Giovanni M. Salerno

Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial.

ObjectiveThe purpose of this study was to determine if laparoscopic inguinal herniorrhaphy represents a viable alternative to the conventional repair and to assess whether a prospective randomized controlled trial comparing both procedures is warranted. MethodsThree types of laparoscopic inguinal herniorrhaphies (transabdominal preperitoneal [TAPP], intraperitoneal onlay mesh [IPOM], and totally extraperitoneal [EXTRA]) were studied in a phase II design. Twenty-one investigators from 19 institutions participated. Approval from the local human research committee was required at each institution before patients could be enrolled. ResultsThere were 686 patients with 869 hernias: 366 (42.1%) were direct, 414 (47.6%) were indirect, 22 (2.5%) were femoral, and 67 (7.7%) were combination hernias. The TAPP procedure was used for 562 hernias, the IPOM was used for 217 hernias, and the EXTRA was used for 87 hernias. Sixtyone patients had additional abdominal procedures performed at the time of laparoscopy without any adverse affects on their herniorhaphies. The overall recurrence rate was 4.5%, with a minimum follow-up of 15 months.Complications were divided into the following three groups: 1) those related to laparoscopy, 2) those related to the patient, and 3) those related to the herniorrhaphy. Complications related to the laparoscopy occurred in 5.4% of patients; bleeding or abdominal wall hematomas occurred 31 times, (two patients required transfusion); one patient had bowel perforation, which was sutured laparoscopically; a bladder injury required laparotomy for management. Patient complications occurred in 6.7%. The majority involved the urinary tract (5.8%). Two patients required secondary abdominal procedures for adhesions, one for pain in the right lower quadrant and the other for adhesive small bowel obstruction. Postoperative myocardial infarction on day 5 resulted in the only operative mortality, for a rate of 0.1%. Complications related to the herniorrhaphy itself occurred in 17.1%. Most of these were minor, consisting of transient groin pain (3.5%), seroma (3.5%), transient leg pain (3.3%), hematoma (1.5%), or transient cord or testicular problems (0.9%). The incidence of leg pain decreased dramatically as surgeons became more familiar with the anatomy of the nerve supply to the groin when viewed laparoscopically. Ninety-three percent of patients were discharged within 24 hours of their operations. ConclusionsLaparoscopic inguinal herniorrhaphy is an effective method to correct an inguinal hernia. It can be offered safely to patients undergoing other abdominal procedures. The TAPP, IPOM, and EXTRA

A laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia.

ObjectiveThis study was done (1) to determine whether congenital indirect inguinal hernias in male pigs could be repaired by placing a polypropylene mesh prosthesis over the defect intra-abdominally, (2) to measure the incidence of adhesions between intra-abdominal viscera and the prosthesis with and without the adhesion barrier oxidized regenerated cellulose, (3) to determine the incidence of other complications, and (4) to assess the effect on fertility. Summary Background DataSeveral techniques for laparoscopic inguinal hemrniorrhaphy are currently being evaluated to determine whether there are advantages over conventional inguinal herniorrhaphy. Perhaps the most controversial is the intraperitoneal onlay mesh procedure (IPOM). Its advantage is its simplicity (in that the repair is accomplished by placing a prosthesis over the hernia defect intra–abdominally, avolding a groin dissection). Its disadvantage is the potential for complications because the prosthesis is in contact with the intra-abdominal viscera. MethodsIn male pigs, polypropylene mesh alone or polypropylene mesh plus the adhesion barrier oxidized regenerated cellulose (composite prosthesis) was fixed to the peritoneum surrounding the hernia defect. In phase 1 (6-week follow-up), two groups of 13 pigs each underwent herniorrhaphy at laparotomy or laparoscopy. In phase 2 (7.1-month follow-up), 21 pigs underwent laparoscopic herniorrhaphy. ResultsAll IPOM herniorrhaphies were successful. The prostheses adhered most frequently to the bladder, followed by small bowel, peritoneum, and cord structures. Prosthetic erosion into these organs was not observed. Laparoscopically placed prostheses in phases 1 and 2 had significantly less surface covered by adhesions (13% ± 13% and 19% ± 27%, respectively) and a lower adhesion tenacity grade (1.5 ± 0.9 and 1.3 ± 1.1, respectively) than those placed at laparotomy (44% ± 27% and 2.5 ± 0.7, respectively; p p, 0.01). In phase 1, a histologic evaluation of laparoscopically placed speciments demonstrated significantly thinner above-mesh fibrotic tissue compared with the prostheses implanted at laparotomy (p < 0.04). In either phase, the use of the adhesion barrier did not produce any histologic difference between the polypropylene alone and the composite prosthesis. Fertility studies were performed in phase 2 and showed no adverse effects caused by either prosthesis.

