Scrotal hernias: a contraindication for an endoscopic procedure? Results of a single-institution experience in transabdominal preperitoneal repair

INTRODUCTION

Endoscopic repair was introduced for use with inguinal hernia therapy more than 10 years ago. The technique as well as the indications for this method are debated, however. As a borderline inguinal hernia situation, the scrotal hernia in particular evokes vehement objections to an endoscopic procedure because of the anticipated problems and complications in dissecting the extended hernia sac. The efficiency of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of scrotal hernia therefore is discussed in this article.

METHODS

Laparoscopic hernia repair (TAPP) has been performed in our department since 1993. Data are collected by a prospective documentation of operative and follow-up results. For evaluation, a comparison of scrotal and normal hernia repair was performed.

RESULTS

Between April 1993 and June 1998 the TAPP technique was used to treat 191 scrotal hernias, 42 (22%) of which were recurrent hernias. The median operating time for a normal inguinal hernia repair was 45 min, whereas scrotal hernias required a median of 65 min and irreducible scrotral hernias a median of 68.5 min. Major complications were observed in 1.6% of scrotal and 0.6% of normal inguinal hernia repairs. The most frequent scrotal hernia repair problem was the formation of a seroma, 10.5% of which had to be evacuated. During a follow-up period of 30 months, we found a total of two recurrences (1.05%).

CONCLUSION

In scrotal hernia repair, TAPP is not associated with higher complication rates and can be performed with efficiency comparable with that in normal inguinal hernia repair.

[Surgical therapy of colonic diverticulitis--how reliable is primary anastomosis?]

INTRODUCTION

The aim of the study was to evaluate the modern principles of surgery in diverticulitis, e.g. early elective resection and primary anastomosis.

METHODS

The data of 445 consecutive patients were retrospectively analysed after classifying all cases in four subgroups according to a modified Hinchey classification (stages 0-III).

RESULTS

Within our study group the morbidity was 26.5% (n = 118) and the mortality was 1.6% (n = 7). In 96% (n = 425) of all cases and in 64% (21/33) of patients with perforated diverticulitis and peritonitis (stage III), a primary anastomosis was performed. Four patients of the study group showed insufficient anastomosis (0.9%). No leakage was observed from any of the anastomoses performed in stage III diverticulitis. Stage of inflammation and age of patient correlate with morbidity and mortality. Some 53% (94/177) of the patients in stage II and 67% (22/33) of the patients in stage III had never showed symptoms of diverticulitis before.

CONCLUSION

Prophylactic surgery to avoid life-threatening situations, including abscess formation or perforation, is not possible in many cases. However, especially patients at risk (age, coexisting illness) should undergo early surgery. Primary anastomosis can be performed safely even at an advanced stage.

Laparoscopic hernia repair -- the facts, but no fashion

BACKGROUND

For about 10 years now, laparoscopic hernia surgery has been introduced as an additional mode of therapy in the treatment of inguinal hernias. This method is being reproached with higher costs of surgery and rate of complications, as well as missing long-term results.

MATERIALS AND METHODS

Within a literature research, data from 25 randomised trials and 16 prospective observational studies on endoscopic and conventional hernia surgery were evaluated. Statistics were calculated using the chi2 test.

RESULTS

Compared with the conventional suture technique and tension-free surgery, the endoscopic repair proved to be advantageous with regard to postoperative pain and period of disablement. There was no significant difference between the methods when evaluating the rate of complications. In two randomised trials, there was a significant difference in favour of endoscopic repair with regard to the recurrence rates, whereas in the other studies a significant difference could not be shown. In the prospective series, recurrence rates were 0.71% for totally preperitoneal repair (TEP) and 1.06% for transabdominal preperitoneal repair (TAPP) repair.

CONCLUSION

Endoscopic hernia surgery (TAPP and TEP) represents an efficient method of treatment in the therapy of inguinal hernias. Recurrent and bilateral hernias can be seen as an absolute indication for endoscopic repair.

