[Hernia as a sports injury]

nema

Quantitative analysis of collagen and elastic fibers in the transversalis fascia in direct and indirect inguinal hernia

PURPOSE

Our previous studies demonstrated structural and quantitative age-related changes of the elastic fibers in transversalis fascia, which may play a role in inguinal hernia formation. To verify whether there were differences in the extracellular matrix between direct and indirect inguinal hernia, we studied the amount of collagen and elastic fibers in the transversalis fascia of 36 male patients with indirect inguinal hernia and 21 with direct inguinal hernia.

MATERIAL AND METHODS

Transversalis fascia fragments were obtained during surgical intervention and underwent histological quantitative analysis of collagen by colorimetry and analysis of elastic fibers by histomorphometry.

RESULTS

We demonstrated significantly lower amounts of collagen and higher amounts of elastic fibers in transversalis fascia from patients with direct inguinal hernia compared to indirect inguinal hernia patients. The transversalis fascia from direct inguinal hernia patients showed structural changes of the mature and elaunin elastic fibers, which are responsible for elasticity, and lower density of oxytalan elastic fibers, which are responsible for resistance. These changes promoted loss of resiliency of the transversalis fascia.

CONCLUSION

These results improve our understanding of the participation of the extracellular matrix in the genesis of direct inguinal hernia, suggesting a relationship with genetic defects of the elastic fiber and collagen synthesis.

[Recurrence after hernioplasty according to Lichtenstein: analysis of the cause]

The performance of surgical interventions of tension-free hernia repair has certainly reduced the recurrence rate in comparison with the previous techniques; notwithstanding this it is not uncommon to observe some recurrences also after a Lichtenstein hernia repair. The aim of this study is that to analyse the causes. In the last 2 years, 42 patients (mean age of 68 years) with recurrent hernia have been operated by Lichtenstein technique; 11 of the 42 patients had been treated before with an useful mesh hernia repair. In 8 of these patients the recurrence was produced by an insufficient medial extension of the mesh; in the other 3 patients the cause was the presence of an unrecognized indirect hernia in patients operated for a direct inguinal hernia. All the patients treated have been submitted to a 18 months time of follow-up.

Inguinal hernia as a rare manifestation of meconium peritonitis: report of a case

The usual manifestations of meconium peritonitis confined to the inguinoscrotal region are soft hydroceles, hard nodules in the scrotum, and, occasionally, calcified nodules in the wall of a hernia sac, with or without calcification on abdominal X-ray. Inguinal hernia is an extremely rare manifestation of healed meconium peritonitis. An unusual presentation of meconium peritonitis encountered during hernia repair is described herein to alert the pediatric surgeon of this possibility to avoid unnecessary abdominal exploration.

Continuing CAPD after herniotomy

There is still controversy as to whether PD-treatment can be safely continued after herniotomy (HT). Many nephrologists withhold PD-treatment for several weeks after HT in fear of dialysate leakage and/or hernia recurrence. We report on 12 patients (2 women, 10 men) in whom HT was performed either for umbilical (n = 6), inguinal (n = 6) or open processus vaginalis (n = 3). Surgery was performed according to the Lichtenstein method with insertion of a Marlex-mesh and ligation of the hernia sac. In all patients PD treatment was paused for the day of surgery and 1 to 3 days postoperatively, depending on RRF. Low volume (1.0 to 1.5 l) and high frequency exchanges (6 exchanges per day) were started for several days with a gradual reinstitution of the former PD-regimen within the next 2 to 4 weeks. All patients did well rapidly with no uraemia-or dialysis-related complications. No leakage and no hernia recurrence could be observed 3 months thereafter. None of the patients had to be haemodialysed intercurrently. In conclusion, continuing a modified regimen of PD-treatment after HT seems to be safe and comfortable for the patient.

