Open vs laparoscopic repair of secondary lumbar hernias: a prospective nonrandomized study

BACKGROUND

Lumbar hernias are uncommon defects of the posterior abdominal wall. Surgical treatment is still controversial in these cases. The aim of this study was to compare outcome and costs of the laparoscopic approach vs the open method.

METHODS

We conducted a prospective nonrandomized study of 16 patients who underwent operation for secondary lumbar hernia between January 1997 and January 2003. Nine were treated via the laparoscopic approach and seven with an open technique. The following variables were analyzed: clinical data, hospital data (operating time and length of stay), patient comfort (consumption of analgesics and time to return to normal activities), and recurrences. Hospital costs were also analyzed.

RESULTS

There were no differences between the two groups in terms of age and history, although the defects of the patients in the laparoscopic group were smaller. Mean operating time, postoperative morbidity, mean hospital stay, consumption of analgesics, and time to return to normal activities were significantly lower in the laparoscopic group (p < 0. 01). No were there any statistical differences between the two types of surgical procedure in terms of hospital costs. However, the final cost did show differences when expenses for readmissions and recurrences were taken into account (p < 0.01).

CONCLUSION

The laparoscopic approach to secondary lumbar hernia repair is more efficient and more profitable than the traditional open technique.

Treatment of long-standing extensive perianal hidradenitis suppurativa using double rotation plasty, V-Y plasty and free grafts

BACKGROUND

Perianal hidradenitis suppurativa is a chronic recurrent inflammatory, suppurating, and fistulizing disease of apocrine glands, adjacent anal canal skin, and soft tissues. The standard treatment used for extensive cases is a staged surgical procedure allowing the wound to heal by secondary intention or the delayed use of skin grafts.

CASE PRESENTATION

A long-standing case, disabling for the patient, with extensive involvement of the buttock region, treated in one stage, which for reconstruction required the use of sliding plasties and free skin grafts, is reported.

RESULTS

The outcome was satisfactory. Primary closure after wide excision using plastic-surgery techniques may help us resolve complex situations and obtain good results and a rapid recovery.

CONCLUSION

The method of closure with a combination of skin flaps and skin graft in one stage can be considered a valid surgical option for a group of patients with extensive perianal hidradenitis.

Laparoscopic surgery in the management of traumatic hemoperitoneum in stable patients

Unnecessary laparotomies in patients with abdominal traumatism (AT) who present hemoperitoneum with stable hemodynamics may be avoided if a diagnostic/therapeutic laparoscopy is performed. Between July 1992 and December 1994, 24 patients with AT and hemoperitoneum underwent this exploration: 5 were found to have a large retroperitoneal hematoma; 2, a tear in the intestinal mesenterium; 4, hepatic injuries; and 13, splenic lesions. Of the 24 patients, 9 needed conversion to open exploration: 8 during the laparoscopy and 1 shortly after operation. Mean hospital stay was 7 days (5-9). There was no morbidity or mortality in the series. Diagnostic/therapeutic laparoscopy is a method that is efficient and economical and can easily be undertaken by surgeons with experience in laparoscopy; it may be a valid alternative to conservative treatment or laparotomy in AT and hemoperitoneum patients who are hemodynamically stable.

Intestinal obstruction and bezoars

BACKGROUND

Bezoars are large conglomerates of vegetable fibers, hairs, or concretions of various substances located in the stomach or small intestine of humans and certain animals, mainly ruminants. Gastrointestinal bezoars have constituted a relatively common clinical reality ever since the introduction of truncal vagotomy associated with drainage or gastric resection in the treatment of gastroduodenal peptic ulcer.

STUDY DESIGN

This study presents a series of 87 cases of intestinal bezoar treated in our department of general surgery. Analysis was made of data obtained retrospectively from clinical histories, together with a clinical and endoscopic review of the patients.

RESULTS

Most of the patients had had previous operative treatment (76.3 percent), the most commonly used technique being bilateral truncal vagotomy plus pyloroplasty (75.8 percent). An excessive intake of vegetable fiber was revealed in 39.5 percent of the cases, and alterations in dentition and mastication in 24 percent. Operative treatment was used in all patients. We attempted to fragment the bezoar and milk it to the cecum. Enterotomy and bezoar extraction were reserved for cases where fragmentation was impossible, as enterotomy was associated with more complications (p < 0.05).

