Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation

PURPOSE

Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. An important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4 × 4 cm onlay-mesh for umbilical hernias ≤ 2 cm.

METHODS

A retrospective study was conducted at a single centre in Sweden on all umbilical hernia repairs during 2015-2019. The follow-up time was at least four months. Patients were identified using the hospital medical database. Repairs performed with suture or a sublay, ventral patch and laparoscopic mesh positioning were excluded. The patient's demographics, comorbidities, intra-and post-operative details were considered. The primary outcome was surgical site complications within 30 days. The secondary outcome was a recurrence.

RESULTS

80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm. The median (range) follow-up time was 29.0 (4.3-50.1) months. The median age was 46 (26-76) years old. The median body mass index was 28 (19-38) kg/m2. The male to female ratio was 2:1. 4 patients were identified with a surgical site post-operative complication; three with seromas and one with a superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound openings bedside. There were no registered cases of recurrence.

CONCLUSIONS

Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess whether mesh can reduce recurrences in umbilical hernia repairs ≤ 2 cm.

SUMMER Trial: mesh versus suture repair in small umbilical hernias in adults-a study protocol for a prospective randomized double-blind multicenter clinical trial

Background

Small umbilical hernia repair is one of the most common surgical performances in general surgery. Yet, a gold standard procedure for the repair is still lacking today. There is an increasing evidence that mesh could be advantageous compared to suture repair in lowering recurrence rates. An additional important question remains with regard to the optimal anatomical positioning of the mesh. We hypothesize that the use of an onlay mesh in small umbilical hernia defects can reduce recurrence rates without increasing the complications compared to a simple suture repair.

Methods

A prospective, national, multicenter, randomized, double-blind clinical trial comparing a standardized 4 × 4 cm onlay mesh to a conventional suture repair will be conducted. A total of 288 patients with a primary elective umbilical hernia ≤ 2 cm from 7 participating Swedish surgical centers will be enrolled. Intraoperative randomization will take place using a centralized web-based system resulting in total allocation concealment. Stratification will be done by surgical site and by defect size. Trial participants and follow-up clinical surgeons will be blinded to the assigned allocation. The primary outcome assessed will be postoperative recurrence at 1 and 3 years. Secondary outcomes assessed will be postoperative complications at 30 days and pain 1 year after surgery.

Discussion

Currently, there has been no randomized clinical trial comparing the recurrence rates between an onlay mesh repair and a simple suture repair for small umbilical hernia defects. How to best repair a small umbilical hernia continues to be debated. This trial design should allow for a good assessment of the differences in recurrence rate due to the large sample size and the adequate follow-up. Surgeons’ concerns surrounding optimal anatomical positioning and fear for larger required dissections are understandable. A small onlay mesh may become an easy and safe method of choice to reduce recurrence rates. Guidelines for small umbilical hernia repairs have stressed the need for reliable data to improve treatment recommendations. We can expect that this trial will have a direct implication on small umbilical hernia repair standards.

Trial registration

ClinicalTrials.gov NCT04231071. Registered on 31 January 2020. SUMMER Trial underwent external peer review as part of the funding process.

Management of Diastasis of the Rectus Abdominis Muscles: Recommendations for Swedish National Guidelines

Background:

Diastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis muscle, which causes uncertainty for the patient and healthcare providers alike.

Methods:

The consensus document was created by a group of Swedish surgeons and based on a structured literature review and practical experience.

Results:

The proposed criteria for diagnosis and treatment of diastasis of the rectus abdominis muscle are as follows: (1) Diastasis diagnosed at clinical examination using a caliper or ruler for measurement. Diagnostic imaging by ultrasound or other imaging modality, should be performed when concurrent umbilical or epigastric hernia or other cause of the patient’s symptoms cannot be excluded. (2) Physiotherapy is the firsthand treatment for diastasis of the rectus abdominis muscle. Surgery should only be considered in diastasis of the rectus abdominis muscle patients with functional impairment, and not until the patient has undergone a standardized 6-month abdominal core training program. (3) The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. In case of pronounced abdominal bulging or concomitant ventral hernia, surgery may be considered in patients with a smaller diastasis. (4) When surgery is undertaken, at least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. (5) Plication of the linea alba is the firsthand surgical technique. Other techniques may be used but have not been found superior.

