C. Peiper

[Long-term results after Spitzy's umbilical hernia repair].

A total of 140 patients presenting with umbilical hernia underwent Spitzys operation and were included in a retrospective study to analyse the recurrence rate.The patients received a questionnaire and were invited for a physical examination including ultrasound.Participation included 108 patients (follow-up 77%).A total of seven patients (6.5%) developed postoperative wound infections.Prolonged postoperative impairment was mentioned by nine patients (8.3%). After a mean period of 16 days, the patients were able to continue their occupation, and after 27 days, they could manage their usual physical activity.The recurrence rate was 13.0%.The risk for a recurrence correlated with the relative bodyweight. In the group with a body-mass-index (BMI) of less than 30, the recurrence rate was 8.1 %, whereas 31.8% of the patients with a BMI of more than 30 developed a recurrent hernia.The size of the hernial orifice also had an influence on the postoperative result. In patients with a hernial gap smaller than 1 cm the recurrence rate was 6.3%, with hernia orifices from 1 to 2 cm the rate was 4.1%, from 2 to 3 cm 14.3%, from 3 to 4 cm 25.0% and in patients with hernial gaps greater than 4 cm the rate of recurrences was 54.5%.Considering these results,we recommend the use of alloplastic material for umbilical hernia repair for patients with a BMI greater than 30.0 and hernia orifice larger than 3 cm.The decision for use of a mesh in hernial gaps from 2 to 3 cm should depend on individual factors.ZusammenfassungIn den Jahren 1995–1999 wurden an der Chirurgischen Universitätsklinik 140 Patienten an einer Nabelhernie operiert.Wir führten eine Befragung der Patienten zum Langzeitergebnis der Operation sowie eine Nachuntersuchung einschließlich Sonographie durch.Insgesamt 108 Patienten beteiligten sich an der Studie und wurden ausgewertet (Follow-up 77%).Bei 7 Patienten (6,5%) kam es zu Wundheilungsstörungen, prolongierte postoperative Beschwerden wurden von 9 Patienten (8,3%) angegeben.Durchschnittlich 16 Tage postoperativ konnten die Patienten wieder ihren Beruf ausüben, nach durchschnittlich 27 Tagen wurde allen Freizeitaktivitäten nachgekommen. Im untersuchten Kollektiv kam es bei 14 Patienten (13,0%) zu einem Rezidiv. Es zeigte sich, dass das Risiko eines Rezidives mit dem relativen Körpergewicht der Patienten korrelierte.So betrug die Rezidivrate bei den Patienten mit einem Body-Mass-Index (BMI) bis 30 lediglich 8,1%, bei den Patienten mit einem BMI ab 30 lag sie bei 31,8%.Auch die Größe der Bruchlücke hatte einen Einfluss auf das postoperative Ergebnis.Die Rezidivrate bei Bruchlücken bis 1 cm betrug 6,3%, bei Bruchlücken von 1–2 cm 4,1%, von 2–3 cm 14,3%, von 3–4 cm 25,0% und bei Bruchlücken ab 4 cm 54,5%.In der Gruppe der Patienten mit einem BMI kleiner 30 sowie Bruchlücken von weniger als 3 cm lag die Gesamtrezidivrate bei 3,6%.Vor dem Hintergrund der Ergebnisse dieser Studie empfehlen wir bei Patienten mit einem BMI ab 30 sowie einer Bruchlücke ab 3 cm eine Meshaugmentation zum Bruchlückenverschluss. Bei Bruchlücken zwischen 2 und 3 cm Größe sollte der Entschluss zur netzverstärkten Reparation individuell gefällt werden.

Stellenwert der subcutanen Drainage bei der Reparation primärer Leistenhernien Eine prospektive randomisierte Studie an 100 Fällen

