[Naturopathy in rehabilitation--a logical option in the German health system]

The present restructuring of the German health system is a reaction to the changing demands resulting from demographic and financial developments. In this context, an increase in patients autonomy is urgently needed which is only possible in cooperation with this group. The rehabilitative sector of the health system with its biopsychosocial model of diseases offers still heavily overlooked solutions, in particular because of its extensive use of complementary medicine, which has a high degree of acceptance among patients and the general population.

Modified approach for apoptosis detection reveals changes in apoptotic processes in the seminoma-associated tissue

Apoptosis morphology (DNA condensation) and internucleosomal DNA cleavage (TdT assay) were measured simultaneously on double fluorescence labeled testis tumor sections, employing conventional immunofluorescence microscopy. Six different apoptosis indices (Al) were determined based either solely on morphological or biochemical criteria, or on a combination of both processes. Measurements were performed in metastasized and non-metastasized seminoma, and in histological regions located distantly and associated with the tumor. Preliminary results on 19 histologies revealed that up to 66% of apoptotic cells were not detected, depending on the method used for apoptosis detection. Besides, no changes of solely morphologically defined Al was found in the different histological regions. By contrast, significant changes (p < 0.0004) in the different histological regions were detected when measuring Als, e.g., defined by DNA fragmentation occurring without DNA condensation in apoptotic cells. Those changes were not detected in metastasized seminoma. These data, for the first time allow a comparison of two widely used approaches for apoptosis detection. Furthermore, the results revealed differences in apoptotic processes in tissue associated with non-metastasized seminoma detectable by a modified evaluated TdT assay but not by morphological changes, although this TdT method fails to show the total amount fo apoptotic cells.

Diagnosis and classification of inguinal hernias

BACKGROUND

The aim of this prospective clinical study was to determine whether the presence of a hernia, its size, and its type can be established preoperatively by clinical and ultrasound, examination.

METHODS

The study population comprised 220 consecutive patients referred to our department for the surgical management of an inguinal hernia. On admission, both inguinal regions were examined clinically and by ultrasound. All patients were operated on laparoscopically.

RESULTS

In regard to the intraoperative findings for both inguinal regions, clinical and ultrasound examination for the diagnosis of inguinal hernia yielded a high total rate of accuracy of 93% respective 94%. However, when the same methods were used to differentiate between lateral and medial hernia, the total rate of accuracy fell to only 54% respective 62%. In the determination of inguinal hernia size, it was even lower: 50% respective 53%.

CONCLUSIONS

Although a diagnosis of inguinal hernia can be established reliably by clinical and ultrasound examination, only an approximate classification is possible by these methods.

Significance of apoptosis in metastasizing testis tumors

Testis tumors of embryonal origin (ten metastasized, six non-metastasized) and 17 mixed testis cell carcinomas (eight metastasized, nine non-metastasized) were examined. A triple immunofluorescence microscopic labeling procedure allowed the simultaneous detection of two features of apoptosis, namely morphological changes in the nucleus (DNA condensation visualized by DAPI staining) and the process of DNA fragmentation (TdT-assay) in tumor cells as well as T-cells (recognized by their CD45RO epitope). Both methods for apoptosis detection showed similar apoptotic indices (AI) only in 2.6% of all tumors. Most tumors (81.6%) showed more cells with DNA fragments than condensed chromatin, but in a number of cases (10.5%) the opposite pattern was found. These data add to the few published in vivo examinations of apoptosis using different methods and help to explain differences in the judgment of apoptosis significance for tumor prognosis. With regard to tumorigenesis, non-metastasized testis tumors were characterized by higher AIs of tumor cells and T-cells compared with metastasized tumors, which could be interpreted as a characteristic of tumors in an earlier stage of their development into an apoptosis-resistant phenotype. For the first time, in metastasized tumors a 5 to 25-fold increase of the T-cell's AIs over the corresponding AIs of tumor cells was shown. This suggests a successful counterattack of tumor cells, thus supporting the process of metastasis. However, only ten out of 33 tumors revealed these AI changes, which again highlights that tumor biology cannot be predicted by a single parametric approach. It remains to be seen whether these characteristics might be suitable for a reliable prediction of metastasis.