Discussion:

The level of evidence behind these statements varies, but they are intended to lay down a standard strategy for treatment of diastasis of the rectus abdominis muscle and to enable uniformity of management.

Patient-reported chronic pain after open inguinal hernia repair with lightweight or heavyweight mesh: a prospective, patient-reported outcomes study

BACKGROUND

Chronic pain after groin hernia repair is a significant problem, and it is unclear whether or not lightweight meshes help. This national register-based study investigated whether patients who underwent open anterior mesh inguinal hernia repair with lightweight mesh had less chronic pain than those who had hernia repair with heavyweight mesh.

METHODS

All patients registered in the Swedish Hernia Register between September 2012 and October 2016 were asked to complete a questionnaire assessing patient-reported outcome measures 1 year after surgery. The present study examined open anterior repair with mesh sutured in place with non-absorbable sutures in male patients only. The primary endpoint, chronic pain, was defined as pain present in the past week that could not be ignored and interfered with concentration (on chores) and daily activities.

RESULTS

In total, 23 259 male patients provided data for analysis (response rate 70·6 per cent). Rates of chronic pain after repairs using regular polypropylene lightweight mesh, composite (poliglecaprone-25) polypropylene lightweight mesh and polypropylene heavyweight mesh were 15·8, 15·6 and 16·2 per cent respectively. Adjusted multiple logistic regression analysis showed no significant differences between regular (odds ratio (OR) 0·98, 95 per cent c.i. 0·90 to 1·06) or composite (OR 0·95, 0·86 to 1·04) lightweight mesh versus heavyweight mesh. The most striking risk factor for chronic pain was young age; 19·4 per cent of patients aged less than 50 years experienced pain 1 year after hernia repair (OR 1·43, 1·29 to 1·60).

CONCLUSION

Patient-reported chronic pain 1 year after open mesh repair of inguinal hernia was common, particularly in young men. The risk of developing chronic pain was not influenced by the type of mesh.

Lower recurrence rate with heavyweight mesh compared to lightweight mesh in laparoscopic totally extra-peritoneal (TEP) repair of groin hernia: a nationwide population-based register study

Purpose

Lightweight meshes (LWM) have shown benefits compared to heavyweight meshes (HWM) in terms of less postoperative pain and stiffness in open inguinal hernia repair. It appears to have similar advantages also in TEP, but concerns exist if it may be associated with higher recurrence rates. The aim of the study was to compare reoperation rate for recurrence of LWM to HWM in laparoscopic totally extra-peritoneal (TEP) repair.

Methods

All groin hernias operated on with TEP between 1 January 2005 and 31 December 2013 at surgical units participating in The Swedish Hernia Register were eligible. Data included clinically important hernia variables. Primary endpoint was reoperation for recurrence. Median follow-up time was 6.1 years (0–11.5) with minimum 2.5 years postoperatively.

Results

In total, 13,839 repairs were included for statistical analysis and 491 were re-operated for recurrence. Multivariate analysis demonstrated significantly increased risk of reoperation for recurrence in LWM 4.0% (HR 1.56, P < 0.001) compared to HWM 3.2%. This was most evident in direct hernias (HR 1.75, P < 0.001) and in hernia repairs with a defect > 3 cm (HR 1.54, P < 0.021). The risk of recurrence with use of LWM in indirect hernias and in hernia repairs with a defect < 1.5 cm was more comparable to HWM.

Conclusions

Lightweight meshes were associated with an increased risk of reoperation for recurrence compared to HWM. While direct hernias and larger hernia defects may benefit from HWM to avoid increased recurrence rates, LWM is recommended to be used in indirect and smaller hernia defects in TEP repair.

Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register

PURPOSE

To investigate which type of hernia that has the highest risk of a recurrence after a primary Lichtenstein repair.