Open laparoscopy for laparoscopic cholecystectomy.

This report deals with the first 350 laparoscopic cholecystectomies performed at Creighton University, beginning in October 1989, by one of the authors (R.J.F., Jr.). An open technique was used for initial access to the abdominal cavity in 343 patients (98%). Patients included 274 females and 76 males, with an average age of 45.5 years. Weight ranged from 72 to 316 pounds (32–142.2 kg). The laparoscopic procedure was successfully completed in 338 (96.6%). Operative cholangiography was performed in 113 (32.3%), and 52 (14.7%) had acute cholecystitis as determined by the final pathological report. Median operating time was 80 min. There was no operative mortality. Bile duct injury was not seen. Postoperative complications occurred in 21 patients (6%), only two of which were directly related to the open technique (cellulitis of the umbilical wound requiring antibiotics). A third patient (0.3% of 343 successful laparoscopies) required reoperation on postoperative day 4 for a small bowel perforation; the exact cause could not be determined, but conceivably it was related to the umbilical minilaparotomy. We conclude that the open technique is safe and effective method for initial peritoneal access prior to laparoscopic cholecystectomy.

Electrical stimulation treatment of dog's denervated orbicularis oculi muscle.

In this investigation, the electrophysiologic and pathology of denervated orbicularis oculi muscles have been studied in dogs during chronic electrical stimulation. The orbicularis oculi muscles were unilaterally denervated in 8 dogs, and 4 of these muscles were directly stimulated on a daily basis for 75 days. No difference in minimum stimulus intensities evoking orbicularis oculi muscle twitch contraction appeared between denervated treated and nontreated muscles. A significant reduction of minimum stimulus intensities evoking upper eyelid complete closure (blink), however, was found in the denervated treated muscles between 10 and 30 days (p < 0.01). At 28 and 75 days, orbicularis oculi muscle biopsies showed no difference in muscle fiber diameter between denervated treated and nontreated muscles. At 75 days, type II muscle fiber distribution, however, was significantly increased in denervated treated muscles compared with denervated nontreated muscles (p < 0.01). These findings of orbicularis oculi muscle electrophysiology were consistent with a transient reversal of denervation changes by electrical stimulation, partially supported by muscle biopsies.

Blink Reflex Recovery after Electrical Stimulation of the Reinnervated Orbicularis Oculi Muscle in Dogs

The paralytic lagophthalmos following palpebral nerve neurotmesis and consequent peripheral denervation of the orbicularis oculi muscle is often associated with harmful effects on the exposed cornea. This study investigated how daily electrical stimulation affects the blink reflex recovery of this muscle after its reinnervation. Six dogs underwent unilateral facial nerve neurotmesis with immediate epineurial repair of the palpebral nerve. Three dogs were randomly chosen to receive electrical stimulation of the reinnervated orbicularis oculi muscles for 75 days. The remaining 3 dogs were controls (nonstimulated muscles). During the study, the reinnervated orbicularis oculi muscle electrophysiology and blink reflex recovery were investigated. The Students t test was used for statistical analysis. The results can be summarized as follows: (1) between 30 and 50 days, the minimum mean stimulus intensities evoking complete upper palpebral closure of the stimulated muscles were significantly lower than those of the nonstimulated muscles (p < 0.01) and (2) the stimulated muscles recovered complete closure of the interpalpebral fissure (blink reflex) at 49.6 days, significantly earlier (p < 0.01) than the nonstimulated muscles (72.6 days). It is concluded that daily electrical stimulation of the orbicularis oculi muscles, if started immediately after epineurial repair of the palpebral nerve neurotmesis, promotes a faster blink reflex recovery in the dog model.

Restoration of paralyzed orbicularis oculi muscle function by controlled electrical current.

A canine model of facial nerve paralysis was studied to apply controlled electrical current to the peripherally denervated orbicularis oculi muscle, in the attempt to effectively restore the absent function of this denervated muscle. After unilateral facial nerve neurotmesis was performed in eight dogs, the denervated orbicularis oculi muscles of four dogs were electrically stimulated for 75 postoperative days (40 min/day). Denervated and normal orbicularis oculi muscles were electrophysiologically studied and compared with the Student t test. During the study period, minimum closure of denervated treated orbicularis oculi muscles was evoked with average stimulus strength (80-ms duration) of 1.61 +/- 0.22 log mA x ms, not significantly different from that of denervated nontreated or normal orbicularis oculi muscles. From days 10 through 30 only, maximum closure of denervated treated orbicularis oculi muscles was achieved with mean pulse strength (80-ms duration) of 2.37 +/- 0.09 log mA x ms, significantly lower (P less than .01) than that evoking the same type of contraction from denervated nontreated muscles (80-ms duration, mean 2.83 +/- 0.10 log mA x ms). In addition, denervated treated muscle pulse strength eliciting maximum contraction was not significantly different from that of normal orbicularis oculi muscles during the same period. This finding was not observed, however, from day 40 through the end of the study. This investigation demonstrates (1) the transient reversal of denervation changes of paralyzed orbicularis oculi muscle by daily electrical stimulation, and (2) the feasibility of restoring orbicularis oculi muscle function by controlled electrical current.

