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PubMed1999

Surgical options in the management of groin hernias.

Inguinal and femoral hernias are the most common conditions for which primary care physicians refer patients for surgical management. Hernias usually present as swelling accompanied by pain or a dragging sensation in the groin. Most hernias can be diagnosed based on the history and clinical examination, but ultrasonography may be useful in differentiating a hernia from other causes of groin swelling. Surgical repair is usually advised because of the danger of incarceration and strangulation, particularly with femoral hernias. Three major types of open repair are currently used, and laparoscopic techniques are also employed. The choice of technique depends on several factors, including the type of hernia, anesthetic considerations, cost, period of postoperative disability and the surgeon's expertise. Following initial herniorrhaphy, complication and recurrence rates are generally low. Laparoscopic techniques make it possible for patients to return to normal activities more quickly, but they are more costly than open procedures. In addition, they require general anesthesia, and the long-term hernia recurrence rate with these procedures is unknown.

Diagnosis, Differential↗

PubMed1999

Surgical options in the management of groin hernias.

Inguinal and femoral hernias are the most common conditions for which primary care physicians refer patients for surgical management. Hernias usually present as swelling accompanied by pain or a dragging sensation in the groin. Most hernias can be diagnosed based on the history and clinical examination, but ultrasonography may be useful in differentiating a hernia from other causes of groin swelling. Surgical repair is usually advised because of the danger of incarceration and strangulation, particularly with femoral hernias. Three major types of open repair are currently used, and laparoscopic techniques are also employed. The choice of technique depends on several factors, including the type of hernia, anesthetic considerations, cost, period of postoperative disability and the surgeon's expertise. Following initial herniorrhaphy, complication and recurrence rates are generally low. Laparoscopic techniques make it possible for patients to return to normal activities more quickly, but they are more costly than open procedures. In addition, they require general anesthesia, and the long-term hernia recurrence rate with these procedures is unknown.

Diagnosis, Differential↗

PubMed1999

Topical treatments of laparoscopic port sites can decrease the incidence of incision metastasis.

BACKGROUND: Anecdotal reports of port site tumor recurrence have dampened the enthusiasm for laparoscopic colectomy for cancer. We developed a rat model that creates a high incidence of port site metastasis following laparoscopic intervention. Our goal was to assess the feasibility of minimizing implantations using port site irrigation prior to wound closure. METHODS: Colon cancer carcinomatosis was established in 46 female BD9 rats using intraperitoneal injections of 10(6) DHD-K12-TRb rat colon cancer cells. This preparation yielded an 81% incidence of port site metastasis in a control group. Laparoscopic sham surgery was performed using four ports and a CO(2) pneumoperitoneum. Four treatment groups were studied by irrigating each port site as follows: Group I, sterile water; group II, normal saline; group III, heparin; group IV, 5-fluorouracil (5-FU). The animals were killed at 4 weeks, and the port sites were examined for tumors. RESULTS: There were no differences in port site metastasis between controls and groups I, II, and III. The 5-FU group showed a significant decrease (30% vs 81%) in metastasis. CONCLUSIONS: Port site irrigation with 5-FU at the time of laparoscopy reduces the incidence of port site tumor implantation in a rat colon cancer model. This finding may have utility in patients at high risk of such metastasis who undergo laparoscopy for colon cancer.

Administration, Topical↗

PubMed1997

Laparoscopic adrenalectomy: history, indications, and current techniques for a minimally invasive approach to adrenal pathology.

Refinements in the field of laparoscopic general surgery have not only made the performance of laparoscopic adrenalectomy technically feasible, but have even made it the preferred method of treatment for benign adrenal pathology. The advantage of the laparoscopic approach lies in the fact that it allows precise, hemostatic dissection of the gland in a minimally invasive fashion. We present here the results of published reports of laparoscopic adrenalectomy as well as our own experience, and compare these data with reports from open procedures. The indications for the surgical removal of the adrenal gland have not changed, and include: endocrine active tumors, suspected malignancies, adrenal masses larger than 6 cm, and masses that have been followed and observed to be growing. Laparoscopic adrenalectomy can be accomplished with one of three approaches: anterior, lateral and posterior. Each approach has advantages and limitations, and our preferences are discussed. The general techniques are briefly described. The findings from many studies show that the blood loss, operative complications, hospital stay and recovery period are significantly reduced with the laparoscopic approach. Based on our experience with 19 laparoscopic adrenalectomies and a review of the current literature, laparoscopic adrenalectomy can be fairly described as the current "gold standard" treatment for benign adrenal disease. Patients benefit from short hospital stays, lower morbidity, and a more rapid recovery. The only question that remains is the appropriateness of laparoscopic adrenalectomy in the treatment of adrenal malignancy, and the answer to this will depend on the results of long-term outcome studies.

Adrenal Gland Diseases↗

PubMedDate not supplied

Complications of laparoscopic paraesophageal hernia repair.

The complications of laparoscopic paraesophageal hernia repair at two institutions were reviewed to determine the rate and type of complications. A total of 76 patients underwent laparoscopic paraesophageal hernia repair between December 1992 and April 1996. Seventy-one of them had fundoplication (6 required a Collis-Nissen procedure). Five patients underwent hernia reduction and gastropexy only. There was one conversion to laparotomy. Traumatic visceral injury occurred in eight patients (11%) (gastric lacerations in 3, esophageal lacerations in 2, and bougie dilator perforations in 3). All lacerations were repaired intraoperatively except for one that was not recognized until postoperative day 2. Vagus nerve injuries occurred in at least three patients. Three delayed perforations occurred in the postoperative period (4%) (2 gastric and 1 esophageal). Two patients had pulmonary complications, two had gastroparesis, and one had fever of unknown origin. Seven patients required reoperation for gastroparesis (n = 2), dysphagia after mesh hiatal closure of the hiatus (n = 1), or recurrent herniation (n = 4). There were two deaths (3%): one from septic complications and one from myocardial infarction. Paraesophageal hernia repair took significantly longer (3.7 hours) than standard fundoplication (2.5 hours) in a concurrent series (P <0.05). Laparoscopic paraesophageal hernia repair is feasible but challenging. The overall complication rate, although significant, is lower than that for nonsurgically managed paraesophageal hernia.

Adult↗