Expression of retinoblastoma gene product in respiratory epithelium and sinonasal neoplasms: relationship with p16 and cyclin D1 expression

Transition from G1 to S phase of the cell cycle is mediated by interactions between the Retinoblastoma gene product (pRb), p16, and cyclin D1. To determine the expression of these proteins in the sinonasal mucosa immunohistochemistry was carried out on archived tissue sections from 46 patients (37 men, 9 women, age range 17 to 82 years, median 55 years). Nuclear immunostaining for these proteins was assessed and the expression rates (percentages of immunoreactive nuclei) in normal respiratory epithelium, inverted sinonasal papillomas, cylindrical (oncocytic) sinonasal papillomas, and squamous cell carcinomas were compared. Normal respiratory epithelium showed significantly higher pRb expression in surface cells compared to basal cells (p < 0.05). In contrast, abundant pRb expression in surface and basal cells was detected in columnar differentiation in sinonasal papillomas and adjacent mucosa. Cuboidal and squamous metaplasia in inverted papillomas showed significantly reduced pRb expression in surface cells compared to columnar epithelium in inverted papillomas (p < 0.05, respectively). Expression of p16 was detected in all epithelial cell layers of normal respiratory epithelium, sinonasal papillomas, and adjacent mucosa. Cuboidal and squamous metaplasia in inverted papillomas showed increased p16 expression in surface cells compared to columnar epithelium in inverted papillomas (p < 0.05 between squamous metaplasia and columnar epithelium). Sinonasal squamous cell carcinomas showed the coexpression of pRb and p16. Expression rates of cyclin D1 higher than 10% were detected only in invasive carcinomas but not in carcinoma in situ, sinonasal papillomas or respiratory epithelium. Conclusively, pRb expression accompanies terminal differentiation in columnar surface cells. Expression of pRb in proliferating basal cells is present in sinonasal papillomas and adjacent mucosa but not in normal respiratory epithelium. Cuboidal and squamous metaplasia in inverted papillomas involves downregulation of pRb expression along with increased p16 expression in surface cells. Sinonasal squamous cell carcinomas coexpress pRb and p16. Overexpression of cyclin D1 in sinonasal lesions is confined to invasive squamous cell carcinomas.

Laparoscopic transperitoneal procedure for routine repair of groin hernia

BACKGROUND

Laparoscopic transperitoneal hernioplasty (TAPP) repair of inguinal hernias is thought to be a difficult surgical technique with high complication rates. The present study evaluated TAPP based on prospective documentation.

METHODS

The primary aim of the study was analysis of the individual learning curve, comparing consultants with trainees. Secondary endpoints included postoperative morbidity, time of disability and rate of recurrence.

RESULTS

A total of 8050 TAPP repairs have been performed since 1993. By 2001, 99.9 per cent of all hernia repairs were done by TAPP. The median operation time dropped from 50 min in the first 600 cases to 42 min thereafter. The morbidity rate decreased from 9.3 to 2.6 per cent, and the rate of recurrence from 4.8 to 0.4 per cent. Within the same interval the proportion of training procedures increased from 1.7 to 44.9 per cent in 2001. Morbidity and recurrence rates were similar for trainees and consultants.

CONCLUSION

TAPP is an effective and safe technique. It can be performed in a standard way for all inguinal and femoral hernias. The present results indicate that TAPP is possible in a routine setting, as well as in the training situation for young surgeons.

Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1336 consecutive cases at a single center

BACKGROUND

We compare the use of unilateral and simultaneous bilateral laparoscopic hernioplasty [transabdominal preperitoneal patch (TAPP)]

METHOD

We employed a prospective consecutive single-center trial lasting from April 1993 to December 2000.