Electrophysiological study of the denervated orbicularis oculi muscle in dogs

This study investigated the electrophysiology of the denervated orbicularis oculi muscle and its clinical application. Orbicularis oculi muscle denervation was achieved by complete transection of the seventh nerve in ten dogs. The parameters studied were the electrical requirements needed to cause a minimal perceptible contraction (twitch) and a complete eyelid closure (blink). Twitch and blink curves were generated. The findings are summarized as follows: (1) Minimum intensities for direct twitch of denervated orbicularis oculi muscle were significantly lower than intensities of normal orbicularis oculi muscle twitch (p < 0.01) when long stimulus duration (5 to 400 ms) was used. (2) Minimum intensities for direct blink of denervated orbicularis oculi muscle were not significantly different from stimulus intensities for blink of normal orbicularis oculi muscle if long stimulus duration (5 to 400 ms) was used. Twitch and blink curves could be used to clinically follow the orbicularis oculi muscle movement return after operations performed in patients affected by lagophthalmos.

Ciprostene and indomethacin partially reverse the mechanisms of distal end necrosis in the rat random skin flap.

&NA; Survival of random skin flap distal end depends on hemodynamic, cellular, and coagulation mechanisms. This study was designed to evaluate whether administration of ciprostene, a stable prostaglandin I2 analogue, and indomethacin, a cyclooxygenase‐hydroperoxydase enzyme inhibitor, would improve the survival rate of random skin flaps. Forty‐five male rats were divided into nine groups and injected with sesame oil (control), ciprostene (20 μg/kg/day), and/or indomethacin (2 mg/kg/day). Injections were done before (pretreatment for 4 days), after (posttreatment for 6 days), and before/after (pre/posttreatment for 4 and 6 days, respectively) the elevation of random dorsal skin flaps. In the pretreatment and pre/posttreatment studies, the flap survival rate of all drug‐injected groups was significantly higher than that of the control group (p < 0.02). In addition, administration of ciprostene alone yielded a trend of better flap survival rate, which, however, was not statistically significant (p < 0.12). Of interest in the posttreatment study, only the simultaneous administration of ciprostene and indomethacin significantly increased skin flap viability compared with the other groups (p < 0.02). Therefore, the results demonstrated that administration of ciprostene and indomethacin either alone or together partially reversed the pathophysiological mechanisms that cause necrosis of random skin flap distal end. These pharmacological changes significantly improved random skin flap survival rate.

The use of 5-aminoimidazole-4-carboxamide riboside (AICA riboside) to improve random skin flap viability in the rat model.

Several experimental studies have demonstrated that granulocytes have an important role in causing the necrosis of ischemic tissue by capillary plugging and superoxide radical formation. Adenosine is spontaneously released by ischemic cells and inhibits the granulocytic superoxide radical formation. 5-Aminoimidazole-4-carboxamide riboside, a naturally occurring by-product in purine biosynthesis, stimulates the release of ischemic cell adenosine and indirectly blocks the granulocyte-induced tissue necrosis. 5-Aminoimidazole-4-carboxamide riboside (10–500 mg/kg) was administered intraperitoneally in a blinded fashion once (single dose, 30 minutes before surgery) or twice (double dose, 30 minutes before and 5.5 hours after surgery) in groups of rats. The controls received intraperitoneal saline solution in the same fashion. Each rat underwent the elevation of a caudally based random skin flap. The flap viability was determined in a blinded fashion on the seventh postoperative day and statistically compared by Fishers exact test. When 300 or 500 mg/kg of 5-aminoimidazole-4-carboxamide riboside was given as a single dose, the mean percentage of rat skin flap necrosis (19.4% ± 3.1% and 19.6% ± 4.2%, respectively) was lower but not significantly different from that of the control group of rats (29.3% ± 2.7%) (p < 0.08). Additionally, two doses of 500 mg/kg of 5-aminoimidazole-4-carboxamide riboside yielded a mean percentage of rat skin flap necrosis (12.24% ± 4.58%) much lower (21.68% ± 3.18%) than that of the control group of rats (p = 0.056). Our blinded fashion study demonstrated an almost statistically significant reduction of random skin flap distal necrosis after intraperitoneal injection of high doses of 5-aminoimidazole-4-carboxamide riboside. A hypothesis of events responsible for skin flap necrosis and their prevention with 5-aminoimidazole-4-carboxamide riboside is presented and discussed in this study.