Fibrin glue for mesh fixation in laparoscopic transabdominal preperitoneal (TAPP) hernia repair: indications, technique, and outcomes

BACKGROUND

The efficacy and safety of prosthesis fixation were studied by means of fibrin glue (Tissucol, Baxter Healthcare) during laparoscopic transabdominal preperitoneal (TAPP) treatment of inguinal and femoral hernias.

METHODS

Between September 2001 and December 2004, fibrin glue was used for mesh fixation during TAPP.

RESULTS

In this study, 320 hernias were treated for 230 patients (225 men and 5 women) with an average age of 45 years (range, 20-75 years). No perioperative complications were observed. After an average follow-up period of 26 months (range, 1-40 months), the only postoperative complications observed were six seromas (1.8%) and one trocar-site hematoma (0.3%). The mean operating time was 30 min for unilateral hernias and 50 min for bilateral hernias, whether primary or recurrent. Patients usually were discharged the day after surgery and returned to work after 5 days.

CONCLUSIONS

The authors' experience demonstrates that fibrin glue (Tissucol) is an effective method for mesh fixation during TAPP.

Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prosthesis fixation systems

BACKGROUND

Various systems exist for prosthesis fixation in hernia repair. These techniques vary in terms of postoperative complications and pain. This study compares prosthesis fixation techniques employed in laparoscopic transabdominal preperitoneal (TAPP) hernioplasty using a visual analog scale (VAS) to quantify postoperative pain.

METHODS

Patients (n = 600) underwent TAPP inguinal hernia repair in a randomized prospective study. Prostheses were fixed with Protak (Tyco, Norwalk, Conn), (Group A; n = 150), EndoANCHOR (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (Group B; n = 150), EMS (Ethicon Endo-Surgery, Inc.) (Group C; n = 150), or Tissucol (Baxter Healthcare, Milan, Italy) (Group D; n = 150). Patients were interviewed up to 1 month post-intervention. Post-operative pain was evaluated on a 0- to 10-point VAS (0 = no pain, 10 = maximum pain). Morbidity, length of stay, return to work and recurrence were also assessed.

RESULTS

Overall, 803 hernias were treated: 397 patients (66.2%) had unilateral hernias and 203 (33.8%) had bilateral hernias. In total, 96 (12%) hernias were recurrences and 707 (88%) were primary. Postoperative pain ranged from VAS1 to VAS2 (mild pain) between 12 hours and 72 hours with Tissucol (Group D), and it was higher in Groups A-C: Maxima ranged from VAS4 (moderate pain) with EMS to VAS7 (severe pain) with Protak at 48-hour follow-up. Significant differences in length of stay occurred, no recurrence or conversion rates were observed among groups, and morbidity was generally lower with Tissucol. Patients in Group D (Tissucol) also returned to work sooner than did Groups A-C (Protak, EndoANCHOR, and EMS).

CONCLUSIONS

We found differences in postoperative pain among different laparoscopic TAPP prosthesis fixation methods. The use of the biocompatible fibrin sealant Tissucol seems to reduce significantly postoperative pain, complications, and resumption to work times compared with other systems.

Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results

INTRODUCTION

Laparoscopic repair of inguinal hernias is usually achieved by totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) techniques. The intraperitoneal onlay mesh (IPOM) could be an interesting alternative as it is much easier to perform and faster to execute. This technique is subject to correct selection of indications and to demonstration of its safety.

MATERIALS AND METHODS

From January 2003 to January 2006 we performed 61 laparoscopic hernia procedures on 60 selected patients (60 males with a mean age of 60 and mean weight of 76 kg) with an IPOM technique combining the Parietex composite mesh (12 cm circular model) and a fibrin glue (Tissucol) for its fixation. The glue was diluted to increase fixation time and applied to the mesh prior to positioning on the hernia defect.

RESULTS

Mean operative time was 10 minutes. Mean hernia diameter was 2.5 cm (+/- 0.8 cm). 10 hernias were direct, 51 were indirect and 10 out of 61 were recurrent. We did not convert any of the laparoscopic procedures. Mean hospital stay was one day; mean recovery time for working and general physical activities was five days. Patients were checked after one week, 1-3-6 months and 1-2 years. Average follow up time was 23.7 months. 1.6 % of patients showed short-term complications: one trocar site haematoma. No additional complications were reported; particularly, we had no recurrence, no seroma, no mesh migration, and no bowel obstruction or fistula.