Laparoscopic repair of access port site hernia after Lap-Band system implantation

BACKGROUND

The appearance of hernia around the access port site after implantation of a laparoscopic adjustable gastric band (LAGB) is a complication that can limit the beneficial effect of the device. We evaluated the incidence of hernias at the port-site for band adjustment and propose a technique for its repair.

METHODS

A retrospective study was conducted of 459 patients who underwent LAGB system implantation for treatment of morbid obesity between January 1999 and July 2001. We recorded all complications that occurred following LAGB placement, with special emphasis on port site hernia.

RESULTS

3 out of the 459 patients (0.65%) had a hernia at the site where the reservoir had been implanted. The use of a trocar > 11 mm should be avoided to prevent this complication. We describe our technique of repair of the hernia by intraperitoneal detachment and pulling of the access reservoir into the peritoneal cavity, intraperitoneal repair of the defect with Gore-Tex Dual mesh, and reimplantation of the reservoir.

CONCLUSIONS

Our technique successfully repaired the hernia, and enabled continuation of adjustments to the gastric band.

The possibility of nervus ilioinguinalis and nervus iliohypogastricus injury in lower abdominal incisions and effects on hernia formation

AIM

The aim of this study was to determine the distances of nervus ilioinguinalis and nervus iliohypogastricus to McBurney's and paramedian incisions.

MATERIALS AND METHODS

This study was performed on 12 adult cadavers. Right and left inguinal regions of the cadavers were dissected by inguinal incision. The points where the nerves perforated the internal obliquus muscles were determined, and the distances of these points to the spina iliaca anterior superior (SIAS) and to the umbilicus were measured. These distances were marked over a diagram, and distances of the nerves to McBurney's and paramedian incisions were measured by illustrating these incisions on the same diagram.

FINDINGS

While the distance of the iliohypogastric nerve from the SIAS was 1.5-8 cm on the right and 2.3-3.6 cm on the left, the distance of the ilioinguinal nerve from the SIAS was 3-6.4 cm on the right and 2-5 cm on the left. The distance of the ilioinguinal nerve from McBurney's incision was 0.2-6.1 cm on the right and 1.8-7.5 cm on the left, and that of the iliohypogastric nerve was 2.2-6.9 cm on the right and 2.9-6.2 cm on the left. The distances of the nerves from paramedian incision were found to be 4.6-10 cm on the right and 6.4-11.2 cm on the left for the ilioinguinal nerve and 5-11.2 cm on the right and 7.4-11.6 cm on the left for the iliohypogastric nerve.

CONCLUSION

Both nerves perforate the musculus obliquus internus, scattered in a wide area. Considering the distances, the paramedian incision seems to be more reliable with respect to the risk of nerve injury. Incisions performed in the lower abdomen carry the risk of injury to the ilioinguinal and iliohypogastric nerves.

Complete separation of the testis and epididymis presenting as inguinal hernia

Complete separation of the epididymis from the testis is a rare phenomenon. In all reported cases, both structures remained undescended. We recently managed a 2-month-old boy with bilateral inguinal hernia and complete dissociation of the epididymis from the testis on the left side. At exploration, a right indirect inguinal hernia was confirmed while on the left side, an indirect inguinal hernia was associated with an undescended abdominal testis completely separated from a normally descended epididymis. This could reflect an essential role of the epididymis in the process of testicular descensus. The diversity of congenital abnormalities possibly encountered in the inguinoscrotal region during infancy and childhood necessitates the acquisition of insightful knowledge in the pathological anatomy of this area and adequate surgical skill to avoid undesirable intraoperative confusion with its negative impact on proper diagnosis and appropriate management.

Unilateral inguinal ectopic scrotum with covered exstrophy

A case of ectopic scrotum located in the right inguinal area and associated with covered exstrophy and ipsilateral renal agenesis is described. Initially, repair of the exstrophy was performed. Scrotal reconstruction was carried out after 1 year, during which time the patient developed an inguinal hernia in the ectopic scrotum. The literature is reviewed and the scrotal reconstruction procedure is discussed.

