M. Korenkov

Unacceptable results of the Mayo procedure for repair of abdominal incisional hernias

OBJECTIVE To evaluate the current practice of incisional hernia repair in Germany and analysis of the results of the Mayo duplication technique done in our hospital over a 10-year period. DESIGN Nationwide survey, retrospective analysis. SETTING University department, Germany. SUBJECTS Survey of most surgical departments and of 114 patients with 135 incisional hernias in our unit. INTERVENTION Mayo duplication repair incisional hernias. MAIN OUTCOME MEASURES Common practice, recurrence rates, quality of life. RESULTS The Mayo overlap is the preferred technique in most surgical departments. The estimated failure rates (12% or less) in general practice are grossly underestimated. In our hospital the recurrence rate after Mayo duplication repair was 61/114 (54%) during a follow up time of 5.7 years with a follow-up-rate of 84%. Univariate and multivariate analyses failed to identify any predisposing factors. All patients with incisional hernias had limitations their physical function. CONCLUSIONS The widely used Mayo procedure leads to unacceptable results for repair of incisional hernias and other techniques should be evaluated and used more often. Repair of an incisional hernia does not improve overall quality of life.

Color Duplex Sonography: Diagnostic Tool in the Differentiation of Inguinal Hernias

We investigated the accuracy of combined physical and color duplex sonographic examination in the preoperative distinction of direct inguinal hernias. After a learning period (with 15 male patients) 50 consecutive male patients who underwent surgery in our department for small inguinal hernias between July 1995 and April 1996 were examined. On color duplex examination the relationship between the hernial sac and the inferior epigastric artery was determined. Intraoperative results were then compared with the data obtained preoperatively. The sensitivity of our physical examination for direct inguinal hernia was 75% with a specificity and a positive predictive value of 100% and a negative predictive value of 80%. The identification of the IEA as well as the hernial sac was successful on every color duplex sonographic study. The sensitivity of color duplex sonography for direct inguinal hernias amounted to 90%, the specificity was 86%, the positive predictive value was 78%, and the negative predictive value was 89%. Both combined hernias found intraoperatively had not been detected either by physical examination or by color duplex examination. Correspondence of results obtained by physical examination and color duplex examination leads to high accuracy in the diagnosis of direct inguinal hernias.

Biomechanical and morphological types of the linea alba and its possible role in the pathogenesis of midline incisional hernia.

OBJECTIVE To review the tensile strength of the different histological types of fibres in the linea alba and correlate the anatomical features of the anterior abdominal wall with the tensile strength of the linea alba to see whether the tensile strength of the linea alba might contribute to the development of midline incisional hernias. DESIGN Laboratory study. SETTING University hospital, Germany. SUBJECTS 46 cadavers in part one, and 9 freshly frozen and 38 formalin-fixed cadavers in part two. INTERVENTIONS In the first part of the study the histological examination was by binocular dissection microscopy, magnification x10, but this was not sufficiently reproducible so in the second part we used an Olympus BX50 microscope, magnification x20, and Optimas 5.22 picture processing software. Tensile strength was measured using a Loosenhausen ZHP 1-6 tensiometer. MAIN OUTCOME MEASURES Correlation between anatomical features and tensile strength. RESULTS The method used in part one of the study failed to differentiate between the three types of fibres in the linea alba (weak, intermediate, and compact). In the second part of the study we found that the fibres were irregular, with no systematic crossing of the fibres of the aponeurosis. There was a significant correlation between the thickness and density of fibres in the linea alba and its tensile strength (r = 0.9). The thickness of fibres ranged from 21.9-38.2 microm and the density from 48% to 90%. The tensile strength ranged from 3-25 kp. CONCLUSION A combination of low density and thin fibres in the linea alba could be a predisposing factor for development of midline incisional hernias

Besonderheiten der implantatassoziierten Infektion in der orthopädischen Chirurgie

