[Recurrent inguinal hernia after mesh hernioplasty. An emerging problem?]

BACKGROUND

In spite of the successful results of tension free hernioplasties, recurrent inguinal hernias are not an uncommon finding in the clinical practice.

METHODS

The authors report their experience in 24 patients observed from January 1994 to December 2000 (23 men, 1 women, min. age 28 yrs, max 78 yrs, mean 58 yrs) who had recurrent inguinal hernia after a tension free hernioplasty. In 22 patients a tension free hernioplasty (Lichtenstein technique 5 patients, Trabucco 7 patients, unclassifiable 10 patients) through an anterior approach was performed while in two, respectively, a Stoppa procedure and a laparoscopic hernioplasty were the first operations; mean recurrence time was 17 months.

RESULTS

Mesh and/or plug dislocation was the most frequent cause of recurrence (15 patients), followed by a failure of the internal ring reconstruction (6 patients) and loss of the pubic stitch (2 patients); in 1 patient the mesh was of reabsorbable type.

CONCLUSIONS

Mesh hernioplasties represent a valuable progress in inguinal hernia therapy, but increasing clinical experience shows that, together with the experience of the surgeon in the surgical technique, suture of a wide mesh to the surrounding tissues and a adequate inguinal ring reconstruction are critical condition for good results.

[Recurrent inguinal hernia. Intraoperative findings and cause of failure]

BACKGROUND

Recurrent inguinal hernia is still frequently observed today.

METHODS

In order to evaluate factors causing failure of hernia repair 64 recurrent hernias are examined (63 men, 1 woman; age: min 32 years, max 88, median 60 years), 54 previously operated with "traditional" Italian surgical school techniques (Bassini and Postempskij) and 10 with "tension free" operations. For every patient previous surgical procedures, complications occurred, timing of recurrence and intraoperative findings at reoperation were recorded.

RESULTS

In the "traditional" hernioplasty group, 31 indirect and 23 direct hernias occurred; median relapse time was 11 years. In "tension free" techniques, 4 mesh suture failures (Lichtenstein), 2 mesh or plug dislocations (Trabucco) and 4 indirect hernias (mesh ring failures) were found at reoperation; median relapse time in this group was 2 years. The findings of a so long relapse time for traditional techniques was surprising, it is obvious now that every new "tension free" technique must have (at least) a such success rate. In the first group, inadequate technique of operation and physiologic weakening of the abdominal wall were responsible for the relapse, while in the second a technical failure was the main reason.

CONCLUSIONS

"Traditional" hernia surgery is now progressively abandoned in favour of "tension free" techniques, in which recurrences are due to the "physiologic" training period of the surgeon; mesh itself doesn't warrant success, but anatomical knowledge and an adequate dissection of musculo-fascial planes are mandatory.

[Annular pancreas in adults: diagnostic considerations on a case]

Annular Pancreas (AP) is a rare congenital anomaly that usually presents in childhood with symptoms referable to duodenal obstruction; nonetheless, this condition can manifest in adulthood with abdominal pain, pancreatitis, duodenal ulcer, pancreatic head mass. The Authors hereby discuss a case of AP observed in a 63 year-old patient in which EUS played a decisive role in achieving a certain diagnosis.

[Crossectomy in the treatment of great saphenous vein insufficiency: a developing technique]

Crossectomy is an old and simple surgical technique for great saphenous vein insufficiency. At present the results in the international literature are not encouraging, possibly owing to a lack of standardized indications. The authors describe their experience. Crossectomy with phlebectomy of collaterals or perforating veins was performed (cross < 8 mm) in 132 patients. The mean follow-up was 21 months in 71 patients: subjective results (patient's opinion) were satisfactory to good in 81% for symptoms and in 77% for cosmetic results (disappearance of varicose veins). Objective results (surgeon's opinion) were less satisfactory: recurrent varicose veins were observed in 17 patients (23%: teleangectasias or truncal varices) and a residual saphenous reflux at color-coded doppler ultrasonography was still present in 43 patients. Postoperative saphenous reflux did not correlate closely with symptoms, suggesting that crossectomy may improve venous pump function even if reflux is not totally abolished. Crossectomy requires further investigation for evaluation of long term results; more accurate indications and preoperative screening may further improve the success rate of this simple technique.

[Surgical indications in the phlebopathic patient. The role of air plethysmography]

A previous history of deep venous thrombosis (DVT) must be carefully evaluated in every patient affected by chronic venous insufficiency (CVI); the assessment of deep venous system patency is the goal of preoperative diagnosis. Air plethysmography examination allows an outpatient noninvasive testing of calf pump function and deep venous outflow. The authors report the results of a study on 37 patients (40 limbs) with a previous history of DVT, suffering from CVI; in 18 limbs air plethysmography showed a marked increase of calf volume on test exercise, suggesting residual venous obstruction. The authors believe that air plethysmography examination is mandatory before operation in patients with a previous history of DVT.

[Tension free hernioplasty in the treatment of recurrent inguinal hernia. Our experience]

BACKGROUND

Despite the new surgical approach with "tension free" techniques, recurrent inguinal hernia repair remains a difficult surgical problem.

METHODS

Personal experience in 61 cases of recurrent inguinal hernia is reported; in all patients a new hernioplasty with a "tension free" technique was performed. Medium follow-up of the study was 27 months (min 6 mm, max 56 mm); 3 recurrences were observed, 2 in Lichtenstein "plug" hernioplasty and 1 with the Trabucco technique.

RESULTS

No recurrences were observed in Lichtenstein "mesh" hernioplasty group.

CONCLUSIONS

Lichtenstein "mesh" hernioplasty can solve every anatomical situation in hernia recurrence and good results, with little or any complications, are achievable; "plug" technique is easier but recurrences in other sites of a weak inguinal wall are possible.

[Non-parasitic splenic cysts]

Nonparasitic cysts of the spleen are uncommon and often result from blunt abdominal trauma. Nonsurgical management of blunt splenic injuries increases the number of observations of the post-traumatic cysts. Complications (infection, rupture and hemorrhage) are lifethreatening, difficult to diagnose and require urgent surgical management. Until recently, splenectomy has been the primary choice of treatment of these cysts. Small (< 4 cm) asymptomatic post-traumatic pseudocysts stand a reasonable chance of involution with time (3-36 months) and so may be initially observed. Splenic preservation by partial splenectomy, enucleation or by marsupialization is actually recommended in children when technically feasible. Splenectomy is required for voluminous, central, multifocal cysts, in the presence of complications and in the adults with low immunologic risk. The Authors report 5 cases of large cysts successfully treated by splenectomy with one 12-year-old girl treated in emergency for infection by Salmonella.

[Lung transplantation. Progress and perspectives]

Techniques and indications for lung transplantation evolved significantly in the past few decades, at present there is a resurgence of interest in single- and double-lung transplantation for end-stage disease. The surgical procedure has been recently simplified and complications at the tracheal anastomosis have been significantly decreased. Many problems, common to organ transplantation, remain to be solved including availability of suitable donor organs, the ability to effectively treat organ rejection and improve the immunosuppressive regimens. The authors report a review of the international literature of the last three years, carrying on a critical analysis with the aim of identifying the problems related to this organ transplantation, progress in the research filed, complications and results.