METHODS

Male patients operated on with a Lichtenstein repair for a primary direct or indirect inguinal hernia and with a TEP for a later recurrence, with both operations recorded in the Swedish Hernia Register (SHR), were included in the study. The study period was 1994-2014.

RESULTS

Under the study period, 130,037 male patients with a primary indirect or direct inguinal hernia were operated on with a Lichtenstein repair. A second operation in the SHR was registered in 2236 of these patients (reoperation rate 1.7 %). TEP was the chosen operation in 737 in this latter cohort. The most likely location for a recurrence was the same as the primary location. If the recurrences change location from the primary place, we recognized that direct hernias had a RR of 1.51 to having a recurrent indirect hernia compared to having a direct recurrence after an indirect primary hernia repair.

CONCLUSIONS

Recurrent hernias after Lichtenstein are more common on the same location as the primary one, compared to changing the location.

Relaxing music as pre-medication before surgery: a randomised controlled trial

INTRODUCTION

Patients who await surgery often suffer from fear and anxiety, which can be prevented by anxiolytic drugs. Relaxing music may be an alternative treatment with fewer adverse effects. This randomised clinical trial compared pre-operative midazolam with relaxing music.

METHOD

Three hundred and seventy-two patients scheduled for elective surgery were randomised to receive pre-operative prevention of anxiety by 0.05-0.1 mg/kg of midazolam orally or by relaxing music. The main outcome measure was the State Trait Anxiety Inventory (STAI X-1), which was completed by the patients just before and after the intervention.

RESULTS

Of the 177 patients who completed the music protocol, the mean and (standard deviation) STAI-state anxiety scores were 34 (8) before and 30 (7) after the intervention. The corresponding scores for the 150 patients in the midazolam group were 36 (8) before and 34 (7) after the intervention. The decline in the STAI-state anxiety score was significantly greater in the music group compared with the midazolam group (P<0.001, 95% confidence interval range -3.8 to -1.8).

CONCLUSION

Relaxing music decreases the level of anxiety in a pre-operative setting to a greater extent than orally administrated midazolam. Higher effectiveness and absence of apparent adverse effects makes pre-operative relaxing music a useful alternative to midazolam for pre-medication.

Randomized clinical trial of groin hernia repair with titanium-coated lightweight mesh compared with standard polypropylene mesh

BACKGROUND

Groin hernia repair is one of the commonest operations in general surgery. Existing techniques have very low and acceptable recurrence rates, but chronic pain and discomfort remain a problem for many patients. New mesh materials are being developed to increase biocompatibility, and the aim of this study was to compare a new titanium-coated lightweight mesh with a standard polypropylene mesh.

METHODS

A randomized controlled single-centre clinical trial was designed, with the basic principle of one unit, one surgeon, one technique (Lichtenstein under general anaesthesia) and two meshes. Pain before and after surgery, and during convalescence (primary outcomes) was estimated in 317 patients. At 1-year clinical follow-up, recurrence, pain, discomfort and quality of life (secondary outcomes) were evaluated.

RESULTS

Patients with the lightweight mesh returned to work after 4 days, compared with 6.5 days for the standard mesh (P = 0.040). The lightweight group returned to normal activity after 7 days, versus 10 days for the standard group (P = 0.005). There was no difference in postoperative pain or recurrence at the 1-year follow-up.

CONCLUSION

Patients with the lightweight mesh had a shorter convalescence than those with the standard heavyweight mesh.

REGISTRATION NUMBER

ISRCTN36979348 (http://www.controlled-trials.com).

Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia

Background

This randomized trial examined whether lightweight (LW) polypropylene mesh (large pore size, partially absorbable) could have long-term benefits in reducing chronic pain and inflammation after inguinal hernia repair.

Methods

Six hundred men with a primary unilateral inguinal hernia were randomized to Lichtenstein repair using a standard polypropylene mesh or a LW mesh in one of six centres. The patients were blinded to which mesh they received. Clinical examination was performed and a pain questionnaire completed 3 years after surgery.

