[Treatment of inguinal hernias. Is the Bassani's technique current yet? A prospective, randomized trial comparing three operative techniques: Bassini, Shouldice and McVay]

OBJECTIVE

To compare late results (recurrence) of three different techniques for treatment of inguinal hernias in the adult: Bassini, Shouldice and McVay.

PATIENTS AND METHODS

The operative late results of three surgical techniques: Bassini, Shouldice and McVay in 119 adult patients with inguinal hernias (some with bilateral pathology, totalizing 136 hernias) were analyzed. The majority of patients were males (93.3%). The analysis was prospective, randomized, with uniform distribution of all three types of inguinal hernia (direct, indirect and combined) among the three groups of operative techniques. The number of recurrences was submitted to an actuarial analysis for a period of 4 years. The results underwent statistical analysis by the Kaplan-Mayer test with actuarial survival curves.

RESULTS

Eight hernia operations by the Bassini technique recurred in this time span, 3 in the Shouldice group and 2 in McVay. Among the Bassini recurrences, the worst results were observed with direct hernias (29% recurrence) when compared with indirect ones (16% recurrence). Overall recurrence rates plotted in an actuarial survival curve for 4 years, revealed statistically significant differences between Bassini and Shouldice: 35.7% versus 23.7%; the same happened when comparing Bassini to McVay: 35.7% versus 8.5%. The differences between Shouldice and McVay were not significant.

CONCLUSION

A recurrence rate of 35.7% for inguinal herniorraphy with the Bassini technique in a General Surgery University Clinic was surprising and obliged us to interrupt the trial. Our observations point to a prohibitive high failure rate when dealing with the Bassini technique, which was, over a century, the most popular treatment of inguinal hernia all over the world. Shouldice and McVay techniques, even though more complex, should be preferred whenever one makes the choice for "conventional" hernia treatment.

[Iatrogenic diaphragmatic hernia following abdominal esophagogastrofundoplication: report of a case]

The authors describe diagnosis and surgical treatment of a patient with iatrogenic diaphragmatic hernia following esophagogastrofundoduplication by Nissen's operation. The patient had presented a hiatal hernia with esophagitis chronic regurgitation and was submitted to esophagogastrofundoduplication. On the third postoperative day, the patient showed signs of dysphagia and intense dyspnea. The computerized tomography showed the presence of the gastric fundus and it's contents inside the leftpleural cavity. The patient was submitted to a left posterolateral thoractomy and an ischemic peptic ulcer in the gastric fundus, blocked by lung parenchyma was sutured. Then, the stomach was reduced into the abdominal cavity with diaphragmatic suture associated with esophageal and gastric fundus fixation to the right diaphragmatic pilar. The patient presented satisfactory immediate and late postoperative follow-up (1 year). The authors discuss and document aspects of diagnosis as well as surgical indication.

Gallstone ileus as a cause of upper intestinal obstruction

Gallstone ileus, a mechanical intestinal obstruction caused by the passage of a gallstone into the intestinal lumen through a fistula, although not common, deserves to more carefully studied due to its morbidity and mortality. Its incidence among older-age groups explains its association with chronic and degenerative diseases, which increase the complexity of the treatment choice. The need and appropriateness of a surgical approach to a cholecystenteric fistula to solve the obstructive emergency, in a one or two stage procedure, has been discussed in the literature. It has also been reported that gallstone ileus is an uncommon cause of upper intestinal obstruction. Intestinal obstruction is seen more frequently after a gallstone impacts at the ileocecal valve. The authors report a case of gallstone ileus as a cause of upper intestinal obstruction and discuss its diagnosis and treatment.

Effects of aging on muscle fibers and collagen content of the diaphragm: a comparison with the rectus abdominis muscle

Age-related changes of muscle fiber and collagen content of the diaphragm (DIA) and rectus abdominis (RA) muscles were examined in rats aged 1, 4, 8 and 18 months. The cross-sectional areas of all muscle fiber types (I, IIa, IIb) and the amount of collagen in both DIA and RA increased up to the age of 8 months after which a decrease in growth following a parabolic curve was found. The older DIA showed an increase in the percentage of type I fibers while in RA there was a high percentage of type IIb fibers. The aged DIA became more resistant to fatigue but at the expense of slow contraction while older RA is faster and stronger. Aged DIA and RA muscles showed a low amount of collagen with great concentration of cross-linkings leading to a tissue with low viscoelastic properties and reduced compliance.