ZusammenfassungDer zunehmende Einsatz von Implantatmaterialien führt zu einem Anstieg des Infektionsrisikos in der modernen Orthopädie. Ist ein Implantatmaterial erst einmal infiziert werden, muss—da die Pathophysiologie dieser speziellen Art von Infektion zu einer relativen Unempfindlichkeit konventioneller Antibiotikatherapien führt—in der Regel das Material explantiert werden. Die Folgen sowohl für den Patienten als auch für unser Gesundheitssystem sind gravierend.Mindestens ein Drittel der Infektionen lässt sich durch striktes hygienisches Arbeiten verhindern. Aufgrund auch geringster Inokulationsmengen als Basis für eine Materialkolonisation und -infektion muss von einem großen Anteil „physiologischer Infektionen“ ausgegangen werden. Deshalb ist die Entwicklung infektionsresistenter Implantatmaterialien eine medizinische Notwendigkeit. Moderne Konzepte solcher Materialien beinhalten antimikrobielle „Drug-delivery-Systeme“, welche in der Lage sind, unphysiologisch hohe Konzentrationen antimikrobieller Substanzen in die Mirkoumgebung des Implantats abzugeben, um damit die phänotypische Resistenz adhärenter Mikroorganismen zu überlisten.AbstractOne of the most important risk factors in orthopedic surgery is implant-associated infection. Adhesion and colonization mediated implant infections are extremely resistant to antibiotics and host defences and frequently persist until the biomaterial or foreign body is removed, which is standard therapy. Tissue damage caused by surgery and foreign body implantation increases the susceptibility to infections, activates host defences and stimulates the generation of inflammatory mediators including radicals that are further aggravated by bacterial activity and toxins.Nearly one third of implant-related infections can be prevented by strictly following established infection control guidelines. However, a significant number of implant-associated infections remains. The escape of bacteria from host defence and antibiotic therapy makes the development of infection-resistant materials as antimicrobial drug delivery systems feasible. This concept consists of the sustained delivery of antimicrobial drugs into the local microenvironment of implants avoiding systemic side effects exceeding usual systemic concentrations by magnitudes of order.

Port function after laparoscopic adjustable gastric banding for morbid obesity

Background: Laparoscopic adjustable gastric banding (LGB) has gained wide popularity, but information on port function is limited. Methods: In a prospective nonrandomized study, we analyzed port function and related symptoms in 50 consecutive patients with severe obesity. All patients underwent LGP in a five trocar technique. In 11 patients, the port was placed subcutaneously in the subxiphoid region. In 39 patients, the port was implanted in the left upper abdomen. Mean duration of follow-up was 2.8 years. Results: Patients (12 males and 38 females) had an initial body mass index (BMI) of 47.1 kg/m2. Puncturing the subxiphoidal port was without problems in all 11 patients. However, seven women reported pain and inconvenience when wearing a brassiere. Two underwent port reimplantation in the left upper abdomen (one due to infection; one due to pain). Among the 39 patients with abdominal port implantation, nine patients required port correction (two of them twice). The causes were port dislocation (four cases), difficult puncturing (three), tube leakage (three), and infection (one).Conclusion: The high number of complications suggests that the port is the Achilles’ heel of LGB. Ports at the subxiphoid site were easier to puncture, but frequently caused pain in female patients.

Laparoscopic Gastric Bypass for Morbid Obesity with Linear Gastroenterostomy

Background: Laparoscopic gastric bypass (LGBP) is a well-established procedure for the surgical management of morbid obesity. Most surgeons create the gastroenteral anastomosis by using the circular EEA stapler. We describe an alternative laparoscopic anastomotic technique using the EndoGIA linear stapling device. Methods: The stomach was proximally transected with a linear stapler (45 mm, Endo-GIA) to create a 15 to 20 ml pouch. Next, an antecolic Roux-en-Y gastroenterostomy was performed, using the 45 mm Endo-GIA. The proximal loop of the intestine was then separated from the anastomotic site by the Endo-GIA. Finally, the Endo-GIA was used for the intraabdominal creation of a side-to-side enteroenterostomy. Results: Between June and August 2001, 5 patients with mean BMI 56.7 kg/m2±7.3 underwent LGBP. All patients were seen 6 months post-surgery. Operating time was 7.5 and 6.5 hours for the first 2 operations, but was under 4.5 h for the next 3 cases. 1 patient suffered from perioperative hypoxia leading to long-term artificial respiration. 6 weeks after surgery, 1 patient developed obstruction due to torsion of the enteroenterostomy and required open revision. The 3 remaining patients made an uneventful recovery. All patients lost considerable weight (mean 36.5 kg; [range 32 to 45] after 6 months). No stenosis or anastomotic leakage was noted. Conclusions: A linear stapled anastomosis is an alternative to the use of the circular stapler.

Combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy

Abstract. A case of combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy is reported. The paresis possibly occurred by a lesion of the N. intercostalis when extending the incision for stone extraction. Possibly the paresis was a predisposing factor for the development of an incisional hernia. The causes of abdominal wall paresis are explored with a review of the literature. In spite of minimal trauma to the anterior abdominal wall in laparoscopic procedures, the risk of iatrogenic lesions remains.

