Faculty Bibliography

Groin pain following inguinal hernia repair remains a challenge to most general surgeons. Prevention of groin pain may be the most effective solution to this management problem and necessitates careful anatomic dissection and precise knowledge of surgical anatomy of the groin as well as potential pitfalls of surgical intervention. When complications arise, a period of watchful waiting is warranted, but surgical intervention with triple neurectomy offers the most definitive resolution of symptoms. This article aims to provide a thorough review of pertinent anatomic landmarks for the proper identification of the nerves that, if injured, result in chronic groin pain and to provide a treatment algorithm for patients suffering with this morbidity.

A 54-year-old man presented with rectal pain and bleeding secondary to ulcerated, necrotic rectal and cecal masses that resembled colorectal carcinoma upon colonoscopy. These masses were later determined to be benign amebomas caused by invasive Entamoeba histolytica, which regressed completely with medical therapy. In Western countries, the occurrence of invasive protozoan infection with formation of amebomas is very rare and can mistakenly masquerade as a neoplasm. Not surprisingly, there have been very few cases reported of this clinical entity within the United States. Moreover, we report a patient that had an extremely rare occurrence of two synchronous lesions, one involving the rectum and the other situated in the cecum. We review the current literature on the pathogenesis of invasive E. histolytica infection and ameboma formation, as well as management of this rare disease entity at a western medical center.

BACKGROUND: Since the authors' report on the lateral approach to laparoscopic colon resection (LCR), medial-to-lateral (M-L) segmental resection has continued to evolve. This report analyzes their learning curve experience with a standardized three-trocar M-L technique, which demonstrates the influence of operative volume on proficiency and outcome. METHODS: From January 1999 to December 2004, 100 consecutive patients underwent a standardized three-trocar M-L segmental LCR. Patient demographics, indications for surgery, operative proficiency (time), and outcome (i.e., blood loss, conversion to open surgery, length of hospital stay, morbidity, and mortality) were recorded. A learning curve analysis was performed using a t-test and analysis of variance (ANOVA). RESULTS: The 100 M-L LCRs included sigmoid (55%), right (34%), left (6%), and transverse (5%) approaches. Overall learning curve proficiency was influenced by increasing operative experience (p = 0.02). However, significant and consistent improvement in the learning curve occurred only after 38 LCRs (p < 0.008). Notably, all conversions to open surgery (3%) occurred during the early learning curve. Similarly, early LCR patients experienced greater morbidity (mean, 21% vs 12%) and mortality (mean, 5% vs 2%) than their later counterparts. CONCLUSION: To obtain optimum proficiency in performing LCR, a minimum of 38 M-L procedures is required. Operative and patient outcomes improve beyond the early learning curve.

Inguinal hernia repair is a common surgical procedure, but the most effective surgical technique remains controversial. The evolution of laparoscopic techniques has allowed reproduction of open preperitoneal repair via an endoscopic total extraperitoneal (TEP) approach. More recently, the advent of comprehensive training in laparoscopy has allowed TEP to continue evolving as the feasibility of this approach gains recognition as a preferable technique. Once considered very difficult to learn, TEP currently is adequately taught in many surgical training programs. This report reviews the fundamentals and details various modifications that make this procedure more desirable than open procedures and other laparoscopic techniques. A resultant decrease in operative time, cost of the procedure, and morbidity to the patient is routine. In addition, the authors review their institutional experience and examine other current evidence-based data.

BACKGROUND: One of today's most highly regarded procedures for treating inguinal hernia is the totally extraperitoneal approach (TEP), but it can on occasion lead to recurrence. This is commonly managed with an open repair, a transabdominal preperitoneal procedure (TAPP), or another TEP. We report here on our years of experience with the latter. METHODS: The endeavor to a secondary TEP is much the same as to a primary one, but certain differences are encountered as the operation proceeds. For example, many anatomical landmarks found in a first TEP cannot be seen in a second. There can also be a diminished amount of working space, and this occasionally leads to an open conversion. RESULTS: From September 1991 to September 2005, we repaired 1,526 hernias in 1,156 male patients, using the TEP in every case. Of these, 21 were TEPs after a previous TEP. In 3 cases, the space could not be opened, and they were converted to the open Lichtenstein. One patient had peritoneal tears that led to conversion and another had conversion because of excessive bleeding. There were no complications, no bladder or bowel injuries, no transfusions, no preperitoneal hematomas, and no fatalities. All patients were discharged the same day. CONCLUSIONS: A secondary TEP, open repair, and TAPP are alternative solutions to the problem of recurrence after TEP. However, any TEP involves a very prolonged learning curve for general surgeons, since they must learn the anatomy as well as the procedure, both at the same time. This is doubly true for the TEP after a previous TEP.

HYPOTHESIS: Outcome following laparoscopic adjustable gastric banding (LAGB) in super morbidly obese patients is significantly worse compared with the standard laparoscopic Roux-en-Y gastric bypass (LRYGB). DESIGN: Prospective case series. SETTING: Community teaching hospital (490 beds). PATIENTS: A prospectively maintained database identified patients who underwent operative treatment for morbid obesity between February 2001 and June 2004. The study group included super morbidly obese patients (body mass index >50 [calculated as weight in kilograms divided by the square of height in meters]) following LAGB and LRYGB. INTERVENTIONS: Among 106 patients with super morbid obesity, 60 (57%) and 46 (43%) underwent LAGB and LRYGB, respectively. MAIN OUTCOME MEASURES: Patient demographics, weight loss, percentage of excess weight loss, change in body mass index, early (<30 days) and late (> or =30 days) complications, reoperations, medical comorbidity, and patient satisfaction were studied. Analysis was performed using the t test and Pearson chi 2 analysis. RESULTS: Overall median follow-up was 16.2 months (range, 1-40 months). Preoperative factors of patient age, sex, weight, body mass index, and medical comorbidity were similar between the 2 groups. Compared with LRYGB, patients who underwent LAGB experienced a greater incidence of late complications (P < .05), reoperations (P < .04), less weight loss (P<.001), and decreased overall satisfaction (P < .006). Likewise, patients who underwent LRYGB had a greater resolution of concomitant diabetes mellitus (P < .05) and sleep apnea (P<.01) compared with the LAGB group. Furthermore, postoperative adjustments to achieve consistent weight loss for LAGB recipients ranged from 1 to 15 manipulations. Our single mortality was in the LAGB group. CONCLUSIONS: In super morbidly obese patients, LAGB is significantly associated with more late complications, reoperations, less weight loss, less reduction of medical comorbidity, and patient dissatisfaction compared with LRYGB. Further evaluation of LAGB in this patient population appears warranted.

BACKGROUND: The incidence of mesh infection during open hernia repair has been reported to be as high as 3%. With the introduction of laparoscopy, the rate of infection is still a matter of debate. METHODS: All 1182 laparoscopic inguinal hernia repairs performed at our institution from September 1991 to June 2002 were retrospectively reviewed to identify both mesh and wound infections. RESULTS: There were two mesh infections (0.17%) during that period, and one wound infection. CONCLUSION: The incidence of mesh infection in laparoscopic repair is considerably lower than in the open procedure. The two main reasons for this are the introduction of mesh through trocars to avoid skin contact, and the mesh is placed far from the trocar incisions, again avoiding contamination. The rate of wound infection is not related to that of mesh infection, and depends mainly on aseptic prepping techniques prior to surgery.