CONCLUSION

Results of this study show intraperitoneal (IP) tolerance to this kind of mesh and the safety of its fixation with Tissucol. The absence of recurrence and complications could be a good reason to extend the indication of IPOM hernia repair. However, these preliminary results should be confirmed by longer follow-up.

Use of fibrin glue (Tissucol) as a hemostatic in laparoscopic conservative treatment of spleen trauma

BACKGROUND

This study aimed to evaluate the effect of fibrin glue in laparoscopic spleen-preserving procedures for traumatic rupture.

METHODS

From January 2002 to December 2005, six laparoscopic spleen-preserving procedures were performed for traumatic rupture using fibrin glue. Two of the cases had previous middle and lower abdominal surgery. Survey of the abdominal cavity was performed by inserting two 5- to 12-mm trocars, one 5-mm trocar, and a 30 degree scope. A complete survey of all the patients was performed.

RESULTS

None of the patients required laparotomy, and no postoperative bleeding occurred. The fibrin sealant achieved immediate hemostasis, and all the patients recovered without further splenic bleeding. The mean postoperative stay was 4.3 days (range, 4-5 days). All the patients were followed up for 3 to 12 months. Postoperative immunoglobulin scanning, ultrasonography, and computed tomography (CT) results were normal.

CONCLUSIONS

Laparoscopic management of spleen trauma can be used once a positive diagnosis has been made. It is useful for assessing the degree of splenic injury. A laparoscopic spleen-preserving procedure can be used safely for patients with stable vital data. It is an effective procedure for the evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial. The topical application of a fibrin sealant in splenic trauma achieves definitive hemostasis safely, rapidly, and reliably. It also is simple to use in either laparoscopic or open procedures.

Laparoscopic versus open incisional hernia repair

BACKGROUND

Incisional hernia is a common complication of abdominal surgery, and it is often a source of morbidity and high costs for health care. This is a case-control study to compare laparoscopic versus anterior-open incisional hernia repair.

METHODS

170 patients with incisional hernia were enrolled in this study between September 2001 and December 2004. Of these, 85 underwent anterior-open repair (open group: OG), and 85 underwent laparoscopic repair (laparoscopic group: LG). The clinical outcome was determined by a median follow-up of 24.0 months for LG and OG.

RESULTS

No difference was noticed between the two groups in age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and incisional hernia diameter. Mean operative time was 61.0 min for LG patients and 150.9 min for OG patients (p < .05). Mean hospitalization was 2.7 days for LG patients and 9.9 days for OG patients (p < .05). Mean return to work was 13 days (range, 6-15 days) in LG patients and 25 days (range, 16-30 days) in OG patients. Complications occurred in 16.4 % of LG patients and 29.4 % of OG patients, with a relapse rate of 2.3% in LG and 1.1% in OG patients.

CONCLUSIONS

Short-term results indicate that laparoscopic incisional hernia repair is associated with a shorter operative time and hospitalization, a faster return to work, and a lower incidence of wound infections and major complications compared to the anterior-open procedure. Further studies and longer follow-up are required to confirm these findings.

Use of fibrin glue (Tissucol) in laparoscopic repair of abdominal wall defects: preliminary experience

INTRODUCTION

The aim of this study was to establish the efficacy and tolerability of human fibrin glue (Tissucol) for the nontraumatic fixation of a composite prosthesis (Parietex) in the laparoscopic repair of small to medium-sized incisional hernias and primary defects of the abdominal wall.

MATERIALS AND METHODS

From October 2003 to October 2005, 40 patients underwent laparoscopic repair at the hands of one surgeon with expertise in laparoscopic surgery; all meshes were implanted in an intraperitoneal position. Follow-up visits were scheduled for 7 days and 1, 6, and 12 months. These included assessments for pain and postoperative complications.

RESULTS

Forty patients (24 females, 16 males) with a mean age of 50 years (range, 26-65 years) and a mean Body Mass Index (BMI) of 27 (range 25 to 30) were included in the study. Sixteen patients had incisional hernias, and 24 had primary defects. The size of the defects varied from 2 to 7 cm. Adhesiolysis was necessary in 92.5% of cases (25/40). There were no intraoperative complications or conversions. After a mean follow-up of 16 months (range, 3-24 months), no postoperative complications were observed. The mean surgical intervention time was 36 min (range, 12-40 min), with an average hospitalization time of 1 day.

