Agneta Montgomery

Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair.

Chronic postoperative pain is a major drawback of inguinal hernia repair. This study compared the frequency of chronic pain after laparoscopic (totally extraperitoneal patch, TEP) and open (Lichtenstein) repairs.

Tissue oxygenation in hemorrhagic shock measured as transcutaneous oxygen tension, subcutaneous oxygen tension, and gastrointestinal intramucosal pH in pigs.

Background and MethodsTissue oxygenation, measured in peripheral tissue as transcutaneous Po2 (Ptco2) and subcutaneous Po2, was compared with the oxygenation in GI mucosa, which was measured as intramucosal wall pH (pHi), during experimental hemorrhagic shock and resuscitation in pigs. The pigs were hemorrhaged stepwise to a BP of 80 and 45 mm Hg, followed by retransfusion. Ptco2 was measured in the groin and subcutaneous Po2 was measured in the hip region. Intraluminal Pco2 was measured in the stomach, in the small intestine, and the sigmoid colon using silicone catheters. A simultaneous determination of arterial blood HCO3 concentration allowed pHi to be calculated using Henderson-Hasselbalch equation. Cardiac output was determined by thermodilution, and oxygen delivery (Do2) was calculated. ResultsEarly indications of shock were decreases in Ptco2 and intestinal pHi (p < .01). All measured variables decreased at the second step of bleeding. Ptco2 and subcutaneous Po2 was correlated to Do2 through the entire experiment (r2 = .25 and .49, respectively). Also, the pHi of the small intestine and the sigmoid colon correlated with Do2 (r2 = .36 and .25, respectively). Ptco2 and subcutaneous Po2 correlated with pHi in the small intestine and sigmoid colon. ConclusionsPtco2 and pHi in the small intestine and sigmoid colon were the variables that most rapidly indicated blood volume loss. Subcutaneous Po2 and Ptco2, and small intestine and sigmoid colon pHi were correlated to total body oxygen transport. Peripheral tissue perfusion followed intestinal perfusion to some extent. (Crit Care Med 1991; 19:205)

Randomized clinical trial of laparoscopic versus open appendicectomy for confirmed appendicitis.

Laparoscopy is safe for diagnostic and therapeutic purposes in patients with suspected acute appendicitis. This study compared recovery after laparoscopic (LA) and open appendicectomy (OA) for confirmed appendicitis, carried out by experienced surgeons in an educational setting.

EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair

BackgroundAlthough the repair of ventral abdominal wall hernias is one of the most commonly performed operations, many aspects of their treatment are still under debate or poorly studied. In addition, there is a lack of good definitions and classifications that make the evaluation of studies and meta-analyses in this field of surgery difficult.Materials and methodsUnder the auspices of the board of the European Hernia Society and following the previously published classifications on inguinal and on ventral hernias, a working group was formed to create an online platform for registration and outcome measurement of operations for ventral abdominal wall hernias. Development of such a registry involved reaching agreement about clear definitions and classifications on patient variables, surgical procedures and mesh materials used, as well as outcome parameters. The EuraHS working group (European registry for abdominal wall hernias) comprised of a multinational European expert panel with specific interest in abdominal wall hernias. Over five working group meetings, consensus was reached on definitions for the data to be recorded in the registry.ResultsA set of well-described definitions was made. The previously reported EHS classifications of hernias will be used. Risk factors for recurrences and co-morbidities of patients were listed. A new severity of comorbidity score was defined. Post-operative complications were classified according to existing classifications as described for other fields of surgery. A new 3-dimensional numerical quality-of-life score, EuraHS-QoL score, was defined. An online platform is created based on the definitions and classifications, which can be used by individual surgeons, surgical teams or for multicentre studies. A EuraHS website is constructed with easy access to all the definitions, classifications and results from the database.ConclusionAn online platform for registration and outcome measurement of abdominal wall hernia repairs with clear definitions and classifications is offered to the surgical community. It is hoped that this registry could lead to better evidence-based guidelines for treatment of abdominal wall hernias based on hernia variables, patient variables, available hernia repair materials and techniques.

Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up.