CONCLUSIONS

Bilateral truncal vagotomy plus pyloroplasty and a excessive ingestion of vegetable fiber are the main factors predisposing to bezoar formation. Clinically, intestinal bezoars manifest themselves in most cases as complete intestinal obstruction. Simple roentgenography of the abdomen is the fundamental technique for diagnosing the occlusive syndrome. Treatment must be operative, during which the bezoar is fragmented and milked to the cecum. The stomach must be explored for associated bezoars.

Quantification of duodenogastric reflux in patients with choledochoduodenostomy

BACKGROUND

Frequently, patients present with symptoms after cholecystectomy (pain or discomfort in the upper part of the abdomen, postprandial fullness, bile vomiting, among others). Duodenogastric reflux has been associated with these symptoms in some patients. Therefore, this study was done to investigate this relationship.

STUDY DESIGN

We evaluated duodenogastric reflux (DGR) in ten healthy patients, in ten patients who had asymptomatic simple cholecystectomy, in ten patients who had asymptomatic cholecystectomy with supraduodenal choledochoduodenostomy (CD), and in ten patients who had cholecystectomy plus CD followed by discomfort in the upper abdomen, postprandial fullness and bile vomiting, but no colicky pain or acute cholangitis. Duodenogastric reflux was quantified using continuous intravenous infusion of technetium-99m labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequently determining its concentration in gastric juice.

RESULTS

All of the patients who underwent operation, whatever the technique used, had higher reflux rates than those in the control group (p < 0.001). Moreover, reflux rates were comparable in the patients who underwent simple cholecystectomy compared with patients in the asymptomatic cholecystectomy plus CD group. Conversely, when patients with cholecystectomy plus CD presented with discomfort in the upper part of the abdomen as well as bile vomiting, they had higher reflux rates than patients who underwent simple cholecystectomy (p < 0.001) and asymptomatic patients with associated CD (p < 0.001).

CONCLUSIONS

Our results suggest that DGR must be involved in the genesis of these dyspeptic symptoms.

Role of Helicobacter pylori infection and duodenogastric reflux in the pathogenesis of alkaline reflux gastritis after gastric operations

In patients undergoing gastric operations, we studied the relationship between data suggesting alkaline reflux gastritis (symptoms, endoscopic alterations and histologic lesions) and two factors that produce chronic gastritis (helicobacter pylori and duodenogastric reflux). Of 225 patients who underwent operations for gastroduodenal gastric ulcer at our General Surgery Unit between 1980 and 1982, 63 agreed to undergo endoscopy and biopsies. Of these 63 patients, 38 agreed to a test to quantify duodenogastric reflux (24 hour gastric pH monitoring associated with the determination of bile acids in gastric juice). According to the clinical questionnaire, patients were classified as symptomatic and asymptomatic. Endoscopy was considered either normal with mucosal lesions or mucosal lesions plus bile. In the histologic study, we considered normal mucosa, superficial chronic gastritis and atrophic chronic gastritis. Furthermore, the presence of atrophy, metaplasia, foveolar hyperplasia and helicobacter pylori was studied. Symptoms, endoscopic alterations and histologic lesions were not significantly related to helicobacter pylori, but were significantly related to the quantity of duodenogastric reflux. The symptomatic patients presented with a greater quantity of reflux than the asymptomatic patients (p < 0.05). The patients with mucosal lesions plus bile who had endoscopy showed a greater quantity of reflux than those with normal endoscopy (p < 0.001) and those with mucosal lesions without bile (p < 0.02 for pH values and p < 0.001 for bile acids). The patients with atrophic chronic gastritis presented with a greater quantity of reflux than those with normal mucosa and superficial chronic gastritis (p < 0.05, respectively), and the patients with atrophy and metaplasia and foveolar hyperplasia had more reflux than those without (p < 0.001, respectively). The patients who were helicobacter positive and negative presented with similar quantities of reflux.

Duodenogastric reflux in patients with biliary lithiasis before and after cholecystectomy

Duodenogastric reflux is quantified in ten patients with biliary lithiasis and a functioning gallbladder, before and six months after performing cholecystectomy. The results are compared with those of a control group (n = 10) with similar age and gender, without gastric or hepatobiliary pathologic factors. To evaluate reflux, we used six hour continuous intravenous infusion and subsequent determination in gastric juice of 99mTc-diethyliminodiacetic acid. Our results showed that patients with cholelithiasis have higher reflux rates than those in the control group (p < 0.001). When comparing patients before and after cholecystectomy, we confirmed that removal of the gallbladder produces a significant increase (p < 0.001) in reflux rates compared with preoperative values.