Laparoscopic surgery complications associated with trocar tip design: review of literature and own results

In the last 10 years, there has not been an abdominal surgical procedure that has not been performed by laparoscopic means. The enthusiasm of surgeons active in this field often neglects problems, especially with basic instruments which are important vehicles for the laparoscopic technique. The purpose of this study was to focus on trocar-related problems with special respect to the tip design. On the basis of a prospective study of laparoscopic transperitoneal hernia repair (TAPP) and laparoscopic Nissen fundoplication, we evaluated our data concerning trocar-related complications at the abdominal wall. We compared two groups of patients treated in a nonrandomized design with either sharp cutting single-use trocars or cone-shaped non-cutting reuseable trocars. The evaluation of our own data showed an incisional hernia in 1.83% of patients treated with a sharp trocar tip, a complication which could be significantly lowered, to 0.17%, with a conic tip design. Similar results could be seen with trocar-related bleeding events at the insertion site in the abdominal wall. In most publications, trocar design and related complications are unmentioned. Our data demonstrate a reasonable benefit for a conic tip design, which enables atraumatic insertion through the abdominal wall. The reuseable steel version furthermore holds a considerable cost-saving potential.

Nemaline myopathy and cardiomyopathy

A case report is presented in which a 4-year-old male is diagnosed with hypertrophic cardiomyopathy, respiratory distress, muscle hypotonia, and psychomotor retardation. Electron microscopic study of skeletal muscle biopsy revealed pathologic changes typical of congenital nemaline myopathy, and biochemical analysis revealed a disorder of mitochondrial fatty acid oxidation. Therefore a previously undescribed combination of a structural and metabolic myopathy is reported.

[Biliary pancreatitis--epidemiology, progress with a new therapy concept?]

In our patients with symptomatic cholelithiasis (n = 3618 in a 6-year period), we found biliary pancreatitis in 4.4% (0.4% severe pancreatitis). Because of therapeutic splitting (ERC/EPT, followed by laparoscopic cholecystectomy), we are able to reduce the hospital stay by about 60%, reduce morbidity significantly (P < 0.05) and reduce lethality.

Fine structural analysis of extraocular muscle spindles of a two-year-old human infant

PURPOSE

To clarify whether structural peculiarities formerly described in extraocular muscle (EOM) spindles of aged persons are already present in EOM spindles of a 2-year-old infant.

METHODS

Distal halves of two EOMs obtained from a 2-year-old multiorgan donor were immersion-fixed and prepared for electron microscopy. The fine structure of 10 muscle spindles and of 1 "false spindle" was investigated.

RESULTS

Extraocular muscle spindles of an infant 2 years of age had 2- to 4-layered outer capsules, 376 microm (range, 217-606 microm) long and 97 microm (range, 55-140 microm) wide. In 10 EOM spindles, 4 to 16 intrafusal muscle fibers (mean, 7.9) were present. From a total of 79 intrafusal fibers, 43 (54%) were nuclear chain fibers, and 8 of the 43 exhibited posttraumatic degenerative changes. Thirty-six (46%) intrafusal fibers indistinguishable from extrafusal fibers were called anomalous fibers. No nuclear bag fibers were found. Each muscle spindle contained a variable number of chain fibers and at least one anomalous fiber. Sensory nerve terminals were restricted to the 35 normal chain fibers but were absent from damaged chain fibers and from anomalous fibers. One "false spindle" without a periaxial space was composed of three anomalous fibers and one chain fiber, all of them devoid of sensory terminals.

CONCLUSIONS

Most structural particularities of human EOM spindles described in aged persons are already found in the infant. They cannot be interpreted as age-related changes, but rather they represent specific features of human EOM spindles.

[Risks and benefits of laparoscopic hernia-plasty (TAPP). 5 years experiences with 3,400 hernia repairs]

In the present study, for the first time the aspects of risk, benefit and the costs of laparoscopic hernioplasty in the transabdominal technique with preperitoneal placement of a polypropylene mesh are examined prospectively in a very large group of patients with 3,400 hernia repairs. The median operation time was 45 min for unilateral primary hernias, 50 min for unilateral recurrent hernias and 76 min for bilateral hernias. The frequency of complications showed a significant dependence on the individual steps in the development of the method and the individual learning curve. The same is true for the rate of recurrency. Whereas initially the rate of serious complications was 2.75%, the rate of minor complications 11% and the rate of recurrences 4.5% the corresponding figures are at present 0.4%, 4.4% and 0.5%. Laparoscopic hernioplasty proved to be equally as effective in the treatment of primary hernias, recurrent hernias and bilateral hernias. The large number of 11 surgeons participating proves that laparoscopic hernioplasty can be learned and that even in a teaching hospital it can be performed safely, efficiently and cost-effectively.