CONCLUSIONS

The use of fibrin glue in the present study provided stable and uniform fixation of the prosthesis and minimized intraoperative and postoperative complications. Consequently, laparoscopic treatment of small to medium-sized abdominal defects using this approach is our therapeutic option of choice.

Prospective clinical study of laparoscopic treatment of incisional and ventral hernia using a composite mesh: indications, complications and results

The aim of this study is to establish the indications, safety, efficacy, feasibility and reproducibility of the laparoscopic technique in treating defects in the abdominal wall, including those of large dimensions, to standardise the surgical technique and to confirm the performance of the composite prosthesis used (Parietex, Sofradim). The study encompassed the period from January 2001 to December 2004 and included 178 nonselected patients (108 women and 70 men), with an average age of 56 years (range: 26-77 years) and an average body mass index (BMI) of 30 (range: 26-40). These patients were treated for either abdominal hernia (156 patients; 89.7%) or a primary defect (22 patients; 10.3%). The dimensions of the abdominal hernias treated varied from 4 to 26 cm (average: 12.1 cm). All patients were treated using the laparoscopic technique, and all meshes were placed in the intraperitoneal position. Eleven (7%) postoperative complications arose after an average follow-up period of 29 months (range: 1-48 months): seven seromas (4.4%) lasting for 4 weeks, with one becoming infected after being punctured repeatedly; we removed the infected prosthesis by laparoscopy; three (1.9%) patients with persistent neuralgia, which were resolved after 2 months with a prescription for FANS; one patient with a haematoma at the trocar site. There were also four recurrences (2.5%), all of which occurred between 1 and 3 months postsurgery: one in the 'small' group of abdominal hernias (less than 9 cm) and three in the 'large' group of abdominal hernias. With the exclusion of any primary defects, an adhesiolysis was carried out in 99.3% of the patients. In seven cases (4.4%) we carried out a raphe for speritonealisations of loops in the small intestine; in four patients (2.5%), following tenacious adhesion (one patient) and loops fixed to the previous scar by stitches (three patients), we carried out an intestinal perforation (ileus) which was sutured by laparoscopy. The average operating time was 65.6 min (range: 28-130 min), with an average postoperative period in the hospital of 2.1 days (range: 1-5 days). No conversion was observed, and mortality was zero. The results obtained during the clinical trial demonstrate the safety and efficacy of the laparoscopic technique and of the mesh used as well as the reproducibility of the technique in the intraperitoneal treatment of congenital and postincision defects in the abdominal wall, including those of large dimensions.

[Prospective study of laparoscopic treatment of incisional hernia by means of the use of composite mesh: indications, complications, mesh fixation materials and results]

The aim of this study was to establish the indications, safety, efficacy, feasibility and reproducibility of laparoscopic techniques in the treatment of abdominal wall defects, even of the larger kind, in order to standardise procedures and confirm the performance of the composite mesh used (Parietex, Sofradim, Trevoux, France). From January 2001 to December 2004, 185 non-selected patients (109 females, 76 males), with a mean age of 56 years (range: 26-77) and a mean BMI of 30 (range: 26-40) were included in the study; 162 patients (87.5%) had incisional hernias and 23 patients (12.5%) primary wall defects. The size of the defects treated ranged from 4 cm to 26 cm (mean: 12.1 cm). All patients underwent laparoscopic repair and all meshes were placed intraperitoneally. Over a mean follow-up period of 29 months (range: 1-48), we observed 11 postoperative complications (6.7%): 7 seromas (4.3%) which were still present after 4 weeks, one of which turned septic after several attempts at percutaneous evacuation and in which the prosthesis had to be removed laparoscopically; 3 (1.8%) experienced persistent neuralgia which disappeared after 2 months' treatment with NSAIDs, and also one case of trocar-induced haematoma. We had 4 recurrences (2.4%), all within 1 to 3 months of surgery; 1 in the size group measuring less than 9 cm and 3 in the larger defect group. Adhesiolysis was performed in 98% of all incisional hernia cases and in 7 cases (4.3%) we had to repair iatrogenic lesions of the small bowel. In 4 patients (2.5%), because of thick adhesions (1 patient) or bowel loop fixation to the previous surgical scar (3 patients), we caused complete bowel perforation repaired by laparoscopic suture. Mean operative time was 65.6 minutes (range: 28-130) and the mean hospital stay was 2.1 days (range: 1-5). We had no conversions and no mortality. We also reviewed the main methods of mesh fixation and believe that the best system at the moment is the EndoAnchor (Ethicon Endo-Surgery, Cincinnati, Ohio) device, although in future the best option is likely to be fixation with non-traumatic biological glue (Tissucol, Baxter, Maurepas), which we have already used in a series of 16 patients with optimal results and no recurrences. The results emerging from this clinical trial confirm the safety and efficacy of laparoscopic repair techniques, of this kind of mesh and of the anchoring devices used as well as the reproducibility of this technique for the intraperitoneal repair of primary and incisional abdominal wall defects, including even those of large size.

