Tension-free procedures in the treatment of groin hernias

Hernia repair is one of the most common surgical procedures performed in the United States, with 700,000 operations performed each year. Improvements in surgical technique, together with the development of new prosthetic materials and a better understanding of how to use them, have significantly improved outcomes for many patients. These improvements have occurred most notably in centers specializing in hernia surgery, with some institutions reporting failure rates of less than 1%. In contrast, failure rates for general surgeons, who perform most hernia repairs, remain significantly higher. This has important socioeconomic implications, adding an estimated $28 billion or more to the cost of treating the condition, based on calculations utilizing conservative estimates of failure rates and the average cost of a hernia repair. Success of groin hernia repair is measured primarily by the permanence of the operation, fewest complications, minimal costs, and earliest return to normal activities. This success depends largely on the surgeon's understanding of the anatomy and physiology of the surgical area as well as a knowledge of how to use most effectively the currently available techniques and materials. The most important advance in hernia surgery has been the development of tension-free repairs. In 1958, Usher described a hernia repair using Marlex mesh. The benefit of that repair he described as being "tension-eliminating", or what we now call "tension-free". Usher opened the posterior wall and sutured a swatch of Marlex mesh to the undersurface of the medial margin of the defect and to the shelving edge of the inguinal ligament. He created tails from the mesh that encircled the spermatic cord and secured them to the inguinal ligament. Every type of tension-free repair requires a mesh, whether it is done through an open anterior, open posterior, or laparoscopic route. The most common prosthetic open repairs done today are the Lichtenstein onlay patch repair the PerFix plug and patch repair, the Prolene Hernia System bilayer patch repair and Trabucco’s sutureless preshaped hernioraphy. General surgeons today have access to a wider and more sophisticated range of synthetic biomaterials for use in hernia repair than ever before. The advantages and disadvantages of each of these devices must be understood however, before surgeons select any of these implants. Meanwhile, a 1997 study of various biomaterials used in abdominal wall hernia repair further reported that the risk of infection, seroma formation biomaterial-related intestinal obstructions, and other complications can be minimized or eliminated by understanding the process underlying these problems and taking proper precautions. The surgeon's choice of the prosthesis used in hernia repair is based on a combination of factors, including patient characteristics; clinical experience, training, interest, and skill; understanding of the range of products available and the clinical studies that may have been performed on each; and the surgeon's familiarity with a particular product and/or surgical approach. Innovations in technique and product design will no doubt continue to spur advances in hernia repair, and it is hoped that they will continue to improve outcomes. The availability of these outcomes data, along with the ongoing accumulation of clinical experience with a broad range of materials and techniques, will help surgeons to better identify the most appropriate prosthesis for the clinician and the patient. It appears that herniology will remain in the realm of the surgeon, since it is doubtful that any medical measures will replace the operative treatment for abdominal wall hernias. Although operative procedures are not yet ideal important advances have been made in herniorrhaphy resulting in improved outcomes: The use of local techniques has maximized the safety of anesthesia time needed for care has been minimized, with most procedures now being done on an outpatient basis; and better instruments and prosthetic devices have dramatically improved patient outcomes. However, a greater appreciation for the vulnerability of the entire myopectineal orifice - and the secondary effects of localized mesh grafts - is necessary to avoid iatrogenically created recurrences. An increased awareness of these factors by both general surgeons and hernia specialists alike will improve results for all patients undergoing hernia surgery