Individualized surgery in the time of evidence-based medicine.

To the Editor: D ifferent reasons (anatomical, instrumental, strategic, etc) can cause difficult surgical situations. Until today, there is no definition of that, but every practical surgeon knows very well what it means and how important it is. We define the difficult surgical situation as every intraoperative surgical problem, which increases the likelihood of intraoperative and postoperative complications. We propose to classify patients according to intraoperative difficulty (I to IV) as (I) ideal cases (ie, easy to operate, no problems), (II) not quite ideal cases (some minor difficulties may occur), (III) problematic cases (difficult to operate, some operative techniques are considerably more difficult than others), and (IV) horrible cases (every operative step is difficult). This classification can be used for pre-, intra-, and postoperative assessment of patients. The frequency and distribution of difficult surgical situations is yet largely unknown, as both uniform definitions and systematic evaluations are so far lacking. It generally is surprising that there is a ubiquitous risk classification of anaesthesiology risk (The American Society of Anesthesiologists’ physical status classification), but no equivalent exists in surgery, although the risk of the procedure has an even higher importance for postoperative outcomes. In a difficult surgical situation, the surgeon gets into dilemma whether to continue the intended operation “at all costs” or to deviate from the initially planned surgical procedure to some alternative technique or procedure.1,2 Choosing the first option can increase the risk of intraand postoperative complications. The consequence of the second alternative might be a lower risk of shortterm complications but at the expense of worse results in the long-term. In surgical oncology, for example, earlier recurrences due to R1 resection status or unsatisfactory functional results represent typical problems. The dilemmatic nature of the difficult surgical situation has motivated us to discuss the following aspects, because they all contribute to the problem: standards in surgery, the deviation from standards, the role of experts, and the focus of research. We also propose a possible classification of difficult surgical situations and the establishment of a reg-

Analyse des Publikationsspektrums der vier deutschsprachigen medizinischen Fachzeitschriften „Der Chirurg“, „Der Unfallchirurg“, „Langenbecks Archiv für Chirurgie“ und „Medizinische Klinik“

Summary. All 1994 publications of four leading journals in surgery, orthopedics and internal medicine in Germany (Der Chirurg, Der Unfallchirurg, Langenbecks Archiv für Chirurgie, Medizinische Klinik) were reviewed by means of a structured analysis. The type of article, authorship, number of references, geographical location, quality, and main conclusion (positive; neutral; negative) of each article were documented. The journals focused on clinical studies (32.2–59.6 %), case reports (11.0–26.1 %) and reviews (6.4–40.9 %). Articles about surgical techniques were mainly found in Der Chirurg (16.9 %), experimental studies in Der Unfallchirurg (14.7 %) and Langenbecks Archiv für Chirurgie (25.7 %). Most articles were written by university clinic personnel (62.6–81.4 %). In 11.0–22.6 % of all articles, the head of a clinic was the first author and the co-author in 36.5–58.7 %. Women were found to be first author in 4 % in surgery, and in 10.4 % in internal medicine. Of a total of 495 publications, 53.9 % were written in Northrhine-Westphalia, Bavaria or Baden-Württemberg and only 1.6 % in the five new federal states. Of all articles 16.4 % were by foreign authors, with 10.5 % originating from German-speaking countries. The portion of controlled randomized trials ranged between 4.9 % (Der Unfallchirurg) and 11.3 % (Der Chirurg) of all published studies. Studies and case reports with negative results were found to be more evident in Der Chirurg and Langenbecks Archiv für Chirurgie (ca. 20 %) as compared to Der Unfallchirurg and Medizinische Klinik (ca. 6 %). All journals provided good general information about the actual developments in a variety of topics to the reader. However, some improvement concerning international contributions, participation of the new federal states, and the quality of studies is recommended.Zusammenfassung. In einer strukturierten Analyse wurde das Publikationsspektrum des Jahrgangs 1994 der Fachzeitschriften „Der Chirurg“, „Der Unfallchirurg“, „Langenbecks Archiv für Chirurgie“ und „Medizinische Klinik“ untersucht. Erfaßt wurden Typ und Herkunft der Artikel, Autorenschaften, Anzahl von Zitaten, sowie mit einfachen Kriterien Qualität und Aussage von Studien. Den Schwerpunkt aller 4 Zeitschriften bildeten klinische Studien (32,2–59,6 %), Kasuistiken (11,0–26,1 %) und Übersichten (6,4–40,9 %). Operationstechniken fanden sich vorwiegend im „Chirurg“ (16,9 %), experimentelle Studien praktisch nur im „Unfallchirurg“ (14,7 %) und in „Langenbecks Archiv für Chirurgie“ (25,7 %). Die meisten Artikel stammten aus Universitätskliniken (62,6–81,4 %). Klinikchefs waren in hohem Maße als Erstautoren (11,0–22,6 %) und Co-Autoren (36,5–58,7 %) vertreten. Frauen traten im chirurgischen Bereich nur zu 4 %, im internistischen dagegen zu 10,4 % als Erstautoren in Erscheinung. 53,9 % der insgesamt 495 erfaßten Arbeiten stammten aus Nordrhein-Westfalen, Bayern und Baden-Württemberg, aber nur 1,6 % aus den neuen Bundesländern. Der Anteil ausländischer Beiträge lag bei 16,4 %, allerdings stammten 10,5 % aus dem deutschsprachigen Raum. Von den publizierten Studien waren nur zwischen 4,9 % („Unfallchirurg“) und 11,3 % („Chirurg“) randomisiert/kontrolliert durchgeführt. Studien und Kasuistiken mit negativem Ergebnis waren im „Chirurg“ und in „Langenbecks Archiv für Chirurgie“ zu ca. 20 %, im „Unfallchirurg“ und in der „Medizinischen Klinik“ nur zu ca. 6 % enthalten. Alle Zeitschriften informierten auf breiter Basis über den aktuellen Stand des Wissens, doch erscheinen Verbesserungen hinsichtlich der Internationalität der Beiträge, der Beteiligung der neuen Bundesländer und der Qualität der Studien empfehlenswert.

