Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia

BACKGROUND

The Shouldice technique is the 'gold standard' of open non-mesh hernia repair. The aim of this study was to compare 5-year recurrence rates after Shouldice and laparoscopic transabdominal preperitoneal patch (TAPP) repair for primary inguinal hernia.

METHOD

Men with a primary unilateral inguinal hernia were randomized to either Shouldice or TAPP operation. An independent observer scored the surgeons' performance. Follow-up comprised clinical examination after 1 year, a questionnaire after 2 and 3 years, and a clinical examination after 5 years.

RESULTS

Between February 1993 and March 1996, 1183 patients were included. Nine hundred and twenty patients were followed for 5 years, 454 in the TAPP group and 466 in the Shouldice group. Recurrences were evenly distributed between groups throughout the follow-up period. The cumulative recurrence rate after 5 years was 6.6 per cent in the TAPP group and 6.7 per cent in the Shouldice group. Postoperative pain was a risk factor for recurrence after Shouldice operation but not after TAPP repair. There was a correlation between a low surgeon's performance score and recurrence.

CONCLUSION

The 5-year recurrence rate is acceptable, with no difference between TAPP and Shouldice repair. Poor operative performance resulted in a higher recurrence rate. The TAPP operation represents an excellent alternative for primary inguinal hernia repair.

Prospective follow-up after ambulatory plain midline excision of pilonidal sinus and primary suture under local anaesthesia--efficient, sufficient, and persistent

OBJECTIVE

Optimal surgical treatment for chronic pilonidal sinus (PS) disease should be easy and efficient. The purpose of this study was to establish the feasibility of and results after ambulatory simple midline excision and primary wound closure under local anaesthesia.

PATIENTS AND METHODS

The prospective nonrandomised single institution study included 131 consecutive PS patients admitted for surgery. After standardized surgery, all patients were prospectively followed until fully healed. Complications were registered. Results after 41 months (mean, range 36-59) were evaluated by questionnaire.

RESULTS

95% were primary closed. All were ambulatory treated and 98% under local anaesthesia. 88% healed in two weeks. 5.6% exhibited minor wound healing defects and 6.4% demanded full debridement of the wound. Mean delayed healing time was 7.5 weeks (range 3-12). 8% developed a recurrence. 10% of the remainders reported a slight tenderness in the scar area. 90% were symptom-free.

CONCLUSION

PS treatment as of above is readily achieved. Wound related complications were reasonably few and in the same magnitude as after more complex excision techniques and induced no significant long-term sequels. Recurrences could, however, be more common. Prospective randomised studies are warranted to determine if there are any significant differences between excision techniques in and out of the midline.

Inhibition of plasma extravasation after burns by D-myo-inositol-1,2,6-trisphosphate using digital image colour analysis

D-myo-inositol-1,2,6-triphosphate (1,2,6-IP3) has beneficial effects in experimental, progressive burn-induced ischaemia and oedema. A 1 cm2 full-thickness burn was made in the skin of 20 rats with a hot aluminium rod followed by infusion of 1,2,6-IP3 (60 mg.kg.-1 h-1) or isotonic saline (n = 10 in each group). One hour later Evans blue was injected intravenously. Colour photographs of the area of the burn were taken in a standard manner before the burn and at intervals for three hours afterwards. The photographs were analysed by digital image colour analysis using normalised red-green-blue values. The increase in normalised blue values between 60 and 180 minutes after the burn was significantly reduced in animals treated with 1,2,6-IP3 compared with control animals (p < 0.001). Spectrophotometric analysis of extravasated Evans blue in the skin 180 minutes after the burn showed that it had been significantly inhibited by treatment with 1,2,6-IP3 (p < 0.001). In conclusion, digital image analysis allowed repeated evaluation over time and confirmed previous data about the ability of 1,2,6-IP3 to inhibit extravasation of plasma after burns.