Summary. Following Shouldice repair of a primary inguinal hernia 50 patients were given subcutaneous Redon drains, while another 50 patients underwent operations without drains in a prospective randomized trial. The amount of postoperative wound secretion in the drainage bottle was added to fluid retention established by sonographic volumetric analysis. The degree of personal impairment was estimated by a visual analogue score. Inflammation parameters were recorded as well as the rate of complications. The drain group showed significantly increased fluid production in comparison to the group without drains on the 1st postoperative day (36.0 vs. 2.5 ml). Wound sepsis was found in two patients in the drain group. Seven patients with drains and eight patients without underwent percutaneous seroma puncture. The drain only slightly affected personal impairment (25.6 % vs 21.4 %, visual analogue score). Body temperature was elevated in the drain group on the 3rd day after operation (37.2 vs 36.7 °C). We believe there is no indication for the routine use of a Redon drain in the repair of a primary inguinal hernia. Instead, percutaneous puncture of subcutaneous fluid retentions should be performed.Zusammenfassung. In einer prospektiven randomisierten Studie wurden im Rahmen der Shouldice-Reparation primärer Hernien 50 Patienten mit subcutaner Redon-Drainage und 50 Patienten ohne Drainage versorgt. Postoperativ erfaßten wir die Menge des produzierten Wundsekrets in der Drainageflasche sowie durch sonographische Volumetrie, das Maß der subjektiven Beeinträchtigung mittels visueller Analogskala, die Höhe der Entzündungsparameter sowie die Komplikationsrate. Am ersten postoperativen Tag fand sich im drainierten Kollektiv mit 36,0 ml eine signifikant erhöhte Flüssigkeitsproduktion im Vergleich zu 2,5 ml in der Gruppe ohne Drainage. Zwei Wundinfekte wurden ebenfalls im drainierten Kollektiv beobachtet. Percutane Serompunktionen waren bei 8 Patienten, die ohne Drainage operiert wurden, und bei 7 drainierten Patienten notwendig. Das subjektive Empfinden war durch die Drainage nur geringfügig (25,6 vs. 21,4 %, visuelle Analogskala) beeinträchtigt. Die Körpertemperatur war im Drainagekollektiv am 3. postoperativen Tag im Vergleich zur nicht drainierten Gruppe erhöht (37,2 vs. 36,7 °C). Das routinemäßige Einlegen einer Redon-Drainage bei der Reparation primärer Leistenhernien ist aus unserer Sicht nicht indiziert. Vielmehr sollte bei Auftreten einer subcutanen Flüssigkeitsansammlung großzügig die Indikation zur percutanen Punktion gestellt werden.

The Influence of Inguinal Mesh Repair on the Spermatic Cord: A Pilot Study in the Rabbit

The permanent implantation of a polypropylene mesh during inguinal hernia repair causes chronic inflammatory changes in the surrounding tissue. We investigated the effect of this foreign body reaction on the structures of the spermatic cord in the rabbit. Eight Chinchilla rabbits underwent unilateral inguinal hernia repair by the Lichtenstein technique using Marlex (n = 4) orUltrapro (n = 4) mesh. The contralateral side was operated upon using the Shouldice repair. Three animals served as controls. Three months after operation we analyzed testicular size, testicular temperature, and arterial perfusion by excitation light of a 780-nm laser after injection of 0.5 mg/kg indocyanin green. Histological evaluation included spermatogenesis (Johnsen score) and foreign-body reaction. Testicular volume increased about 10% after each operation. The decrease of arterial perfusion and testicular temperature was more significant after mesh repair than following Shouldice operation. After mesh implantation we found fewer seminiferous tubules classified as Johnsen 10 (Marlex: 51.3%, Ultrapro: 45.0%) than after Shouldice repair (63.8%) or in the controls (65.8%). The spermatic cord showed a typical foreign-body reaction at the interface between mesh and surrounding tissue, which was not detectable after Shouldice repair. Preserved cremasteric muscle fibers protected the structures of the spermatic cord. The inflammatory foreign-body reaction of the surrounding tissue induced by the inguinal prosthetic mesh includes the structures of the spermatic cord. This may have an influence also on spermatogenesis. Therefore, we recommend strict indications for implantation of a prosthetic mesh during inguinal hernia repair.

Abdominal musculature and the transversalis fascia: an anatomical viewpoint

This anatomical study investigated the connection of the muscles of the abdominal wall to the transversalis fascia in the groin. In six unfixed male corpses we prepared the single levels of the inguinal abdominal wall and examined their interrelationships. Of special interest were the direction of the force vectors determined by the direction of the muscular fibers in relation to the transversalis fascia. We found no confirmation of a direct connection between the muscles of the abdominal wall and the transversalis fascia in the inguinal region. No force vector of the different muscular layers points away from the triangle of Hesselbach. By contraction each muscle thus relaxes the transversalis fascia of the Hesselbach triangle.

