Biomedical subjects
Publications and source records attributed to R Stoppa.
Attempts are now progressing to improve laparoscopic hernia surgery, which need our interest and reflexion. Widely informed on these new techniques, though not directly dealing with them, the author proposes, here, his own remarks.
During many years the use of prosthesis for abdominal wall repair was not accepted by all surgeons. Now the laparoscopic repair has brought some surgeons to do it nearly systematically and industry proposes new materials. To allow comparing new materials the authors have developed an experimental proceeding of which they analyse technical difficulties and limits.
In the first part the authors report their experience in Hernia surgery from 1980 to 1989. The comparison between 4 personal series shows that local anesthesia favoured short hospital stay, that the length of hospital stay decreased from 95% of more than 7 days hospitalization to 49% of less than 2 days; local anesthesia has almost suppressed post-anesthetic functional, respiratory and urinary troubles; no patient operated under local died; lastly the recurrence rate has not been related to hospital stay duration. Comments follow on Ambulatory surgery in general, technical and deontological principles. Ambulatory and short stay hospitalization in Hernia Surgery, and on advantages and pitfalls of these type of Surgery. The authors conclude on the feasibility, acceptability, benefits and usefulness of to day ambulatory surgery in hernia repair in the frame of a Universitary Hospital Center.
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Anatomical reasons explain that the diagnosis of femoral hernia is sometimes difficult, that controversies still exist on their treatment and that their strangulation is often ignored. The authors propose some remarks on the anatomy of the femoral canal and the femoral hernias, the repair of the latter, and some of the problems related to strangulating. They conclude that research on the femoral canal and hernias anatomy should be valuable; similarly stimulation of surgeons for a better management of the diagnosis of strangulated femoral hernias and for systematically considering surgical repair of all femoral hernias whatever be the risk, should be beneficial. Lastly they underline that a prospective comparison between prosthetic and non prosthetic repairs of common femoral hernias could be organized easily because they are comparative lesions.
The authors report a new case of duodenal leiomyoblastoma. Since local anatomical factors were favorable, the tumor was removed by resecting the entire second portion of duodenum with reanastomosis of the remaining ends. This case can be added to the very small number of cases reported in the literature regarding leiomyoblastoma at this site in the gastrointestinal tract. Since diagnostic is difficult, and often made per-operatively following and acute complication, a precise topographical study of the region needs to be performed. It is only by this means that a completely safe operative procedure may be chosen and performed. From an anatomo-pathological viewpoint, several criteria exist to distinguish the potentially benign from the potentially malignant form. However, this remains to be confirmed given the controversial aspects of the subject. Study has mainly involved gastric localisations where a greater number of lesions have been found. At present, only time will show whether these tumors are benign or malignant.
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The authors report a rare case of ileo-caecal-appendicular endometriosis which presented as an acute peritonitis. In their commentary they review the notions concerning the most frequent acute manifestations in the intestinal localization and discuss the therapeutic management and prognosis of the condition.
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A double anomaly of extrahepatic biliary pathways was detected in the same patient. The first anomaly involved the cystic duct, which emptied into the third part of duodenum, the second anomaly the common bile duct which was implanted into the right side of the cystic duct one centimeter from the papilla. An anomaly of this type has not been reported previously in the literature and surgeons should be aware of its possible occurrence.
A case of double localization of a leiomyoma is reported and used as a basis for an update review of the relevant literature. Esophageal and gastric leiomyomas, of relatively simple diagnosis by radiologic and endoscopic imaging, require surgery in most cases: enucleation of esophageal and resection of gastric tumors. Leiomyoma of esophagus is usually diagnosed during investigation of atypical clinical symptomatology or when it is associated with another disorder, such as hiatus hernia as in the present case. Leiomyoma of stomach is usually revealed by a complication initially, frequently of the hemorrhagic type. Despite the absence of documented data on leiomyoma of double localization in two digestive organs simultaneously, this possibility does exist and extensive digestive investigations are necessary prior to therapy.
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Utilitarian aspects of hernia pathogenicity are envisaged to assist comprehension of surgical gestures, the choice of effective techniques and the abandon of those which are not and may be of medicolegal interest: all inguinal hernias are due to parietal weakness. Anatomical factors are studied based on data from dissection, from in front backwards and then from behind forwards, from which certain major notions are drawn: that of role of transverse fascia in imperviousness to intra-abdominal pressure; that of uniqueness of inguinal hernias, all of which cross the transverse fascia in the region of the regional osteomuscular framework; that of the necessary degradation of musculofascial plane for a hernia to develop, with as a corollary the need for inguinal imperviousness at the transverse fascia level to be restored. Factors may be present that increase the "natural weakness" of the groin: anatomical variations affecting inguinal triangle; biological disorders affecting inguinal structures (aponeurotic and fascial senescence, collagen diseases, musculo-tendino-aponeurotic dystrophy). A breakdown in mechanisms of protection against increased intra-abdominal pressure promoted a summary of features defining intra-abdominal pressure under physiologic conditions and classical herniogenic circumstances. A summary of pathogenic mechanisms of inguinal hernia is presented while emphasizing the two principal theories: the saccular theory and that of musculo-fascial weakness, with their consequences for choice of therapies to be opposed to the polymorphism of hernial lesions.
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