RESULTS

In our study, 5524 consecutive patients underwent 6860 laparoscopic hernia repairs. The median age in group A (unilateral repair, n = 4188) was 58 years (16-94 years), and that in group B (simultaneous bilateral repair, n = 1336) was 60 years (19-97 years) in (simultaneous bilateral repair, n = 1336). Morbidity in group A was 3.2% (135/4188) with a 0.6% reoperation rate (24/4188); in group B morbidity was 5.0% (67/1336) with a 1.4% reoperation rate. (19/1336). Morbidity and reoperation rates showed no statistically significant difference between the two groups in relation to number of repairs in group B. After a median 24-month clinical follow-up period (1-84 months) (follow-up rate 93.1%) 38 recurrences were observed in group A (0.9%) and 17 in group B (0.6%; 17/2672) (p = 0.2668). Median time off work was 14 days after unilateral (2-63 days) and 17 days after bilateral repair (3-100 days) (p = 0.1359). Pain levels (numerical analogue scale) and incidence of persistent inguinal and scrotal pain are not higher after bilateral repair.

CONCLUSION

Compared to unilateral repair, bilateral simultaneous laparoscopic hernia repair (TAPP) is safe, comfortable for patients, and cost-effective, without increased morbidity or recurrence risk. Bilateral inguinal hernia is an ideal indication for endoscopic transabdominal repair.

Patterns of p21(waf1/cip1) expression in non-papillomatous nasal mucosa, endophytic sinonasal papillomas, and associated carcinomas

AIMS

To clarify p21(waf1/cip1) expression in sinonasal lesions.

METHODS

Archived surgical specimens from 38 patients were investigated by means of immunohistochemistry. p21(waf1/cip1) staining was evaluated in the different layers of the epithelium. In addition, human papillomavirus (HPV) infection and p53 protein overexpression were assessed and correlated with p21(waf1/cip1) expression.

RESULTS

p21(waf1/cip1) staining was negative in non-papillomatous nasal mucosa. HPV infection and p53 protein overexpression were not seen. Sixteen of 20 inverted papillomas showed p21(waf1/cip1) expression. HPV infection was found in 16 cases and p53 protein overexpression was present in 13 specimens. Expression of p21(waf1/cip1) was restricted to surface cells in five cases, but involved basal/parabasal cells in 11 specimens. Immunoreactivity for p21(waf1/cip1) in basal/parabasal cells colocalised with p53 protein overexpression. Enhanced expression rates for p21(waf1/cip1) were seen in transitional and squamous epithelium compared with columnar epithelium. p21(waf1/cip1) expression involved only surface cells in cylindrical cell papillomas. HPV infection and p53 protein overexpression were detected in all specimens. One of five squamous cell carcinomas showed p21(waf1/cip1) expression. HPV infection was seen in two cases, and all carcinomas showed p53 protein overexpression.

CONCLUSIONS

Expression of p21(waf1/cip1) is associated with terminal differentiation in surface cells in inverted papillomas and cylindrical cell papillomas, but not in non-papillomatous nasal mucosa. Overexpression of p53 protein colocalises with p21(waf1/cip1) expression in basal/parabasal cells in inverted papillomas but not in cylindrical cell papillomas. Expression of p21(waf1/cip1) in squamous cell carcinomas involves a subset of tumours with p53 protein overexpression.

Cytokeratin expression and epithelial differentiation in Warthin's tumour and its metaplastic (infarcted) variant

AIMS

Warthin's tumour is characterized by a bilayered columnar epithelium. Transformation into metaplastic (infarcted) Warthin's tumour includes squamous metaplasia of the epithelium along with regressive changes in the stroma. Misinterpretation of metaplastic Warthin's tumour for malignancy is a serious diagnostic pitfall. This study assesses the utility of cytokeratin expression in Warthin's tumour and its metaplastic variant.