Objectives:To compare a laparoscopic (totally extraperitoneal patch (TEP)) and an open technique (Lichtenstein) for inguinal hernia repair regarding recurrence rate and possible risk factors for recurrence. Summary Background Data:Laparoscopic hernia repair has been introduced as an alternative to open repair. Short-term follow-up suggests benefits for those patients operated with a laparoscopic approach compared with open techniques; ie, less postoperative pain and a shorter convalescence period. Long-term results, however, are less well known. Methods:The study was conducted as a multicenter randomized trial with a 5-year follow-up. A total of 1512 men aged 30 to 70 years, with a primary unilateral inguinal hernia, were randomized to either TEP or Lichtenstein repair. Results:Overall, 665 patients in the TEP group and 705 patients in the Lichtenstein group were evaluable. The cumulative recurrence rate was 3.5% in the TEP group and 1.2% in the Lichtenstein group (P = 0.008). Test for heterogeneity revealed significant differences between individual surgeons. The exclusion of 1 surgeon, who was responsible for 33% (7 of 21) of all recurrences in the TEP group, lowered the cumulative recurrence rate to 2.4% in this group, which was not statistically different from that of the Lichtenstein group. Conclusions:The recurrence rate for both TEP and Lichtenstein repair was low. A higher cumulative recurrence rate in the TEP group was seen at 5 years. Further analysis revealed that this could be attributable to incorrect surgical technique.

Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia

The Shouldice technique is the ‘gold standard’ of open non‐mesh hernia repair. The aim of this study was to compare 5‐year recurrence rates after Shouldice and laparoscopic transabdominal preperitoneal patch (TAPP) repair for primary inguinal hernia.

Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair

Laparoscopic herniorrhaphy has emerged as a recognized operative method for inguinal hernia repair. This study compared the short‐term results of two tension‐free methods of repair: totally extraperitoneal (TEP) laparoscopic patch repair and the open Lichtenstein mesh technique.

Diagnostic Laparoscopy in 1043 Patients with Suspected Acute Appendicitis

OBJECTIVE To evaluate the efficacy of diagnostic laparoscopy in patients with suspected acute appendicitis, the number of complications associated with the laparoscopic technique, and the effect of leaving a macroscopically normal-looking appendix in place. DESIGN Three prospective protocols. SETTING Three departments of surgery, one in Norway and two in Sweden. SUBJECTS 1043 patients aged 15 years or over. INTERVENTIONS Diagnostic laparoscopy in patients with signs and symptoms of acute appendicitis who were to be operated on. MAIN OUTCOME MEASURES Morbidity, mortality, and histological appearance of removed appendices, and outcome whether or not the patient was operated on. RESULTS 819 patients had appendectomies (61% laparoscopically and 39% by conversion to open operation) with a total complication rate of 10%. In 211 patients a diagnostic laparoscopy was done as a single procedure. There were 181 women in this group and 86 of them had gynaecological disorders. The complication rate was 2% among these 211 patients and after a follow up of two years no patients had been readmitted for appendicectomy. 13 patients were subjected to other open procedures. The overall mortality was 0.4%. CONCLUSION Diagnostic laparoscopy is safe and can be recommended in patients with suspected acute appendicitis, particularly in women. A macroscopically normal-looking appendix can be left in place.

Incisional hernia repair in Sweden 2002

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.

Postoperative fever, bowel ischaemia and cytokine response to abdominal aortic aneurysm repair — a comparison between endovascular and open surgery

OBJECTIVES To study bowel ischaemia in transfemorally placed endoluminal grafting (TPEG) for abdominal aortic aneurysms, and any relation to cytokine response or postoperative fever. DESIGN Prospective not randomised. University hospital setting. MATERIAL Fourteen cases of conventional surgery and 23 cases of endovascular technique for infrarenal abdominal aortic aneurysm repair. METHODS Tonometry was used for sigmoid colon pH, and ELISAs for serum IL-6. RESULTS Mucosal pH in the sigmoid colon fell significantly during clamping and reperfusion in both groups. Lowest measured sigmoid colon pH was 7.10 in the open group, compared to 7.22 in the TPEG group (p < 0.05). The IL-6 levels in serum peaked after 4 h of reperfusion; 249 pg/ml in the open group, compared to 89 pg/ml in the TPEG group (p < 0.05). High levels of IL-6 in the postoperative period and persisting low sigmoidal pH were associated with serious complications. Postoperative temperature did not differ significantly between the groups, and no significant correlation could be found with sigmoid colon pH or IL-6 levels. CONCLUSIONS The less pronounced perioperative bowel ischaemia in TPEG patients indicates an advantage of the TPEG technique. Splanchnic ischaemia was not related to postoperative fever, nor the IL-6 or TNF response.