Results

Of the 590 men who had surgery, 243 (82·7 per cent) of 294 in the standard mesh group and 251 (84·8 per cent) of 296 in the LW mesh group were examined in the clinic, a median of 37 (range 30-48) months after hernia repair. There were nine recurrent hernias in each group (3·7 per cent with standard mesh and 3·6 per cent with LW mesh). Patients who had LW mesh had less pain on examination, less pain on rising from lying to sitting, fewer miscellaneous groin problems and felt the mesh less often than patients with standard mesh.

Conclusion

Use of LW mesh for Lichtenstein hernia repair did not affect recurrence rates, but improved some aspects of pain and discomfort 3 years after surgery.

One year results of a randomised controlled multi-centre study comparing Prolene and Vypro II-mesh in Lichtenstein hernioplasty

A standard polypropylene mesh used in Lichtenstein's operation induces a strong foreign tissue reaction with potential harmful effects. A mesh with less polypropylene could possibly be beneficial. Six hundred men with primary unilateral inguinal hernias were randomised to Lichtenstein's operation using a Prolene- or Vypro II-mesh in six centres. The patients were blinded to which mesh they received. A validated questionnaire assessing recurrence and pain along with SF-36 Health Survey was sent after 1 year to all patients and a selected group was clinically examined. Of the 591 operated patients, 526 (89.0%) returned the questionnaire. 188 patients had some complaints or sensations of which 111 patients were clinically examined. The mean follow-up time was 13.6 (SD. 4.0) months. The incidence of hernia recurrence (four vs. four patients) and neuralgia (three vs. four patients) did not differ between Prolene and Vypro II-groups, respectively. One Vypro II-patient was re-operated due to neuralgia. There was no difference in the SF-36 scores. The results of Lichtenstein's operation with either Prolene or Vypro II do not seem to differ significantly.

Early results of a randomised trial comparing Prolene and VyproII-mesh in endoscopic extraperitoneal inguinal hernia repair (TEP) of recurrent unilateral hernias

The purpose of this study was to compare a lightweight mesh to a standard polypropylene hernia mesh in endoscopic extraperitoneal hernioplasty in recurrent hernias. A total of 140 men with recurrent unilateral inguinal hernias were randomised to a totally extraperitoneal endoscopic hernioplasty (TEP) with Prolene or VyproII in a single-blinded multi-center trial. The randomisation and all data handling were performed through the Internet. 137 patients were operated as allocated. Follow-up was completed in 88% of the patients. The median operation times were 55 (24-125) min and 53.5 (21-123) min for the Prolene and VyproII groups, respectively. The meshes had comparable results in the surgeon's assessment of the handling of the mesh, return to work, return to daily activities, complications, postoperative pain and quality of life during the first 8 weeks of rehabilitation, except in General Health (GH) SF-36, where the VyproII-group had a significantly better score (P=0.045). The use of Prolene and VyproII-meshes in endoscopic repair of recurrent inguinal hernia seems to result in similar short-term outcomes and quality of life.

Early results of a randomized multicenter trial comparing Prolene and VyproII mesh in bilateral endoscopic extraperitoneal hernioplasty (TEP)

BACKGROUND

The use of mesh in inguinal hernia surgery has become increasingly popular despite the potentially harmful effects that foreign material may exert on human tissue. The purpose of this study was to compare the use of a lightweight mesh vs a standard hernia mesh in bilateral endoscopic hernioplasty.

METHODS

This single-blinded multicenter trial, 140 men with bilateral inguinal hernias were randomized to undergo totally extraperitoneal endoscopic hernioplasty (TEP) with either Prolene or VyproII. The randomization and all data management were done via the Internet.

RESULTS

A total of 139 patients were operated on as allocated. The follow-up was complete in 94% of the patients. The median (range) operating times were 85 min (45-140) and 73 min (35-165) for the Prolene and VyproII groups, respectively. (p = 0.01). The difference was due to uneven distribution of the allocated patients to study groups among individual surgeons. The time to return to work was similar (11 vs 9 days, p = 0.08). The time to return to normal daily activities was 19 days (1-133) in the Prolene group and 12.5 days (0-237) in the VyproII group (p = 0.06). There were no significant differences between the groups in their scores on the Visual Analogue Scale or SF-36 Health Scores during the 8-week follow-up.