An unusual case of penile augmentation: subcutaneous stone implantation

Different techniques for penile augmentation have been published. We report a 45-year-old man who had undergone a subcutaneous penile stone implantation for enlargement, which is the first published report to our knowledge.

Intestinal atresia presenting as bilateral scrotal pneumatocele: A case report

The authors report on a newborn baby with congenital hydrocele in whom pneumoscrotum developed. Air and meconium were found over the hernia sac, owing to ileal atresia with perforation. Gas in the scrotum usually is inside herniated bowel, but it can be the first sign of pneumoperitoneum.

Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias

BACKGROUND

This study was designed to investigate age, sex, and side of hernia presentation at clinical examination as potential intrinsic risk factors for bilateral inguinal hernia (BIH), and to quantify the characteristics of clinical examination versus laparoscopy as a diagnostic tool for BIH.

METHODS

A cross-sectional study was utilized to analyze 99 consecutive patients undergoing laparoscopic inguinal hernia repair.

RESULTS

The incidence of BIH based on clinical examination alone was 49%, compared with 71% laparoscopically. Clinical examination of BIH resulted in 69% sensitivity, 100% specificity, 100% predictive value for bilateral diagnosis, and 57% predictive value for unilateral diagnosis. Left hernia presentation at clinical examination (prevalence rate ratio = 10.5, 95% confidence interval: 3.6 to 30.7) and male sex (prevalence rate ratio = 6.6, 95% confidence interval: 1.3 to 35.0) were found to be independent risk factors for BIH.

CONCLUSIONS

Laparoscopy yields detection of BIH that would be missed by clinical examination alone. Furthermore, left-sided hernia and male sex were associated with BIH.

High +Gz induced acute inguinal herniation in an F-16 aircrew member: case report and review

This paper describes previously unreported, acute inguinal herniation during high +Gz air combat maneuvers. The flight surgeon aircrew member involved incorrectly analyzed the etiology of the abdominal wall discomfort during and immediately after the mission. Several factors contributed to the delayed diagnosis. Surgical exploration and repair revealed larger than expected defects. An open, anterior "tension-free" repair using polypropylene mesh grafts adequately reinforced the muscular and fascial defects. Return to full flight status occurred 4 wk following surgery. Post-operatively, repeat exposures to both a high +Gz flight environment and exertionally induced increased intra-abdominal pressures were well tolerated. Minimal sequelae from the injury and repair resolved within 1 yr of the surgery and did not affect mission capability or lifestyle activities. This article includes a review of hernia repairs and their aeromedical implications, with a discussion of epidemiology, surgical techniques, risk factors, surgical complications and recovery times for return to full activity.

Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases

PURPOSE

We critically examined the intraoperative and postoperative complications associated with radical retropubic prostatectomy in the modern era.

MATERIALS AND METHODS

Between April 18, 1994 and July 13, 2000, 1,000 men underwent radical retropubic prostatectomy performed by a single surgeon. The whole inpatient hospital medical record of 909 patients, the outpatient charts of 955 and a self-administered patient survey completed by 679 were reviewed by 2 data managers not involved in surgical management or followup care. In all 1,000 cases at least 1 of the 3 data sources was reviewed.

RESULTS

Mean patient age was 60.3 years. In 73%, 99.8% and 95.7% of cases serum prostate specific antigen was 10 ng./ml. or less, disease was clinical stage T1 or T2 and Gleason score was 7 or less, respectively, while 19.9% of pathological specimens showed positive margins. There were 8 intraoperative complications (0.8%). All 5 rectal injuries and the single ureteral injury were detected during the initial surgical procedure and repaired without sequelae. Only 14 men (1.4%) had any other complications during hospitalization. Until postoperative day 30, 4 pulmonary emboli (0.4%) with or without deep vein thrombosis and 5 myocardial infarctions (0.5%) developed. There were no intraoperative or in-hospital postoperative deaths and only 1 postoperative death secondary to myocardial infarction during the initial 30 days. Reexploration was done for hemorrhage and a disrupted anastomosis in 3 and 2 cases, respectively. Mean hospitalization was 2.3 days, 9.7% of patients required allogenic blood transfusion and 15 (1.5%) were rehospitalized.