Postoperative analgesia by D-myo-inositol-1,2,6-trisphosphate in patients undergoing cholecystectomy

D-myo-inositol-1,2,6-trisphosphate (1,2,6-IP3) possesses antiinflammatory properties, such as reduced eicosanoid synthesis and inhibition of inflammation-induced edema. These properties suggest possible analgesic effects. The analgesic effect of 1,2,6-IP3 was evaluated in a double-blind, randomized study in 24 patients undergoing cholecystectomy. Ten patients received 1,2,6-IP3 as an intravenous (i.v.) bolus dose of 240 mg, followed by a continuous i.v. infusion at 90 mg/h for 24 h. The placebo group (n = 14) received corresponding volumes of isotonic saline. Postoperative pain (visual analog pain scale; VAS) and opiate analgesic requirements (ketobemidon) were evaluated during five postoperative days. Results showed significantly reduced pain during the first five postoperative days in patients treated with 1,2,6-IP3, as measured by using a VAS (P < 0.05). The requirements of opioid analgesics were significantly reduced during the first three postoperative days (P < 0.05). No drug-related side effects were observed. Results of the present study demonstrate a potent and long-lasting analgesic effect of 1,2,6-IP3, possibly related to its antiinflammatory properties.

IMPLICATIONS

A new antiinflammatory drug under investigation, inositol-1,2,6-trisphosphate, was evaluated as a possible analgesic in a pilot study during the postoperative period in cholecystectomized patients. Results showed significantly lower pain assessment and opioid consumption, which should encourage further studies.

Increased dermal perfusion after skin burn injury by D-myo-inositol-1,2,6-trisphosphate

Full-thickness burn injury results in a continuous deterioration of blood flow due to vascular sludging, thrombosis formation and oedema leading to irreversible ischaemia and tissue necrosis. D-myo-inositol-1,2,6-trisphosphate (IP3) has previously been shown to reduce burn-induced oedema formation and inflammation involved in the pathophysiology of progressive ischaemia. A full-thickness burn injury (1 cm2) was induced in the abdominal skin of anaesthetized rats using an electrically heated thermoprobe. Blood flow in the experimental area was measured by laser Doppler flowmetry during 6.5 h postburn. The experiments included five groups. Three burned groups were treated intravenously with IP3 and received respectively: a bolus dose of 4 mg/kg followed by a continuous intravenous infusion of 20 mg/kg/h, 8 mg/kg + 40 mg/kg/h or 16 mg/kg + 60 mg/kg/h. One burned and one unburned control group received a corresponding bolus dose and infusion of saline. Results showed a significant inhibition of dermal ischaemia in the burned groups receiving IP3 at all dose intervals as compared to saline-treated burned rats (all P < 0.001). We conclude that IP3 improved local dermal perfusion in burned skin. Probable mechanisms of action could be the vasodilatory and anti-inflammatory properties of the agent.

Patterns of propulsive motility in the human colon after abdominal operations

Twenty patients about to undergo elective cholecystectomy who were not using laxatives or drugs known to affect gastrointestinal motility and who did not give a history of gastrointestinal disease were investigated in a prospective open study. Patients swallowed two capsules each containing four radio-opaque markers every 12 hours starting 48 hours before operation. The pattern of resolution of postoperative colonic paralysis was monitored by serial abdominal radiographs taken every 12 hours until motility had returned to the rectum/sigmoid colon. In all 17 patients who completed the study propulsive motility started significantly earlier in the right colon (mean 61 hours) than in any other part (p less than 0.01). The gradient of resolution of postoperative colonic paralysis was always from proximal to distal, adding to the accumulating body of experimental evidence that implicates the right colon to return to normal first.

Lack of effect of metoclopramide on colonic motility after cholecystectomy

The effect of metoclopramide on postoperative colonic ileus was evaluated in a randomised, double-blind study in 20 patients after cholecystectomy. The start of propulsive colonic motility and colonic transit time after operation were measured by radio-opaque markers and serial abdominal radiographs. Metoclopramide 20 mg given intravenously three times a day until the fourth postoperative day (n = 10) did not significantly reduce the duration of postoperative colonic paralysis compared with control patients (n = 10), nor were there any differences between the groups when the time of first postoperative passage of gas and faeces were compared. In conclusion, the use of metoclopramide in the postoperative period did not result in a quicker return of propulsive motility in the right or left colon as judged by the radio-opaque markers and serial abdominal radiographs.

