Male inguinal hernia repair with mesh. Short- and long-term results and the question of infertility.

Background: In the nineties, the patients with inguinal hernias were exposed to several newly developed repair techniques using alloplastic mesh prosthesis. Although the scientific knowledge was limited, the new techniques were rapidly introduced due to surgical enthusiasm, but also by an eagerness to reduce the recurrence rate and to shorten the time to recovery. When the first study of this thesis was initiated there were almost no randomized controlled trials comparing the short- and long-term results of open tension free repair (Lichtenstein) and totally extraperitoneal laparoscopic repair (TEP). The recurrence rates have since then been markedly reduced and the focus has moved towards studying other side effects of inguinal hernia surgery. The use of mesh in inguinal hernia surgery has been proposed to increase the incidence of male infertility due to inflammatory obstruction of the structures of the spermatic cord. Aims: To compare the Lichtenstein and the TEP operation techniques regarding short- as well as long-term results. To assess the risk of male infertility following inguinal hernia mesh repair. Methods: The first two publications were based on a prospective randomized controlled study comparing the two repair techniques, with both short- and long-term follow-up. The next two publications were derived from the Swedish Hernia Register. One was a prospective study, comparing by questionnaire, involuntary childlessness after bilateral inguinal hernia repair with or without mesh. The other was a retrospective study comparing the expected and observed incidences of diagnosed male infertility after inguinal hernia repair with or without mesh. Results: TEP resulted in less consumption of analgesics, shorter sick leave, faster recovery, longer operation time, higher hospital costs and less impaired inguinal sensibility. In the long-term both methods had a high patient satisfaction rate, almost no impact on day-to-day life and a low frequency of persistent severe chronic pain. Bilateral inguinal hernia mesh repairs in men did not increase the incidence of involuntary childlessness. Inguinal hernia mesh repairs were not associated with a clinically important increase of diagnosed male infertility. Conclusions: TEP and Lichtenstein are comparable techniques which both have overall good short- and long-term results. Inguinal hernia mesh repair is a safe method regarding male infertility

Mesh hernia repair and male infertility: A retrospective register study.

BACKGROUND: Previous studies have suggested that the use of mesh in groin hernia repair may be associated with an increased risk for male infertility as a result of inflammatory obliteration of structures in the spermatic cord. In a recent study, we could not find an increased incidence of involuntary childlessness. The aim of this study was to evaluate this issue further. METHODS: Men born between 1950 and 1989, with a hernia repair registered in the Swedish Hernia Register between 1992 and 2007 were cross-linked with all men in the same age group with the diagnosis of male infertility according to the Swedish National Patient Register. The cumulative and expected incidences of infertility were analyzed. Separate multivariate logistic analyses, adjusted for age and years elapsed since the first repair, were performed for men with unilateral and bilateral repair, respectively. RESULTS: Overall, 34,267 men were identified with a history of at least 1 inguinal hernia repair. A total of 233 (0.7%) of these had been given the diagnosis of male infertility after their first operation. We did not find any differences between expected and observed cumulative incidences of infertility in men operated with hernia repair. Men with bilateral hernia repair had a slightly increased risk for infertility when mesh was used on either side. However, the cumulative incidence was less than 1%. CONCLUSION: Inguinal hernia repair with mesh is not associated with an increased incidence of, or clinically important risk for, male infertility

Gråsoner : en kvalitativ studie av grensedragning og korrupsjonsbeslektet praksis mellom entreprenørnæringen og Oslo kommune