CONCLUSIONS

Our series represents a rigorous assessment of the complications associated with radical retropubic prostatectomy. It shows that in the hands of an experienced urological surgeon, this procedure is associated with minimal intraoperative and postoperative morbidity. Of the patients 98% had no intraoperative or postoperative complications. Our series enables appropriate contemporary comparisons to be made with laparoscopic prostatectomy and radiation therapy. This outcomes analysis implies that radical retropubic prostatectomy cannot be assumed to have greater morbidity than radiation therapy and it sets a high standard for those advocating laparoscopic radical prostatectomy.

Magnetic resonance imaging and abdominal wall hernias in aortic surgery

BACKGROUND

The aim of this study was to evaluate the incidence of abdominal wall hernias (AWH) in patients operated on for abdominal aortic aneurysm (AAA) compared with patients treated for aortoiliac occlusive disease. The efficacy of MRI in early diagnosis of AWH also was studied.

STUDY DESIGN

One hundred fourteen patients operated for either AAA (51 patients, group A) or aortoiliac occlusive disease (63 patients, group B) constitute the study. The presence of AWH onset was evaluated by clinical observation followed by ultrasonography. Data acquired by ultrasonography were compared with those obtained by MRI to determine the efficacy of this diagnostic tool in all 114 patients. The prevalence of inguinal hernias in both groups also was determined.

RESULTS

A significant difference was found in the incidence of AWH. AWH developed in 31.7% (16 of 51) of group A patients and 17.4% (11 of 63) of group B patients (p < 0.03). A significant prevalence ofinguinal hernias was detected in group A (p < 0.01). The Cox hazard regression analysis revealed as independent predictors of postoperative AWH only the presence of AAA and a history of laparotomy.

CONCLUSIONS

Ours and other studies recall collagen synthesis disorders to explain the statistical association observed among AAA, inguinal hernias, and AWH. MRI, especially in patients at risk, appears to be an effective diagnostic approach to early detection of AWH.

The importance of the size of Hessert's triangle in the etiology of inguinal hernia

The aim of this study was to compare the inguinal area, known as "Hessert's triangle", in patients undergoing surgical treatment for inguinal hernia with the area in fresh cadavers without hernia. The 73 cadavers, which were not fixed in formalin, were examined within 15 h post mortem. A total of 132 measurements were made in these cadavers and compared with 130 measurements in 115 hernia patients. The average age was 44.2 years for patients and 32.7 years for cadavers. The mean height and weight were 1.68 m and 69.9 kg for hernia patients and 1.67 m and 70.0 kg for the cadavers, respectively. The mean area of Hessert's triangle was 8.97 cm2 (range 2.28-29.62 cm2) in the hernia patients and 2.95 cm2 (range 1.37-5.92 cm2) in the cadavers. This difference was statistically significant (P < 0.00). A larger triangle is created by a higher intersections of the internal oblique and transversus muscles and its aponeurosis to the rectus sheath. When these muscles contract, they move toward the inguinal ligament to occlude the triangle, but with a larger triangle, the occlusion is incomplete. Our anatomical measurements verified that the size of Hessert's triangle is an important factor in the etiology of inguinal hernia.

Inguinal hernia after radical retropubic prostatectomy for prostate cancer: a study of incidence and risk factors in comparison to no operation and lymphadenectomy

PURPOSE

The incidence, mechanisms and risk factors of inguinal hernia after radical retropubic prostatectomy are sparsely elucidated in the literature. We determined the rate of inguinal hernia after radical retropubic prostatectomy and compared it to the incidence in patients with prostate cancer who did not undergo operation or underwent only pelvic lymph node dissection.