Treatment of postoperative paralytic ileus with cisapride

The effect of cisapride on postoperative colonic motility was studied in 40 patients undergoing cholecystectomy under randomized, double-blind conditions. The patients received 10 mg of cisapride or placebo by intravenous injection starting on the day of surgery and repeated every 12 h until the 3rd postoperative day. The return of propagative motility in the colon was visualized by means of radiopaque markers and serial abdominal radiographs. Cisapride induced a significantly earlier return of propulsive motility in the right colon, as indicated by the propagation of markers from the ascending colon to the transverse colon (p less than 0.05). Radiopaque markers reached the descending colon (p less than 0.05) and the rectosigmoid colon (p less than 0.05) significantly earlier in the cisapride group than in controls. The first passage of feces occurred significantly earlier in cisapride-treated patients than in controls (p less than 0.05). The first passage of gas after surgery did not differ significantly between the groups. Our results suggest that cisapride can be used to induce earlier return of propagative motility in the colon after major abdominal surgery.

Treatment of postoperative paralytic ileus by intravenous lidocaine infusion

The effects of continuous intravenous infusion of lidocaine on postoperative paralytic ileus in cholecystectomized patients was investigated in this double-blind study. An infusion of lidocaine (3 mg/min, n = 15) or an infusion of an equal volume of saline (n = 15) was started 30 min before induction of anesthesia and continued for 24 h after surgery. Postoperative colonic motility was evaluated by radiopaque markers and serial abdominal radiographs. A record was kept of the first passage of gas and feces. Results showed significantly earlier return of propulsive motility in the colon of lidocaine-treated patients. Radiopaque markers in the lidocaine group were propelled significantly earlier from the cecum/ascending colon to the transverse colon (P less than 0.05) and appeared significantly earlier in the descending colon (P less than 0.05) and the rectosigmoid colon (P less than 0.05) than in saline-treated patients. Despite the fact that the mean time for postoperative defecation occurred 17 h earlier in lidocaine-treated patients, differences between the groups were not statistically significant--a fact due, perhaps, to great individual variations in defecation habits. The time to first passage of gas, a variable representative of changes in anorectal or colonic tone rather than propagative motility, also did not differ significantly between the groups. No adverse reactions to lidocaine were reported. The results suggest that continuous intravenous infusion of lidocaine during the first postoperative day shortens the duration of paralytic ileus in the colon after abdominal surgery. Suppression of inhibitory gastrointestinal reflexes by reduction of postoperative peritoneal irritation is suggested as the mechanism of action.

Inhibition of peritonitis by amide local anesthetics

Peritonitis was induced in rats by exposing the peritoneal surface to 0.1 M hydrochloric acid (HCl). Peritonitis was quantified by extraction of Evans blue-bound albumin from the tissue exposed to HCl and analyzed by a spectrophotometric technique. In the first set of experiments, one group of rats had the peritoneal surface exposed to HCl following local pretreatment with isotonic saline; a second group of rats had the peritoneum exposed to HCl after topical pretreatment with an equal volume of lidocaine 1%, whereas in a third group the peritoneal surface was exposed only to saline without HCl. The experimental design in the second set of experiments was similar to that of the first set except that bupivacaine 0.5% was used instead of lidocaine in the second group. Results show a significant inhibition of peritonitis in the groups pretreated with lidocaine (P less than 0.01) and bupivacaine (P less than 0.05) compared with rats in the saline pretreated group. In the lidocaine-pretreated group Evans blue-albumin extravasation did not differ significantly from the rats not receiving HCl, whereas the bupivacaine-pretreated group showed a slightly but significantly (P less than 0.05) more pronounced peritonitis than control rats not exposed to HCl. In the third set of experiments the peritoneum was topically treated with either lidocaine 1%, bupivacaine 0.5%, or isotonic saline after first having exposed the peritoneal surface to HCl. A significant inhibition of albumin extravasation was seen following lidocaine (P less than 0.001) or bupivacaine (P less than 0.001) treatment compared with treatment with isotonic saline.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of lidocaine infusion on the sympathetic response to abdominal surgery