CONCLUSIONS

The use of Prolene and VyproII meshes in bilateral endoscopic repair of inguinal hernia seems to result in similar short-term outcome and quality of life. However, there was a tendency toward faster return to normal activity among VyproII patients.

Intestinal obstruction after inguinal and femoral hernia repair: a study of 33,275 operations during 1992-2000 in Sweden

The risk of intra-abdominal intestinal obstruction after open or laparoscopic hernioplasty is, to our knowledge, not known. The transabdominal laparoscopic (TAPP) route brings a potential risk of abdominal adhesions, which may increase the risk of postoperative intestinal obstruction. The pre-peritoneal route laparoscopically, totally extraperitoneal laparoscopic hernioplasty (TEP), should not increase this risk since the abdominal cavity is not entered. The Swedish Hernia Register, with 33,275 patients operated on for single primary unilateral groin hernia during the period 1992-2000, was linked to the Swedish Inpatient register and the Swedish Death register for the period 1987-2000. The risk of postoperative intestinal obstruction was low, 1.02 per 1,000 personyears. The highest adjusted relative risks (RR) were found in patients with previous admissions for abdominal inflammations or operations. The risk increased with the number of admissions. After an acute operation, and in patients older than 60 years, there was also a significantly increased risk. The RR was 2.79 (95% CI 1.01-7.42) after TAPP and 0.57 (95% CI 0.07-4.33) following TEP compared to patients operated on by the Lichtenstein method. None of the patients undergoing open hernia operations had a significantly increased risk. TAPP increased the risk of postoperative intestinal obstruction, but other risk factors, especially previous abdominal surgery or inflammation, have greater influence.

Five-year outcome of laparoscopic and Lichtenstein hernioplasties

BACKGROUND

Laparoscopic hernia repair has been proved superior to open repairs in terms of short-term results, but long-term results of laparoscopic and open mesh repairs have been lacking until recently.

METHODS

A total of 123 patients were randomly allocated to two treatment groups comparing laparoscopic and Lichtenstein hernioplasties in three separate trials. The first and second trials compared small and large mesh used in transabdominal preperitoneal repairs, and the third study compared totally extraperitoneal hernioplasty with the Lichtenstein operation. A 5-year follow-up visit was scheduled to assess recurrencies, symptoms, and patient satisfaction.

RESULTS

For the follow up evaluation, 121 (98.4%) of the patients were reached. There were five hernia recurrences in the laparoscopic group (small mesh) and two in the Lichtenstein group (difference, 5%; 95% confidence interval, -4-13%; p = 0.3). One patient who underwent the transabdominal preperitoneal polypropylene procedure underwent reoperation 3 years later because of dense small bowel adhesions at the inguinal surgical site. Chronic groin pain was more common after open operation (0 vs 4) patients (difference 7%; confidence interval, -0.4-16%; p = 0.04). Ten patients (16%) in the laparoscopic group and 12 (20%) in the open group reported discomfort or pain at the surgical site.

CONCLUSIONS

Both laparoscopic and Lichtenstein hernioplasties have a low risk for hernia recurrence if proper mesh size is used. The patients who undergo hernioplasty with open mesh hernioplasty seem to experience chronic symptoms and pain more often than those managed with the laparoscopic procedure.

Pneumoperitoneum versus abdominal wall lift: effects on central haemodynamics and intrathoracic pressure during laparoscopic cholecystectomy

BACKGROUND

It has been shown repeatedly that laparoscopic cholecystectomy using pneumoperitoneum (CO2 insufflation) may be associated with increased cardiac filling pressures and an increase in blood pressure and systemic vascular resistance. In the present study, the effects on the central circulation during abdominal wall lift (a gasless method of laparoscopic cholecystectomy) were compared with those during pneumoperitoneum. The study was also aimed at elucidating the relationships between the central filling pressures and the intrathoracic pressure.

