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Query: UMLS:C0019270 (hernia)
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A patient with morbid obesity and insulin-dependent diabetes was admitted to the surgical intensive care unit, four days status postsurgical repair of an umbilical hernia. A pulmonary embolus (PE) was diagnosed by ventilation/perfusion scan and confirmed by transthoracic echocardiogram. A right ventricular ejection fraction/volumetric/oximetry pulmonary artery catheter revealed a very low ejection fraction and cardiac index. Systemic urokinase therapy was initiated and the patient improved considerably over the ensuing 12 hours. Anesthesiologists must be able to diagnose the signs and symptoms of PE and should be familiar with treatment modalities to reverse right ventricular dysfunction. Review of the literature regarding thrombolytic therapy in the perioperative period indicates potential benefit in select patients.
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PMID:Thrombolytic therapy for treatment of pulmonary embolism in the postoperative period: case report and review of the literature. 898 98

The aim of this study was to compare prospectively the incidence of incisional hernia in two groups of patients operated on for morbid obesity, with or without intraperitoneal polyglactin mesh. From October 1990 to September 1993, a total of 288 patients were randomly assigned to the two groups. There were 144 patients in the mesh group and 144 in the no-mesh group. Altogether 240 patients (83%) were reviewed personally, 45 (16%) were interviewed by phone (n = 39) or mail (n = 6), and 3 (1%) were inaccessible for follow-up since discharge from the hospital. The mean follow-up period was 29.8 months (range 0-67 months). A total of 33 incisional hernias were observed in the mesh group and 41 in the no-mesh group. There was no significant difference in the distribution of herniation time between the two groups (p = 0.43). The two main predictive factors of herniation were age and weight. In conclusion, the use of an intraperitoneal polyglactin mesh does not prevent postoperative incisional hernias in obese patients.
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PMID:Long-term results of polyglactin mesh for the prevention of incisional hernias in obese patients. 956 92

Morbid obesity is a serious disease that is responsible for several comorbid conditions. Body mass indices > 40 require surgical procedures if diet programs fail. Laparoscopic adjustable gastric banding (LAGB), a more recently introduced gastric restrictive procedure, was designed to be a minimally invasive and reversible operation. 184 patients (164 women, 20 men) with a mean body mass index of 47.8 kg/m2 (range 36-79) were operated on. All patients had been excessively overweight for > 5 years. Each patient was given general anesthesia, and an adjustable LAP-BAND was implanted laparoscopically. The pouch size was 15 ml in all cases; and 3-4 sutures were placed to prevent dislocation. The conversion rate was 0%. The median operating time was 65 min (range 45-190). The mortality was 0%. The mean hospital stay was 5 days (range 4-6). The mean excess weight loss was 16% in 4 weeks, 23% in 3 months, 31% in 6 months, 58% in 1 year, and 87% in 2 years. The patient satisfaction index was 97.6%. Once a surgeon has acquired the necessary laparoscopic surgical experience, LAGB is a feasible, safe, and simple procedure with excellent postoperative results. LAGB does not permanently modify the anatomy of the stomach and maintains the natural continuity of the alimentary tract, while at the same time ensuring a steady weight reduction in morbidly obese patients. The fact that the gastric band can be applied laparoscopically is a significant advantage in this group of high-risk patients, who have less pain, faster postoperative recovery, more rapid return to normal activities, fewer wound infections, fewer hernia problems, and better cosmetic results. The rate of postoperative complications is approximately 9%. In 1.1% of patients, erosion occurred, and in 2.2%, slippage of the band. The rate of port-related complications was 3.2%. Reoperations were necessary in 6.4% of the patients.
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PMID:Laparoscopic gastric banding for morbid obesity. 1019 89

There were 140 patients with morbid obesity operated on for postoperative abdominal hernia. In 2 (1.4%) patients an acute cardiopulmonary insufficiency occurred, and in another 2 (1.4%) an acute thrombophlebitis of the lower extremities veins. Two patients died. The hernia recurrence have occurred in 3 (2.1%) patients operated according to Mayo method in terms from 1 to 5 years later.
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PMID:[Surgical treatment of postop large size abdominal hernia in patients with obesity]. 1037 Mar 14

BACKGROUND: gastric banding (GB) has been used for treatment of morbid obesity. METHODS: a banding device, introduced by Broadbent and consisting of a self-blocking nylon strip covered with a silicone tube, was used in 13 patients who have completed 1-year follow-up. This device was used for its mechanical properties, biocompatibility, ease of insertion and low cost. RESULTS: at 1 year, mean excess weight loss was 51.6%, with all but one patient losing more than 25% of excess weight. Associated illnesses resolved. There were two complications (15%): one patient required band removal for self-induced vomiting and one patient required repair of an incisional hernia. CONCLUSIONS: GB has had good results thus far. Reported differences depend on materials, stoma diameter, pouch size, and developing techniques.
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PMID:Gastric Banding for Treatment of Morbid Obesity: Preliminary Results. 1073 95