Increased sensitivity to rocuronium and atracurium in mitochondrial myopathy

PURPOSE

To describe the prolonged effect of the intermediate-acting, non-depolarising neuromuscular blocking agents rocuronium and atracurium in a 29-yr-old apparently healthy woman.

CLINICAL FEATURES

Because of abdominal pain the patient was scheduled for explorative laparoscopic pelvic examination. General anaesthesia was induced with fentanyl, midazolam and propofol. Muscle relaxation was achieved with 0.6 mg.kg-1 rocuronium. Anaesthesia was maintained with nitrous oxide and propofol. Two Hz train-of-four stimulation every 15 sec evoked no twitch responses until 60 min after rocuronium. Further relaxation was achieved with 0.075 mg.kg-1 atracurium after which twitch responses recurred after 45 min. Fifteen minutes later neuromuscular blockade was successfully reversed with atropine and neostigmine. The postanaesthetic course was uneventful. Because of the increased sensitivity to rocuronium and atracurium the patient was re-evaluated postoperatively. History revealed occasional double vision, fatigue, muscle cramps, stiffness and myoglobinuria. Clinical neurological examination showed ptosis, tremor, ataxia and bradydiadochokinesia. A standardised lactate stress testing on a bicycle was pathological and, after muscle biopsy, the diagnosis of mitochondrial myopathy was established.

CONCLUSION

An increased sensitivity to rocuronium and atracurium may occur in patients with mitochondrial myopathy. In these patients appropriate dosing of muscle relaxants and adequate monitoring of the neuromuscular blockade are required. If an increased sensitivity to rocuronium and atracurium occurs in an apparently healthy subject, further neurological investigations should follow.

A single institution's experience with transperitoneal laparoscopic hernia repair

BACKGROUND

Previous evaluations of endoscopic hernia surgery mostly are based on small prospectively documented series or on a few randomized comparative studies. In the following, results of a large single-institution experience concerning the transabdominal preperitoneal patch (TAPP) technique with regard to the development of methods and the routine use are described.

METHODS

From April 1993 to March 1997, 2,700 TAPP procedures were performed at the Department of General and Visceral Surgery, Marien-hospital, Stuttgart, Germany. The follow-up was documented prospectively in all cases by use of computed data base.

RESULTS

The majority of patients (83.8%) were operated because of primary hernias. In 17.2% a first or multiple recurrence of an inguinal hernia was indicated. At a median postoperative observation period of presently 20 months and a follow-up rate of 86.5%, 28 recurrences have been determined so far (total recurrence rate 1.03%), 6 of which occurred after a recurrent hernia reparation (1.33%) and 22 after primary hernia repair (0.97%). The most common cause for recurrence was in 39.3% a mesh (12 x 8 cm) being too small. The total complication rate was 4.6%; as an expression of the learning curve it was reduced from 7.8% (operations 1 to 500) to 2.8% (operations 2,200 to 2,700).

CONCLUSIONS

According to our experience, the TAPP technique is sufficiently applicable as a standard method for an unselected group of patients in a routine setting. It is especially suited to the repair of recurrent and bilateral hernias as well as for patients with a high risk for recurrence that can profit from a tension-free endoscopic procedure, particularly in case of obesity.

Influence of the Glass-Transition Temperature and the Chromophore Content on the Grating Buildup Dynamics of poly(N-vinylcarbazole)-based Photorefractive Polymers

The influence of the glass-transition temperature T(g) and the electro-optical chromophore content on the grating buildup dynamics in photorefractive polymer composites is investigated. The response times were found to be strongly dependent on both parameters. In the low-T(g) regime, composites of different chromophore content respond similarly quickly (200-500 ms), whereas significant differences occur for T(g) above the measurement (room) temperature. The composites with the highest chromophore content give the best steady-state performance; however, their response is much slower than that for those containing less chromophore.

