[Anatomy of pelvic nerves and ileo-anal anastomosis]

The risk of sexual sequelae after proctectomy for inflammatory disease or polyposis is moderate, but real. The pelvic nerves can be easily spared at the sites where they are most frequently damaged, i.e. anterior to the sacral promontory and on the lateral walls of the pelvis. In contrast, damage to the cavernosal nerves situated on either side of the posterior surface of the prostate is more difficult to avoid, essentially because of the anatomy of these nerves is poorly understood.

Hepatectomy with initial suprahilar control of intrahepatic portal pedicles

In 1985 Couinaud described an original technique for left hepatectomy. This technique is based on initial control of the left intrahepatic portal pedicle after wedge incision of the hepatic capsule is made and the hilar plate is lowered before the hepatic parenchyma is opened. The vascular and biliary pedicular elements are dissected concomitantly at a point where they are protected by and contained within a sheath emanating from the hepatic capsule. After elective clamping of the pedicle at this level is done, the territory to be removed becomes obvious by the change of color produced by ischemia, and bleeding is minimized preventively. Although Couinaud's technique concerned only one case of left hepatectomy, we confirmed the ease, safety, and reproducibility afforded by this technique in four left hepatectomies. Based on the same principles, this technique may be used for other types of hepatic resections, notably, left hepatectomy extended to segments 5 and 8 (trisegmentectomies). We report our experience with this technique in 15 cases of major hepatic resections.

Local antibiotic prophylaxis in inguinal hernia repair

We compared the effects of single dose (750 milligrams) prophylactic cefamandole delivered directly into the operative wound with local anesthesia (n = 162) with a control group (no antibiotics) (n = 162) in a randomized trial. No adverse effects were observed. There were seven wound abscesses in the untreated group compared with none in the group receiving antibiotic prophylaxis (p = 0.007). Six of the seven abscesses occurred as late as one month after the patient was discharged from the hospital. The costs of antibiotics used were ten times less than the costs of treatment of wound complications in the control group.

Distal intramural spread of carcinoma of the rectum correlated with lymph nodal involvement

One hundred and nineteen operative specimens of carcinoma of the rectum were prospectively studied to evaluate distant microscopic intramural spread with respect to gross tumoral margins and to determine if the degree of spread was related to involvement of the lymph nodes. Eighty-eight of the 119 specimens (74 per cent) did not have intramural extension distal to the gross distal margin of the tumor. Twenty-five (21 per cent) had intramural extension of less than 5 millimeters from the gross distal limit of the tumor. In these instances, tumoral spread was contiguous. In six (5 per cent), tumoral spread was found at more than 5 millimeters from the gross distal margin of the lesion. In all six specimens, the tumoral extension was separated from the gross lesion by undiseased tissue, the foci being located between 5 and 15 millimeters from the distal margin of the lesion. Lymph nodal involvement was found in 19 of 88 lesions without distal intramural spread, in 14 of 25 tumors with intramural spread of less than 5 millimeters and in five of six with intramural extension of 5 millimeters or more, respectively. The difference was statistically significant. With respect to the same three categories of distal extension, more than one lymph node was involved in 11 of 88 lesions, six of 25 and five of six, respectively. This difference was also statistically significant. In the six instances with distal intramural extension, results of immunohistochemical staining demonstrated the presence of tumoral embolism in both the blood and lymphatic vessels. In carcinoma of the rectum, lymph nodal involvement and its multiplicity are directly related to the extent of intramural spread.

[Inguinal hernia. The Shouldice parietal repair]

Parietal repair according to the Shouldice technique consists of a double line of sutures on each of three musculo-aponeurotic layers of the groin, i.e. successively: plicature of the transverse muscle and attachments; aponeuroplasty by back-to-back suture of the internal and external oblique muscles, and plicature of the aponeurosis of the external oblique muscle. Parietal repair of this kind is only possible after wide dissection of the inguinal region. It can be performed under local anaesthesia during a short hospitalization period. Normal activity is rapidly resumed, and in the experience of those who favour this technique, the recurrence rate is a mere 1%.

Synchronous abdominotrans-sphincteric resection of low rectal cancer: new technique for direct colo-anal anastomosis

Sixty-five patients with low rectal cancer 4-9 cm from the anal margin were treated by rectal resection and direct colo-anal anastomosis. The procedure simultaneously combined abdominal dissection with the patient in the lateral position with a trans-sphincteric approach. In 57 cases a temporary defunctioning colostomy was performed. There were no postoperative deaths. Six patients (9 per cent) developed pelvic sepsis or anastomotic leakage. Faecal continence was normal in 46 of 51 patients (91 per cent) who were operated on at least 1 year previously. The remaining 5 complained of occasional minor soiling. No patients require a permanent colostomy for incontinence. Of 29 patients treated for potential cure greater than 3 years previously, 24 (82 per cent) were alive without recurrence. Local recurrence occurred in four patients (6 per cent). Direct colo-anal anastomosis using a combined abdominotrans-sphincteric approach has produced good functional results without impairing the patient's life expectancy.