[Use of fibrin glue (Tissucol) for mesh fixation in laparoscopic transabdominal hernia repair]

The aim of this study was to demonstrate the efficacy and safety and report the results of prosthesis fixation by means of fibrin glue during laparoscopic treatment of inguinal and femoral hernias. From September 2001 to December 2004 we employed fibrin glue (Tissucol, Baxter, Maurepas) as a means of fixation during a transabdominal preperitoneal procedure in 230 patients (225 M, 5 F) with an average age of 45 years (range: 20-75) presenting a total of 320 hernias: 140/230 (60.8%) were monolateral and 90 (39.2%) bilateral; 267/320 hernias (83.6%) were primary and 53 (16.4%) recurrent. We had no perioperative complications. After an average follow-up of 26 months (range: 1-40) the only postoperative complications we encountered were 6 seromas (1.8%) and 1 trocar-site haematoma (0.3%). None of the patients developed scrotal haematomas. None of the patients complained of immediate or subsequent paraesthesia or cruralgia. No recurrences have occurred to date. The mean operative time was 30 minutes for monolateral hernias (range: 15-45) and about 50 minutes for bilateral hernias (range: 30-75). This was true of both primary and recurrent hernias. Patients are usually discharged on day 1 postoperatively. In the absence of pain, working activities are resumed after 5 days and sports can be practiced after 10 days. In our experience, fibrin glue (Tissucol) is the best way of fixing the mesh during a transabdominal preperitoneal procedure. It is better than mechanical devices because, though guaranteeing prosthetic stability, it is completely non-traumatic and presents none of the problems of metal clips.

Results of laparoscopic versus open abdominal and incisional hernia repair

BACKGROUND

Incisional hernia is a frequent complication of abdominal surgery. The object of this study was to confirm the safety, efficacy, and feasibility of laparoscopic treatment of abdominal wall defects.

METHODS

Fifty consecutive laparoscopic abdominal and incisional hernia repairs from September 2001 to May 2003 were compared with 50 open anterior repairs.

RESULTS

The 2 groups were not different for age, body mass index, or American Society of Anaesthesiologists scores. Mean operative time was 59 minutes for the laparoscopic group, 164.5 minutes for the open group. Mean hernia diameter was 10.6 cm for the laparoscopic group, 10.5 cm for the open group. Mean length of stay was 2.1 days for the laparoscopic group, 8.1 days for the open group. Complications occurred in 16% of the laparoscopic and 50% of open group. Median follow-up was 9.0 months for the laparoscopic group, 24.5 months for the open group. Recurrence rates were 2% for laparoscopic group and 0% for the open group.

CONCLUSION

Results for laparoscopic abdominal and incisional hernia repair seem to be superior to results for open repair in terms of operative time, length of stay, wound infection, major complications, and overall hospital reimbursement.

[Laparoscopic transabdominal preperitoneal repair of inguinal hernia: indications, technique, complications and results in 10 years experience]

AIM

Inguinal hernia play a major role in a general surgical division. In the last 10 years laparoscopy has gained a key role even in the treatment of this disease. This study aims to review a single institution's experience with laparoscopic transabdominal preperitoneal repair of inguinal hernia (TAPP).

METHODS

A retrospective study of 715 operations in 500 patients from 1992 to September 2002. Two hundred and eight six (56.6%) of these were monolateral hernias and 214 (43.4%) were bilateral while 215 (30%) were recurrent.

