Intraperitoneal Tension-free Repair of a Small Midline Ventral Abdominal Wall Hernia: Randomized Study with a Mean Follow-up of 3 Years

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients’ characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster ( P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Long-Term Outcomes of the Laparoscopic Adjustable Gastric Banding: Weight Loss and Removal Rate. A Single Center Experience on 301 Patients with a Minimum Follow-Up of 10 years

BACKGROUND

Obesity is a chronic disease that requires procedures to enable to maintain good long-term results. Laparoscopic adjustable gastric banding (LAGB) studies with a long-term follow-up are limited and have often given conflicting results. We report our results in terms of banding life span and weight loss in a cohort of 301 patients operated on LAGB with a minimum follow-up of 10 years.

METHODS

All patients who underwent LAGB at our university hospital between 1998 and 2004 were included in this study. The main outcome was band survival and complications that led to band removal, and the secondary outcome was weight loss. We present raw data and data after imputation for patients lost at follow-up.

RESULTS

Most patients were women (83 %), and the mean body mass index (BMI) baseline was 45.2 ± 6.7. The pars flaccida technique was performed in 50.9 % of the patients. All patients had at least 10 years of follow-up (range 10-16 years). Data were available at 10 years for 79.7 % and at 15 years for 80.6 %. Band survival was 65.8 % at 10 years and 53.3 % at 15 years. Mean excess weight loss (EWL) at 5, 10, and 15 years was 41.4, 38.7, and 35.1 %, respectively.

CONCLUSION

Despite the encouraging short-term results, LAGB shows long-term disappointing results in terms of weight loss and complication rates. The removal rate increases with time (about 3-4 % per year), and at 15 years, almost half of the bands had been removed.

Inguinal Hernia Repair Using Self-adhering Sutureless Mesh: Adhesix™: A 3-Year Follow-up with Low Chronic Pain and Recurrence Rate

To review our experience and outcomes after inguinal hernia repair using the lightweight self-adhering sutureless mesh "Adhesix™" and demonstrate the safety and efficacy of this mesh. This is a 3-year retrospective study that included 143 consecutive patients who underwent 149 inguinal hernia repairs at our department of surgery. All hernias were repaired using a modified Lichtenstein technique. Preoperative, perioperative, and postoperative data were prospectively collected. Incidence of chronic pain, postoperative complications, recurrence, and patient satisfaction were assessed three years postoperatively by conducting a telephone survey. We had 143 patients with a mean age of 58 years (17-84), who underwent 149 hernia repairs using the Adhesix™ mesh. Ninety-two per cent (131 patients) were males. Only 10 patients (7%) had a postoperative pain for more than three years. In our series, neither age nor gender was predictive of postoperative pain. Only one patient had a hematoma lasting for more than one month and only four patients (2.8%) had a recurrence of their hernia within three years of their initial surgery. Ninety per cent of the patient expressed their satisfaction when surveyed three years after their surgery. In conclusion, the use of the self-adhering sutureless mesh for inguinal hernia repair has been proving itself as effective as the traditional mesh. Adhesix™ is associated with low chronic pain rate, recurrence rate, and postoperative complications rate, and can be safely adopted as the sole technique for inguinal hernia repair.

Inguinal Hernia Repair Using Self-adhering Sutureless Mesh: Adhesix™: A 3-Year Follow-up with Low Chronic Pain and Recurrence Rate

To review our experience and outcomes after inguinal hernia repair using the lightweight self-adhering sutureless mesh “Adhesix™” and demonstrate the safety and efficacy of this mesh. This is a 3-year retrospective study that included 143 consecutive patients who underwent 149 inguinal hernia repairs at our department of surgery. All hernias were repaired using a modified Lichtenstein technique. Preoperative, perioperative, and postoperative data were prospectively collected. Incidence of chronic pain, postoperative complications, recurrence, and patient satisfaction were assessed three years postoperatively by conducting a telephone survey. We had 143 patients with a mean age of 58 years (17–84), who underwent 149 hernia repairs using the Adhesix™ mesh. Ninety-two per cent (131 patients) were males. Only 10 patients (7%) had a postoperative pain for more than three years. In our series, neither age nor gender was predictive of postoperative pain. Only one patient had a hematoma lasting for more than one month and only four patients (2.8%) had a recurrence of their hernia within three years of their initial surgery. Ninety per cent of the patient expressed their satisfaction when surveyed three years after their surgery. In conclusion, the use of the self-adhering sutureless mesh for inguinal hernia repair has been proving itself as effective as the traditional mesh. Adhesix™ is associated with low chronic pain rate, recurrence rate, and postoperative complications rate, and can be safely adopted as the sole technique for inguinal hernia repair.