MATERIALS AND METHODS

We followed 375, 184 and 65 men who underwent radical retropubic prostatectomy plus pelvic lymph node dissection, pelvic lymph node dissection only and no surgery with respect to inguinal hernia for a mean of 39, 47 and 45 months, respectively. The prostatectomy group was also evaluated in regard to the potential risk factors of previous hernia surgery and post-prostatectomy anastomotic stricture.

RESULTS

The incidence of hernia was 13.6%, 7.6% and 3.1% in the prostatectomy, lymph node dissection and unoperated group, respectively. The difference was statistically significant in the prostatectomy and unoperated groups according to the Mantel-Cox log rank test and Cox proportional hazards rate. Previous hernial surgery and post-prostatectomy anastomotic stricture were more common in patients with an inguinal hernia after prostatectomy.

CONCLUSIONS

The incidence of inguinal hernia is clearly increased in men who have undergone radical retropubic prostatectomy plus pelvic lymph node dissection compared with those who undergo no surgery for prostate cancer. Inguinal hernia appears to develop more often in men with prostate cancer who undergo radical retropubic prostatectomy and pelvic lymph node dissection than in those who undergo pelvic lymph node dissection only. While surgical factors trigger hernial development, previous hernial surgery and post-prostatectomy anastomotic stricture may be important risk factors. In fact, the latter may largely explain the difference in the incidence of inguinal hernia in our lymph node dissection and prostatectomy groups. Prophylactic surgical procedures must be evaluated to address this problem.

The inguinal bladder diverticulum: a rare differential diagnosis of hernias

We report a rare case of an inguinal herniation of a large bladder diverticulum due to obstructive uropathy. Diagnostic means, therapeutic strategies and complications are discussed.

A rare case of pseudomyxoma peritonei presenting an unusual inguinal hernia and splenic metastasis

Pseudomyxoma peritonei (PMP) is a rare clinical entity in which a diffuse collection of intraperitoneal gelatinous fluid is associated with gelatinous implants on the peritoneal surfaces and omentum. Hematogenic or lymphatic metastasis is extremely rare. In addition, an inguinal mass as an initial presentation is also relatively rare. This is a case report of a PMP patient who had splenic metastasis and showed an inguinal tumor as an initial presentation. A 59-year-old female patient, who had undergone bilateral oophorectomy because of a ruptured ovarian mucinous tumor of boderline malignancy 12 years previously, presented a presumptive diagnosis of a left inguinal irreducible hernia. Computed tomography revealed a low density mass in the pelvic cavity and in the inguinal lesion, as well as in the spleen without any diseases around the organ. The preoperative serum carcinoembryonic antigen (CEA) level was elevated. The patient underwent a resection of gelatinous tumor in the pelvic cavity, splenectomy, and appendectomy, as well as left inguinal herniorrhaphy. Histological examinations revealed a splenic metastasis of PMP originating from the ovarian low-grade mucinous tumor. She received postoperative intraperitoneal lavage as well as chemotherapy, and has survived for over 7 years postoperatively without any evidence of recurrence, as confirmed by repeated follow-up CT examinations and CEA determination. Splenic metastasis of PMP is extremely rare; this represents only the third reported case of its kind in the literature. Furthermore, it should be noted that an inguinal tumor can sometimes be an initial presentation of PMP.

Laparoscopic closure of patent canal of Nuck for female indirect inguinal hernia

STUDY OBJECTIVE

To determine the efficacy of concomitant laparoscopic closure of the patent canal of Nuck in treatment of indirect inguinal hernias in women.

DESIGN

Prospective clinical trial (Canadian Task Force classification II-2).

SETTING

University-associated tertiary care referral center.

PATIENTS

Six women scheduled for laparoscopy for gynecologic indications. Intervention. Concomitant simple closure of the patent canal of Nuck from the peritoneal cavity during laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Inguinal hernias were repaired in all six patients, with no recurrence.

