Bilateral Herniorrhaphy Research Articles

Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanism: a study in postoperative patients

Patients with unilateral ( n=14) and bilateral ( n=4) herniorrhaphy participated in this study. With bilateral herniorrhaphy, at the end of the surgery, the wound was infiltrated with a solution of bupivacaine 0.5% and ketamine 0.3% on one side and a solution of bupivacaine 0.5% only, on the other. With unilateral herniorrhaphy, the patients were randomly assigned to one of two groups ( n=7). One group at the end of the surgery received the infiltration with a solution of bupivacaine 0.5% and ketamine 0.3%, the other group received the infiltration with a solution of bupivacaine 0.5% only. The duration of the local anesthetic (response to a von Frey filament) and postoperative analgesic (time to mild spontaneous pain) effects of the infiltrations, as well as wound pain threshold 24 h after surgery (pressure algometry), were determined. In patient with unilateral herniorrhaphy, the addition of ketamine for wound infiltration enhanced the duration of infiltration anesthesia (206±76 versus 343±108 min, P<0.02) and analgesia (240±45 versus 420±151 min, P<0.03). Similar enhancement of the local anesthetic effect was observed in patients with bilateral herniorrhaphy. The increase in pain threshold to pressure on the wound with the addition of ketamine was evident in bilateral herniorrhaphy patients and also with a combination of bilateral and unilateral results (1.39±0.40 versus 2.35±0.92 kg, P<0.02). In the group of five volunteers, the subcutaneous infiltration with 0.3% ketamine produced a local anesthetic effect lasting only 10–20 min. The results indicate that ketamine acting via a peripheral mechanism can profoundly enhance anesthetic and analgesic actions of a local anesthetic administered for infiltration anesthesia.

Clips or sutures for herniorrhaphy wounds?

This study compares the pain experienced by fifty patients following bilateral herniorrhaphy using two different methods of wound closure. No significant difference was found between the use of Michel clips and interrupted monofilament nylon sutures. Clips were preferred by a significant majority of patients, probably because they cause less pain on removal. The use of Michel clips should not be limited by the belief that they cause more pain than conventional sutures.

Embryonal remnants in inguinal hernia sacs

Inguinal herniorrhaphy is the most common general surgical procedure performed on the neonate or young pediatric patient. The vas deferens and epididymis are vulnerable to damage, including transection during inguinal exploration or hernia repair. Occasionally the surgical pathologist encounters glandular or tubular epithelial-lined structures in hernia sac tissue. Significant medicolegal implications arise when embryonal remnants are mistakenly identified as true vas deferens or epididymis. This study evaluates the incidence and morphology of these embryonal remnants in hernia sacs from patients of The Children's Hospital, Denver, CO. Embryonal remnants were found in 1.5% of 599 hernia sacs from 427 consecutively operated males aged 37 weeks gestation to 19 years. True vas deferens and epididymis were each identified once for an incidence of 0.33%. The remnants resemble either vas deferens or epididymis. The average remnant diameter is 0.17 mm, and did not change significantly with age. Remnants are surrounded by varying amounts of condensed mesenchyme, trichrome-negative for muscle. The testes and vasa differentia from 32 autopsy cases, ranging in age from 26 weeks gestation to 7 years of age, were used to evaluate normal development and morphology of the vas deferens, epididymis and embryonal remnants. The vas deferens is well developed by 26 weeks gestation. The surrounding smooth-muscle coat does not stain with trichrome until 32 weeks gestation. The vas deferens increases in diameter in a linear fashion during gestation, and continues to increase in diameter in the postnatal period. The vas deferens at 4 months of age is 1.2 to 1.4 mm in diameter; this is also the age of highest incidence of bilateral herniorrhaphies and presence of remnants.

Preperitoneal herniorrhaphy: a historical review.

From ancient times, both the transabdominal (posterior) and the groin (anterior) approach have been used either singly or in combination in the management of inguinofemoral herniation. Development accelerated in the nineteenth century after Lister introduced antisepsis. Although Bassini and Halsted conducted their classic procedures in the preperitoneal plane, it was Cheatle, in 1920, who first performed transabdominal preperitoneal herniorrhaphy. In 1950, McEvedy described the lateral approach, which was made popular by Nyhus and Condon in the 1960's. The problem of relaxing incisions and the importance of prosthetic repair through this exposure are substantiated along with the anatomy of the preperitoneal fatty layer and the results of sutureless bilateral herniorrhaphy.

Unilateral inguinal hernias in children: What about the opposite side?

The decision for or against bilateral exploration in unilateral hernias in infants is necessitated by the high incidence of obscure anatomic hernias on the opposite side. On the basis of studies done in 400 pediatric patients (mostly under 2 years of age), we believe that unilateral repair of a known hernia without ascertaining the presence of a contralateral hernia is unjustified. Because of an appreciable risk to the gonads and/or vas deferens, we do not believe routine bilateral herniorrhaphies in all infants are indicated. The attempts at an intraoperative, transperitoneal insertion of a Bakes dilator into a contralateral sac were unreliable in our hands. Herniography is a reliable, safe way to reduce the incidence of unnecessary contralateral exploration. It should be liberally used where the necessary radiologic expertise is available.

Sickness absence after inguinal herniorrhaphy.