Two stages conversion of failed laparoscopic adjustable gastric banding to laparoscopic roux-en-y gastric bypass. A study of one hundred patients

INTRODUCTION

Conversion to laparoscopic gastric bypass (LRYGB) appears to be the treatment of choice after failed LAGB. To reduce the risk of postoperative complications, some surgeons routinely adopt a two-stage strategy. The purpose of this study was to analyze our institution's experience with the two-stage procedure for LAGB conversion to LRYGB MATERIALS AND METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of LAGB to LRYGB from November 2007 to June 2012.

RESULTS

One hundred patients were included. Of these, 62 (62%) required conversion to LRYGB for inadequate weight loss or weight regain and 38 for band-related complications. All the procedures were performed in two stages and laparoscopically. The average time between band removal and LRYGB was 17.3 months. The mean follow-up after LRYGB was 31 ± 18.7 months. The mean BMI prior to LRYGB conversion was 45.3 ± 5.2. Early complications occurred in 15 patients (15%), while late complications occurred in only 3 patients (3%). The average %EWL at 24 months and 48 months after conversion was 70.1 and 69.4%, respectively.

CONCLUSION

Although a two-stage conversion strategy increases the number of operations and hospital stay without decreasing the rate of early complications compared to one-stage conversion; it has shown to be associated with low rates of GJA stenosis and excellent %EWL.

Intraperitoneal tension-free repair of a small midline ventral abdominal wall hernia: randomized study with a mean follow-up of 3 years

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients' characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster (P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Ileocolic intussusception due to a cecal endometriosis: case report and review of literature

Abstract

Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. We report a case of a woman who presented an ileocecal intussusception due to a cecal endometriosis. The patient gave two months history of chronic periombilical pain requiring regular hospital admission and analgesia. The symptoms were not related to menses. A laparotomy was performed and revealed an ileocolic intussusception. The abdominal exploration did not find any endometriosis lesion. Ileocaecal resection was performed. Microscopic examination showed a cystic component, lined by a regular cylindric epithelium. Foci of endometrial tissu were oberved in the cecal subserosa and muscularis mucosal, with irregular endometrial glands lined by cylindric epithelium without atypia immunostained with CK7, and characteristic endometrial stroma immunostained with CD10. Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. Diagnose of etiology remains challenging due to the absence of clinical and radiological specific characteristics.

Virtual slide

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2975867306869166

High-grade poorly differentiated retroperitoneal sarcoma. Report of a case and review of the literature

Retroperitoneal sarcomas (RPS) are uncommon tumors associated with a poor prognosis. This is particularly true in case of high-grade sarcomas of specific histological subtypes, as demonstrated by the largest surveys of the last decade. Up to the present day, unfortunately there are no powerful tools available except for surgery. On the other hand, the resection rate of RPS is significantly increased over the last decades allowing to deliver the best treatment available. This paper reports on the case of a young patient who was incidentally diagnosed with a retroperitoneal mass. The patient underwent surgery in our department and the histological report showed a spindle cell sarcoma of high grade of malignancy with an incomplete muscular phenotype. The patient was discharged on the seventh postoperative day and he is still free of local and distant recurrence.

Papillary carcinoma of the thyroglossal duct cyst: report of two cases

AIM

To present two cases of papillary carcinoma of the thyroglossal duct cyst (TDC) and to report their management.

PATIENTS AND METHODS

Two patients, a 47-year-old woman and a 60-year-old man, were operated in 2006 and 2008 in the Department of Digestive and Metabolic Surgery of the "Jean Verdier" Hospital.

RESULTS

The diagnosis of papillary carcinoma was established after the pathological examination carried out on the thyroglossal duct cyst, after its complete surgical excision. A total thyroidectomy followed by a treatment by radioactive iodine and a substitutive hormonal therapy were carried out in the second time for one of the two patients. For the other patient, a total thyroidectomy followed by a substitute hormonal therapy, were achieved. The evolution was favorable, with a follow-up of four years for the first patient and two years for the second one.

