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Like Hernia Surgery, itself, its complications must be regularly reviewed for permanent teaching. The necessity of this information is linked to the daily frequency of hernia cures. Complications are rather infrequent in classical repairs, where difficulties and pitfalls have been listed since a long time. Nevertheless their list is large and deserves to be recalled. Coelioscopic hernia surgery, recently appeared, revealed some complications which were unknown in classical surgery; its evaluation, to day in progress, should take account of these.

Among postoperative incisional hernias, mid-epigastric eventrations have peculiar features for physiopathological reasons that are summed up in general and specifically in the first paragraph of this paper; they are characterized by the quick retraction of the lateral belt, with the chondrocostal margin of the thorax participating as the upper limit of the cleft, and by the rapidly irreducible diastasis--hence the importance of an early decision to operate. The authors propose three regular procedures with which they are experienced: repair with a large retromuscular nonabsorbable synthetic tulle prosthesis for extensive epigastric eventrations, fillup aponeuroplasty using the sheath of the rectus abdominis associated with a premuscular patch in case of diastasis or of multiple superimposed orifices and suture associated with a small retromuscular auxiliary patch to treat small incisional hernias. The article, mainly dealing with the technical details of the three procedures and of their variants, is concluded by a brief report of the personal results obtained with a series of 616 postoperative eventrations, including 91 mid-epigastric ones, controlled after an average time lapse of 5.5 years.

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.

The 247 eventrations operated upon concerned 230 patients (60% women and 40% men) mean age 54.5 years. Eventrations were large (collar greater than 10 cm) in 18, 5% and were in the median line in 81%. Serial laparotomies by the same approach had been performed in 21%, the principal causes of eventration being biliary and gynecologic surgery. Parietal sepsis developed in 31,5% of cases after operation for the original affection. Classical favoring factors found included obesity (51%), multiparity (42% of women) and chronic lung disease (14%). Preoperative preparation involved the use of Goni Moreno's progressive pneumoperitoneum in 18,5% of patients. Procedures used were parietal repair by raphe (22%), the same but with the addition of a dacron prosthesis (6%) or the large dacron tulle prosthesis for wide reinforcement of the visceral sac (67% of cases). Early sepsis was a slightly more frequent occurrence after dacron tulle, predisposing factors being the prosthesis itself, a previous history of parietal sepsis, swabs and the number of Redon tubes. After use of dacron tulle complications were mainly also hematoma (3.2%) and skin necrosis (2,6%). Postoperative course in general was uncomplicated in 91% of the 247 operations. Follow up of 67% of operated patients for a mean of 5 1/2 years showed recurrence in 50% of raphe procedures and 18.5% of prosthesis implantations; factors of aseptic recurrence (16,5%) were multiparity and chronic lung disease. Delayed sepsis after dacron tulle use affected 8% of patients and were related to chronicity of early sepsis, nonresorbable sutures and sepsis complicating the primary laparotomy. Doming of the parietal wall was noted in 4% of cases repaired by prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective multicenter study involving 12 digestive surgery centers was conducted on 497 cases of colon obstruction. The most frequent cause of colon obstruction was colo-rectal cancer (71 p. cent of cases), but many other etiologies were involved, including 61 cases of torsion and 37 patients with occlusive sigmoiditis. Differential clinical and radiological features in each etiological group are discussed, the results of therapy undertaken analyzed, and a reasonable line of conduct proposed, adapted to each situation, with the objective of attempting to reduce mortality which still affects 25 p. cent of cases operated upon.

This analysis of 24 cases of primary carcinoma of the gall bladder is compared with series in the literature. The extremely poor prognosis of this carcinoma, recognised by all authors, may be explained by the unfavourable background, delay in diagnosis at all stages, early regional spread, difficulty in laying down the therapeutic indications. A Pathological classification for prognosis has been proposed for the surgeon with stages: O, I, II, II a and b, IV a and b, in relation to the spread of the gall bladder carcinoma and reflexions inspired by analysis of the operative results in the literature. Even with better knowledge of predisposing factors, and if new methods of treatment gave greater hope in the future, more frequent use of cholecystectomy seems the best prevention of bladder carcinoma in any case of cholelithiasis whether symptomatic or not, in the absence of any contra-indication.

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.

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.

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.