METHODS

Twenty patients (ASA I), scheduled for laparoscopic cholecystectomy, were randomised into two groups, pneumoperitoneum or abdominal wall lift. Measurements were made by arterial and pulmonary arterial catheterization before and during pneumoperitoneum or abdominal wall lift with the patient in the horizontal position. Measurements were repeated after head-up tilting the patients as well as after 30 min head-up tilt. The intrathoracic pressure was monitored in the horizontal position before and during intervention using an intraesophageal balloon.

RESULTS

After pneumoperitoneum or abdominal wall lifting there were significant differences between the two groups regarding MAP, SVR, CVP, CI, and SV. Analogous to previous studies, in the pneumoperitoneum group CVP, PCWP, MPAP, and MAP as well as SVR were increased after CO2 insufflation (P < 0.01), while CI and SV were not affected. In contrast, in the abdominal wall lift group, CI and SV were significantly increased (P < 0.01), as was MAP (P < 0.01), while CVP, PCWP, MPAP, and SVR were not significantly affected. There was a significant difference in intraesophageal pressure between the two groups. In the pneumoperitoneum group, the intraesophageal pressure was increased by insufflation (P < 0.01) while, in the abdominal wall lift group, it was unaffected. In the pneumoperitoneum group the mean increases in cardiac filling pressures were of the same magnitude as the mean increase in the intraesophageal pressure.

CONCLUSIONS

In healthy patients, abdominal wall lift increased cardiac index while pneumoperitoneum did not. Cardiac filling pressures and systemic vascular resistance were increased by pneumoperitoneum but unaffected by abdominal wall lift. The recorded elevated cardiac filling pressures during pneumoperitoneum may be only a reflection of the increased intra-abdominal pressure.

The Arg 389 Gly beta1-adrenergic receptor gene polymorphism and human fat cell lipolysis

BACKGROUND

The beta1-adrenoceptor is a candidate gene for obesity because of its role in catecholamine-induced energy homeostasis. A common Arg 389 Gly variant polymorphism has been shown in recombinant cells to influence its-coupling properties.

OBJECTIVE

To investigate the effect of the Arg 389 Gly beta1-adrenoceptor polymorphism on catecholamine-induced lipolysis in native human fat cells obtained by subcutaneous biopsy.

SUBJECTS

Two-hundred and ninety-eight apparently healthy male and female subjects with a wide variation in body mass index (BMI, 18-60 kg/m2).

MEASURES

The lipolytic sensitivities and maximum lipolytic action of noradrenaline and the selective adrenoceptor agonists dobutamine (beta1), terbutaline (beta2) and CGP 12177 (beta3) were determined in isolated subcutaneous adipocytes and related to beta-adrenoceptor radioligand binding parameters.

RESULTS

No differences in the sensitivity or maximum lipolytic capacity of the agonists were found between the genotypes. This was true both when all subjects were analyzed together and when subgroups (lean, obese, men, women) were analyzed separately. Radioligand binding to beta1- or beta2-adrenoceptors was also similar between genotypes. The polymorphism had no important influence on either BMI or the distribution of obese and non-obese subjects between the genotypes.

CONCLUSION

The distribution of the Arg 389 Gly polymorphism is similar in lean and obese subjects and has no apparent effect on the lipolytic response to beta-adrenergic stimulation in native human adipocytes. This suggests, despite the altered coupling properties reported in recombinant cells, that the Arg 386 Gly polymorphism has no important influence on human obesity.

Is a dissection balloon beneficial in bilateral, totally extraperitoneal, endoscopic hernioplasty? A randomized, prospective, multicenter study

SUMMARY

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to gain the initial working space in totally extraperitoneal endoscopic (TEP) hernioplasty, but this increases its cost. Forty-four men with bilateral, primary or recurrent inguinal hernias were randomized to undergo TEP with or without dissection balloon. There were two conversions to transabdominal preperitoneal hernioplasty, or open herniorrhaphy, in the group with balloon and four in the group without balloon. There was no difference in the postoperative morbidity or operation time between the two groups, and there were no major complications in either group. The recurrence rate was 4.3% in the group with the balloon and 7.1% in the group without the balloon. There were no statistically significant differences between the groups. Although our study population is too small to detect small differences between the groups, it seems that the use of a dissection balloon is not beneficial in a bilateral TEP.