DISCUSSION

Total thyroidectomy after the complete excision of the cyst is currently the recommended treatment for the papillary carcinoma of the TDC. It was shown that a latent thyroid cancer could develop even 15 years after the initial excision of the thyroglossal cyst. The treatment is curative in 95% of the cases.

CONCLUSIONS

Current treatment of papillary carcinoma of the thyroglossal duct cyst is well codified, allowing an excellent prognostic.

[Comparison of quality of life in morbidly obese patients and healthy volunteers. A prospective study using the GIQLI questionnaire]

BACKGROUND

Morbid obesity decreases the quality of life. The aims of surgical and medical treatment are weight loss, reduction of co-morbidity, and improved quality of life.

AIMS

To compare the quality of life between obese patients (BMI: 40 or>35+comorbidity) and healthy volunteers using the GIQLI (Gastrointestinal Quality of Life) questionnaire.

PATIENTS

Between January 2001 and December 2002, 127 morbidly obese patients (109 female, 18 male) with a mean age of 40.1 years were surgically treated with laparoscopic gastric banding. Quality of life, as measured by the GIQLI questionnaire, was systematically evaluated pre-operatively. During the same period, a control group of 125 healthy volunteers of comparable age, gender, and prior surgical history were evaluated using the same questionnaire.

RESULT

The two groups, while comparable in age and gender, were significantly different in terms of weight (123 vs. 66 kg), BMI (44.3 vs. 22.2) (p<0.001), co-morbidity factors (p=0.001), and professional activity (p=0.02). The mean global GICLI score was 122 for healthy individuals and 95 for morbidly obese patients. (p=0.001), and the differences were most marked in the super obese. These differences particularly involved social dysfunction, physical status, and emotional symptoms but were not significantly different for gastrointestinal symptoms.

CONCLUSION

The quality of life in morbidly obese and super obese patients is significantly diminished from that of a control population. There was good correlation between the degree of obesity (BMI) and the alteration of the GIQLI global and subscales scores. Quality of life should be systematically evaluated before and after both medical and surgical therapy.

A comparison of two techniques for inserting the Airtraq™laryngoscope in morbidly obese patients

We postulated that video-controlled tracheal intubation with the Airtraq laryngoscope using the reverse manoeuvre instead of the standard technique of insertion could facilitate the airway management of morbidly obese patients. For the reverse manoeuvre the laryngoscope is inserted 180 degrees opposite to that recommended, and once in place rotated into the conventional pharyngeal position. Eighty (40 lean and 40 morbidly obese) ASA I-III adult patients were randomly allocated to four equal groups to compare the standard technique to the reverse manoeuvre for inserting the Airtraq laryngoscope. Video-controlled and clinical tracheal intubation characteristics were recorded. The reverse manoeuvre did not influence tracheal intubation characteristics in the group of lean patients. In the group of morbidly obese patients, the standard technique of insertion was not satisfactory in 20% of cases and the reverse manoeuvre facilitated, speeded and secured tracheal intubation.

Repair of giant incisional abdominal wall hernias using open intraperitoneal mesh

BACKGROUND

Very large and complex incisional hernias, especially those involving loss of abdominal wall, present a particular challenge to the surgeon.

AIMS

The open intraperitoneal technique was used prospectively for the repair of incisional hernias in a selected group of patients with large defects, often those with major loss of abdominal wall, overweight patients, and previous failures of incisional repair.

MATERIALS AND METHODS

Between 1 January 1999 and 31 December 2005, out of 275 patients operated on for incisional hernia repair, 61 of them, most of whom were obese with multiorificial recurrent or giant hernias and contraindicated for laparoscopy, were treated using an open intraperitoneal mesh technique. There were 50 females and 11 males, with a mean age of 61. The median ASA score of the group was 2.3, with a mean BMI of 34 kg/m(2) and a mean hernia surface of 182 cm(2). Sixty-four percent of the patients had undergone one or more previous incisional hernia repairs.

RESULTS

Mean operating time was 130 min, with an average hospital stay of 13 days. None of the patients died. Postoperative complications occurred in 21% of the patients; most of which were minor, but two cases (3.3%) developed deep abscesses requiring surgery and removal of the mesh. A recurrence rate of 5% was found after a mean follow-up of 35 months (8-88).

CONCLUSION

Open intraperitoneal mesh repair appears to be a good option for the treatment of complex incisional hernia (at least 10 cm in diameter or multiorificial) in obese patients contraindicated for laparoscopy.