METHODS AND RESULTS

Twenty-six cases of Warthin's tumour, among them eight metaplastic Warthin's tumours, were investigated employing immunohistochemistry. Both Warthin's tumour and its metaplastic variant regularly expressed cytokeratins (CK) 7, 8, 18, and 19. Staining results with antibodies to CK10, 10/13, 1/2/10/11, and 20 were negative in all specimens. Immunoreactivity for CK 5/14 and 17 was restricted to basal cells in Warthin's tumour, but involved basal as well as surface cells in metaplastic Warthin's tumour.

CONCLUSIONS

Warthin's tumour and its metaplastic (infarcted) variant both express CK 7, 8, 18, and 19, which are typical for columnar differentiation. Cytokeratins typical of squamous differentiation are absent from Warthin's tumour and its metaplastic variant, irrespective of the squamous morphology of the epithelium in metaplastic Warthin's tumour. The expression of CK 5/14 and 17, which are typical of regenerative cells, is restricted to basal cells in Warthin's tumour, but is expressed also in surface cells in metaplastic Warthin's tumour.

Laparoscopic transperitoneal hernia repair of incarcerated hernias: Is it feasible? Results of a prospective study

BACKGROUND

Laparoscopic transperitoneal hernia repair (TAPP) has proved its efficiency in elective surgery. However, TAPP results with incarcerated hernias still are unknown.

METHODS

Data from a prospective study were evaluated with regard to TAPP repair for both chronically and acutely incarcerated hernias.

RESULTS

During a 6-year period, 220 incarcerated hernias were repaired (194 via TAPP). The median operation time for TAPP was 55 min. An accompanying resection therapy became necessary for only four of the emergency cases (11.1%) and two of the chronically incarcerated cases (1.3%) in the TAPP group. Postoperative morbidity was 2.8% in the emergency group and 3.8% in the chronically incarcerated group, which does not differ from the rate for TAPP used on reducible hernias. One recurrence was found 26 months after TAPP reconstruction (0.5%).

CONCLUSION

Laparoscopic inguinal hernia repair (TAPP) represents an efficient therapeutic concept in the treatment of both chronically and acutely incarcerated inguinal hernias.

Characterization of sequence determinants within the carboxyl-terminal domain of chemokine receptor CCR5 that regulate signaling and receptor internalization

The CC chemokine receptor CCR5 mediates chemotaxis of leukocytes and serves as a principal co-receptor for macrophage-tropic human immunodeficiency virus type 1. To identify determinants on the CCR5 carboxyl-terminal domain that regulate receptor signaling and internalization, we generated several CCR5 mutants, which were progressively shortened from the COOH terminus or had carboxyl-terminal serine, cysteine, or leucine residues substituted by alanine and expressed them in RBL-2H3 cells. Using fluorescence resonance energy transfer between beta-arrestin and CCR5 tagged with cyan and yellow variants of green fluorescent protein, we show that high affinity association of the two molecules in living cells requires intact carboxyl-terminal serine phosphorylation sites. Phosphorylation-deficient truncation or Ser/Ala replacement mutants of CCR5 mediated a sustained calcium response and enhanced granular enzyme release in RANTES-stimulated cells. Carboxyl-terminal serine residues are critically involved in CCR5 endocytosis and a dileucine motif, similar to that implicated in the regulation of CXCR2 and CXCR4, contributes to the internalization of CCR5 in a phosphorylation-independent manner. Despite their prominent role in receptor desensitization and internalization, beta-arrestins are dispensable for the CCR5-mediated stimulation of mitogen-activated protein kinase pathways in RBL-2H3 cells. We also show that CCR5 is palmitoylated on carboxyl-terminal cysteine residues. Inhibition of CCR5 palmitoylation by alanine mutagenesis of cysteines or treatment with a palmitate analogue inhibitor profoundly reduces phorbol 12-myristate 13-acetate- and RANTES-induced receptor phosphorylation, homologous desensitization, and internalization. Alanine mutagenesis of serine, cysteine, or leucine residues or the limited carboxyl-terminal truncation of CCR5 did not impair chemokine-stimulated migration of RBL-2H3 cells. Together these results indicate that post-translational modifications of carboxyl-terminal serine and cysteine residues have a significant impact on receptor deactivation and internalization.

