P. Mendes da Costa

A retrospective study of 74 laparoscopic repairs of abdominal incisional hernias

Abstract Introduction: A laparoscopic procedure is used more and more frequently to treat incisional hernia with the potential benefits of shorter hospitalisation and a decrease in postoperative pain. The purpose of this retrospective study was to analyse the results of the laparoscopic treatment of incisional hernia at our institution and to identify potential risk factors for recurrence. Methods: The medical data (pre-operative, peri-operative, and postoperative) of patients who received a laparoscopic repair of their incisional hernia between January 2003 and February 2007 were recorded. The follow-up was based on a retrospective analysis of the information found in the patients’ medical records. Results: Seventy-four laparoscopic interventions were performed on 71 patients. Polyester implants with an average size of 412.16 cm2 were used to cover the hernia. The mean operative time was 76.8 ± 55.6 min (range, 20 to 295 min) and the mean duration of post-operative hospitalisation was 3.75 ± 2.3 days (range, 2 to 12 days). One breach in the small intestine (1.4%) (sutured with 3/0 silk thread) and 1 conversion to laparotomy (1.4%) for a voluminous incisional hernia occurred during surgery. The post-operative morbidity was 8.2%, the rate of long-term complications was 27%, and 13 recurrences (including 3 with complications) were noted (17.6%) during a mean follow-up of 13 months. There was no postoperative mortality. Recurrences were linked to the use of large meshes corresponding to large incisional hernia diameter (p < 0. 05). Conclusion: Although the morbidity/mortality rates are acceptable, technical improvements must be found to reduce the recurrence rate, in particular for large incisional hernias.

Restoration of Digestive Continuity after Hartmann's Procedure: ASA Score is a Predictive Factor for Risk of Postoperative Complications

Abstract Background/aims: Re-establishment of colonic continuity (RDC) following Hartmann’s procedure is associated with high morbidity (anastomotic leak 4–16%) and mortality (0–4%) rates. The aim of this retrospective study was to evaluate the morbidity of RDC following Hartmann’s procedure, and analyse the various factors that may influence the rate of complications. Methodology: From 1996 to 2008, 158 patients were treated by Hartmann’s colectomy. Hartmann’s procedure is generally indicated in cases with infection in the abdominal cavity, combined with a distended or non-prepared intestine, or both. Of the 158 patients, 111 (70.3%) underwent a re-establishment of colonic continuity. The mean patient age was 63.4 years (26–91 years) ; the female/male ratio was 1:64. Results: The mean delay between the Hartmann’s procedure and the RDC was 169.7 days (21–1095 days) and the mean duration of the hospital stay was 16.7 days (8–57 days). The mortality rate was 0.9% and incidence of anastomotic stricture was 3.6%. The morbidity was 38.7%. The majority of patients presenting complications had an ASA score > II, and most of the patients without complications were classified as ASA < II. Conclusions: The RDC is an intervention performed safely after a 3 to 5-month delay with acceptable morbidity and negligible mortality. The ASA score is a determining factor for the risk of complications (p < 0.05).

Surgical management of acute perforation of peptic ulcers. A single centre experience.

Abstract Introduction : Acute perforation may occur in gastric and duodenal ulcers. During the past decade, the need for elective operation for peptic ulceration has decreased as medical treatment has improved. However, emergency operations for acute complications such as perforation or bleeding remain constant. Actually, the treatment of choice is simple suture-closure, with or without omentoplasty, and peritoneal lavage or even omentoplasty alone, associated with a high intravenous dose of inhibitors of the proton pump and Helicobacter pylori eradication, if needed. Patients and method : The standard treatment in our team is to perform a peritoneal lavage and drainage and a simple closure of the ulcer with an omentoplasty. A first retrospective analysis was made on data collected from 1996 to 2001 and we completed a prospective study from 2001 to 2003 to compare our results with our old data and with data collected from other teams. Results : The mean age and the mean ASA score were similar in the two groups. For the majority of the patients, the diagnosis was made from symptoms and the presence of free abdominal air. The delay between arrival in the emergency room and the operating room was significantly shorter in the second group, but operating time was longer in this group. Morbidity was more frequent in the first group but mortality remained quite similar. Our results indicate that in a trained team the morbidity has decreased as the delay in surgery decreased and that the rate of diagnosis on plain abdominal film has increased. Laparoscopic suture of a perforated peptic ulcer is as safe as the open procedure but allows the surgeon to search for another cause of free air and offers the possibility, if conversion is needed, to perform a shorter laparotomy.

