisis): a preliminary study.

BACKGROUND: Groin pain in athletes is caused by a wide range of musculoskeletal disorders. Occasionally, a palpable bulge at the external ring or ultrasound may not demonstrate a hernia. When athletes do not respond to conservative treatment, a "sports" hernia should be considered. METHODS: A retrospective review of 750 laparoscopic preperitoneal hernias was performed. A sports hernia was defined as a tear in the transversalis fascia that was not evident by preoperative physical exam. A 7 x 10-cm biologic mesh, Surgisis, was placed, uncut, over the myopectinate orifice and fixed with five tacks or fibrin glue. Patients were followed up at 2 and 6 weeks, 6 months, and 1 year. RESULTS: Ten professional and amateur athletes were found to have sports hernias. Operative time averaged 32 min. There were no major complications. All athletes returned to full activities in 4 weeks. Only one patient did not show improvement in his symptoms. No patient developed a recurrent hernia. CONCLUSIONS: Laparoscopic exploration should be considered in athletes with chronic groin pain that does not improve after conventional treatments have failed. Furthermore, biologic mesh (Surgisis) should be considered for the repair of inguinal sports hernias.

Extraperitoneal laparoscopic hernia repair with local anesthesia.

BACKGROUND: This review aimed to compare laparoscopic preperitoneal herniorrhaphy (LPPH) using a laryngeal mask airway and local anesthesia with conventional open herniorrhaphy using similar anesthetic conditions. METHODS: A retrospective review of 238 hernia operations was conducted from October 1996 through September 1998. Laparoscopic preperitoneal hernia repairs with the patient under laryngeal mask airway anesthesia were performed initially using 10 ml of 0.5% bupivacaine (LPPH+10 group). This was compared with hernia repair using 30 ml of 0.5% bupivacaine (LPPH+30 group). Both LPPH groups were compared with a plug and patch "Gilbert" hernia repair group. Postoperative pain was compared in the recovery room and outpatient suite. RESULTS: The LPPH+30 group required significantly less postoperative pain medication than the LPPH+10 group. The LPPH+30 group required slightly more pain medication in the recovery room than the open hernia repair group, but in the postanesthesia care unit (PACU) unit, the LPPH+30 group used less pain medication. A similar number of LPPH+30 patients, and open hernia repair patients required no pain medication. CONCLUSIONS: The use of a long-acting local anesthetic, (30 ml of 0.5% bupivacaine via laryngeal mask airway) for laparoscopic preperitoneal hernia repair compared favorably with conventional open hernia repair using similar anesthetic techniques.

Gastric cancer in the elderly.

The surgical treatment of gastric cancer in the elderly (over 65 years of age) was retrospectively studied in the department of surgery, at the Mount Sinai Medical Center, Miami Beach, Florida. The authors found 22 patients who were operated on for gastric cancer between 1979 and 1982. Ages ranged from 69 to 90 years of age. The male-to-female ratio was 1:1. Twenty of 22 patients were found to have carcinoma. Eleven of 20 had regional spread to the perigastric nodes, transverse colon, omentum, spleen, and liver. Stage of disease was: stage I--four patients, stage II--five patients, stage III--eight patients, and stage IV--three patients. Two of 22 patients had lymphoma. The mean hospital stay was 17.1 days, but decreased to 12.4 days if no complications occurred. Postoperative complications were minimal and included pneumonia, urinary tract infection, wound infection, and dumping syndrome. There were two postoperative deaths (9%) due to sepsis and myocardial infarction, respectively. Six of the remaining 18 patients died within 1 year. Seven of 18 were alive after 2 years, and six patients survived greater than 36 months (33%). Of the six long-term survivors, two had stage III and one had stage IV disease at the initial exploration. The average survival was 23.5 months. The authors conclude that gastric resection should not be withheld in the elderly. The elderly have the same morbidity and mortality from surgery for gastric cancer as patients under age 65.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous endoscopic gastrostomy. A mandate for complete diagnostic upper endoscopy.