[Simulator training in medicine and health care. A new pedagogic model for good patient safety]

Advanced simulation within medicine and health care is a rapidly growing field. Simulator based training can be applied in minimal invasive surgery, in endoscopic procedures as well as in anaesthesia and critical care management. At Huddinge University Hospital a center for advanced simulation of both endoscopic surgery and anaesthesia/critical care management is currently being set up. The objective is to focus on improved medical and health care training and thus improving patient safety by reducing medical errors.

Outpatient laparoscopic cholecystectomy. A prospective study with 100 consecutive patients

One hundred patients with cholelithiasis were included in a prospective consecutive follow-up study to evaluate laparoscopic cholecystectomy in a day surgical setting. The median operating time was 70 min. In 96% of the patients, it was possible to perform peroperative cholangiography. The median time off work was 7 days and the median time to full recovery was 14 days. Five patients were admitted due to weakness/nausea. Six patients were admitted due to conversion to open surgery or choledocholithiasis. Eighty-nine patients were treated in ambulatory surgery. We conclude that laparoscopic outpatient cholecystectomy can be performed safely with a low unplanned admission rate.

Increased expression of eNOS protein in omental versus subcutaneous adipose tissue in obese human subjects

OBJECTIVE

To investigate the expression of eNOS and iNOS mRNA and protein in adipose tissue from subcutaneous (s.c.) and omental adipose tissue of obese subjects.

DESIGN

Subcutaneous and omental adipose tissue was obtained from subjects undergoing weight reduction surgery. Messenger RNA and protein levels were measured in tissue extracts and related to basal lipolysis, which was measured in isolated adipocytes from the same subjects.

SUBJECTS

Eight overweight but otherwise healthy male subjects (age 43.4+/-10.3 y, BMI 39+/-3.5 kg/m(2), mean+/-s.e.m.).

MEASUREMENTS

For mRNA detection a competitive reverse transcription polymerase chain reaction method was used while protein was detected by Western blot. Glycerol release was determined in isolated adipocytes using a standard luminometric assay.

RESULTS

Tissue mRNA levels for eNOS in s.c. tissue were 6098+/-1969 amol/mg RNA and in omental tissue 6987+/-2914 amol/mg RNA (mean+/-s.e.m., P=0.75). iNOS mRNA levels were substantially lower; in s.c. tissue 227+/-127 amol/mg RNA and in omental tissue 245+/-162 amol/mg RNA (P=0.8). In Western blot, eNOS protein levels in s.c. and omental tissue were 1.88+/-2.0 and 7.47+/-4.11 (OD/mm(2) 100 microg total protein, P=0.0063), respectively. iNOS protein was expressed at significantly lower levels and barely detectable in both s.c. and omental tissue. Basal rate of lipolysis was two times higher in s.c. compared to omental fat cells (P=0.028).

CONCLUSIONS

eNOS protein is markedly increased in omental compared to s.c. adipose tissue in human obese subjects, probably due to post-transcriptional mechanisms. Since basal lipolysis is much lower in omental vs s.c. adipose tissue it is possible that regionally increased NO production, primarily by eNOS, may be involved in the site difference of basal lipolysis in obese subjects.

Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter study

BACKGROUND

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation.

METHODS

A total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon.

RESULTS

In the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p = 0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8).

CONCLUSION

The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

Comparison of laparoscopic and open Nissen fundoplication 2 years after operation. A prospective randomized trial

BACKGROUND

Laparoscopic operation has replaced the conventional open procedure in the treatment of gastroesophageal reflux disease (GERD) in spite of the fact that long-term results based on controlled clinical trials have been lacking. The objective of this study was to compare outcome, quality of life, and patient satisfaction after laparoscopic and open Nissen fundoplication in a community hospital setting with a 2-year follow-up.

METHODS

Forty-two patients with GERD were randomized to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Outcome evaluation included reflux symptoms, gastrointestinal quality of life (GIQLI), and upper GI endoscopy.