RESULTS

Of 214 operations recurrence rate was 0.43 with a mean operating time of 30 min (range 25-50) for monolateral hernias and of 70 min (range 45-120) for bilateral hernias. Mean length of stay was 2 days (range 1-10). Return to work occurred in 6 days while sports were resumed after 10 days. Complications occurred in 40 (8.6%) patients with only 2 (0.4%) major complications. Mean follow up time was 58.3 months.

CONCLUSION

According to personal experience, and in agreement with international literature, laparoscopy showed to be effective mostly in treating bilateral and recurrent hernias, particularly for faster recovery and less postoperative pain compared to traditional techniques.

[Laparoscopic surgery of the liver: state of the art]

Laparoscopic hepatic surgery has recently claimed its place among the minimally invasive techniques. Adequate technologies and experience both in laparoscopy and liver surgery are essential for its correct use. A review of the English literature on this subject is presented and the present state of the art discussed. Various topics are considered: staging, treatment of cystic lesions and treatment of benign and malignant primary and secondary tumours. Over the past five years various groups have published papers regarding case series, mainly concerning hepatic resection. More correct indications for the use of laparoscopy in liver surgery have been defined. In particular, laparoscopy is of great importance in the staging of primary and secondary liver cancer and in the treatment of cystic and benign lesions, mainly of the anterior segments. Less univocal are surgeons' attitudes towards the treatment of primary and secondary liver cancers. Laparoscopic liver surgery is gradually gaining wider and clearer acceptance in the treatment of hepatic lesions, while it has now virtually consolidated its role in the treatment of cystic lesions and in the staging of primary and secondary liver cancer.

Laparoscopic liver resection with radiofrequency

BACKGROUND/AIMS

In this report, the feasibility, efficacy and safety of laparoscopic liver resection with radiofrequency has been evaluated in a small series of patients.

METHODOLOGY

From January 1993 to May 2002 we carried out 7 laparoscopic liver resections (3 men and 4 women), five of which were for benign pathology and two for metastases from colorectal cancer. In four of the above resections we used an argon coagulator; the last three were accomplished by means of a radiofrequency instrument.

RESULTS

We had no perioperative or postoperative complications in this small series of patients. There were no deaths. Perioperative blood loss was of 120 mL (range 80-200) and the procedure took about 90 minutes (range 80-110). Hospitalization was of 4 days and pain was adequately controlled by 2 mL of Toradol twice a day.

CONCLUSIONS

We think that the advantages of laparoscopic techniques together with the efficacy of the radiofrequency instrument in hepatic surgery will allow the diffusion of this method and its extension to safe execution of major resections.

[Laparoscopic liver resection using a radiofrequency dissector. Initial experience]

Laparoscopic liver surgery, especially when resective, requires both the skill of an expert laparoscopist and the experience of a liver surgeon. The aims of the study were to assess the feasibility of minor laparoscopic liver resection by means of a radiofrequency dissector and to evaluate the laparoscopic approach. From January 1993 to November 2002 we carried out 7 laparoscopic liver resections (3 men, 4 women), 5 of which for benign diseases and 2 for metastases from colorectal cancer. In 4 of the above resections we used an argon coagulator, while the last 3 were performed using a radiofrequency instrument. We had no perioperative or postoperative complications in this small series of patients. The mean perioperative blood loss was 120 ml (range: 80-200) and the procedure took about 90 minutes on average (range: 80-110). The mean hospital stay was 4 days and pain was adequately controlled by administering 2 ml of Toradol twice daily. We believe that the advantages of the laparoscopic technique together with the efficacy of the radiofrequency instrument in liver surgery will lead to a more widespread use of this procedure and extension of its use to include the safe execution of both minor and major resections.

[Hernioplasty using a Lichtenstein polypropylene mesh]

"Tension free" technique with prosthetic mesh for inguinal hernia repair was introduced since 1988 in Authors' Institution. In a review of 98 hernioplasties performed, only one relapse was observed (around 1%), while prosthetic infection cases were never observed. The disorder most frequently complained by the patients is a pain in the pubic area, persisting even months after the operation. Therefore this technique seems to be reliable, safe, and easy. While waiting for a long-term follow up to confirm these results, the Authors however suggest to limit the indications for this technique avoiding the use of prosthetic material in young patients since Shouldice's hernioplasty assures a low percentage of relapse for them.