One hundred patients underwent upper endoscopy for the placement of percutaneous endoscopic gastrostomies (PEGS) during a four year period from 1984 to 1988. These cases were retrospectively reviewed to document the need for total endoscopy during PEG. Ninety-seven per cent of the procedures were successful. In 89 per cent, a complete exam of the esophagus, stomach, and duodenum was performed, revealing pathologic findings in 59 per cent. The most common abnormalities were in the esophagus (23%) and the stomach (27%); however, a portion of the findings were also present in the duodenum (12%) and the pylorus (11%). Additional findings present in the complete esophagogastroduodenoscopy (EGD) done at the time of PEG included a five per cent incidence of gastric outlet obstruction and antral ulcers or polyps in six per cent. The breakdown of findings in the duodenum included eight per cent incidence of duodenal ulcers and four per cent incidence of duodenitis. A total of 22 per cent of the patients had some evidence of peptic ulcer disease. Many of the cases in which pathology was found required a change in medications and, when postoperative bleeding occurred after PEG, the other pathologic entity was much more likely to be the cause of the complication than the PEG. A careful and complete EGD is mandated every time a patient is scheduled for PEG.

Tracheostomy. A new indication for percutaneous endoscopic gastrostomy tube placement.

A review of patients undergoing elective tracheostomy (TRACH) and percutaneous endoscopic gastrostomy (PEG) was undertaken to decide whether addition of PEG to a planned tracheostomy was safe and indicated by conditions mandating the tracheostomy. Charts were reviewed for demographic data, details of operation, outcome, and disposition. Sixteen patients with an average age of 61 years were studied. Primary diagnosis included CNS disease (7), trauma (6), and multisystem failure (3). These patients had 35 associated diseases. Indications for tracheostomy were respiratory failure (9) and prolonged intubation (7). The average time from admission to procedure was 23.7 days. Average operative time was 50 minutes. There were three postoperative complications. Ten patients were discharged (5 home, 5 skilled facility) and six expired. All patients had functioning tracheostomies and PEGs at the time of disposition. Percutaneous endoscopic gastrostomy is a logical adjunct to planned tracheostomy, adding little morbidity but with potential benefit to long-term management in this special group of chronic care patients.

Laparoscopic appendectomy versus open appendectomy: a single institution study.

PURPOSE: The purpose of this study was to compare the safety and efficacy of laparoscopic appendectomy versus open appendectomy at Baptist Hospital in Miami, Florida. METHODS: A retrospective review was performed on all appendectomies performed at Baptist Hospital from October 1, 1994 to September 30, 1995. There were a total of 244 cases; 137 open appendectomies and 107 laparoscopic appendectomies. The cases were reviewed with regard to pathology, operating time, length of hospital stay and complications. RESULTS: The pathologic findings at surgery were similar for the two groups. Concomitant pathology was more likely to be found laparoscopically than in open surgery. There was a greater percentage of ruptured appendices in surgery done via the open method. Operative time was slightly longer, but complications were less in the laparoscopic group. Length of stay was lower in the laparoscopic appendectomy group. CONCLUSIONS: Although very similar, our method of appendectomy favors the laparoscopic technique.

Safe esophageal bougie placement for laparoscopic hiatal hernia repair.

The increased use of laparoscopy for treatment of reflux esophagitis has been associated with a 1-8% complication rate. Perforation of the esophagus from bougie placement, wrap breakdown or too tight a wrap are some of the complications seen from this surgery. An esophageal dilator system was developed to overcome these problems. Thirty patients had an esophageal dilator system used whereby a 48 F or 58 F dilator was placed over a 18 F orogastric tube. Intraoperative gastroscopy documented a properly created wrap. There were no esophageal perforations or morbidity associated with the dilator.

Laparoscopic paraesophageal hernia repair with mesh.

A type II paraesophageal hernia is usually an asymptomatic condition found incidentally in an elderly patient. It is a potentially devastating problem because it can present as severe blood-loss anemia or acute, life-threatening gastric volvulus. The medical and surgical literature is replete with recommendations for surgical repair, but underlying medical illnesses have led to delays in the use of this treatment of choice. Five extreme elderly patients safely underwent the standard "Boerema" repair with gastropexy under laparoscopic guidance. With the advent of laparoscopy, a safe, minimally invasive approach is available to the high-risk patient group.

Eosinophilic enteritis. A case for diagnostic laparoscopy.

Eosinophilic enteritis is rare. This report of a single case involving the distal ileum demonstrates the importance of laparoscopy in the diagnosis of this disease. An adequate biopsied segment of intestine can be obtained using complete intracorporeal techniques and three portals. Histiopathologic confirmation will insure proper treatment. The effectiveness of laparoscopy as a diagnostic tool cannot be understated. Surgeons should continue to encourage its use in similar patients with ill-defined abdominal pain, nonspecific laboratory results, and radiographic findings that are inconclusive and do not allow one to initiate appropriate therapy.

Laparoendoscopic approaches to enteral access.