Differentiation-related p53 protein expression in nondysplastic sinonasal inverted papillomas

To clarify p53 protein expression in nondysplastic sinonasal inverted papillomas, archived surgical specimens from 19 patients were studied using immunohistochemistry. Staining results were compared between inverted papillomas and adjacent, nonpapillomatous nasal mucosa. Further, immunoreactivity was compared between columnar (respiratory), transitional (cuboidal), and squamous epithelium in inverted papillomas. Positive staining was found in 17 of 19 inverted papillomas (89%). Immunoreactivity involved predominantly basal and parabasal cells and was either comparable or higher in inverted papillomas compared with adjacent mucosa. In 65% of immunoreactive inverted papillomas comparable staining results were seen between columnar (respiratory), transitional (cuboidal), and squamous epithelium. In 35% of p53 protein-positive inverted papillomas, enhanced immunoreactivity was observed in transitional (cuboidal) and squamous epithelium compared with columnar (respiratory) epithelium. Within these cases, immunoreactivity was either comparable or higher in squamous compared with transitional (cuboidal) epithelium. Conclusively, the expression of p53 protein is present in 89% of nondysplastic sinonasal inverted papillomas and also involves the adjacent, nonpapillomatous nasal mucosa. A tendency toward increasing p53 protein expression from nonpapillomatous nasal mucosa to inverted papilloma as well as along the metaplastic process from columnar (respiratory) to transitional (cuboidal) and finally squamous epithelium within inverted papillomas can be postulated.

Coexpression of cytokeratins typical for columnar and squamous differentiation in sinonasal inverted papillomas

Cytokeratin (CK) expression was studied in 22 sinonasal inverted papillomas. Columnar (respiratory) epithelium in inverted papillomas abundantly expressed CK7, CK8, CK18, and CK19. Immunoreactivity for CK5/14 and CK17 was found in basal and parabasal/suprabasal cells. Transitional (cuboidal) and squamous epithelium in inverted papillomas comparably expressed CK7, CK8, CK18, and CK19. In addition CK13 was found in subluminal and surface cells. Immunoreactivity for CK5/14 and CK17 involved all layers of the epithelium. In nonpapillomatous nasal mucosa adjacent to inverted papillomas, CK expression in columnar (respiratory) epithelium exactly matched the findings in inverted papillomas. Transitional (cuboidal) and squamous epithelium in nonpaillomatous mucosa were negative for CK7, CK8, CK18, and CK19. CK13 was expressed in subluminal and surface cells. Immunoreactivity for CK5/14 and CK17 was restricted to basal and parabasal/suprabasal cells. Conclusively, transitional (cuboidal) and squamous epithelium in inverted papillomas but not in the adjacent mucosa coexpress CKs typical for columnar and squamous differentiation.

Stability of aneuploid clones during oral squamous cell carcinoma metastasis

BACKGROUND

The development of aneuploid clones contributes to the expression of metastatic growth properties in head and neck squamous cell carcinomas. Controversy persists as to whether aneuploid clones acquire an autonomous metastatic potential or instead activate diploid tumor cells to disseminate.

PATIENTS AND METHODS

DNA flow cytometry was performed on 73 primary oral squamous cell carcinomas and their synchronous lymph node metastases as well as on 20 other patients who experienced delayed manifestation of occult lymph node involvement.