Langzeitergebnisse der Nabelhernienreparation nach Spitzy

A total of 140 patients presenting with umbilical hernia underwent Spitzys operation and were included in a retrospective study to analyse the recurrence rate.The patients received a questionnaire and were invited for a physical examination including ultrasound.Participation included 108 patients (follow-up 77%).A total of seven patients (6.5%) developed postoperative wound infections.Prolonged postoperative impairment was mentioned by nine patients (8.3%). After a mean period of 16 days, the patients were able to continue their occupation, and after 27 days, they could manage their usual physical activity.The recurrence rate was 13.0%.The risk for a recurrence correlated with the relative bodyweight. In the group with a body-mass-index (BMI) of less than 30, the recurrence rate was 8.1 %, whereas 31.8% of the patients with a BMI of more than 30 developed a recurrent hernia.The size of the hernial orifice also had an influence on the postoperative result. In patients with a hernial gap smaller than 1 cm the recurrence rate was 6.3%, with hernia orifices from 1 to 2 cm the rate was 4.1%, from 2 to 3 cm 14.3%, from 3 to 4 cm 25.0% and in patients with hernial gaps greater than 4 cm the rate of recurrences was 54.5%.Considering these results,we recommend the use of alloplastic material for umbilical hernia repair for patients with a BMI greater than 30.0 and hernia orifice larger than 3 cm.The decision for use of a mesh in hernial gaps from 2 to 3 cm should depend on individual factors.ZusammenfassungIn den Jahren 1995–1999 wurden an der Chirurgischen Universitätsklinik 140 Patienten an einer Nabelhernie operiert.Wir führten eine Befragung der Patienten zum Langzeitergebnis der Operation sowie eine Nachuntersuchung einschließlich Sonographie durch.Insgesamt 108 Patienten beteiligten sich an der Studie und wurden ausgewertet (Follow-up 77%).Bei 7 Patienten (6,5%) kam es zu Wundheilungsstörungen, prolongierte postoperative Beschwerden wurden von 9 Patienten (8,3%) angegeben.Durchschnittlich 16 Tage postoperativ konnten die Patienten wieder ihren Beruf ausüben, nach durchschnittlich 27 Tagen wurde allen Freizeitaktivitäten nachgekommen. Im untersuchten Kollektiv kam es bei 14 Patienten (13,0%) zu einem Rezidiv. Es zeigte sich, dass das Risiko eines Rezidives mit dem relativen Körpergewicht der Patienten korrelierte.So betrug die Rezidivrate bei den Patienten mit einem Body-Mass-Index (BMI) bis 30 lediglich 8,1%, bei den Patienten mit einem BMI ab 30 lag sie bei 31,8%.Auch die Größe der Bruchlücke hatte einen Einfluss auf das postoperative Ergebnis.Die Rezidivrate bei Bruchlücken bis 1 cm betrug 6,3%, bei Bruchlücken von 1–2 cm 4,1%, von 2–3 cm 14,3%, von 3–4 cm 25,0% und bei Bruchlücken ab 4 cm 54,5%.In der Gruppe der Patienten mit einem BMI kleiner 30 sowie Bruchlücken von weniger als 3 cm lag die Gesamtrezidivrate bei 3,6%.Vor dem Hintergrund der Ergebnisse dieser Studie empfehlen wir bei Patienten mit einem BMI ab 30 sowie einer Bruchlücke ab 3 cm eine Meshaugmentation zum Bruchlückenverschluss. Bei Bruchlücken zwischen 2 und 3 cm Größe sollte der Entschluss zur netzverstärkten Reparation individuell gefällt werden.

Intraoperative Messung der Nahtkräfte bei der Shouldice-Reparation primärer Leistenhernien