[Laparoscopic hernia repair: prevention and therapy of complications]

Following the surgical steps in laparoscopic (transperitoneal) hernia repair, the corresponding groups of complications relate to: (1) laparoscopy; (2) the trocars; (3) the dissection of the inguinal region; (4) the hernia sac dissection; (5) the mesh placement; (6) the peritoneal closure. Inadequate surgical technique can lead to injuries of the intestine, urinary bladder and blood vessels; peri- and postoperative bleeding and hematoma; severing of testicular blood vessels, with consecutive testicular atrophy; and nerve lesions when fixing the mesh with clips and intestinal obstruction subsequent to insufficient peritoneal closure. With an adequate surgical technique, complication rate is very low. Preconditions for this are: strict compliance with the safety tests, when establishing the pneumoperitoneum; application of blunt conical trocars; precise knowledge of the anatomy; gentle dissection in the avascular tissue layers; subtle hemostasis; absolutely no diffuse electrocoagulation or placement of any clips below or up to 1 cm above the ileopubic tract; and safe peritoneal closure by suture under reduced intraabdominal pressure.

Targeted inactivation of plectin reveals essential function in maintaining the integrity of skin, muscle, and heart cytoarchitecture

Previous studies suggest that plectin, a versatile cytoskeletal linker protein, has an important role in maintaining the structural integrity of diverse cells and tissues. To establish plectin's function in a living organism, we have disrupted its gene in mice. Plectin (-/-) mice died 2-3 days after birth exhibiting skin blistering caused by degeneration of keratinocytes. Ultrastructurally, hemidesmosomes and desmosomes appeared unaffected. In plectin-deficient mice, however, hemidesmosomes were found to be significantly reduced in number and apparently their mechanical stability was altered. The skin phenotype of these mice was similar to that of patients suffering from epidermolysis bullosa simplex (EBS)-MD, a hereditary skin blistering disease with muscular dystrophy, caused by defects in the plectin gene. In addition, plectin (-/-) mice revealed abnormalities reminiscent of minicore myopathies in skeletal muscle and disintegration of intercalated discs in heart. Our results clearly demonstrate a general role of plectin in the reinforcement of mechanically stressed cells. Plectin (-/-) mice will provide a useful tool for the study of EBS-MD, and possibly other types of plectin-related myopathies involving skeletal and cardiac muscle, in an organism amenable to genetic manipulation.

Muscle transformation of the sartorius muscle in a canine model: clinical impact for electrodynamic graciloplasty as a "neosphincter"

PURPOSE

Transformation of fast-twitching skeletal muscles to slow-twitching, slowly fatigable muscles has become of clinical interest in the recent past. Transposition and transformation of the gracilis muscle to use it as a substitute for a resected or defected anal sphincter (graciloplasty) have been reported as achieving promising results in the treatment of fecal incontinence caused by sphincter defects or following abdominoperineal anorectal excision for cancer.

METHOD

This experimental study used a canine model and the sartorius muscle to evaluate the functional efficiency of two different configurations of the muscle loop to compare the presently applied transformation program (8 weeks) with a shorter (5 weeks) protocol. In six beagle dogs, both sartorius muscles were wrapped around two stomas, either in an alpha fashion or in the so-called split-sling technique. Muscle transformation was achieved by controlled neuromuscular stimulation either during eight (Program A) or five weeks (Program B). After completion of the transformation period, the function of the muscle slings was evaluated by manometry, and histomorphologic evaluation of the sartorius muscles was performed.

RESULTS

It was shown that muscle transformation led to a slowly fatigable muscle that made it possible to perform continuos (tetanic) contraction, regardless of the configuration or the duration of the transformation. Median pressures created by these muscles also did not differ significantly. In accordance with these functional findings, the histologic evaluation showed the typical, significant increase of Type I fibers in both muscle slings and following both transformation protocols. Although the decrease of fast-twitching Type II fibers was more pronounced following the conventional (8 weeks) program, this finding did not influence the functional results.

CONCLUSIONS

Results of our experiment indicate the possibility for using a shorter transformation protocol for transformation of the gracilis muscle during graciloplasty in the clinical setting. Furthermore, the efficacy and safety of the modified (split-sling) wrap technique was demonstrated.

