Biomedical subjects
R Bendavid
Publications and source records attributed to R Bendavid.
Transversalis fascia rediscovered.
The transversalis fascia is a layer in the make-up of the posterior inguinal wall. It is the deepest, thinnest, and least important layer in terms of the prevention of herniation. It is a segment of the wider endoabdominal fascia. The true posterior wall of the inguinal canal is formed, in varying degrees, by the muscles or aponeuroses of the internal oblique and transversus abdominis. Plainly, Daedalus was not needed to show surgeons and anatomists how to make a labyrinth out of a rabbit hole!
Complications of groin hernia surgery.
Groin hernias represent one of the most common procedures performed in general hospitals. The rapid changes that have been witnessed in prosthetic materials, open-approach surgeries, and laparoscopic techniques have made hernia surgery a most interesting field of endeavor that demands renewed discipline and dedication.
[Shouldice herniotomy].
The Shouldice operation has evolved to become the classic procedure for open pure tissue repair for inguinal hernias. The operation is an important part of a surgeon's repertoire as he may need to perform the procedure at some critical time, especially when faced with strangulation, when tension-free prosthetic repairs and laparoscopic approaches fail. When properly done, the Shouldice repair yields results that have set standards for all other techniques to emulate. Other particular advantages of the technique are: safety, the use of local anaesthesia, benign postoperative complications and the cost, which is the most reasonable of all surgical techniques.
Laparoscopic herniorrhaphy revisited.
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The Shouldice technique: a canon in hernia repair.
Controversy exists on the merits of the various approaches to inguinal repair. Evolution of the classic open repair has culminated in the Shouldice repair. Challenges from newcomers, namely, tension-free repair and laparoscopy, are being examined. These two techniques have a number of disadvantages: the presence of foreign bodies (prostheses) and their implication in cases of infection; the cost of prosthetic material, which is no longer negligible (particularly with expanded polytetrafluoroethylene); and problems of safety in that the laparoscopic approach is no longer a dependable asset except in the hands of a highly specialized and dextrous operator. Still, complications occur with laparoscopic repair that should not be associated with a surgical procedure that is considered benign, safe and cost-effective. Surgeons must recognize the pertinent facts and decide according to their conscience which method of repair to use.
Laparoscopic alternatives for the repair of inguinal hernias.
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The space of Bogros and the deep inguinal venous circulation.
The ideal reconstruction of the floor of the inguinal canal during a herniorrhaphy implies a good anatomic dissection and exposure. This cannot be accomplished without entering the subinguinal space of Bogros. This space presents a venous circulation that has not been entirely identified in the past. As an aid to accomplishing a safe and bloodless dissection, these vessels have been described--the deep inferior epigastric vein, the iliopubic vein, the rectusial vein, the retropubic vein and the communicating rectusio-epigastric vein, and their relationship into a venous circle. The need to map these vessels is becoming more crucial as surgeons choose varied approaches to the space of Bogros and insert synthetic mesh that requires anchoring.
Incisional parapubic hernias.
A parapubic hernia, distinct from other lower abdominal wall hernias, is identified as a particular type of incisional hernia. This hernia results from the disruption of the musculotendinous elements of the abdominal wall as they insert into the pubis. This disruption is brought about by either the destruction of these musculotendinous tissues at their lower end or the resection of portions of the pubic bone as is sometimes done in suprapubic radical prostatectomies for easier access to the prostate. Seven cases have been identified and reported. Men and women were seen to make up a clinical picture that is suggestive of the diagnosis, namely, multiple previous operations through the lower abdominal wall, procedures of a gynecologic or urologic nature, a herniation that mimics an incisional or inguinal hernia, and a defect that cannot possibly be corrected without the use of a prosthesis. When the diagnosis is accurately established, the polypropylene mesh is inserted in the preperitoneal space and anchored laterally to the ligaments of Cooper and in between to the arcuate pubic ligament and the periosteum of the posterior aspect of the pubis. Excellent results have been obtained, and the success must be ascribed to the recognition of the parapubic hernia as a distinct entity.
A femoral "umbrella" for femoral hernia repair.
The morbidity associated with primary and recurrent femoral hernias is reviewed herein, along with the use of the "femoral umbrella" in the management of failure prone femoral hernia and recurrent femoral hernia. Thirty patients have been operated upon with excellent results. The only complication reported was a seroma in two patients. The follow-up period was more than two years. This procedure is a significant and promising one for the cure of large primary femoral hernias and difficult recurrent femoral hernias.
New techniques in hernia repair.
The surgical treatment of inguinal and femoral hernias has evolved through several stages to reach a modern and successful era. This success was shared by all our predecessors who contributed some knowledge with respect to anatomy, physiology, and surgery. Although most patients are treated with satisfaction by primary herniorrhaphy, difficult recurrences can also be treated successfully. The special features that characterize the modern treatment of difficult hernias are the preperitoneal approach and the availability of reliable prosthetic materials. Some of the techniques currently available are discussed. They are the femoral umbrella, transversalis fascial replacement, and the fletching. The results have been encouraging. As surgeons, we are behooved to look, assess, and reconsider in order to improve.
The rational use of mesh in hernias. A perspective.
The decision to use mesh in abdominal wall hernia repairs is not always based on rationale. Some surgeons use mesh on nearly all cases, encouraged by the impression that they never get recurrences. Other surgeons rarely use mesh, citing the fact that there is always enough tissue on site and that foreign bodies can have their complications. A third group of surgeons will respond to the particular need of that herniorrhaphy. Because few surgeons have a large personal experience, it becomes difficult to scan the spectrum of hernias seen in the surgical population. Yet, when numbers are available, a pattern may be discerned which reveals four classes of hernias. These four classes are those which require mesh--"rarely" (less than 1%), "sometimes" (less than 5%), "frequently" (38% and 63.3%) and "always" (91.0% and 100%). These statistics should provide surgeons with some insight as to when mesh may be used.
Femoral hernias: primary versus recurrence.
A primary femoral hernia, as a surgical entity, differs markedly from a recurrent femoral hernia in terms of prognosis and outcome. Whereas most primary hernias present with adequate tissues for a reliable repair, the same does not hold true for recurrences, where most immediate and adjacent tissues are scarred or destroyed. The surgeon is then faced with a situation where the necessary structures for a successful repair (ligaments of Poupart, Henle, Gimbernat and Cooper) are relatively rigid. This rigidity precludes the approximation of those structures without tension. This study review 508 femoral herniorrhaphies on 453 patients (251 primary femoral repairs and 257 recurrent femoral hernia repairs). The recurrence rate for primary herniorrhaphies is 6.1%; for recurrent herniorrhaphies, the rate of recurrence is 22.2% on average with a range of 11.8% to 75%.
The "Fletching": a new implant for the treatment of inguino-femoral hernias.
Inguino-femoral hernias present a special problem. Destruction of vital structures such as the inguinal ligament, the femoral sheath, the transversalis fascia and the conjoined tendon, is usually extensive. Repairs have often relied upon the use of sheets of prosthetic materials but never on a three dimensional implant. This article will examine such an implant, the "Fletching". The latter is a three leaved prosthesis with a common reinforced backing, the aim of which is to replace the inguinal ligament and associated structures necessary for the successful repair of the much feared inguino-femoral hernia. This prosthesis has been implanted in 24 patients with excellent results. Follow-up has now been longer than 2-1/2 years and careful steps are taken to continue this follow-up.
The Shouldice operation.
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