Surgical treatment of gallbladder polypoid lesions

INTRODUCTION Polypoid lesions of the gallbladder can be divided into benign and malignant categories. Malignant polypoid lesions include carcinomas of the gallbladder, which is the fifth most common malignancy of the gastrointestinal tract and the most common malignancy of the biliary tract. Benign polypoid lesions of the gallbladder are divided into true tumors and pseudotumors. Pseudotumors account for most of polypoid lesions of the gallbladder, and include polyps, hyperplasia, and other miscellaneous lesions. Adenomas are the most common benign neoplasms of the gallbladder. Cholesterol polyps are the most common pseudotumors of the gallbladder. The polyps can be single or multiple, usually less than 10 mm in size. They have no predilection for any particular gallbladder site, and usually are attached to the gallbladder wall by a delicate, narrow pedicle. No malignant potential has been identified for this type of pseudotumor. Adenomas are the most common benign neoplasms of the gallbladder. They have no predilection site in the gallbladder, and may also be associated with gallstones or cholecystitis. The premalignant nature of adenomas remains controversial. Ultrasonography (US) has been demonstrated to be significantly better in detecting polypoid lesions of the gallbladder as compared with computed tomography and cholecystography. A mass fixed to the gallbladder wall of normal thickness, without shadowing, is seen in case of gallbladder polyp. Since gallbladder cancers usually present as polypoid lesions, differentiation between benign polypoid lesion and malignant lesion can be very difficult, even with high-resolution imaging techniques. PATIENTS AND METHODS Retrospectively we have analyzed 38 patients with ultrasonographicaly detected gallbladder polyps during the period from January 1995 to December 2000, who were treated at surgical department of Health Centre in Uzice and at Surgical clinic of Clinical Centre in Nis. We have analyzed patients demographical data as well as their symptoms and radiographic findings. If the patient was operated, patohistological findings were analyzed also. RESULTS In our study 38 examined patients had mean age of 53.2 years (standard deviation of 12.8 years; range 26-80 years). The male-female ratio was 1:1. Overall 36 patients had symptoms that could be related to gallbladder diseases. Among these patients, 32 had pain in the upper-right quadrant of the abdomen that could be defined as biliar colic, and two had symptoms of acute cholecystitis. Among remaining four patients, two were examined because of the pain in the lower part of the abdomen. One patient had high temperature of unknown origin and the gallbladder polyp was detected accidentally during the ultrasonographic examination of the abdomen. Second patient had jaundice of unknown origin with ultrasound showing no significant changes in biliary tract. Preoperative ultrasound findings were inconsistent. The size of the lesion was marked only in 18 out of 38 patients. Among 34 operated patients, just 11 of them had patohistologicaly verified polipoid lesion. Patohistological analyzes of extirpated gallbladders showed one normal gallbladder, seven cholesterol polyps, one polipoid cholecystitis, and two real gallbladder neoplasms. One patient had gallbladder adenoma while the other had adenocarcinoma. Malignancy rate was 2.94% (one in 34). All patients with neoplastic polyps had solitary lesion larger than 1 cm in diameter, while the patients with non-neoplastic lesions had multiple lesions smaller than 1 cm in diameter. All operated patients, with the exception of one, had pathologically verified abnormal gallbladders. This results showed the presence of chronic cholecystitis even in the absence of the polyps. DISCUSSION Generally, no treatment is required in young patients with very small gallbladder polyps who are completely free from any symptoms. A patient with dyspeptic symptoms but no painful episodes consistent with biliary colic should be managed conservatively. Cholecystectomy is also indicated in patients with large gallbladder polyps sized over 10 mm irrespective of symptomatology. In patients with gallbladder polypoid lesions smaller than 10 mm, cholecystectomy is indicated only if complicating factors are present, e.g., age over 50 years and coexistence of gallstones. If the gallbladder polyp is smaller than 10 mm and complicating factors are absent, the "watch-and-wait" strategy seems to be recommendable. CONCLUSION Although gallbladder polyps are rare, they represent a significant health problem because they may be a precursor to gallbladder cancer. On the basis of the available data, and the results that we have gained in our study we suggest that gallbladder should be extirpated in cases when: 1. symptomatic lesions are present regardless of size; 2. polyps larger than 10 mm are present because they represent a risk for gallbladder cancer; 3. polyps are showing rapid increase in size. Polyps less than 10 mm that are incidentally identified and not removed should be assessed by ultrasonography at least every six months. This is especially critical for sessile polyps, in which the possibility of a small cancerous polyp is greater than in pedunculated polyps. Also, asymptomatic lesions less than 10 mm in diameter should be removed if patient is older than 50 years or if he has concomitant gallbladder calculosis