Spatial distribution of beta-spectrin in normal and dystrophic human skeletal muscle

Spectrin, a major component of the erythrocyte membrane skeleton, has previously been shown to form a two-dimensional lattice in erythrocytes, and in avian or chicken skeletal muscle. Those results were mainly obtained with antibodies against alpha-spectrin. Using immunofluorescence of semithin cryosections and single muscle fiber preparations, we show here that beta-spectrin forms a costameric network which covers the plasma membrane of human skeletal muscle. These spectrin costameres are correlated with the Z-bands. They are longitudinally connected by fine strands and interrupted by myonuclear lacunae. Under mechanical stretching, the costameres retained their correlation to the Z-bands in normal and dystrophin-deficient muscle, up to the point at which the sarcolemma was disrupted. In stretched muscle, in some regions of the stretched fibers in which the costameres seemed to form double strands, the usually 1:1 correlation of spectrin to the Z-bands changed to a 2:1 relation. In dystrophin-deficient muscle, the costameric scaffold of spectrin in the well-preserved fibers appeared normal, indicating that spectrin can be correctly localized in the absence of dystrophin and that the subcellular spectrin organization does not primarily depend on dystrophin expression. The regular organization and the correlation of spectrin costameres to the Z-bands was notable even in stretched Duchenne muscular dystrophy (DMD) muscle. On the other hand, single teased muscle fibers of DMD muscle showed various degrees of morphological alterations of the costameric network, ranging from a focal disarray to complete loss of costameric organization. Because these findings indicate that the costameric spectrin scaffold undergoes secondary changes during the course of the dystrophic process in dystrophin-deficient muscle, spectrin staining of isolated muscle fibers may also serve as a tool to monitor the effect of gene therapy experiments at the single fiber level.

[Laparoscopic cholecystectomy in therapy of acute cholecystitis: immediate versus interval operation]

From January 1991 to May 1996 a total of 3,010 cholecystectomies was performed for cholelithiasis. Pathohistologically an acute cholecystitis was found in 483 patients (16%). The overall proportion of laparoscopic operations has increased from 12.5% in 1991 to 96.6% at present. In patients with acute cholecystitis the proportion of laparoscopic operations has increased from initially only 1.87% up to 83.3%. The duration of surgery (81 min versus 54 min), rate of conversion (12% versus 1.07%) and rate of complications (7.76% versus 2.2%) were all significantly higher in cases of acute cholecystitis than in those without inflammation. There was no mortality in either group. Furthermore no significant difference was found between patients with histopathologically proven acute inflammation and patients with an acute episode of chronic cholecystitis. The duration of complaints, however, had a significant influence on surgical results. In patients that were either operated on within 48 h after the onset of disease or more than 10 days later, the length of the operation was shorter and the rates of conversion and complications were lower. Our results prove that laparoscopic cholecystectomy is also very successful in cases of acute cholecystitis, though a long learning curve has to be expected. Taking efficiency and economy into consideration, surgery within a few days of the onset of disease must be recommended.

Duodenum-preserving pancreatic head resection: Long-term results

Early and late results from 298 patients with chronic pancreatitis who were surgically treated by means of duodenum-preserving pancreatic head resection (DPPHR) were prospectively analyzed. The aim of this operative procedure is to treat complications of chronic pancreatitis caused by inflammatory enlargement of the pancreatic head by decompressing the common bile duct, the pancreatic duct, the duodenum, and the retropancreatic intestinal vessels. End points of the study were early and late postoperative outcome. The follow-up period ranged from 1 to 22 years with a median follow-up of 6 years. In-hospital mortality was 1%, postoperative morbidity was 28.5%, and the rate of repeat laparotomy was 5.7%. Diabetes mellitus developed early in the postoperative period in six patients (2%). After a median follow-up of 6 years, late mortality was 8.9%. In the late follow-up period 88% of our patients were completely free of pain or had infrequent episodes and 63% were able to return to work. DPPHR might be considered as an alternative surgical technique in the treatment of chronic pancreatitis if the dominant lesion is in the pancreatic head.