[Lumbar hernias in adults. Apropos of 4 cases and review of the literature]

Lumbar hernias are rare (2% of abdominal wall hernias). Symptomatology consists frequently only of an arch formation seen best with the patient sitting and when coughing. In adults it is twice as frequent in women and on the left side. Acute events, dominated by incarceration of a digestive segment, particularly colic, often suggest the diagnosis (10% of cases). Diagnosis is simple when confronted with a large hernia, but difficulties arise with those less than 5 cm in diameter, often diagnosed as a lipoma or parietal tumor. Conventional radiographs and ultrasound images are usually sufficient to establish the correct diagnosis and to determine the content of the hernial sac, but computed tomography scans can provide data on the exact limits of the defect and allow evaluation of possible problems during surgical repair. Rarely congenital (10%), these hernias occur either secondary to a violent lumbo-abdomino-pelvic injury (25%) or following surgical intervention to the lumbar region (50% of cases). Small hernias can be repaired using the direct approach but larger deficits require the insertion of a reinforcing non absorbable prosthesis. Long term results, both for the 4 cases reported and those published in the literature, were assessed as satisfactory.

[Should routine exploratory laparotomy be performed in the presence of an abdominal wound? Discussion apropos of 176 cases]

Management of abdominal wounds is presently the subject of discussion between the partisans of routine laparotomy and those preferring "armed" surveillance. Results of study of a series of 176 abdominal wounds subjected to surgical dogma showed: that the diagnosis of non penetrating wounds (17.6%) was not always evident, due either to their anatomical localization (frontier region wounds) or to insufficient local exploration in urgent cases (6.6% of false-negatives), that the existence of serious clinical signs (50 cases) was always associated with one or more visceral lesions, requiring urgent laparotomy with a morbidity of 20% and a mortality of 8% (4 cases), that in the case of asymptomatic penetrating wounds (96 cases), routine laparotomy did nevertheless allow the diagnosis of visceral lesions in 50 cases (including 23 major lesions) but was of no utility in 46 cases (31.5% of blind laparotomies for the total series). The elevated proportion of useless laparotomies (30% in the literature), the result of a dogmatic attitude, or the risk of a delayed intervention (5 to 8%) in the series practising the selective method, led to a modification in the authors' attitude. The existence of serious signs should obviously result in a laparotomy. In their absence, and when confronted with a penetrating or doubtful (frontier region) wound, an exploratory celioscopy is proposed to ensure complete abdominal exploration, to confirm the presence or absence of penetration, to treat minimal lesions and to perform a classical laparotomy in case of evident necessity.

[What is the role of elective surgery in diverticular sigmoiditis?]

From 1981 to 1991 inclusive, 188 operations were carried out for diverticular sigmoiditis. One hundred and thirty-nine patients were operated in emergency for acute complications (123) or fistulae (16), and another 49 had surgery scheduled outside acute crisis periods. Mortality and morbidity respectively are 16.5 and 31% in the first group, against 0 and 12% in the second one. Similarly, the stay in hospital varies from 13 days for scheduled surgery to 23 days for emergent surgery, the latter also requiring to account for risks and for the duration of a second operation that is far from exceptional (40%). Considering the severity of some evolutive complications, the authors advocate early radical surgery for symptomatic diverticular sigmoiditis, after the second crisis or as soon as the first one if it has been severe, and in young subjects and patients at risks.