CONCLUSION

l Laparoscopic closure of the patent canal of Nuck is an easy, safe, and effective treatment of indirect inguinal hernias in women. (J Am Assoc Gynecol Laparosc 8(1):143-146, 2001)

Retroperitoneal liposarcoma presenting a indirect inguinal hernia

A 60-year-old man was admitted to our hospital with a right inguinal swelling that had been growing in size without any pain for 7 months. We diagnosed the growth as a right inguinal hernia and operated on him. The growth, however, was found to be a tumor it situated along the spermatic cord and testicular vessels. We diagnosed it as a lipoma. The tumor was resected near part of the internal inguinal ring. Histopathological diagnosis showed well-differentiated liposarcoma of the sclerosing type. Postoperative computed tomography (CT) revealed a large residual tumor in the retroperitoneum. We believed that the tumor was a retroperitoneal liposarcoma and that it developed in the inguinal region. The residue of the liposarcoma was resected onto the right inguinal tract. A periodic follow up has been performed and no evidence of recurrence or metastasis has been seen in the 4 years and 9 months since the second surgery. No adjuvant therapy was performed. Inguinal liposarcomas are relatively rare and in most cases these tumors are thought to originate in the spermatic cord. The origin of the tumor is believed to be the retroperitoneum.

Scar endometriosis manifested as a recurrent inguinal hernia

A 24-year-old woman was initially found to have a right inguinal hernia that occurred suddenly after heavy lifting. A right direct inguinal hernia was found during the initial operative procedure. The round ligament was excised, the internal ring was closed, and the hernia was repaired with mesh placed on the floor of the inguinal canal. Four months after an uneventful postoperative recovery, the patient returned with pain in the right inguinal area. Over the next 2 months, a deep painful bulge developed. Inguinal exploration revealed an endometrioma rather than recurrent inguinal hernia. A portion of the original hernia incision included part of a previous Pfannenstiel incision made 3 years previously for a cesarean section. Scar endometriosis most probably occurred from peritoneal seeding from the Pfannenstiel incision and mimicked the findings of a recurrent inguinal hernia.

The undescended testicle: diagnosis and management

Early diagnosis and management of the undescended testicle are needed to preserve fertility and improve early detection of testicular malignancy. Physical examination of the testicle can be difficult; consultation should be considered if a normal testis cannot be definitely identified. Observation is not recommended beyond one year of age because it delays treatment, lowers the rate of surgical success and probably impairs spermatogenesis. By six months of age, patients with undescended testicles should be evaluated by a pediatric urologist or other qualified subspecialist who can assist with diagnosis and treatment. Earlier referral may be warranted for bilateral nonpalpable testes in the newborn or for any child with both hypospadias and an undescended testis. Therapy for an undescended testicle should begin between six months and two years of age and may consist of hormone or surgical treatment. The success of either form of treatment depends on the position of the testicle at diagnosis. Recent improvements in surgical technique, including laparoscopic approaches to diagnosis and treatment, hold the promise of improved outcomes. While orchiopexy may not protect patients from developing testicular malignancy, the procedure allows for earlier detection through self-examination of the testicles.

[Benzodiazepines and pregnancy]

The use of benzodiazepines is not negligible in pregnant woman and self-medication is considerable. To investigate the effects on the fetus of benzodiazepines used during pregnancy, we reviewed animal and clinical studies completed with observations of CRPV (Centres Régionaux de Pharmacovigilance). Pooled results indicate that the risk of malformations associated with first-trimester exposure to benzodiazepines remains small. However, in a fetus exposed essentially to long-acting benzodiazepines on a long-term basis, neonatal hypotonicity, failure to feed and/or withdrawal syndrom could be observed.