Summary. A special instrument was developed in order to quantify intraoperatively the traction forces which are employed during Shouldice repair of a primary inguinal hernia while adapting the lateral edge of the rectus sheath and the iliopubic tract. Further investigations were performed under the Valsalva manoeuvre and simultaneous measurement of the intra-abdominal pressure. In 25 patients an average increase in traction forces of 3.62 ± 0.60 N was registered when the hernial gap was decreased to 0.3 cm. By applying the Valsalva manoeuvre with an average increase of 32 mm Hg in intra-abdominal pressure, traction was increased by a further 1.67 ± 0.20 N on average. Hernia repair, tensing of the abdominal muscles and increasing the intra-abdominal pressure, however, have a small effect on the traction forces affecting the edges of the hernial gap. It may therefore be concluded that these factors, frequently believed causal for early hernia recurrence, are actually less influential as the force vector stressing the repair zone points in a different direction.Zusammenfassung. Zur Quantifizierung der mechanischen Zugkräfte in der Inguinalregion, die durch Reparation primärer Leistenhernien nach Shouldice verursacht werden, wurde ein Instrument konstruiert, das intraoperativ diese Kräfte während der Adaptation von lateralem Rand der Rectusscheide und Basis des Leistenbandes erfaßt. Weitere Messungen wurden während des Valsalva-Manövers unter gleichzeitiger Registrierung des intraabdominellen Druckes durchgeführt. Hierbei fand sich bei 25 Patienten eine durchschnittliche Steigerung der Zugkräfte um 3,62 ± 0,60 N, wenn durch Adaptation der oben genannten Strukturen die Bruchpforte auf 0,3 cm verkleinert wurde. Durch das Valsalva-Manöver mit einer durchschnittlichen intraabdominellen Drucksteigerung von 32 mm Hg wurde der Zug noch um 1,67 ± 0,20 N gesteigert. Insgesamt belasten Hernienreparation, Anspannen der Bauchmuskulatur und Erhöhung des intraabdominalen Druckes die Ränder der Bruchpforte aber nur gering. Die entstehenden Kraftvektoren liegen offensichtlich in einer die Reparation nicht belastenden Ebene; sie können für Frührezidive allein nicht verantwortlich gemacht werden.

Effect of tension induced by Shouldice repair on postoperative course and long-term outcome.

OBJECTIVE To record intraoperative tension during Shouldice hernioplasty and correlate it with postoperative course and long-term outcome. DESIGN Prospective clinical trial. SETTING University clinic, Germany. SUBJECTS 20 male patients undergoing elective primary inguinal hernia repair by Shouldice technique. INTERVENTION Measurement of intraoperative tension during hernioplasty (low 0-2.0 N, moderate 2.1-4.0 N, high > 4.1 N). MAIN OUTCOME MEASURES Postoperative pain measured by visual analogue scale (VAS) at rest and activity, pain-related change of ventilatory measurements (8, 24 and 48 hours after intervention), postoperative complications, length of stay in hospital, and recurrence rate at mean 46.7 (range 43-54) months after operation. Data are given as mean (SD). RESULTS The results for 18 patients were analysed, 2 being lost to follow up. Mean pain score was 17.5 (15.6), 14.8 (15.6) and 12.3 (14.9) at rest 8 hours, 24 hours and 48 hours after operation, during activity 42.0 (16.5), 36.4 (18.5) and 33.7 (19.1) respectively. Most depression of ventilatory measurements was found 8 hours after operation (vital capacity 88.4 (12.5)%. peak flow 81.3 (17.2)%) compared with preoperative values. Complications comprised one seroma, one subcutaneous wound infection, and 3 haematomas. Mean length of stay in hospital was 4.3 (range 2-7) days. At follow up, no recurrences were found. No correlation with intraoperatively-induced tension was found. CONCLUSIONS Postoperative pain and recurrences depend on many factors, but induced intraoperative tension can be excluded. The reported advantages of tension-free procedures are not based on the avoidance of tension. The Shouldice repair can therefore continued to be used as a routine technique in uncomplicated primary inguinal hernia repair.