BACKGROUND: gastric banding has been performed for morbid obesity, with the last nine patients having a laparoscopic approach. MATERIALS: forty-five patients who had undergone primary operations for morbid obesity between 1986 and 1993 were selected for retrospective analysis. All patients had undergone gastric banding. Average pre-operative BMI was 50.9 (kg m(2)) and average pre-operative weight was 135.1 kg. RESULTS: the 3 year mean post-operative BMI reached 28.7 and the 3 year mean post-operative weight loss was 55.7 kg. Blood pressure significantly decreased from the mean 151/ 96 mmHg to l32/90 mmHg at 1-year follow-up. There were no significant changes noted in the levels of RBC, electrolytes and transaminase. There were post-operative wound-healing complications in 18.1% of the patients, wound discharge in 8.8% and incisional hernia in 8.8% of the patients. In 1993 we commenced laparoscopic gastric banding which enabled us to shorten the hospital stay and decrease post-operative complications. CONCLUSION: we are achieving the same good weight-loss results with the laparoscopic technique as after 'open' laparotomy gastric banding.
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PMID:New Approach in Surgical Treatment of Morbid Obesity: Laparoscopic Gastric Banding. 1073 98

Preoperative pneumoperitoneum is used to re-establish the right of domain for abdominal viscera before repair of otherwise inoperable giant abdominal hernias. The aim of this study was to evaluate the use and safety of preoperative pneumoperitoneum in the repair of giant hernias in relation to surgical treatment of obesity. The medical records of patients who underwent preoperative pneumoperitoneum in the treatment of giant hernias between 1953-1993 were reviewed. There were 27 patients (11 males, 16 females; mean age: 56 years) whose mean preoperative weight was 99 kg (range: 69-183). Hernias were predominantly in the midline (17). Other locations were right lower quadrant (5), right upper quadrant (3) and groin (2). The mean duration of preoperative pneumoperitoneum was 28 days (3-100). Subcutaneous emphysema developed in three patients with no sequelae. Primary repair of the giant hernia without Marlex mesh was possible in 19 patients (70%). Marlex mesh was used in seven (26%). One patient had a fascia late graft. Operative complications were one pulmonary embolus and one hematoma. There were no deaths. We conclude that preoperative pneumoperitoneum is a useful adjunct to giant hernia repair. Severe obesity should be corrected before preoperative pneumoperitoneum and hernia repair. Some patients may need mesh to replace insufficient abdominal wall or to reinforce repair.
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PMID:The Use of Pneumoperitoneum in the Repair of Giant Hernias. 1074 95

VBG and vertical Silastic ring gastroplasty are simple gastric restriction procedures that have defined technical standards. Two recent improvements in the operation have been the development of the six-row endolinear cutting-stapling instrument that divides the vertical partition without an increase in GI leakage and the application of minimally invasive laparoscopic techniques that have reduced the incidence of incisional hernia to less than 1%. VBG and vertical Silastic ring gastroplasty are procedures that can effectively help select patients to manage their morbid obesity. However, these procedures are critically dependent on patient compliance. It is not possible to know preoperatively whether a candidate will make the lifelong behavior modifications necessary for sustained weight loss. Experience has demonstrated that bariatric surgeons have limited control over a patient's level of motivation for compliance.
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PMID:Vertical banded gastroplasty. 1158 47

There is mounting concern that internal hernia formation after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity remains unrecognized until complications develop. In this report we present our experience with this complication. Out of 100 patients who underwent LRYGB we identified five patients who were diagnosed with postoperative internal hernia formation. The medical records and operative details of these patients were reviewed. Of the five patients four were female and the average age was 36 years (range 30-43). All Roux limbs were placed in a retrocolic position. The average time interval to presentation was 104 days (range 4-305). All patients had abdominal pain and four patients experienced vomiting. One patient had obstipation. Only one patient had fever (38.1 degrees C) and the highest white cell count was 14,500. The average loss in body-mass index was 5.21 kg/m2 (range 2.5-14.8). Plain abdominal films revealed dilated bowel in the upper abdomen in three patients. Contrast bowel series was diagnostic in only one patient. One patient had a CT scan, which was diagnostic of small bowel obstruction. All patients underwent operative reduction of the internal hernia; two of these were completed laparoscopically. All hernias had occurred at the mesocolic window and were caused by sutures that had pulled through tissue at the dorsal and lateral aspect of the initial repair. One patient had a nonviable segment of small bowel. There were no deaths. Patients who undergo LRYGB are at a 5 per cent risk for developing small bowel obstruction secondary to internal hernia formation at the mesocolic window. Clinical evaluation and traditional study modalities may not be effective diagnostic tools. A high index of suspicion and low threshold to explore these patients may be the best way to avoid serious sequelae. Modification of operative techniques may reduce the occurrence of internal hernia formation.
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PMID:Internal hernia formation after laparoscopic Roux-en-Y gastric bypass for morbid obesity. 1213 50

Experience of stimultant operations performance in 113 patients with morbid obesity, coexistant with postoperative abdominal wall hernia (POAWH), was summarized. In the planned order 108 patients were operated on and for urgent indications--5. The approach was proposed for the choice of method and volume of operative intervention. The substantiated performance of stimultant operations for POAWH in patients with morbid obesity and other diseases of abdominal cavity organs constitutes the perspective trend in surgery, secures high medical-social and economic efficacy.
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PMID:[Surgical strategies in the treatment of postoperative abdominal wall hernia complicated by other abdominal diseases in patients with morbid obesity]. 1214 55


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