Perduodenoscopic retrograde cholangiography in a 15 year old boy with cystic dilatation of common bile duct demonstrated lithiasis of Vater's ampulla and collateral shunt for Wirsung's duct in the form of a functional Santorini duct. Cases of combined cystic dilatation of common bile and Vater's ducts reported in the literature are reviewed and a study conducted of frequency of cystic dilatation of common bile duct, its classification as described by Longmire and Hadat (enlarging that proposed by Alonso-Leij), and its diagnosis and complications. Routine retrograde cholangiography can delect lithiasis of Vater's ampulla and allow preoperative determination of therapy. Current investigatory procedures for these anomalies have allowed rediscussion of the etiopathogenicity of cystic dilatation of common bile duct and a tendency towards a duoalist hypothesis, without its definite confirmation at the present time.

The cases of patients with anaerobic organisms were collected for a period of one year from the results of bacteriological examinations sent to the Bacteriology Laboratory and from the file of operation reports of all the gastrointestinal surgery performed at the University Surgical Clinic of Amiens. The authors wanted to determine whether the anaerobic bacteria were really responsible for the infections observed, whether they acted alone or in association, what antibiotics should be used specifically against them, and what was the incidence of the initial infection in the discovery of the anaerobic organisms. It was found that the rate of infectious complications was higher in men than in pre-menopausal women and higher in emergency operations than in routine scheduled operations. Overall, it seems that the anaerobic bacteria, considered individually, do not have an important pathogenic action. They are widespread saprophytes which are present before the post-operative immune depression. It is their extraordinary development under certain local conditions and their association with other organisms which explain their pathological emergencies.

The subparietal cleavable spaces in the abdomen were studied with the view to their practical application in general surgical practice. These studies formed part of an applid anatomy research project on the repair of anterolateral gaps in the abdominal wall, using large prostheses, inserted without direct fixation, as a means of reinforcement of the visceral sac. The spaces were meeasured at different levels in 20 adult cadavers, and the values obtained were used to prepare representations on a plane surface. These morphological and metric data should enable the surgeon to make his incisions more easily, and to obtain a more effective insertion and use of prostheses for reinforcement of the peritoneal sac, thus avoiding the waste of time and material, and the various difficulties usually encountered.

This technique was derived from Nissen-Rossetti's fundoplication operation. Anatomical bases for the method are described which allow the simple performance of a regulated and measured version (in spite of regional anatomical variations), that is non-calibrating (to avoid exposure to conventional sequelae of fundal plication) and reproducible (essential when comparing results assessed for global series). Technical features are described in detail and discussed, while emphasizing the importance of the following rules; respect of regional fascial structures, avoidance of vagal trunks, observation of the compliance of the gastrosplenic omentum and conformation of the gastrophrenic ligament to allow simple mobilization of the anterior and posterior hemivalves. A summarized report on 295 operations, performed on and 233 patients reviewed after 3 to 9 years, indicates low mortality (1.35% from complications arising from patients' condition generally), an acceptable morbidity (5.5% of complications requiring lengthened hospital stay) and very correct long-term results (no "gas bloat syndrome", 8 dysphagias, 15 radiologic and/or endoscopic recurrences including 11 cases with clinical evidence of recurrence of reflux). The fact that distal esophageal cuffing can be adapted for cases of hiatus hernia, of peptic stenosis of esophagus, of undroppable cardia, and of associated duodenal ulcer or bile calculi suggests its use as a routine operation, if possible at an early stage, for all cases of pathologic gastroesophageal reflux.

The authors believe that utilisation of calibrating drainage is justified in case of difficult restauration of the C.B.D. of normal caliber, either throughout its length or in one segment. They underline that "axial exit" has not the disadvantages of the "lateral exit" of T-tubes. They recall the various modalities of "axial exit" (transcystic, transpapillary, transhepatic, "en seton") and their own contribution to the improvement of the transpapillary drainage by the association of a systematic sphincterotomy. Abstract of their clinical series, technics, postoperative mortality and morbidity, calibrating drainage duration and results (in connection with etiology) are reported. Main advantages of the "axial exit" are the absence of any risk of stenosis on a non dilated C.B.D. (as for the "lateral exit") and the facility for long time calibration up to several years. No hemorrhage, no bile leakage have been observed. The one only risk of this sort of drainage is the premature fall of transcystic or transpapillary drains ; but this disadvantage does not exist for "en seton" drainage. Shortly : "axial exit" calibrating drainage is recommandable when a very long time calibration after restauration of non dilated C.B.D. is necessary.