Leistenhernienreparation in Lokalanästhesie —eine vergleichende Analyse

Since February 1992 local anaesthesia has been routinely used for repair of inguinal hernias at the Surgical Department of the RWTU Aachen. All 607 patients undergoing Shouldice repair of primary inguinal hernia between January 1990 and March 1993 were retrospectively analysed with reference to need for analgesics, length of stay in hospital, and rate of complications. In addition, 50 patients treated with local anaesthesia and 50 patients treated under general anaesthesia underwent prospective pain analysis using a visual analogue scale and spirometric tests. Following local anaesthesia we found fewer need of analgesics, shorter stays in hospital, and less complications. The pain level was lower and ventilatory function was better. Repair of inguinal hernia with local anaesthesia is a safe method of lowering the risks involved in the operation and improving patient comfort without increasing complications.Since February 1992 local anaesthesia has been routinely used for repair of inguinal hernias at the Surgical Department of the RWTU Aachen. All 607 patients undergoing Shouldice repair of primary inguinal hernia between January 1990 and March 1993 were retrospectively analysed with reference to need for analgesics, length of stay in hospital, and rate of complications. In addition, 50 patients treated with local anaesthesia and 50 patients treated under general anaesthesia underwent prospective pain analysis using a visual analogue scale and spirometric tests. Following local anaesthesia we found fewer need of analgesics, shorter stays in hospital, and less complications. The pain level was lower and ventilatory function was better. Repair of inguinal hernia with local anaesthesia is a safe method of lowering the risks involved in the operation and improving patient comfort without increasing complications.ZusammenfassungSeit Februar 1992 wird die Lokalanästhesie als Routineverfahren zur Reparation der primären Leistenhernie in der Chirurgischen Klinik der RWTH Aachen eingesetzt. Retrospektiv wurden alle 607 Patienten, die sich zwischen Januar 1990 und März 1993 einer primären Leistenhernienreparation nach Shouldice in Lokalanästhesie oder Allgemeinnarkose unterzogen, bzgl. Analgetikabedarf, Dauer des stationären Aufenthalts und Komplikationsraten analysiert. Zusätzlich wurden an jeweils 50 Patienten aus jedem Kollektiv eine prospektive Schmerzanalyse mittels visueller Analogskala und Spirometrie durchgeführt. Nach Lokalanästhesie fanden wir einen geringeren Analgetikabedarf, eine kürzere Dauer des Krankenhausaufenthalts und weniger Komplikationen. Das subjektive Schmerzniveau und die schmerzbedingte Beeinträchtigung der Lungenfunktion waren ebenfalls niedriger. Die Anwendung der Lokalanästhesie zur Reparation der primären Leistenhernie ist ein Verfahren zur Senkung der Invasivität des Gesamteingriffs bei gleichzeitig gesteigertem Patientenkomfort, ohne damit die Komplikationsrate zu erhöhen.

Ultrasound-based volumetric evaluation of fluid retention after inguinal hernia repair

AbstractBackground: Daily routine has shown that there are differences between the aspirated volumes of subcutaneous liquid retention after inguinal hernia repair and the results of sonographic-based volumetry using the standard rotating ellipsoid formula. Methods: In 83 patients, subcutaneous fluid retention after Shouldice repair was visualized by ultrasound and calculated as cuboid, cylinder, and rotating ellipsoid, respectively. The results were compared to the aspirated volume. Data were analyzed retrospectively. Results: The volume obtained by percutaneous punction averaged 12.18 ± 1.50 ml. The calculated volumes were distinctly less: cuboid, 11.98 ± 1.59 ml; cylinder, 10.26 ± 1.45 ml; rotating ellipsoid, 5.99 ± 0.80 ml. We found different coefficients of regression for the aspirated and the calculated volumes (cuboid; 0.75; cylinder; 0.82; rotating ellipsoid; 1.50). The coefficients of correlation, however, were 0.79 for all modes of calculation. Conclusion: Because its results were closest to the aspirated volumes, we recommend the cuboid formula for the ultrasound-based calculation of liquid retention after inguinal hernia repair.

Load on the Inguinal Region under Standard Conditions in Pigs

OBJECTIVE To find out the effect of standardised stress on the load of the inguinal region. DESIGN Experimental study. SETTING Surgical university clinic, Germany. SUBJECTS 15 uncastrated adult male pigs. INTERVENTIONS The tension force between the lateral edge of the rectus sheath and the base of the inguinal ligament was measured after simulation of the Shouldice repair. Standard stresses (coughing, straightening up into the upright position, small or large pneumoperitoneum, and electrical stimulation of abdominal muscles) were imposed. MAIN OUTCOME MEASURES Intra-abdominal pressure and tension force in the inguinal region. RESULTS We found the highest (mean, SEM) intra-abdominal pressure during coughing (33.1, 5.2 mm Hg) with an increase in inguinal tension force of 4.1, 0.5 N. The upright position (20, 0.7 mm Hg) and the large pneumoperitoneum (25 mm Hg) produced similar values (4.7, 0.8 N and 3.7, 0.4 N, respectively), whereas the small pneumoperitoneum (10 mm Hg) and the electrical stimulation of muscles of the abdominal wall (4.4, 0.1 mm Hg) resulted in distinctly smaller changes (1.1, 0.2 N and 0.7, 0.1 N, respectively). CONCLUSIONS The amount of tension on the simulated Shouldice repair depended largely on the increase in intra-abdominal pressure. Compared with the force required to disrupt the normal inguinal canal (68.6 N) the inguinal load seems to be negligibly low. This finding strengthens the modern recommendation to allow only a short convalescence after Shouldice hernia repair.