Stapled colorectal anastomoses: peroperative integrity of the anastomosis and risk of postoperative leakage

Eighty-two patients underwent colorectal anastomosis using the circular mechanical stapling instrument. Integrity of the anastomosis was assessed intraoperatively by the air test and examination of doughnuts for completeness. A proctogram using a water soluble contrast preparation was performed in 79 patients postoperatively. In 68 patients doughnuts were complete and no air leak was found in any case. Postoperatively three clinical and one radiological leak occurred. In 14 patients at least 1 doughnut was incomplete. Of these, 4 had an air leak whilst 10 did not. There was no leak postoperatively in these 10 patients but 2 of the 4 patients with an intraoperative air leak developed a radiological leak postoperatively. The data suggest that the air test is useful since absence of air leakage in cases with an incomplete doughnut was followed by sound anastomotic healing. Further, the demonstration of air leakage enables immediate repair of the anastomosis perhaps avoiding subsequent clinical leakage.

Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum

Rectal resection with colo-anal anastomosis was performed in 65 patients with carcinoma of the lower rectum. In 20 a pelvic colonic reservoir was constructed while in 45 a direct anastomosis was carried out. There were no postoperative deaths and morbidity was comparable in the two groups. Functional results were determined by clinical examination and manometry. The frequency of bowel movements was inversely related to the maximum tolerated volume (P less than 0.001). During the first year 60 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two stools per day (P less than 0.05). After one year, 86 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two bowel movements per day (P less than 0.01). The maximum tolerated volume was increased by the reservoir (P less than 0.05). The loss of reservoir capacity of the rectum increases frequency of bowel movements in colo-anal anastomosis. The creation of a colonic reservoir improves function by increasing the maximum tolerated volume without any increase in mortality or morbidity.

[Treatment of inguinal hernia using Shouldice's technic]

The very high frequency of recurrence of inguinal hernia after surgical repair during the 30s led Earl Shouldice to devote his efforts to the study of this affection. In 1945 he opened an institution for the purpose of treatment of hernia, and since then a total of 130,000 operations have been performed. Progressive advances in the techniques used have enabled the relapse rate to be reduced to less than 1%, and the procedure used at the present time is described.

Early and late complications after endoscopic sphincterotomy for biliary lithiasis with and without the gall bladder 'in situ'

Endoscopic sphincterotomy has gained wide acceptance in the treatment of biliary lithiasis. We attempted endoscopic sphincterotomy in 443 patients and were successful in 407 (92%). Sphincterotomy was carried out with the gall bladder in situ in 234 cases (57%) of advanced age or high surgical risk. Immediate complications occurred in 7%, of which haemorrhage was the most frequent. The mortality rate was 1.5%. Three hundred and sixteen endoscopic sphincterotomies were performed more than six months before writing and follow up was available for 226 (72%) from six to 78 months. Late complications were observed in 16 patients with gall bladder 'in situ' (12%); the most frequent was cholecystitis in 6%. In five patients of the group without gall bladder, four had cholangitis related to retained or recurrent stones, and one restenosed . No episodes of cholangitis were observed in patients without stones despite reflux of barium up the biliary tree as observed during a barium meal examination.

[Evaluation of systemic antibiotic preventive treatment in colorectal surgery]

A comparison was made of two methods of prophylactic antibiotic therapy against the septic complications of colonic and rectal surgery: --preoperative oral antibiotics associated with peroperative systemic antibiotics; --peroperative systemic antibiotics only, continued for 24 hours after surgery. Both types of antibiotic therapy were of short duration and were designed to cover aerobic and anaerobic organisms. Two groups of 30 patients were selected at random. They were homogeneous. The septic complication rate was 10% in the oral plus systemic and 24% in the systemic group. It is felt that the combination of oral and systemic antibiotics remains preferable, in particular bearing in mind the efficacy of oral metronidazole.

Comparison between oral and systemic antibiotics and their combined use for the prevention of complications in colorectal surgery

Ninety patients were included in this prospective randomized trial. Each required electric colorectal surgery and was prepared for operation with oral preoperative antibiotic therapy, systemic peroperative therapy, or by a combination of both. The number of each type of septic postoperative complication and their total did not differ between the group treated by oral antibiotics prior to operation and the group treated peroperatively with systemic antibiotic therapy. The total number of septic complications (wall abscesses, fistulas, subdiaphragmatic abscesses, septicemia, peritonitis), however, was significantly less (P less than 0.05) in the group treated by both preoperative oral antibiotics and peroperative systemic antibiotic therapy (3.3 per cent) than in either groups treated only orally preoperatively (30 per cent) or by systemic antibiotic therapy during the operation (23 per cent). The combination of oral antibiotic therapy prior to operation and of systemic peroperative antibiotic therapy, therefore, presents the most effective prophylactic effectiveness.