Influence of blood transfusions on surgery-induced immune changes in colorectal carcinoma

Perioperative blood transfusions have been shown to enhance recurrence rates in patients with operable solid tumors, perhaps by inducing immunosuppression through unknown mechanisms. Since the surgical treatment per se has been proven to induce immune alterations, the present study was carried out to evaluate the immune effect of blood transfusions on surgery-induced immune variations. The study included 27 patients with resectable colorectal carcinoma, 18 of whom received no transfusion, while the other 9 received blood transfusions in the perioperative period. Total lymphocytes, total T lymphocytes (CD3) and soluble IL-2 receptor serum levels (SIL-2R) were measured on venous blood samples collected from each patient either before or 7 days after surgery. Both in non transfused and in transfused patients, SIL-2R mean levels were significantly higher after than before surgery. Their increase was associated with a significant decrease in both lymphocytes and CD3 cells in non-transfused patients, while in the transfused ones lymphocytes and CD3 cells did not show significant changes with surgery. This study shows that blood transfusions modify the relation between changes in SIL-2R and those in lymphocyte number induced by major surgery. It remains to be understood which relation exist between these immune effects and the promoting action of blood transfusion on relapse frequency in cancer.

Effects of a preoperative course of interleukin-2 on surgical and immunobiological variables in patients with colorectal cancer: a phase 2 study

OBJECTIVE

A phase 2 study to evaluate the effects of a short preoperative course of interleukin-2 (IL-2) on the postoperative course of patients with cancer.

DESIGN

Open study.

SETTING

San Gerardo Hospital, Monza, Italy.

SUBJECTS

16 Consecutive patients with locally advanced colorectal cancer, with or without metastases.

INTERVENTION

IL-2 in a dose of 9 x 10(6) IU/m2 twice daily for three days; patients were operated on within 36 hours of the cessation of IL-2 treatment.

MAIN OUTCOME MEASURES

Morbidity, mortality, and changes in numbers of lymphocytes, T lymphocytes, natural killer (NK) cells, and CD25 (cluster of determination) positive cells.

RESULTS

There was no morbidity or mortality--in particular, there were no infections even in the patients who were at highest risk. The mean numbers of lymphocytes, T lymphocytes, NK cells, and CD25 positive cells increased significantly during the postoperative period. All patients showed evidence of infiltration of lymphocytes or eosinophils (or both) into the tumour tissue.

CONCLUSIONS

The results suggest that a three day course of IL-2 preoperatively is well tolerated, stimulates would repair, neutralizes the lymphocytopenia induced by major operation, and induces immune cells to infiltrate the tumour. Randomised studies are needed to confirm these results.

Effects of a preoperative therapy with interleukin-2 on surgery-induced lymphocytopenia in cancer patients

It is known that major surgery may determine immunosuppression. This side effect might have a prognostic significance particularly in cancer patients, in whom the decrease in host defenses during the postoperative period could promote the proliferation of possible micrometastases. Since antitumor immune response is an IL-2-dependent phenomenon, a study was started to evaluate the effects of a preoperative injection of IL-2 on surgery-induced immune changes in cancer patients. The study included 12 colon cancer patients, treated subcutaneously with IL-2 at a dose of 9 x 10(6) IU/m2 twice daily for 3 consecutive days before surgery. Patients underwent surgery within 36 h from IL-2 interruption. The results were compared to those found in a control group of 18 colon cancer patients. Mean number of lymphocytes, T lymphocytes and NK cells significantly decreased after surgery in control patients; on the contrary, no postoperative decrease in immune cells was seen in IL-2 group. No anesthesiologic or surgical complication was seen in patients pretreated with IL-2 before surgery. This preliminary study would suggest that a preoperative therapy with IL-2 is an effective and well tolerated medical approach to neutralize surgery-induced immunosuppression in cancer patients.

[Choice of technique in "difficult" inguinal hernias. Personal experience]

The authors refer on their positive results in the treatment of so-called difficult inguinal hernias (relapsing or multiple hernias) with the use of prosthetic prolene mesh according to Stoppa's procedure (partly modified) through a preperitoneal approach after a Pfannenstiel's incision. On the other hand recurrent hernias in risky patients as well as gross hernias are treated by Rives' method which consists in a prolene mesh placement through the inguinal approach.