Inguinal hernia repair: the choice of prosthesis outweighs that of technique

BACKGROUND

The use of prostheses in inguinal hernia repair reduces the incidence of recurrence. Quality of life and pain after hernia repair are largely correlated with the technique and type of prosthesis.

AIMS OF STUDY

To evaluate the 2-year incidence of recurrence and pain for two types of hernioplasty, Lichtenstein repair and laparoscopy (totally extraperitoneal approach or TEP), and two types of mesh, polypropylene mesh and beta-D: -glucan-coated mesh (Glucamesh).

PATIENTS

A total of 410 consecutive patients of mean age 54 years (18-84) underwent repair of inguinal hernias, 96 (23%) of which were bilateral and 56 (13%) recurrent. A total of 273 (66.5%) patients underwent Lichtenstein repair: 215 (78.7%) with polypropylene mesh, 58 (21.3%) with Glucamesh; 137 patients underwent laparoscopy: 80 (58.4%) with polypropylene mesh, 57 (41.6%) with Glucamesh. In each group, the populations were comparable and the techniques utilized were identical.

METHODS

The patients were followed-up for at least 2 years, after which the incidence of recurrence was determined, and chronic pain was assessed by means of a visual analog scale and a validated questionnaire.

RESULTS

A total of 349 patients (85.1%) were reassessed, 117 of whom had undergone laparoscopy and 232 Lichtenstein repair. There were ten recurrences (2.8%), and incidence which was independent of the technique (laparoscopy 1.7% vs. Lichtenstein 3.4%) (ns) and the type of prosthesis (Glucamesh 1.9% vs. polypropylene 2.4%) (ns). Chronic pain was noted in 69 patients (19.7%) and severe pain in 11 (3.1%). The incidence of chronic pain was the same for the two techniques: laparoscopy 17.9% vs. Lichtenstein 20.7% (ns). The same was true for severe pain: laparoscopy 3.4% vs Lichtenstein 3% (ns). The incidence of chronic pain was closely correlated with the type of prosthesis utilized: Glucamesh 4.8% vs. polypropylene 26.5% (P = 0.02), irrespective of the technique. The same was true for severe pain (0.9 vs. 4%) (P = 0.02).

CONCLUSION

The utilization of beta-D: -glucan-coated mesh did not involve more recurrence and was accompanied by a significant decrease in chronic pain at 2 years, independent of the technique. After 2 years, the results of hernia repair show that the choice of prosthesis was more determinant than choice of technique.

Le consentement éclairé : quelle est sa valeur en chirurgie digestive ?

SITUATION

In 1997 the Supreme Court of Justice decreed that "the doctor is responsible for giving his patient certain information and is obliged to prove that the information has been given". French surgical societies recommend using a form of informed consent signed by the patient applicable to all practices.

AIMS

To evaluate a step taken systematically since 1999 in our department.

PATIENTS AND METHODS

A prospective study was put into place for 259 patients candidate for elective surgery. All patients signed and returned the "informed consent" before surgery. The day of leaving the hospital, they answered a post-operative questionnaire to evaluate what they remembered of the "informed consent form" and the quality of information.

RESULTS

Ninety three per cent of them remembered it. Eight per cent signed it without reading it. Eighty two per cent of the patients think that this document is useful for their medical records. Among the patients who did not read the informed consent form: 38% wished it gave more information, whereas only 16% of those who had read it, considered the given information inadequate. This difference is statistically (p=0.03) significant.

CONCLUSION

The informed consent form gives a lot of information to the patients, but the surgeon is still obliged to do likewise. Patients who did not read the consent were less satisfied with the given information than those who had read it. The positive reaction of the patients in favour of the form makes it evident that the existence of the form reassures them.