Eight hundred and ninety-nine men were studied, aged 16-65 inclusive, who underwent an elective inguinal herniorrhaphy during 1970 and 1971 in eight hospitals in Wessex, and under nine consultant surgeons. There was a significant variation in postoperative inpatient stay and total sickness absence between hospitals and between consultants. The physical activity involved in the patient's occupation, his age at operation, previous sickness absence, bilateral herniorrhaphy, attendance at follow-up outpatients' clinic, type of repair, and the influence exerted by three hospitals and two consultants accounted for only 21% of the variation in total sickness absence. The general practitioners who had referred patients to the hospitals for herniorrhaphy, and the consultant surgeons who carried out the operations, were sent a questionnaire to ascertain their attitudes towards follow-up outpatient appointments and the various factors identified in the first part of the study as significantly influencing total sickness absence. A higher proportion of GPs who felt that an outpatient appointment was necessary before return to work was found in relation to the patients who had the longest mean total sickness absences than among the GPs who looked after the patients with shorter total sickness absences.

Infertility as a Consequence of Bilateral Herniorrhaphies

The involvement of internal genitalia in inguinal hernias occurring in female infants and children has been reported. We present here an interesting infertility problem as a consequence of accidental "tubal ligation* secondary to bilateral inguinal herniorrhaphies during childhood. Several postulated etiologic factors in the development of such hernias are presented, and the potential occurrence of similar problems in other individuals is emphasized. We urge very meticulous technique when such hernias are repaired, and we reiterate the importance of a thorough medical history during infertility investigation. The potential frequency of this uncommon but devastating problem presenting in an infertility investigation may be underestimated. Additionally, it is conceivable that, with the increasing survival rates of prematurely born infants who are at increased risk for such hernias, this problem may become more frequent.

Hemophiliac with Hemolytic Anemia Resulting from Factor VIII Concentrate

Bilateral herniorrhaphy was successfully performed on a group AB hemophiliac with cirrhosis of the liver. Adequate hemostasis was maintained with infusions of commercial factor VIII concentrates and fresh frozen plasma. An anti-A antibody mediated hemolytic reaction occurred in the postoperative period. Hemolysis subsided after the cessation of commercial factor VIII infusions. The risk of such hemolytic reactions could be eliminated through the use of group-specific cryoprecipitated factor VIII.

Trial of Oxyphenbutazone for Postoperative Edema After Bilateral Herniorrhaphy

A double-blind controlled trial was carried out to test the value of oxyphenbutazone (Tandearil; Geigy Pharmaceuticals) in preventing the troublesome edema of external genitalia that may occasionally develop after bilateral inguinal herniorrhaphy. Oxyphenbutazone, 200 mg., or a placebo identical in appearance, was given orally to each of 133 patients the day before their first operation and 300 mg. was administered on each subsequent day until discharge. The second operation was performed 48 hours after the first, and each patient was discharged 72 hours thereafter, at which time his edema was assessed. Strictly double-blind conditions governed distribution of tablets and assessment of edema. Sixty-eight patients received oxyphenbutazone and 65 the placebo. The degrees of edema observed in both groups were approximately the same. It is possible that mechanical factors associated with herniorrhaphy may help to produce edema, in addition to the ordinary tissue response to injury. No toxic reactions to oxyphenbutazone were observed.

Inguinal hernia in infants and children

There is no unanimity of opinion concerning advisability of routine bilateral herniorrhaphy. The ultimate answer awaits critical review of complete follow-up studies on large numbers of patients who initially undergo unilateral hernial repair. At present the majority of such studies [4,9,10] and the one reported herein indicate that the incidence of hernia on the unoperated side is low, and consequently suggests that exploration of a clinically normal inguinal canal is unnecessary and, possibly, unwarranted. Ladd [12] and Donovan [11] concur in this opinion. The suggestions of Potts [13] constitute a most rational approach to the problem, although our results and those of Kiesewetter [4] suggest that the side initially affected has little bearing on the eventual appearance of a second hernia.

Bilateral inguinal herniorrhaphies on infants and children.

Indirect inguinal hernias and hydroceles of the cord or tunica vaginalis together comprise the most common pediatric surgical problems in infancy and childhood. It has been well shown by many surgeons active in the pediatric field, that the morbidity and occasional mortality of an incarcerated hernia can be prevented by a simple, elective herniorrhaphy, done as soon as the diagnosis of inguinal hernia is established. 2,5 Yet, the high frequency of an unsuspected contralateral hernia has proved to be embarrassing to the surgeon, distressing to the child, and costly to the parents. Kiesewetter 6 found that 34% of the children who had unilateral herniorrhaphies returned to the hospital for a similar procedure on the opposite side. There has been a slow but definite trend toward bilateral herniorrhaphies in infants and children. 1,6-8,10 Most authors report an unsuspected hernia or patent processus vaginalis (potential hernia) in over half of the patients

Vasomotor Reactions Persisting for Twenty Years in a Male Treatment with Androgens

Rhythmic vasomotor reactions, analogous to those which occur in the menopause, are quite rare in the male. In the case to be reported here,1 flushes associated with profuse perspiration first began following testicular atrophy that supervened on a bilateral herniorrhaphy. The disturbances occurred approximately every half-hour and the syndrome persisted for twenty years. Under adequate androgen therapy2 the flushes and sweating disappeared; they recurred whenever the dosage was reduced below the maintenance level. S.H., a 52-year-old unmarried white male, a former resident of Austria, bookkeeper by trade, was first seen on Aug. 18, 1940. He complained of flushes and perspiration which occurred about every half-hour and were so severe that they interfered with his work and embarrassed him socially. Twenty-five years previously he had received roentgen therapy under the chin and to the pubic region for a dermatitis that had resisted other therapy.