RESULTS

Esophagitis was cured among all patients in the LNF group and in 90% of the ONF group. There were two patients (10%) in both groups who had medicine-dependent recurrent reflux together with significant worsening in the GIQLI scores. One patient in the LNF group has been reoperated due to a suture granuloma in the left epigastric port. Two patients in the LNF group needed esophageal dilatation due to persistent dysphagia. GIQLI scores (scale, 0-144) were equally normalized in both groups. Overall, 90% in the LNF and 100% in the ONF group were either satisfied or very satisfied with the operation. There was only one patient (LNF) who would not choose to have the operation again.

CONCLUSIONS

Laparoscopic and open Nissen fundoplication seem to be equally effective methods for improving reflux symptoms and quality of life, resulting in a high rate of satisfaction among patients with an intermediate follow-up period of 2 years.

Increased adipose angiotensinogen gene expression in human obesity

OBJECTIVE

Adipose angiotensinogen has been suggested as a stimulator of adipose tissue growth and development. Therefore, the association of subcutaneous adipose angiotensinogen gene expression with human obesity was studied.

RESEARCH METHODS AND PROCEDURES

The study group consisted of 17 men, undergoing either gastric banding for obesity or elective laparoscopic cholecystectomy (7 obese, 10 non-obese men; body mass index 22 to 51 kg/m2; age 26 to 68 years). Subcutaneous adipose angiotensinogen mRNA and 18S ribosomal RNA (reference gene) levels were measured using competitive quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

Adipose angiotensinogen mRNA expression was about two times increased in obesity. The levels of 18S rRNA did not differ between the two groups. Body weight correlated independently and positively with adipose angiotensinogen mRNA expression after adjusting for differences in age and height.

DISCUSSION

Adipose angiotensinogen gene expression is elevated in obesity in men.

The association of human adipose angiotensinogen gene expression with abdominal fat distribution in obesity

OBJECTIVE

To investigate in obese subjects the relationship between angiotensinogen gene expression in the abdominal omental and subcutaneous adipose tissue on the one hand and body fat distribution as measured by waist-to-hip ratio (WHR) on the other hand and to compare angiotensinogen gene expression between the two adipose tissue regions.

SUBJECTS

Twenty obese subjects undergoing weight reduction surgery with adjustable gastric banding (12 men, eight women; WHR 0.89-1.09; body mass index (BMI) 29-51 kg/m2, age 26-54 y).

MEASUREMENTS

Omental and subcutaneous adipose angiotensinogen mRNA and 18S ribosomal RNA (reference gene) levels were measured by competitive quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

Angiotensinogen mRNA levels were one-third higher in the omental than in the subcutaneous adipose tissue region (P=0.02). The 18S rRNA levels did not differ significantly between the two adipose tissue regions. WHR correlated positively and significantly with angiotensinogen mRNA in both the subcutaneous and the omental adipose tissue (r=0.5). This relationship was independent of age and BMI. However, WHR did not correlate with 18S rRNA in any of the adipose tissue regions.

CONCLUSION

The angiotensinogen gene in adipose tissue might be involved in the development of upper-body obesity.

Introduction of herniorraphy with mesh plug and patch

OBJECTIVE

To evaluate the introduction of the Perfix mesh plug and patch system for inguinal hernia repair.

DESIGN

Prospective consecutive follow-up study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

139 patients with 145 hernias who were operated on for inguinal hernia with the Perfix mesh plug and patch technique during 1997.

MAIN OUTCOME MEASURES

Operating time, sick leave, time to full recovery, morbidity, recurrence rate.

RESULTS

The median operating time was 35 minutes (range 15-105) and the mean follow-up was 9 months (range 4-13). Office workers required a mean of 7 days off work (range 0-43) and manual workers 15 days (range 0-90). Retired patients took 21 days (0-30) to recover fully, office workers 22 days (7-70), manual workers 30 days (7-90), students 34 days (0-60) and unemployed patients 60 days (21-150). There were 17 minor complications within 30 days and 2 recurrences during the follow up period.

CONCLUSION

Herniorraphy with a mesh plug and patch can easily be introduced with good short-term results.