Denne oppgaven handler om grenselandet og gråsoner mellom legale og moralske normer i forhold til korrupsjonsbeslektet praksis mellom entreprenørnæringen og Oslo kommune. I den senere tid har skandaler i forbindelse med smøring, relasjonsbygging og korrupsjon blitt mer aktuelt i den offentlige debatt. Ambisjonen i dette prosjektet har vært å undersøke hvordan aktørene forholder seg til normer for uetisk praksis, hvor og hvordan grenser trekkes og hvordan aktørene forstår korrupsjon og tilliggende praksis som fenomen i Norge. Oppgavens spørsmål besvares på grunnlag av empiri fra kvalitative intervjuer av tre grupper: Entreprenører, kommunepolitikere og kommunalt ansatte. I tillegg til dette har jeg gjennomført observasjon av møter der aktørene selv diskuterer disse tingene. Oppgaven sverger ikke til én spesiell teoretisk ”skyttergrav” eller tradisjon. Goffman og symbolsk interaksjonisme er likevel det som viste seg mest fruktbart. Særlig Goffmans dramaturgiske metaforer har blitt benyttet hyppig. Videre er bytteteorien til Peter Blau av betydning. Slike teorier kan benyttes til å analysere empirien, men ikke til å lokalisere fenomenet korrupsjon. Andre teorietikere, som Andersson og Kjellberg, har omtalt fenomenet korrupsjon som analytisk problem. Ved hjelp av deres modeller kan man lokalisere korrupsjonen analytisk. Ved hjelp av disse har jeg skissert fem sentrale kjennetegn ved ethvert korrupsjonsforhold. Når en omtaler en gråsone er ikke alle fem nødvendigvis til stede. Disse er relasjon, transaksjon, normbrudd, utilbørlighet og tilslørthet. De to første er i seg selv ikke et tegn på noe korrupt. Det er imidlertid ulike typer av relasjoner og transaksjoner, og disse kan innebære normbrudd, utilbørlighet og, i sin, tur forsøkt tilslørt. Oppgavens første analysekapittel tar for seg hvordan aktørene forholder seg til normer som gjelder for uetisk og korrupsjonsbeslektet praksis. Til tross for et klart legalt rammeverk er kjennskapen til lovverket begrenset og varierende. Det er store rom for skjønnsmessige vurderinger. Mange har derfor konstruert egne normer i form av etiske retningslinjer. Disse viser seg å være konstruert av hensyn til publikum og omdømme og fungerer i mange tilfeller som moralsk glasur og er ikke alltid implementert i organisasjonen. Det andre analysekapitlet tar for seg grensedragningen. Jeg har sett på hvor og hvordan aktørene setter sine personlige grenser for hva som er greit og ikke greit i forhold til påvirkning og relasjonsbygging. Det er snakk om vurderinger av utilbørlighet i relasjons- og transaksjonstypene. Relasjonene må ikke ha for vennskapelig karakter, samtidig som det å kjenne noen personlig er å foretrekke. Ytelsen må være liten nok til å ikke være mistenkelig, men stor nok til at man påvirker. Her var det en meget stor variasjon. Som vi kan lese hos Peter Blau er ikke ytelsens materielle verdi av stor betydning for at det skapes en forventning om gjenytelser. Ytelsene ansees forskjellig og beskrives med forskjellige ordvalg. Gaver kan sees på som en høflighetsgest, og turer og middager kan betraktes som legitim relasjonsbygging. Informantene hadde ulike syn på hvor grensen gikk, men alkohol synes å være en symbolsk grense for de fleste – det appellerer til noe sosialt og uprofesjonelt når det gis som gave, men er ok når det serveres i forbindelse med en tilstelning. Informantenes begrunnelse henspiller på to hensyn, en indre og en ytre moral. En ytre moral henspiller på hvordan ting ser ut fra utsiden – redsel for mistenkeliggjøring. Goffman er sentral: Dersom publikum misforstår en situasjon kan denne misforståelsen likevel bli reell i form av sine konsekvenser. Aktører som motiveres av en indre moral argumenterer mer idealistisk og er mer opptatt av sin personlige integritet. Den indre moralen beror på moralske normer og den ytre på sosiale. Der hvor det er konflikt prøver aktørene å følge den ytre moralen, slik at de unngår å få noen ”riper i lakken”. Det tredje og siste analysekapitlet omhandler aktørenes forståelse av korrupsjon og hva de anser som nærliggende fenomener. Folk er, mer enn tidligere, innebefattet med at korrupsjon nok tar andre former i Norge enn under fjerne himmelstrøk og at den kanskje derfor har blitt ignorert i offentligheten. Informantene kommer med historier og erfaringer som de anser som relevante. De mener at kameratskap har mer å si enn en materiell gave fordi det skaper generelt gode relasjoner. Enkelte er så redde for å bli påvirket gjennom slike relasjoner at de forsøker å avstå fra det. Det er tvilsomme praksiser og omgangsformer, men de er mer raffinerte enn man gjerne tenker seg. Mange av informantene har selv blitt tilbudt ytelser de anser utilbørlige. Funnene viser at på tross av klare rammer er dette vanskelig og uklart for aktørene. Samtidig som ingenting er lov må man selv vurdere hva man kan ta imot eller gjøre. Det er stor grad av egenjustis og moralsk forvirring. Flere hevder at det beror på ”egen ryggrad”. Selv om funnene er flertydige, mener jeg at denne oppgaven bidrar med ny og nyttig kunnskap om fenomenet ”korrupsjon på norsk”

Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: long-term follow-up of a randomized controlled trial.