Access to the stomach for long-term enteral feeding or decompression can be achieved with numerous methods. The methods include laparotomy, gastroscopy, laparoscopy, and fluoroscopy. All methods have been shown to be safe and effective. Percutaneous endoscopic gastrostomy (PEG) was introduced by Ponsky in 1990, and laparoscopic gastrostomy was introduced 10 years later. PEG rapidly replaced open gastrostomy as the method of choice for enteral nutrition. The laparoscopic alternative was ideal for patients who were not candidates for PEG placement. The laparoscopic or laparoendoscopic placement of enteral tubes allows visualization of the intestinal tract to ensure proper tube positioning. Many patients are not candidates for a PEG because of head and neck cancer, esophageal obstruction from stricture or carcinoma, large hiatal hernia, gastric volvulus, overlying intestine or liver, facial trauma with wired mandible, or severe stomatitis secondary to radiation therapy. Lastly, laparoscopy lessens the chance of injury to the surrounding structures, adhesions can be safely lysed, and metastatic or concomitant disease may be identified. This report will review the numerous methods available to the laparoscopic surgeon for gaining access to the stomach or intestine.

Alternative laparoscopic technique for cholecystectomy during pregnancy.

Laparoscopic cholecystectomy had been considered contraindicated during pregnancy. A few brief clinical reports have appeared in the literature, but no trials attesting to the safety to the fetus (and mother) have been published. Laparoscopic cholecystectomy during pregnancy has advantages for the mother in that it speeds her recovery, giving her less pain, and decreasing the chance of incisional hernias from large incisions. Using an open, Hasson technique combined with low-pressure pneumoperitoneum via an "abdominal wall lift," safety to the fetus is enhanced. Herein is described a laparoscopic cholecystectomy in a 14-week-pregnant woman under continuous epidural anesthesia and wearing sequential-compression-device hose; no untoward events occurred.

Bile leak from the liver bed following laparoscopic cholecystectomy.

Intraperitoneal accumulation of bile from accessory bile ducts following cholecystectomy is an uncommon, but well-described, occurrence. It is not unique to laparoscopic cholecystectomy. The presence of accessory channels between the liver and gallbladder has long been recognized by anatomists and surgeons. They are commonly known as the "ducts of Luschka". Recognition and treatment of liver bed bile leaks vary. Usually the surgeon can treat this problem without an exploratory celiotomy depending on availability of ERCP or interventional radiology. This article will review clinical diagnosis, radiologic confirmation, and treatment for this complication.

Carcinoma of a gallbladder polyp: treated by laparoscopic laser cholecystectomy.

To define the significance of polyps of the gallbladder, we undertook a retrospective review of all gallbladders removed over a 10-month period in our institution. The discovery of polyps are usually incidental and treated as benign. Polyps can form because of cholecystitis, cholesterolosis, hypertrophy of the epithelial lining (adenoma or papilloma), or carcinoma. Of 461 gallbladder specimens, 12 had polyps with one containing carcinoma, and two more specimens had carcinoma. All but one case were treated by laparoscopic cholecystectomy. Herein is described a case of a symptomatic patient presenting with a 1.1-cm polyp treated by laparoscopic laser cholecystectomy. An aggressive approach for gallbladder polyps with laparoscopy is proposed, especially in symptomatic patients or for polyps larger than 1 cm.

Bipolar versus monopolar cautery scissors for laparoscopic cholecystectomy: a randomized, prospective study.

The most efficacious energy source for laparoscopic surgery is constantly being debated. Monopolar electrocautery has gained wide popularity over laser energy because of its lower cost and ease of use. Bipolar current has been extensively used by gynecologists for peritoneoscopic surgery after reports of injuries from monopolar current. The purpose of this study was to compare bipolar scissors (Evershears, Everest Medical) and monopolar scissors (Endoshears, United States Surgical Corporation). Eighty patients were prospectively randomized as to the type of scissors to be used for dissection of the gallbladder from the liver bed during laparoscopic cholecystectomy. The scissors were evaluated subjectively with regard to cutting, coagulation, char, and smoke. The two groups were similar in age, sex, weight, blood loss, and hospital stay. Cutting ability and charring were equal. Coagulation was superior in the monopolar group. Smoke was much less with bipolar energy. Overall satisfaction was similar. We concluded that bipolar scissors are a good, safe device for dissection of the gallbladder from the liver bed during laparoscopic cholecystectomy and compare favorably with monopolar scissors.

Laparoscopic gastrostomy and jejunostomy: review of 22 cases.