Quality of life after laparoscopic gastric banding: Prospective study (152 cases) with a follow-up of 2 years

To evaluate influence of laparoscopic gastric banding (LGB) on quality of life (QOL) in patients with morbid obesity. Laparoscopic adjustable gastric banding is a popular bariatric operation in Europe. The objectives of surgical therapy in patients with morbid obesity are reduction of body weight, and a positive influence on the obesity-related comorbidity as well the concomitant psychologic and social restrictions of these patients. In a prospective clinical trial, development of the individual patient QOL was analyzed, after LGB in patients with morbid obesity. From October 1999 to January 2001, 152 patients [119 women, 33 men, mean age 38.4 y (range 24 to 62), mean body mass index 44.3 (range 38 to 63)] underwent evaluation for LGB according the following protocol: history of obesity; concise counseling of patients and relative on nonsurgical treatment alternatives, risk of surgery, psychologic testing, questionnaire for eating habits, necessity of lifestyle change after surgery; medical evaluation including endocrinologic and nutritionist work-up, upper GI endoscopy, evaluation of QOL using the Gastro Intestinal Quality of Life Index (GIQLI). Decision for surgery was a multidisciplinary consensus. This group was follow-up at least 2 years, focusing on weight loss and QOL. Mean operative time was 82 minutes; mean hospital stay was 2.3 days and the mean follow-up period was 34 months. The BMI dropped from 44.3 to 29.6 kg/m and all comorbid conditions improved markedly: diabetes melitus resolved in 71% of the patients, hypertension in 33%, and sleep apnea in 90%. However, 26 patients (17%) had late complications requiring reoperation. Preoperative global GIQLI score was 95 (range 56 to 140), significant different of the healthy volunteers score (120) (70 to 140) P < 0.001. Correlated with weight loss (percentage loss of overweight and BMI), the global score of the group increased to 100 at 3 months, 104 at 6, 111 at 1 year to reach 119 at 2 years which is no significant different of healthy patients. Analyzing the subscale, physical condition, emotional status, and social integration increased significantly (P < 0.001) from preoperative to end of follow-up. Digestive symptoms were not modified. In case of failure of the procedure (10.5%) global Giqli score is not modified. Patients who have required successful revisional surgery for late complications (6.5%) have an excellent QOL outcome that are not different from the whole group. Together with a satisfactory reduction of the excess overweight, laparoscopic gastric banding may lead in a carefully selected population of patients with morbid obesity to a significant improvement of patient QOL, in at least 2 years follow-up.

Impact of peritoneal tears on the outcome and late results (4 years) of endoscopic totally extra-peritoneal inguinal hernioplasty

BACKGROUND

The reported rate of intra-operative peritoneal laceration during endoscopic extra-peritoneal hernioplasty (TEP) ranges from 10 to 64%.

AIMS

To evaluate in a prospective study the predictive factors of peritoneal tears, their consequences in terms of outcome and late results.

PATIENTS AND METHODS

Between July 1994 and December 2000, we performed 467 endoscopic extra-peritoneal hernia repairs (TEP). In 14.8% of the cases, single or multiples recurrences after conventional open herniotomy were treated. One hundred and forty-nine patients (38%) had had previous surgery (appendectomy); 277 procedures (70.8%) were performed by experienced surgeons and 114 (29.2%) by surgical trainees. We used a diathermic hook in 26.3% of the procedures. The mean follow-up period was 68 months (48-100).

RESULTS

Peritoneal tears occurred in 43 patients (10.9%). Six of them (13%) required operative closure, and six a conversion (four Lichtenstein, one Shouldice, and one TAPP). In 37 cases (86%), the tears were not closed. Peritoneal tears were significantly correlated with surgical experience, Nyhus classification, scar adhesion from previous surgery and the use of sharp instruments. Peritoneal tears interfere significantly (P=0.001) with the operating time (82 vs. 63 min) and conversion rate (13.9 vs. 1.7%). It does not affect the outcome and late results in terms of recurrences, pain, or small bowel obstruction.

CONCLUSION

Our data suggest that peritoneal tears in the vast majority of cases may be safely managed without peritoneal closure. In case of peritoneal laceration, the operative time was significantly longer, and the conversion rate was increased. These situations do not affect the outcome and late complications compared with the procedures without peritoneal tears.

L'enseignement de la chirurgie influence-t-il les résultats des cures de hernies de l'aine ?

AIMS

To evaluate influence of surgical experience on inguinal hernia repair.

PATIENTS

From 1997 to 2003, 380 patients (mean age 55 years old) with primary unilateral inguinal hernia were treated by Lichtenstein technique.

METHODS

In this retrospective study, surgeons were classified in three groups: group 1: hernia repair was performed by an experimented surgeon (consultant or senior registrar) and a young surgical trainee (resident) (161 cases); group 2: surgery was performed by a junior surgeon (resident) under the control of an experimented surgeon (135 cases) and in the group 3 (84 cases), Lichtenstein technique was performed by two residents, alone, supervised by an experimented surgeon, in the operative room. Evaluation criterion were operative time, hospital stay, morbidity, time to return to normal and professional activities, recurrences and chronic pain with a follow up of, at least, 2 years.