BACKGROUND: We have conducted a randomized controlled trial of totally extraperitoneal hernia repair (TEP) versus tension-free open repair (Lichtenstein repair); we have presented the results previously up to 1 year after the operation. The aim of this study was to compare patient outcome in both groups at a median follow-up of 7.3 years after operation. METHODS: Of 168 patients included in a prospective, randomized controlled trial designed to compare TEP with an open tension-free technique, 154 patients (92%) answered a questionnaire and 147 patients (88%) were followed up at an outpatient clinic after a minimum of 6 years after operation. RESULTS: Overall, 89% of patients in the TEP group and 95% of patients in the open group reported complete long-term recovery (P = .23). Permanent impaired inguinal sensibility was more common in the open group (P = .004), whereas the proportion of patients with reported testicular pain was higher in the TEP group (P = .003). Three recurrences were found in the TEP group, and 4 recurrences were found in the open group (P = .99). Four patients in the TEP group underwent operations for complications related to the hernia repair (small bowel obstruction, umbilical hernia, testicular pain, and neuralgia). CONCLUSION: Overall, both groups showed good long-term results with low rates of recurrences. However, the TEP group was associated with a higher proportion of patients with long-term testicular pain, whereas impaired inguinal sensibility was more common in the open group

Male infertility after mesh hernia repair: A prospective study.

BACKGROUND: Several animal studies have raised concern about the risk for obstructive azoospermia owing to vasal fibrosis caused by the use of alloplastic mesh prosthesis in inguinal hernia repair. The aim of this study was to determine the prevalence of male infertility after bilateral mesh repair. METHODS: In a prospective study, a questionnaire inquiring about involuntary childlessness, investigation for infertility and number of children was sent by mail to a group of 376 men aged 18-55 years, who had undergone bilateral mesh repair, identified in the Swedish Hernia Register (SHR). Questionnaires were also sent to 2 control groups, 1 consisting of 186 men from the SHR who had undergone bilateral repair without mesh, and 1 consisting of 383 men identified in the general population. The control group from the SHR was matched 2:1 for age and years elapsed since operation. The control group from the general population was matched 1:1 for age and marital status. RESULTS: The overall response rate was 525 of 945 (56%). Method of approach (anterior or posterior), type of mesh, and testicular status at the time of the repair had no significant impact on the answers to the questions. Nor did subgroup analysis of the men </=40 years old reveal any significant differences. CONCLUSION: The results of this prospective study in men do not support the hypothesis that bilateral inguinal hernia repair with alloplastic mesh prosthesis causes male infertility at a significantly greater rate than those operated without mesh

Elective splenectomy in the elderly - perioperative and long-term course

Background: The hazards of elective splenectomy in the elderly have not been thoroughly investigated. The aim was to assess such a well-defined cohort with respect to perioperative and long-term outcome. Methods: Fifty-two consecutively splenectomised patients during the period 1971-1995, aged 65 years or older, were followed until death (44 cases) or the end of 1999 (8 cases). Results: No intraoperative deaths occurred, while three patients (5.8%) died postoperatively in the 1970s. Twenty-four patients suffered from thirty-four postoperative complications, dominated by infections and haematomas. No differences were seen comparing patients with and without complications related to the American Society of Anesthesiologists' classes, total transfusion rate, steroid medication, preoperative risk diseases, "giant spleens" or the time period during which the operations were performed. In 69% of the patients, the splenectomy was beneficial. During the long-term followup, 25 patients suffered from 59 infectious and thromboembolic episodes and 1 surgical complication. The dominating causes of death were the primary disease (29%), myocardial infarction (20%), sepsis (12%) and cerebrovascular lesions (12%), i.e. not directly related to late effects of the operation. Conclusion: Highrisk patients older than 65 years with haematological disorders can safely undergo splenectomy with a low mortality rate and a reasonable rate of morbidity. The long-term course demonstrates a fair response rate, minimal surgically related complications, but thromboembolic and infectious events, and the majority of deaths unrelated to late effects of the splenectomy

Selected contribution: role of spleen emptying in prolonging apneas in humans

This study addressed the interaction between short-term adaptation to apneas with face immersion and erythrocyte release from the spleen. Twenty healthy volunteers, including ten splenectomized subjects, participated. After prone rest, they performed five maximal-duration apneas with face immersion in 10 degrees C water, with 2-min intervals. Cardiorespiratory parameters and venous blood samples were collected. In subjects with spleens, hematocrit and hemoglobin concentration increased by 6.4% and 3.3%, respectively, over the serial apneas and returned to baseline 10 min after the series. A delay of the physiological breaking point of apnea, by 30.5% (17 s), was seen only in this group. These parameters did not change in the splenectomized group. Plasma protein concentration, preapneic alveolar PCO2, inspired lung volume, and diving bradycardia remained unchanged throughout the series in both groups. Serial apneas thus triggered the hematological changes that have been previously observed after long apneic diving shifts; they were rapidly reversed and did not occur in splenectomized subjects. This suggests that splenic contraction occurs in humans as a part of the diving response and may prolong repeated apneas