RESULTS

Diploidy for both the primary and metastatic tumor was recognized in 6.5% of patients; 5.4% showed a shift from diploidy to aneuploidy while 3.2% had aneuploid tumors that associated with diploid metastases. Aneuploid clones in corresponding lesions were identified in 84.9% of cases. Despite the wide variation of individual DNA contents, 86.1% of the latter group expressed aneuploid clones with identical DNA indices in both the primary and metastatic tumors. The stability of initially established aneuploid clones was monitored even after 58 months of occult metastasis growth.

CONCLUSION

Lymph node metastases preferentially originate from pre-existing aneuploid tumor clones.

Prognostic value of graph theory-based tissue architecture analysis in carcinomas of the tongue

Several studies on oral squamous cell carcinomas (OSCC) suggest that the clinical value of traditional histologic grading is limited both by poor reproducibility and by low prognostic impact. However, the prognostic potential of a strictly quantitative and highly reproducible assessment of the tissue architecture in OSCC has not been evaluated. Using image analysis, in 193 cases of T1-2 (Stage I-II) OSCC we retrospectively investigated the prognostic impact of two graph theory-derived structural features: the average Delaunay Edge Length (DEL_av) and the average homogeneity of the Ulam Tree (ELH_av). Both structural features were derived from subgraphs of the Voronoi Diagram. The geometric centers of the cell nuclei were computed, generating a two-dimensional swarm of point-like seeds from which graphs could be constructed. The impact on survival of the computed values of ELH_av and DEL_av was estimated by the method of Kaplan and Meier, with relapse-free survival and overall survival as end-points. The prognostic values of DEL_av and ELH_av as computed for the invasive front, the superficial part of the carcinoma, the total carcinoma, and the normal-appearing oral mucosa were compared. For DEL_av, significant prognostic information was found in the invasive front (p < 0.001). No significant prognostic information was found in superficial part of the carcinoma (p = 0.34), in the carcinoma as a whole (p = 0.35), or in the normal-appearing mucosa (p = 0.27). For ELH_av, significant prognostic information was found in the invasive front (p = 0.01) and, surprisingly, in putatively normal mucosa (p = 0.03). No significant prognostic information was found in superficial parts of the carcinoma (p = 0.34) or in the total carcinoma (p = 0.11). In conclusion, strictly quantitative assessment of tissue architecture in the invasive front of OSCC yields highly prognostic information.

Update: what is left for laparoscopic hernia repair?

The risks, benefits and costs of laparoscopic hernia repair are still being debated. According to a current survey on the situation of hernia surgery in Germany in 1996, laparoscopic hernioplasty was done in about 60% of the answering hospitals; about a quarter of all hernia repairs are done laparoscopically. Since April 1993, about 2, 700 laparoscopic hernia repairs were done at Marienhospital Stuttgart. The operating time was on the average 50 min. The rate of complications was about 3%. The postoperative period of disablement was a median of 20 days; included in this time was the postoperative hospital stay. The recurrence rate was about 1%. It is remarkable that laparoscopic hernia repair was equally efficient in repairing unilateral primary hernias, recurrent hernias or bilateral hernias. The cost analysis showed that the application of multipath articles will make the operation costs of laparoscopic hernia repair only about DM 100 higher than for a conventional operation.

[Laparoscopic hernia therapy (TAPP) as a teaching operation]

INTRODUCTION

Because of an increasing number of endoscopic hernia procedures, it is important to look into the possibility of standardizing these techniques helping surgeons to acquire the operative skills necessary.

MATERIAL AND METHODS

To discuss these aspects, the documented data on TAPP operations that have been carried out in this department since 1993 were analyzed. The results of teaching procedures were compared with those of experts after they had gotten past the learning and development curve.

RESULTS

A total of 778 teaching procedures were performed by 10 surgeons with an individual experience of 30.5 operations (median). Before starting the first procedure, 89 were done by assistants operating the camera. The morbidity of teaching operations was 1.9% compared to 1.4% for those performed by experts. After a median follow-up of 23 months there were two recurrences (0.23%) in the expert group and none in the teaching group (follow-up 16 months).