RESULTS

The three groups were comparable in term of socio economic data, hernia and follow up. The only significant (P=0.01) difference concern operative time which increased from 20% for group 2 and 3 (residents) compared to the group 1. There was also no difference between junior and senior resident.

CONCLUSION

Lichtenstein hernia repair should be performed by young surgeon in training alone in condition of precise teaching organization and experimented surgeon supervision. For patient, in this condition, there is no trouble in term of surgical results.

Laparoscopic resection of low rectal cancer with a mean follow-up of seven years

The role of laparoscopic surgery in the management of cancer of the rectum remains controversial. The main concern is the risk of port-site metastasis and neoplastic dissemination. The aim of this study was to evaluate prospectively 29 patients who underwent laparoscopic resection with total mesorectum excision for lower rectal carcinoma with a mean follow-up of 7 years. From January 1993 to December 1998, 29 patients with proven low (<10 cm from the anal verge) rectal cancer were operated by a laparoscopic approach. They were followed up at 1-, 3-, and then every 6-month intervals, postoperatively for an average of 7 years. Mean operative time was 157 +/- 46 minutes. The conversion rate was 13.7% (4 cases): 1 for tumor invasion of adjacent structures, 2 for inadequate margins of resection, and 1 for locally advanced cancer. First flatus occurred after 37.3 +/- 11.5 hours, and oral feeding started at 48.3 +/- 23 hours postoperatively. The length of the suprapubic incision for extraction of the specimen was 5.6 +/- 1.7 cm. Hospital stay was 7.2 +/- 3.0 days. There were no deaths. The morbidity rate was 14.8%. Length of the specimen, lateral and distal margins, and the number of lymph nodes resected were comparable to those of an open surgical approach. The average postoperative follow-up was 7 years (5-10 years). The late complication rate was 3.7%. There were no port-site metastases. Five-year recurrence rates were 0%, 22%, and 37% for Duke's A, B, and C cancers, respectively. The 5-year survival rate was 100% for Duke's A, 89% for B, and 50% for C. Laparoscopic resection for low rectal cancer with total mesorectum excision can be performed with the same oncologic principles, low morbidity, and long-term complications. Five-year survival and recurrence rates are comparable to those of open surgery.

Existe-t-il des facteurs prédictifs de succès dans le traitement de l'obésité morbide par anneau périgastrique modulable ? Étude prospective

BACKGROUND

Surgical treatment of morbid obesity by perigastric adjustable banding give at mid term follow up, contrasted results which associate success, failure and intermediate situations.

AIMS

The objective of this work was to prospectively validate predicting items that would predict success in the surgical treatment of morbid obesity by adjustable gastric banding.

MATERIAL AND METHODS

Eighty patients with morbid obesity have been treated with adjustable gastric banding. Seventy-one women, and nine men with a mean age of 37.8 years (20-59) with a mean follow up of 17 months (12-52). They have been classified in three groups: success, failure, and intermediate results. Uni- and multivariate analysis was performed on six criteria: age, sex, professional activity, metabolic disorders, length of obesity and body mass index (BMI).

RESULTS

Concerning age, sex, professional activity, metabolic disorders, and length of obesity, there was no difference between the three groups. However, a BMI more than 50 kg/m(2) has a strong predictive value. Patients called "super obese", BMI >50, has a high rate of failure (64%) even the weight loss is often important in absolute value, but the BMI at the follow up remain high and more than 40. In this situation: gastric banding does not seem a good treatment because it does not protect these patients against the lethal risk of their comorbidities.

CONCLUSION

In this study, there is not a specific candidate "profile" to a successful treatment of morbid obesity by adjustable gastric banding. Meanwhile the initial BMI appear to be a predictive factor of success or failure. In the case of patients with high BMI >50 (super obese) gastric banding did not seen to be a good treatment and another technical approach (gastric bypass) must be discussed.

[Use of prosthesis in inguinal hernia repair]

AIMS

To evaluate the use of mesh in the evolution of hernia repair technique during a period of twelve years.

