Biomedical subjects
Publications and source records attributed to S D Berliner.
Selection of a subinguinal, inguinal, or preperitoneal approach permits the surgeon flexibility in managing femoral hernias. A 20-year experience is reviewed, with 44 incarcerated or strangulated femoral hernias corrected using the preperitoneal Henry operation. It is an effective and safe method of repair. Examination of the contralateral side revealed an unsuspected femoral hernia in seven (16%) of the cases.
Hernias are one of the most common causes of symptoms in the groin. Surgery is needed for all femoral and indirect inguinal hernias to prevent incarceration and strangulation. Asymptomatic direct hernias can be observed if they are not enlarging. Atypical symptoms in a patient with a hernia must be evaluated to exclude other disease. Fortunately, most groin hernias can be repaired electively.
The transversus abdominis aponeurosis and its investing sheath of transversalis fascia are the first line of defense against groin herniation. If transversus abdominis fibers insert on the superior pubic ramus as a narrow band, a cone shaped defect will result. With an increase in intra-abdominal pressure, preperitoneal fat, with or without a peritoneal sac, can enter this femoral cone. It is an asymptomatic internal hernia that will be detected only if the preperitoneal space is explored during inguinal herniorrhaphy. This is stage I in the development of a femoral hernia. Should the contents within the femoral cone protrude through its narrow distal orifice, a stage II external hernia results. Incarceration or strangulation may then occur. Herniation into and through the femoral cone was encountered in 159 instances while repairing 3,609 hernias of the groin in adults. Sixty-seven external (stage II) hernias were diagnosed preoperatively. Sixteen per cent were irreducible, 18 per cent were incarcerated and 3 per cent were strangulated. During inguinal herniorrhaphy, an unsuspected stage II femoral hernia was found in 12 instances, and a stage I precursor was present in 80. Flexibility in management is important. The choice of the low, inguinal or preperitoneal approach is determined by the mode of presentation of the hernia.
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The incidence of large-intestinal anastomotic leaks remains unacceptably high. For this reason, we studied the resistance to dehiscence of a telescoping type of anastomosis and compared it with the conventional one-layer, two-layer, and stapled anastomoses in a canine model. These experiments demonstrated that the telescoping anastomosis provided a more resistant suture line during the early postoperative phase and did not cause encroachment of the lumen by the diaphragm, which was consistently produced when an inverting suture line was used. Three days postoperatively the mean bursting pressures of the one-layer, two-layer, and stapled anastomoses were 31 +/- 12, 120 +/- 46, and 52 +/- 21 mm Hg, respectively. The telescoping anastomosis had a mean bursting pressure of 210 +/- 44 mm Hg, which was significantly (P less than 0.01) higher than those of all the other anastomoses tested. However, seven and 14 days after operation, there was no statistically significant difference among the bursting pressures of the various anastomoses. When the different types of anastomoses were examined histologically, it was found that there was considerably more suture-line inflammation, edema, micro-abscess formation, mucosal ulceration and pericolic inflammation of the fat in the one-layer, two-layer, and stapled anastomoses than in the telescoping anastomosis.
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