Three procedures for pre-operative preparation of the colon were compared during a controlled multicentre study in 215 patients. Though mechanical irrigation with a 10 p. cent mannitol solution is definitely superior as far as the degree of intestinal emptying obtained, no significant difference was noted in the frequency or severity os postoperative infections after conventional preparations by digestive tract irrigation with or without intestinal antibiotics. This method is limited by its tolerance (67 p. cent), its advantages are its rapidity and cost, elective indications being ascending colon lesions with little or no stenosis in young subjects. In other circumstances it has to be compared with the conventional methods of preparation, which should still be employed before operation in subjects who are elderly and/or have moderate to severe stenosis. The addition of antibiotics (neomycin, metronidazole by mouth) reduces the incidence of postoperative sepsis to a marked but non-significant degree, independently of the lesion (cancer, sigmoiditis) and its site. A recent study by F. Lazorthes has led him to prefer an association of antibiotics active against aerobic and anaerobic flora: orally preoperatively, and systemically during surgery.

General anesthesia in the rabbit in spontaneous ventilation, followed by normal awakening and prolonged survival, has been studied here in order to have a series of chronic preparations which the authors could use in their research on digestive surgery. These type of anesthesia requires less personnel, but raises certain difficulties due to the closeness of the thresholds of efficacy and toxicity, the length of the experiment and program requirements. The reliable technic exposed here permits prolonged anesthesia (up to eight hours) with normal survival of the animals. The mortality due to anesthesia was low.

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.

Initially a simple anatomical curiosity discovered at operation or autopsy, agenesis of the ball bladder has now, and despite its rarity, become of the greatest interest from a pathogenic, physiopathological and diagnostic standpoint. Embryogenesis explains that this a developmental abnormality affecting the hepatic diverticulum which is probably of genetic origin, hence its frequent association with other malformations and the hereditary nature of the condition. The usual finding of a syndrome of blockage of the sphincter of Oddi with dilatation of the common bile duct raises the problem of synergism between the sphincter of Oddi and the gall bladder. The discovery of lithiasis of the hepatic and common bile ducts in agenesis of the gall bladder leads to discussion of the reality of organ lithiasis or the role of the distended wall of the common duct. Cholecystography and echotomography would appear to be the two techniques of investigation to be recommended preoperatively in order to increase support for the presumptive diagnosis once disorders affecting neighbouring structures have been eliminated. The definite diagnosis is made peroperatively by manual exploration, peroperative cholangiography or even coeliac arteriography during the operation. The indication for surgery is based upon clinical symptomatology. This does not treat the agenesis but the associated lesions which are its complications, in particular: lithiasis the common duct, sphincter of Oddi block syndrome and dilatation of the common duct.

The authors relate about a case of tumorlike eosinophilic infiltration of the duodenum and pancreas. The preoperative workup included the traditional gastroduodenography and arteriography but also more modern investigations as echography and scanography which have not been often employed previously in this pathology. This case shows also how the involvement of the duodenum by the infiltration usually leading to carry out a cephalic duodenopancreatectomy for a benign lesion. The authors recommend conservative management if clinic, duodenographic, echographic and scanographic findings are not associated with the evident signs of carcinoma of the pancreas or of the Vater's region especially in tired patients.

In the experience of the Universitary Surgical Clinic of Amiens, anaesthesia of more than 8 hours duration appears for 3 p. thousand of the total amount (9/3 000 on 1978). The authors distinguish between them "provided" very long duration operations and the "involuntary" ones (complex multitrauma, unexpected difficulties, etc.); that distinction is justified by many reasons among which one must consider mostly the team work setting up. The authors briefly report V. L. D. A. events in their own experience as in that reported in the medical literature. Also the practical difficulties resulting of V. L. D. A. in the intra-operative or post-operative periods are appraised. Then the authors propose some means able to reduce the number of V. L. D. A. and to assure a better proceeding of very long duration operations.

The authors emphasise the necessity for rigourous criteria of histological identification, the basis of the therapeutic decision; the risk on onset of hemoperitoneum suggests radical treatment before the compliction, considering the operative risk, in relation to the site of the lesions and their macroscopic appearance. The notion of rareness and the histogenesis of the disease are also considered.