Gallstone ileus resulting in strong intestinal obstruction

Mechanic intestinal obstruction, caused by the passage of biliary calculus from vesicle to intestine, through fistulization, although not frequent, deserve study due to the morbi-mortality rates. Incidence in elder people explains the association with chronic degenerative diseases, increasing complexity in terms of therapy decision. Literature discusses the need and opportunity for the one or two-phase surgical attack of the cholecyst-enteric fistule, in front of the resolution on the obstructive urgency and makes reference to Gallstone Ileus as an exception for strong intestinal obstruction. The more frequent intestinal obstruction observed is when it occurs a Gallstone Ileus impacting in terms of ileocecal valve. The authors submit a Gallstone Ileus manifestation as causing strong intestinal obstruction, discussing aspects regarding diagnostic and treatment.

Sonographic assessment of normal spleen volume

Thirty-two morphologically normal spleens from adult corpses were excised and immersed into a graduated water tank and the water volume displaced was considered as the actual spleen volume. After that, the splenic maximal height, width, and breadth were determined by a pachimeter. All the reference points were marked with a metal clip. Utilizing the metal clip references ultrasound maximal height, width, and breadth were determined. It was assumed that the ultrasound spleen volume was the result of the multiplication of the three ultrasonographic measurements previously obtained. There was no significant difference between pachimeter and ultrasound determinations. The mean actual spleen volume was 147.5 cm3 (SD = 81.46). The mean ultrasound spleen volume was 283.8 cm3 (SD = 168.27). A roughly linear correlation between actual spleen volume (y) and ultrasound spleen volume (x) was found, y = 14.23 + 0.469 x (R2 = 0.94, P < 0.01).

[Morphofunctional architecture of the testicular veins in adults]

The correlation between varicocele and male sterility, mentioned by several authors, led us to study the disposition of the testicular veins, especially at the level of their ending, trying to provide an anatomical description, which may contribute with new etiopathogenic information, in order to interpret that pathologic entity. The arrangements of the muscular fiber bundles show a different disposition in the right and left side, mainly in their distinct orientation. The collagen and elastic tissue show an arrangement similar to the muscular fibers, in order to improve the blood flow, sometimes in the reno-testicular and sometimes in the cavo-testicular junction.

Immunofluorescence on skeletal muscle and skin biopsy specimens in muscle diseases

A series of 110 muscle and 40 skin biopsy specimens were examined using direct immunofluorescence aiming to identify features that may differentiate the myopathy of connective tissue disease from other muscle diseases. The skeletal muscle fluorescence was positive in 75% of the patients with muscle diseases. The sarcolemmal staining was higher in mitochondrial encephalomyopathy. Fiber and vascular staining occurred in all muscle diseases, except in cases of myasthenia. Our results showed that 42% of patients with polymyositis and 43% of patients with peripheral motor neuron diseases have vascular deposits of immune complexes suggesting that these two diseases could result from an immune-complex-induced vasculopathy. The IF test in skin specimens was positive in 60% of the patients with muscular diseases. The absence of immunoglobulin deposit at the dermoepidermal junction and at epidermal nuclei in cases of peripheral motor neuron disease suggest that this skin test may be useful in the differentiation of muscle diseases.

[Morphologic study of the inferior cavo-atrial transition in man. Morphofunctional considerations]

PURPOSE

Analysis the fibrous elements of the transition between the inferior vena cava and right atrium.

METHODS

Twenty adult (20-40 ys) were used. Properly preserved samples were analysed macro and microscopically. Fragments were excised from the inferior cavo-atrial transition and analysed under stereomicroscopic.

RESULTS

The inferior vena cava valve was disposed at the wall of the vein. Insertions of striated muscular cardiac fibers bundles are seen at the anterior wall of inferior vena cava. These muscular bundles are directed towards the intima of the vein. There were at the venous posterior wall insertions of the cardiac muscular bundles, originated from the crista terminalis and from the interatrial septum, these bundles show an orientation predominantly oblique, with tendency to become circular. At the transition level, the bundles of smooth muscular fibers of the inferior vena cava, presented an oblique disposition, becoming predominantly circular.

CONCLUSION

As the disposition of muscular cardiac fibers presents a predominantly circular direction and, the bundles of smooth muscular fibers of the inferior vena cava present the same direction, we could postulate that, when the atrial systole occurs, these muscular bundles would obliterate the cavo-atrial transition, preventing, this way, the venous reflux.