Stellenwert der stationären ösophagusdurchzugsmanometrie zur präoperativen Abklärung von Patienten mit gastro-ösophagealer Refluxkrankheit

Einleitung: Die stationare Osophagusdurchzugsmanometrie hat sich inzwischen als Standard in der Diagnostik von Osophagusfunktionsstorungen etabliert. Jedoch ist die Bedeutung der einzelnen Komponenten des Manometrieprotokolls fur die Wahl der OP-Methode bei gastroosophagealer Refluxkrankheit (GERD) nicht adaquat untersucht. Ziel dieser Studie war die Evaluierung des Einflusses der verschiedenen Parameter der Osophagusmanometrie auf die chirurgischen Strategie bei GERD. Patienten und Methoden: Von Januar 1995 bis Januar 2000 wurden 123 konsekutiv zugewiesene GERD-Patienten untersucht. 97 dieser Patienten (52 Frauen und 45 Manner, mittleres Alter 48 Jahre) wurden mit einer Fundoplikatio nach Nissen in konventioneller oder laparoskopischer Technik versorgt. Praoperativ wurden bei jedem Patienten eine stationare Osophagusdurchzugsmanometrie mit Wasserperfusionskatheter, sowie Gastroduodenoskopie und 24 h-osophagus-pH-Metrie standardmasig durchgefuhrt. Unabhangig von den Ergebnissen der Osophagusmanometrie erhielt jeder Patient eine 360°-Fundoplikatio mit 2 cm langer Manschette („floppy-Nissen“). Ergebnisse: Praoperativ wiesen 85 der 97 Patienten (88%) eine Inkompetenz des unteren osophagussphinkters auf. Bei 17 (18%) Patienten wurde eine Osophagushypomotilitat diagnostiziert. Bei 2 bzw. 1 nicht operierten Patienten wurde eine amotile Achalasie bzw. ein diffuser Osophagusspasmus festgestellt. Postoperativ wurden 92% der Patienten nachuntersucht (mittlere Nachuntersuchungszeit 1,8 Jahren). 5 bzw. 8 Patienten (1 bzw. 2 davon hypomotil) entwickelten postoperativ eine persistierende Dysphagie bzw. ein Rezidiv (Relatives Risiko 1,2 bzw. 1,6). Zwei Patienten (einer hypomotil) wurden reoperiert. Schlussfolgerungen: Die praoperative Osophagusmanometrie bei GERD kann auf die Bestimmung der oberen Grenze des unteren Osophagussphinkters, sowie den Ausschluss spezieller Osophagusmotilitatsstorungen eingeschrankt werden. Die „floppy-Nissen“ Fundoplikatio kann ohne zusatzliches Dysphagierisiko bei Patienten mit hypomotilem Osophagus angewandt werden.