PATIENTS--METHODS

From january 1991, to december 2002, 1306 patients 1136 men, 190 women, with inguinal hernia, with a mean age of 47.4 years old (15-98) have had an elective surgical repair. 1097 (83.9 per cent) were unilateral. 209 (16.1 per cent) were recurrent hernia. Clinical data, operative technique have been prospectively evaluated: Four techniques were used: Shouldice procedure, Stoppa operation and laparoscopic repair (TEP) in 1992 and Lichtenstein technique since 1993.

RESULTS

During the study, meshes were used in 65.7 per cent of the patients respectively 33.3 per cent for Lichtenstein, 26.9 per cent for laparoscopic repair and only 5.3 per cent for Stoppa open procedure. During the study, prosthesis rate increased from 9.1 to 85.4 per cent for primary hernia and from 10 to 100 per cent for recurrent hernias. To day, Stoppa procedure is not yet performed. Herniorraphies decrease from 91.9 to 14.6 per cent.

CONCLUSIONS

"Tension free" techniques represent 85.4 per cent of all procedures at the end of the study, specially Lichtenstein operation (65 per cent) which seems to become the new "Gold Standart" in inguinal hernia repair.

[Colorectal cancer: 74 patients treated by laparoscopic resection with a mean follow-up of 5 years]

OBJECTIVE

The aims of this study were to analyse the results and long term outcome in a prospective non randomised trial of 74 patients treated by laparoscopic colo-rectal resection for cancer, and to determine wether survival and recurrence are or are not compromised by an initial laparoscopic approach.

PATIENTS AND METHODS

Seventy-four patients with colo-rectal carcinoma were included in a prospective trial and treated by laparoscopic resection. All patients were reviewed at 1, 3, and 6 months interval. A median of 5 years follow up was available. Forty-eight patients (65%) had more than 3 years of follow up.

RESULTS

Six conversions (8.1%) were necessary: 2 for tumor invasion of adjacent organs, 2 for limited margin resection in lower rectal tumors, 1 for small bowel injury and 1 for obesity. After surgery, passing flatus occurred at 34.3 +/- 16.7 h and oral intake could be reinstaured at 42.6 +/- 22 h. Mean postoperative stay was 8.2 +/- 3.4 days. No death occurred. The overall morbidity was about 13.5%. The rate of late complications was 5.4%. Two port site metastasis (2.6%) were seen in locally advanced carcinoma. Recurrence rate at 5 years was 0% for Dukes A, 20% for Dukes B, 39.2% for Dukes C. Survival rate at 5 years was 100% for Dukes A, 80% for Dukes B, and 60.7% for Dukes C. These results are similar to those of conventional open surgery.

CONCLUSION

Laparoscopic colorectal resection for cancer can be performed safely, with a low morbidity and rare late complications. Long term follow up (5 years) assessment shows similar outcome compared with conventional surgery.

[Evaluation of pancreatic cancer by combined laparoscopy and echolaparoscopy]

STUDY AIM

This prospective study was undertaken to evaluate the efficiency of staging laparoscopy associated with laparoscopic ultrasonography in the assessment of tumoural extension and surgical resectability in patients with carcinoma of the pancreatic head.

PATIENTS AND METHODS

From June 1995 to March 1997, 26 consecutive patients (11 male and 15 female patients), with a mean age of 62.5 years, were included in this study. The lesion was located in the pancreatic head with jaundice. Four staging methods were used: percutaneous ultrasonography (n = 26) computed tomography (n = 26), endoscopic ultrasonography (n = 26). The assessment of resectability by each procedure was verified by surgical exploration and histologic examination.

RESULTS

Results of percutaneous ultrasonography and computed tomography were similar, predicting unresectability in 50% of the patients. Endoscopic ultrasonography performed in the 16 patients without visible metastases according to the previous procedures predicted surgical resectability in seven patients only. With staging laparoscopy associated with laparoscopic ultrasonography, undiscovered metastases were found and unresectability was predicted in 21 patients out of 26; the sensitivity was 100% for liver metastases, peritoneal metastases and vascular involvement, 90% for lymph node involvement and 88% for diagnosis of the primitive lesion. A Whipple procedure was performed in five patients and a palliative bypass in all the other patients except one. An unnecessary laparotomy was avoided in 12 patients.

CONCLUSIONS

Staging laparoscopy associated with laparoscopic ultrasonography is superior to all other staging methods. It should be the first step of a potentially curative surgical treatment (five cases only in this series) or of a palliative bypass. Laparotomy was avoided in 12 cases.