Gallbladder injuries due to blunt abdominal trauma: report on five cases and review of the literature

Gallbladder lesions by blunt abdominal trauma are rare, due to the organ's anatomical particularities. Diagnosis is difficult, and it generally occurs during surgery. The trauma is usually associated with other lesions and is related to very serious traumas or to deceleration. Due to the scarcity of publications on this topic and to its reduced incidence, we present here a report of five patients who had suffered blunt abdominal trauma with gallbladder lesion and who were attended at the General Hospital (of the University of São Paulo Medical School) Emergency Service between 1986 and 1991. Furthermore, we analyze the incidence of this trauma, presence of associated lesion, treatment, morbidity and mortality of the patients, as well as a review of the literature.

[Effect of electromagnetic fields on osteogenesis: an experimental study on rats]

The authors studied experimentally the electromagnetic pulsing field effects in an experimental model in rats, for evaluation of the velocity of consolidation of tibial and fibular fractures. The animals were followed for a period of three weeks under continuous stimulation and there were done radiological evaluation weekly and histological study at the end of the study. There were no histological, clinical or radiological differences between the group of rats submitted to electromagnetic pulsing fields and the control group.

[Recurrence in post-splenectomy spherocytosis anemia due to presence of accessory spleens]

A young female patient had a recurrence of severe spherocytic anemia there years after having been submitted to splenectomy. The presence of two accessory spleens with a size of 3.5 cm and 4.0 cm, was demonstrated by technetium scanning and ultrasound images. Surgical removal of these noduli resulted again in prompt recovery. The development of the spleen beings in the fifth week of intrauterine life at the dorsal mesogastrium. The lack of fusion of splenic lobuli is responsible for the occurrence of accessory spleens. A surgeon performing splenectomy for the treatment of hemolytic anemia should always search for possible existences of accessory spleens.

Structural and cytochemical study of the rat exocrine pancreas treated with dl-ethionine. I. Multilayered bodies and lesioned areas

The fine structural changes and the reactivity for acid phosphatase (AcPase) and thiamine pyrophosphatase (TPPase) were studied in thin sections from rat pancreatic acinar cells exposed to dl-ethionine for 2-10 days. The cells from ad libitum and pair-fed controls exhibit occasionally 0.2-0.6 microns circular profiles showing reaction for AcPase and considered as presumptive lysosomes. At days 2 and 4 of dl-ethionine treatment the acinar cells exhibit presumptive lysosomes, autophagosomes and membrane-bounded cytoplasmic areas devoid of electron density and AcPase activity, containing scattered membranous elements. These regions were named lesioned areas. On 6th, 8th and 10th days a membrane bound anomalous cytoplasmic structure that represents a dense pile of layered membrane-like material (multilayered bodies, MB) was seen. The MBs consistently show AcPase activity and in rare instances TPPase activity. Freeze fracture studies reveal that the limiting membrane of the MBs has intramembranous particles whereas the multilayered membranous contents are devoid of such particles. The structure and disposition of the lamellae of the MBs seen in the replicas are similar to those of artificially prepared phospholipidic membranes.

[Comparative analysis of the diagnostic value of ultrasonography and laparoscopy in acute abdomen]

Patients with traumatic or non-traumatic acute abdomen, often exhibit difficulties in the assessment of the real intra-abdominal visceral compromise. This study intends to compare laparoscopy and ultrasonography in patients with non-traumatic or traumatic acute abdomen, in whom there is a doubt on the actual visceral compromise. Forty-five patients were studied in this protocol. Both procedures were performed in 28 and in 17 patients with non-traumatic or traumatic acute abdomen, respectively. The laparoscopic examination was shown to be superior to the ultrasound even when one subtracts from the ultrasound data all pathologies that involved bowel transit and the bowel wall such as the acute appendicitis and cases of pelvic inflammatory disease. The laparoscopic and ultrasound accuracy were 97.8% and 53%, respectively.

Angioarchitecture of the esophagogastric veins in portal hypertension

Based on our previous studies on the human normal venous angioarchitecture of the esophagogastric transition segment, we performed a similar analysis in 25 postmortem specimens obtained from subjects with a diagnosis of portal hypertension. The specimens were injected with India ink or barium sulfate and sectioned for histological examination. A 'weak' zone (point of lesser resistance) was described as being the most probable site of origin for the development of varicosities in the complex venous system of the esophagogastric junction. Such a system can be considered to be a physiological hemodynamic venous blockade mechanism interposed between the portal system and the systemic veins. The 'weak' zone is made up by the scarce submucous veins (shunt veins), by the submucous confluent and final confluent trunks, and by the true perforating veins of the tunica muscularis which compose a venous unity located about 3-5.5 cm above the Z (epithelioglandular) line.