Is There Still a Role for Autopsy in Abdominal Surgery in 2008

Introduction: Although autopsy has been shown to play an important role in certain surgical disciplines as cardiac surgery, few studies have been performed in digestive surgery. The purpose of the study is to determine if autopsy still has a role to play in abdominal surgery in 2008. Type of study: Retrospective study for the period 01.01.1996 to 31.12.2005. Methods: 8,586 patients underwent abdominal surgery during this period. The average age was 55.2 years and male/female sex ratio was 1.1. Surgery was elective in 82% and emergency in 18% of cases. The surgical approach was laparoscopic in 65% and open surgery in 35% of cases. In-hospital morbidity, reintervention and mortality rates were 9.5%, 0.9% and 2.4% respectively. Results: Among the 210 patients who died, thirty-three with generalized cancer or an extensive mesenteric infarct did not have an indication for autopsy ; 74 of the remaining 177 patients, (42%) had an autopsy. The most frequent causes of death were respiratory complications, sepsis and cardiac complications. In 8% of cases, a surgical complication may have caused death. In 44.5% of cases, the results of autopsy showed either a missed major diagnosis that would have changed the patients prognosis (Goldman class I: 18.9%), or a missed major diagnosis that would not have changed the patients prognosis (Goldman class II: 25.6%). Conclusion: Despite technological progress, autopsy still has an important role to play in the assessment and improvement of the quality of surgical practice.Abstract Introduction: Although autopsy has been shown to play an important role in certain surgical disciplines as cardiac surgery, few studies have been performed in digestive surgery. The purpose of the study is to determine if autopsy still has a role to play in abdominal surgery in 2008. Type of study: Retrospective study for the period 01.01.1996 to 31.12.2005. Methods: 8,586 patients underwent abdominal surgery during this period. The average age was 55.2 years and male/female sex ratio was 1.1. Surgery was elective in 82% and emergency in 18% of cases. The surgical approach was laparoscopic in 65% and open surgery in 35% of cases. In-hospital morbidity, reintervention and mortality rates were 9.5%, 0.9% and 2.4% respectively. Results: Among the 210 patients who died, thirty-three with generalized cancer or an extensive mesenteric infarct did not have an indication for autopsy; 74 of the remaining 177 patients, (42%) had an autopsy. The most frequent causes of death were respiratory complications, sepsis and cardiac complications. In 8% of cases, a surgical complication may have caused death. In 44.5% of cases, the results of autopsy showed either a missed major diagnosis that would have changed the patient’s prognosis (Goldman class I: 18.9%), or a missed major diagnosis that would not have changed the patient’s prognosis (Goldman class II: 25.6%). Conclusion: Despite technological progress, autopsy still has an important role to play in the assessment and improvement of the quality of surgical practice.

Long-term results of a non-ramdomized prospective mono-centre study of 1000 laparoscopic totally extraperitoneal hernia repairs

Abstract Background: Information concerning short-term results for laparoscopic extraperitoneal hernia repair is available, but long-term results remain poorly documented. The purpose of this non-randomized prospective study was to evaluate recurrence and chronic pain after hernia repair over a period longer than 10 years. Materials and methods: From 1995 to 2004, all patients aged 30 years or more, manifesting with inguinal hernia, were included in our study. Patients aged 20 to 30 years presenting with bilateral hernia, recurrent hernia, or who were heavy workers were also included. Patients who had pelvic irradiation, strangulated hernia, prostatic cancer resection, or a contra-indication to general anaesthesia were excluded. Of 1096 hernia repairs performed, 248 patients were excluded and underwent open repair and 848 patients (77.4%) were included in our prospective study, which corresponded to 1000 laparoscopic hernia repairs. Results: The sex ratio (male: female) was 5:8, and the average age was 56 years. Seven hundred and fifty-three hernias (75.3%) were first repairs, 247 (24.7%) were recurrent hernias, and 161 were bilateral hernias. There were no mortalities. The conversion rate was 1.1%, and the global postoperative morbidity rate was 10.3%. Average follow-up was 39 months in 92.2% of the patients. Hernia recurrence rate was 1.5%. Chronic pain occurred in 2.9%. During this follow-up, 22 contra-lateral hernias appeared in those patients who initially had unilateral hernia repair (3.2%). All of these contra-lateral hernias could be successfully treated using a laparoscopic total extraperitoneal approach. Conclusions: The long-term results of this study demonstrate that preperitoneal laparoscopic hernia repair is a safe technique with a very low recurrence rate and low prevalence of chronic pain.