Activation of afferent nerves in the area of surgery is a cause for surgical pain and stress. Intravenous (IV) lidocaine has been shown to inhibit postoperative pain. In the present double-blind study, the effects of a continuous IV infusion of lidocaine (2 mg/min) on the sympathoadrenal stress response to surgery were evaluated in 38 patients scheduled for elective cholecystectomy who were randomly assigned to two groups. In one group, lidocaine infusion was started 30 min before the operation and continued for 24 hr after surgery (n = 18). In the second group (n = 20), saline was infused. The increases in heart rate and blood pressure after tracheal intubation were not significantly different between the groups, but tachycardia and hypertension associated with extubation was prevented in patients given lidocaine. Differences in blood pressure and heart rate between the two groups were otherwise not significant intra- or postoperatively, nor were differences in blood glucose or plasma catecholamine concentrations during the first 24 hr after skin incision. Urinary catecholamine concentrations did not differ significantly in the two groups during the first postoperative day, but during the second postoperative day urinary output of epinephrine and norepinephrine were significantly less in the group of patients receiving lidocaine infusion. It was concluded that the IV infusion of lidocaine during and after major abdominal surgery suppresses extubation-induced hypertension and tachycardia but does not inhibit the general sympathetic response during the first postoperative day. However, lidocaine infusion reduces urinary output of catecholamines during the second postoperative day, suggesting a more rapid decline in the sympathoadrenal response postoperatively in the experimental group.

Failure of epidural anesthesia to prevent postoperative paralytic ileus

This study used radiopaque markers and serial abdominal radiographs to assess the effect of epidural anesthesia on postoperative colonic ileus. Epidural anesthesia did not result in significantly faster return of propulsive motility in the colon after surgery as compared with control (P greater than 0.05). In addition, no significant difference was seen between the groups in colonic transit time and time for the first passage of gas and feces. The level of inhibition of sympathetic efferent nerves to the abdominal cavity was assessed by repeated measurements of blood glucose levels during the first postoperative day. Blood glucose levels were found to be significantly lower in the epidural group, demonstrating an inhibition of efferent sympathetic nerves below the level of T-5. Results show lack of effect of continuous epidural anesthesia in the prevention of postoperative paralytic ileus and suggest that mechanisms other than spinal reflexes play a major part in the development and maintenance of intestinal paralysis.

Effect of intra-abdominal bupivacaine instillation on postoperative colonic motility

Effect of intra-abdominal instillation of a local anaesthetic, bupivacaine, on postoperative colonic adynamic ileus was studied in a double blind manner in a randomised series of patients undergoing upper laparotomy. Propulsive colonic activity was studied postoperatively with radio-opaque markers and serial abdominal radiographs. Intra-abdominal instillation of bupivacaine 2 mg/kg bw significantly shortened the period of postoperative colonic inhibition (p less than 0.01), but did not hasten colonic transit. Furthermore, bupivacaine significantly decreased the hyperglycaemic response to surgery. It is suggested that bupivacaine inhibits the inflammatory response within the bowel wall, a response which may maintain the inhibitory spinal reflexes in the postoperative period. Blood concentrations of bupivacaine were shown to be well below toxic levels and no adverse reactions were observed.

Inhibition of postoperative pain by continuous low-dose intravenous infusion of lidocaine

Intravenous lidocaine has been reported previously to inhibit postoperative pain when given either as single injections or as short infusions in amounts usually causing adverse reactions. To determine the efficacy of a continuous low-dose (2 mg/kg) intravenous infusion of lidocaine, postoperative pain (visual analogue pain scale) and the requirements for postoperative analgesics were measured in a double-blind randomized trial in 20 patients after cholecystectomy. Lidocaine infusion was started 30 min before the operation and continued for 24 hr after surgery (n = 10). Saline was infused in a comparable group of ten patients. The lidocaine-treated patients had significantly lower pain scores during the first day after surgery (P less than 0.001) and required significantly less meperidine during the first (P less than 0.02) and second postoperative days (P less than 0.01). No adverse reactions to lidocaine were observed. Whole blood levels of lidocaine ranged between 1 and 2 micrograms/ml. The results suggest that low-dose continuous infusions of lidocaine decrease the severity of postoperative pain and are devoid of side effects.