[Surgery for groin and lower abdominal pain in soccer players]

We treated 57 professional soccer players with groin and lower abdominal pain, 44 of them successfully, using conservative methods and 13 by surgery. Because of its anatomical site, the gracilis muscle is involved in almost all movements of the femur. It therefore is frequently involved in injury due to overuse, especially at its insertion (enthesopathy). In all 13 operated on, the gracilis was cut percutaneously, sometimes as a single procedure and sometimes with concomitant sportsmen's inguinal hernioplasty. All except 1 of those operated on returned to their professional sport activities.

Multimodal cancer chemotherapy during the first and second trimester of pregnancy: a case report

This paper reports treatment with combined chemotherapy during pregnancy. A 39-year-old woman with breast cancer was given adjuvant chemotherapy including cyclophosphamide, methotrexate and 6-fluorouracil from the 6th to the 24th week of gestation. The possibility of teratogenic effects on the fetus was explained to the patient however she refused to terminate the pregnancy. A 30-week male infant with only a minor malformation was delivered. The authors reviewed the literature regarding chemotherapeutic agents given during the first trimester of pregnancy. Most cytotoxic drugs have teratogenic effects on experimental animal subjects. However, actual data on human fetuses are sparse because of the variety of therapeutic regimens and the rarity of administering chemotherapy during pregnancy. The long-term effects of exposure to cytotoxic drugs in utero, needs further research.

[Inguinal hernia: accident sequela?]

The evaluation of an inguinal hernia as a result of an accident has to be newly discussed because of new radiologic tools like US, CT and MRI. Therefore an injury of the abdominal wall after an adequate trauma has to be proved. This can also be achieved by radiology, in which signs of injury, as contusion and hematoma, can be detected. Moreover the histological signs of injury and bleeding, i.e. fibrinexudation, capillary granulation tissue, round cells, siderophages, fibrocytes and fibroblast proliferation must be proved.

Obliterated processus vaginalis diagnosed by intraoperative laparoscopy is unlikely to develop into a clinical hernia

BACKGROUND

This study was conducted to evaluate if a subsequent inguinal hernia would occur in the contralateral obliterated processus vaginalis shown by intraoperative laparoscopic examination.

METHODS

From July, 1993 to February, 1994, 120 patients with a unilateral inguinal hernia were identified as obliterated processus vaginalis by intraoperative laparoscopic examination of the contralateral internal ring when they received unilateral herniorrhaphy. A five-year follow-up of the contralateral side to determine the rate of subsequent inguinal hernia was carried out during an outpatient clinic check-up or by telephone contact.

RESULTS

One patient, among the first few patients having laparoscopic examinations, had a subsequent contralateral inguinal hernia. Two patients had hydroceles and each of the operative findings was a communicating hydrocele that could not possibly develop into a clinical hernia.

CONCLUSIONS

It is unlikely for an obliterated processus vaginalis indicated by intraoperative laparoscopic examination to become a clinical inguinal hernia.

[Incarcerated and strangulated hernias--surgical approach and management]

Acute symptomatic groin hernias with potential or definite ischemia represent a special group of all the groin hernias. The method of choice to treat these hernias has to fulfill the following criteria: 1. Easy reduction of the hernia sac and its contents without causing damage. 2. Good exposure and easy access for possible resection. 3. Safe hernia repair through the same access. According to our experience with 44 incarcerated and strangulated groin hernias operated between 1993 and 1997 and after a literature review, we took the following procedure as our routine: Posterior approach and mesh repair. We do not use a meshgraft only in the presence of colonic necrosis or peritonitis.

Inguinal hernia: medicolegal implications

Repair of an inguinal hernia is one of the commonest operations undertaken by surgeons but the role of trauma in causing inguinal hernia is not well understood. This paper does not attempt to discuss the cause of inguinal hernia but seeks to analyse the cases which may be accepted by the Courts as being due to trauma.

The inguinal rings

The inguinofemoral area constitutes the frontier between the abdomen and the lower limb. Because of the human standing position, the inguinal region is a zone supporting the abdominal thrust, and is weakened by the orifice of the inguinal and femoral passages. Peritoneal diverticula may externalize into these orifices, leading to the formation of hernias. This article reviews the anatomic constituents of the inguinofemoral region and the anatomic basis for the treatment of hernias.