Surgical management of recurrent colon haemorrhage of unknown origin

Abstract Although both endoscopy and angiography have profoundly changed the management of lower GI bleeding, the choice, timing and sequence of these procedures as well as the indications for surgery remain a matter of debate. In cases of massive bleeding, early angiography should be performed as the first choice examination. When this fails, exploratory laparotomy, including peroperative colonoscopy after colonic wash-out, should not be discarded as a diagnostic possibility. If no source of bleeding is identified notwithstanding colonoscopic evaluation in excellent conditions, and it can be assumed that the bleeding has ceased, a conservative attitude may reasonably be advocated.

Abdominal surgery during pregnancy: A retrospective study of 23 patients

Abstract Objective : The aim of this study was to demonstrate that during pregnancy a large variety of non-gynaecological abdominal pathologies can be safely managed with surgery. Methods : The medical records of twenty-three patients that were pregnant and underwent open or laparoscopic surgery from 1997 to 2007 were reviewed. Results : Twenty-one of the 23 patients have given birth and all but one of the babies were healthy with normal weights, sizes, and APGAR scores. One patient had spontaneous termination of pregnancy one week after the surgical procedure and one patient is out of follow-up. Preterm partus was induced in three patients due to life-threatening conditions for the mother. Each laparoscopy was performed safely without peri-operative complications. Conclusion : Open or laparoscopic abdominal surgery poses little or no additional risk for mother or child.

Localized renal cell carcinoma of an unusually large size: Case report

Abstract Renal cell carcinoma has a variable clinical course. Size is a prognostic factor correlated with venous invasion, lymph node or distant metastases.These are more often encountered when the size exceeds 10 cm. For 20 years, incidental renal tumours have represented the majority of diagnosed cases, as a result of more common use of imaging techniques. We report a case of renal cell carcinoma of an unusually large size, without metastatic or locally advanced disease. Histology revealed a pT2 clear cell renal cell carcinoma of 31 x 31 x 10 cm, which was totally resected. It is the first case reported of localized conventional renal cell carcinoma reaching such a size.

And Now, Can we Operate Colon Cancers Laparoscopically ?

The first publication concerning laparoscopy-assisted colectomy was made by JACOBS et al. (1) in 1991. From 1991 to 1993 we have observed the devel opment of laparoscopy-assisted colectomies for cancer throughout the world. Between 1991 and 2004, numerous publications appeared concerning subcutaneous and wound metastasis after laparoscopic-assisted colectomy (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) and it appeared necessary to initiate prospective randomised studies comparing open versus laparoscopic-assisted colectomy for cancer. The four main questions to answer were :

Evolution during half a century of the results of digestive surgery in geriatric patients. A review of the literature, experience at C.H.U. brugmann and the medium term outlook

Abstract The undertaking of complex and major surgical procedures on frail elderly patients with multiple disorders has always been and still remains a controversial and enigmatic issue. At the same time, in an increasingly ageing society, the need for such procedures will extend and patients will expect a more favourable outcome. Surgery in old age will, therefore, pose an ongoing challenge. With better anaesthetic management, surgical techniques and comprehensive geriatric assessment, the overall results for all surgery have improved remarkably over the last few decades. Stringent pre-operative assessment and rigorous post-operative care have achieved a significant reduction in mortality and morbidity; surgery has become a lot safer.