Laparoscopic gastrostomy (LG) and laparoscopic jejunostomy (LJ) were performed successfully on 22 consecutive patients after development of the procedure on a porcine model. Patients did not undergo percutaneous endoscopic gastrostomies (PEG) due to obstruction from head and neck, esophageal cancer, gastropexy for gastric volvulus, perforated esophagus, failed PEGs, or surgeon's preference. Operative time averaged < 20.5 min. Five patients underwent the procedure under local anesthesia with intravenous sedation and three patients were operated on in a strictly outpatient setting. There was one postoperative death. LG and LJ are safe alternatives to open enterostomy in patients who cannot undergo PEG.

Gastroscopic-assisted laparoscopic wedge resection of B-cell gastric mucosa-associated lymphoid tissue (MALT) lymphoma.

Helicobacter pylori has been implicated as an etiologic agent for B-cell gastric mucosa-associated lymphoid tissue (MALT) lymphoma. This tumor is considered a low-grade entity with an associated indolent course. Some instances of tumor regression with adequate antibiotic treatment and irradication of H. pylori have been reported. Gastric malignancy and more specifically, lymphoma, should be considered in all patients with recurrent or nonhealing ulcers. Diagnostic and treatment strategies for these patients remain controversial. Two patients were evaluated, one for recurrent disease, another for a 3-cm nonhealing ulcer. Both patients refused total gastrectomy. Both patients underwent gastroscopy with simultaneous laparoscopic visualization. The mucosal lesions were identified and removed via laparoscopic stapled wedge resection. A combined endoscopic and laparoscopic approach can be considered as an alternative to radical surgery in the treatment strategy of these tumors. Wedge resection allows for staging and thorough pathologic classification. Further studies are necessary to define the natural history and the role of laparo-endoscopy in the diagnosis, staging, and treatment of B-cell gastric MALT lymphoma.

Laparoscopic gastrostomy.

Laparoscopic gastrostomy was performed successfully on six consecutive patients after the procedure was developed using a porcine model. These patients were unable to undergo percutaneous endoscopic gastrostomies because of obstruction from cancer or anatomical blockage. Operative time averaged less than 18 min. Three patients underwent the procedure under local anesthesia with intravenous sedation, and two patients were operated on in a strictly outpatient setting. No complications or deaths occurred. Laparoscopic gastrostomy appears to be a safe alternative to open gastrostomy in patients who cannot undergo percutaneous endoscopic gastrostomy.

Laparoscopic gastrostomy versus percutaneous endoscopic gastrostomy. A comparison.

A retrospective study was carried out at our institution to compare patients who underwent percutaneous endoscopic gastrostomy (PEG) to those who underwent laparoscopic gastrostomy (LG). There were 17 patients who had a PEG with a mean age of 81 years (43-97 years). The procedure time, including complete esophago-gastroduodenoscopy, averaged 28 min. There were four deaths (23%) in a 30-day period, but none of these were directly related to the procedure. The LG group consisted of 14 patients with a mean age of 66 years (20-94 years). Mean duration of the procedure was 18 minutes. Thirty-day mortality rate was 35% (five patients) with one death (7%) directly related to the tube. Indications for gastrostomy were similar in both groups, being predominantly inability to eat and/or recurrent aspiration. However, LG was done because of 4 technical failures, 5 patients with tumors of the head and neck, 2 patients with esophageal obstruction and radiation stenosis precluding safe PEG, and 1 patient with hiatal hernia; 2 LGs were performed at the surgeon's preference. Outcomes for LG and PEG were comparable. LG is a suitable, safe alternative to PEG in selected patients who cannot undergo gastroscopy and should be considered the procedure of choice in patients with head and neck tumors or intrathoracic pathology that prevents PEG.

Laparoscopic approach to gallstones in the morbidly obese patient.

Obesity has been suggested to be a contraindication to laparoscopic cholecystectomy (LC). In our center, in which all patients presenting with symptomatic gallstones are considered to be candidates for LC, 24 of the first 325 LC candidates were retrospectively found to be morbidly obese. In all, 20 were women and 4 were men. The average age was 51 years (range 32 to 83 years); the average height and weight amounted to 72 inches and 298 pounds, respectively, for men; and 63.5 inches and 258 pounds, respectively, for women. One-third of these patients suffered from acute cholecystitis, and more than 50% had undergone prior abdominal surgery. The average duration of LC in these subjects was 114 min., which was 25% longer than that in nonobese patients. The average length of the hospital stay was 1.6 days, with patients returning to normal activities within an average of 6.5 days. There was no major morbidity and no mortality. Since obese patients tolerated LC as easily as did normal patients, we concluded that obesity is an indication rather than a contraindication to LC.