CONCLUSION

Because of the potentials of standardization of the TAPP technique, the results of teaching were equal to expert operations. Therefore, TAPP is suitable for application in a routine setting.

[Neurinoma of the nasal cavity]

A 35 years old male patient presented with serous nasal secretion, relapsing epistaxis and a slowly progredient nasal obstruction. Clinical examination and CT scans showed a tumor occupying the left middle meatus and the whole nasal cavity displosing the nasal septum to the right side. The tumor was resected by a midfacial degloving approach. Histological examination showed a neurinoma. By means of the presented case report and a review of literature, diagnosis and treatment of this rare nasal tumor are discussed.

Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation

BACKGROUND

Even though the introduction of endoscopic surgical techniques to inguinal hernia therapy dates back 10 years, only a few data exist concerning the problem of development of a recurrence after endoscopic repair. Similarly there are only anecdotal reports on the feasibility of an endoscopic reintervention for this situation. For the first time we are able to present data of a prospective study on both issues.

STUDY DESIGN

We analyzed the data of a prospectively documented series of 46 transperitoneal hernia repair reinterventions after endoscopic hernia repair. In 33 patients from our own clinic we evaluated the cause of recurrence after transperitoneal hernia repair. Together with these and 13 more patients sent to us from external clinics we examined the efficiency of an endoscopic reoperation.

RESULTS

When implanting a 13 x 8-cm mesh with an incision (phase I) we found the main cause of recurrence to be that the mesh was too small (47.4%) and the region of the mesh incision was insufficient (42.1%). After a change to a 15 x 10-cm implant without incision (phase II) the main cause of recurrence was found to be a mesh dislocation (38.9%) and the rate of recurrence dropped from 2.8% (phase I) to 0.36% (phase II). The transperitoneal reoperation lasted for a median of 75 minutes (range 45 to 170 minutes) for the medial recurrence and a median of 110 minutes (range 65 to 190 minutes) for the lateral recurrence (p = 0.009). The total rate of complications was 10.9%, and the rate of re-recurrence was 0% after a median followup of 26 months (range 2 to 72 months).

CONCLUSIONS

To avoid hernia recurrence after transperitoneal hernia repair operations a sufficiently large mesh (at least 15 x 10 cm) has to be implanted, preferably without an incision, after an extensive parietalization. The endoscopic reoperation for recurrence can be done only in a transperitoneal way and is effective with comparably low complication rates. The procedure is significantly easier for a medial recurrence compared with a lateral recurrence. This method of reoperation should be reserved for endoscopically experienced surgeons.

Long-term results of a randomized clinical trial between laparoscopic hernioplasty and shouldice repair

BACKGROUND

At present only short-term follow-up data are available to compare endoscopic and conventional hernia surgery. This paper presents data from a randomized study 6 years after initial recruitment.

METHODS

In 1993 a randomized comparative study of transabdominal preperitoneal (TAPP) and Shouldice repair was commenced. Endpoints were rate of recurrence, late complications, complaints and patient satisfaction.

RESULTS

The rate of recurrence in the TAPP group was one (2 per cent) of 48 patients and in the Shouldice group two (5 per cent) of 43. Only five patients in the Shouldice and three in the TAPP group reported slight discomfort in the inguinal region at 6-year follow-up. In neither group was chronic pain syndrome observed. Altogether, 46 (96 per cent) of 48 patients in the TAPP group and 35 (81 per cent) of 43 of those having the Shouldice procedure stated complete satisfaction with the hernia repair.

CONCLUSION

Long-term evaluation demonstrated greater satisfaction with the result of the repair in the endoscopic group. The difference between the groups in the recurrence rate was not significant, because of the small numbers. The TAPP method appears to be an effective surgical alternative in patients with inguinal hernia.