Incarcerated indirect inguinal hernia: a complication of spilled gallstones

Spillage of gallstones during laparoscopic cholecystectomy is not a rare event. We present a patient with spilled calculi causing an incarcerated hernia.

Bilateral inguinal hernia repaired by laparoscopic technique: a rare complication of femorofemoral bypass

Femorofemoral bypass is an established procedure for limb salvage and disabling claudication. However, surgical exposure of the femoral artery may result in damage leading to development of an inguinal hernia. Herein we report the first case of laparoscopic repair of bilateral inguinal hernias that developed after femorofemoral bypass.

[Changes in strategy and technics in the surgical treatment of hernias]

During last five years, 1,271 patients with the diagnosis of hernia were operated at the IIIrd Surgical clinic, 1st Faculty of Medicine, Charles University in Prague. Types of hernia were not differentiated. The patients group includes primary inguinal hernias and their relapses, hernias in other localizations as well as hernias in cicatrices. Ligation of the hernia sac as a separated intervention was used in no case. Herniorrhaphy was performed in 52% of cases, hernioplasty in 48%. The hernioplasty/herniorrhaphy ratio increases every year. While the hernioplasty was performed in 34% of patients in 1993, in 1997 was used already in 53% of cases. During that period of time, prolene mesh fixed in the defect with prolene suture was almost exclusively used as implant. In very complicated cases, Goretex was applied with a very good result. Polytetrafluoroethylene is the best implant material at the present time, but its price restrains its general use. Prolene is available for a moderate price and complies sufficiently with requirements on mechanical strength and non-irritability.

Anatomic basis of chronic groin pain with special reference to sports hernia

Chronic pain on the ventral surface of the scrotum and the proximal ventro-medial surface of the thigh especially in athletes has been diagnosed in various ways; recently, in Europe the concept of "sports hernia" has been advocated. However, since few reports discuss the detailed course of the nerves in association with the pain, we examined the cutaneous branches in the inguinal region in 54 halves of 27 adult male cadavers. From our results, in addition to the cutaneous branches from the ilioinguinal n. (in 49 of 54: 90.7%), cutaneous branches originating from the genital branches of the genitofemoral nerve were found in the inguinal region in 19 of 54 halves (35.2%). In 7 cases (in 7 of 54: 13.0%) the genital branch and the ilioinguinal nerve united in the inguinal canal. In 6 cases the genital branch pierced the inguinal lig. to enter the inguinal canal, and in three cases the genital branch pierced the border between the ligament and the aponeurosis of the obliquus externus m. to be distributed to the inguinal region. Therefore, the courses of the genital branches vary considerably, and may have a very important role in chronic groin pain produced by groin hernia. In addition, entrapment by the ligament may be a reasonable candidate for the cause of chronic groin pain.

[New prospects in the etiology of groin hernias]

AIM OF THE STUDY

To explore new etiological hypotheses of groin hernias, using a biomechanical and histochemical study of the transversalis fascia and of the rectus sheath.

PATIENTS AND METHODS

The samples were collected from 63 patients with uni- or bilateral hernias and from 30 control subjects without hernia. The biomechanical properties were assessed using a computerized-suction device (Cutometer). Sections were stained with hematoxylin and eosin, Masson-trichrome and double-stained with sirius red and orcein.

RESULTS

There was no major biomechanical and histological difference between the control and patient aponeuroses. The patient fasciae from the non-herniated sides presented an increased extensibility and elasticity, as compared with the control fasciae. Those fasciae also showed a collagen framework with disorganized areas and an increased number of isolated fibers.

CONCLUSION

The transversalis fascia from the nonherniated side appears to be a pathological fascia. Therefore, a connective tissue pathology seems to be involved in the genesis of groin hernias, with a preferential manifestation in the inguinal region which affects mainly the collagen fibers.