[Surgical treatment of inguinal hernias with local anesthesia]

Eighty-four cases of inguinal hernioplasty by Bassini's modified technique were performed using 1% lidocaine in regional infiltration block. The report analyzes the use of local anesthesia in the treatment of inguinal hernias. All patients had small reducible and non-recurrent inguinal hernia. Twenty-six compensated high risk patients were operated in the hospital and dismissed in the second post-operative day, whereas the others were operated as outpatients and dismissed two hours after the surgical procedure. The rate of complication was low, but pain was a common complaint. In general, there was a good acceptance of this kind of anesthesia. The authors concluded that local anesthesia is a valuable method for the treatment of inguinal hernia.

[Esophagoplasty with bypass using an isoperistaltic gastric tube in the treatment of cancer of the thoracic esophagus: study of 13 cases]

In order to relieve complete obstruction of the thoracic esophagus due to spinocellular carcinoma, thirteen patients, all of them in good or at least regular general conditions were submitted to a bypass using a isoperistaltic gastric tube. The disease itself was treated by radiotherapy after surgery. Only one patient died at the hospital due to an error in the radiotherapy schedule. Cervical fistula was observed in six patients seven days after surgery; local treatment was enough for complete healing in five out of six. In one patient surgery was performed in order to repair the anastomotic area. Stenosis was observed in three patients but in all cases it was possible to overcome it by endoscopy. With the progress of the disease other complications were observed such as hemoptysis and respiratory distress. The survival rate was nine months (running between five and sixteen) but it should be noted that swallow capacity was maintained until death. The employed of a bypass of isoperistaltic gastric tube seems to be a desirable alternative in the treatment of esophageal cancer because it allows the reestablishment of deglutition before any treatment such as radiotherapy alone or combined with surgery.

Labeling of Salmonella typhimurium with iodine-131 to study phagocytic function in rats

The present study describes a method for labeling Salmonella typhymurium with iodine-131 to evaluate both the morphological and the functional characteristics of the reticulo-endothelial system. A suspension containing 2 x 10(9) bacteria per ml was labeled with carrier-free Na131I without reductor, with a labeling yield of 46.5 +/- 3% and 3.5 +/- 1.3% of free Iodine-131. The biodistribution of the labeled bacteria in rats was studied with a large-field-of-view scintillation camera equiped with a pinhole collimator. Whole body images were obtained 15 and 30 minutes after intravenous injection of the labeled microorganisms. Images showed accumulation of bacteria in the liver and both normal and transplanted spleens of the animals. Autoradiographs of liver and spleen demonstrated labeled bacteria within the cells of the reticulo-endothelial system. The method described is easy to perform, has a good labeling yield and allows the functional evaluation of the reticulo-monophagocytic system, including transplanted spleens.

[Recurrent inguinal hernia: study of 87 cases]

A retrospective analysis is made of the data of 87 patients with recurrent inguinal hernias operated at the Hospital das Clínicas of the University of São Paulo in a period of six years. As it happened with other authors, frequency of recurrence was: direct hernia (43.5%), indirect hernia (50%), the less often seen mixed form (3.9%), and crural hernia (2.6%). They discuss local and systemic etiopathogenic factors, strain in the early postoperative period being indicated as a major factor, responsible for 43.1% of the cases. More than half of recurrences (48/85) occurred in the first year, some occurring after a longer period of time (30.6% after three years). The mostly used repair techniques were modified Bassani's technique (suture of the transverse arch to the inguinal ligament) and the Lotheissen-McVay technique, in 46.1% and 42.5% of the cases, respectively. In 9 of the 85 cases, tightening the deep inguinal orifice was enough. Analysis of the rate of surgical failure was difficult, as patients did not routinely return for follow-up visits.

[Spontaneous implantation of splenic tissue after traumatic rupture of the spleen. Report of a case of splenosis]

The authors report one case of peritoneal splenosis. The patient submitted to a gastrectomy had a past history of traumatic rupture of the spleen. The morphologic and immunologic aspects of splenosis are discussed. The value of imaging splenic tissue by scynthscanning are pointed out in basis of infection prophylaxis.