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There are no clear guidelines when an additional CT scan should be obtained for the treatment of displaced intra-articular distal radius fractures (DRF). This study aimed to investigate whether surgeons can predict the usefulness of CT scans to facilitate choice of treatment plan and/or pre-operative planning for DRF. Four surgeons evaluated 51 patients with displaced DRF. The choice of treatment (operative or nonoperative) was based on conventional radiographs. Subsequently, the surgeons were asked whether they would have requested an additional CT scan to determine this treatment choice, and also whether they required a CT scan for pre-operative planning. After 4 weeks, the additional CT scan was provided and the cases were assessed again. Based on these data, we calculated the number needed to scan (NNS) and number needed to harm (NNH) for two decision models. Model 1: Only provide a CT scan if the surgeon requested one based on their judgment of the X-rays. Model 2: CT scans for all displaced intra-articular DRF. For choice of treatment, the NNS was lower for model 1 than for model 2 (2.6 vs. 4.3) and the NNH is higher for model 1 (3.1 vs. 1.3). For pre-operative planning, the NNS (1.3 vs. 1.4) and NNH (3.7 vs. 3.4) were comparable for both models. Surgeons are able to predict the usefulness of an additional CT scan for intra-articular displaced DRF for OR indication. However, for pre-operative planning the usefulness of a CT scan is much harder to predict.

Objectives: Current studies on the additional benefit of using computed tomography (CT) in order to evaluate the surgeons' agreement on treatment plans for fracture are inconsistent. This inconsistency can be explained by a methodological phenomenon called 'spectrum bias', defined as the bias inherent when investigators choose a population lacking therapeutic uncertainty for evaluation. The aim of the study is to determine the influence of spectrum bias on the intra-observer agreement of treatment plans for fractures of the distal radius., Methods: Four surgeons evaluated 51 patients with displaced fractures of the distal radius at four time points: T1 and T2: conventional radiographs; T3 and T4: radiographs and additional CT scan (radiograph and CT). Choice of treatment plan (operative or non-operative) and therapeutic certainty (five-point scale: very uncertain to very certain) were rated. To determine the influence of spectrum bias, the intra-observer agreement was analysed, using Kappa statistics, for each degree of therapeutic certainty., Results: In cases with high therapeutic certainty, intra-observer agreement based on radiograph was almost perfect (0.86 to 0.90), but decreased to moderate based on a radiograph and CT (0.47 to 0.60). In cases with high therapeutic uncertainty, intra-observer agreement was slight at best (-0.12 to 0.19), but increased to moderate based on the radiograph and CT (0.56 to 0.57)., Conclusion: Spectrum bias influenced the outcome of this agreement study on treatment plans. An additional CT scan improves the intra-observer agreement on treatment plans for a fracture of the distal radius only when there is therapeutic uncertainty. Reporting and analysing intra-observer agreement based on the surgeon's level of certainty is an appropriate method to minimise spectrum bias. Cite this article: Bone Joint Res 2015;4:190-194., Competing Interests: ICMJE Conflict of Interest:None declared, (©2015 Kleinlugtenbelt et al.)

Background: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care., Methods: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017., Results: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence., Recommendations: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.

Purpose: In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence., Methods: The original Oxford Centre for Evidence-Based Medicine ranking was used. All relevant level 1A and level 1B literature from May 2008 to June 2010 was searched (Medline and Cochrane) by the Working Group members. All chapters were attributed to the two responsible authors in the initial guidelines document. One new chapter on fixation techniques was added. The quality was assessed by the Working Group members during a 2-day meeting and the data were analysed, especially with respect to any change in the level and/or text of any of the conclusions or recommendations of the initial guidelines. In the end, all relevant references published until January 1, 2013 were included. The final text was approved by all Working Group members., Results: For the following topics, the conclusions and/or recommendations have been changed: indications for treatment, treatment of inguinal hernia, day surgery, antibiotic prophylaxis, training, postoperative pain control and chronic pain. The addendum contains all current level 1 conclusions, Grade A recommendations and new Grade B recommendations based on new level 1 evidence (with the changes in bold)., Conclusions: Despite the fact that the Working Group responsible for it tried to represent most kinds of surgeons treating inguinal hernias, such general guidelines inevitably must be fitted to the daily practice of every individual surgeon treating his/her patients. There is no doubt that the future of guideline implementation will strongly depend on the development of easy to use decision support algorithms tailored to the individual patient and on evaluating the effect of guideline implementation on surgical outcome. At the 35th International Congress of the EHS in Gdansk, Poland (May 12-15, 2013), it was decided that the EHS, IEHS and EAES will collaborate from now on with the final goal to publish new joint guidelines, most likely in 2015.

Background: Recurrence and pain are the two most important outcomes after inguinal hernia surgery. The concept of lightweight or partially absorbable macroporous meshes was developed under the assumption that the observed pain rate could be decreased without increasing the number of recurrences. Few randomized trials were published to analyze their clinical value, and some concern was raised because of an increased risk of recurrence. A systematic review and a meta-analysis of RCTs were carried out to determine whether the use of lightweight meshes influenced the pain and recurrence rate after Lichtenstein hernioplasty., Methods: To assess the value of the lightweight mesh, an extensive literature search was performed. The random-effect meta-analysis model was used to correct for clinical diversity and methodological variations between studies. Recurrence rate, aspects of chronic pain and foreign body feeling at 6-60 months postoperatively were assessed., Results: Eight prospective RCTs of good quality were identified. Analysis demonstrated no significant difference regarding recurrence (OR, 1.11; 95 % CI, 0.57-2.14; p = 0.77). No significant difference was observed concerning severe pain (OR, 0.99; 95 % CI, 0.48-2.02; p = 0.97). Description of any pain resulted in a significant improvement in the lightweight group (OR, 0.65; 95 % CI, 0.50-0.84; p = 0.001). The presence of foreign body feeling was favoring the lightweight group (OR, 0.62; 95 % CI, 0.41-0.94; p = 0.02)., Conclusions: The use of lightweight mesh did not neither increase the recurrence rate nor reduce the incidence of severe pain. A significant reduction in foreign body feeling and overall pain rate in the postoperative period was recorded. Lightweight meshes could be considered as a material of choice in primary inguinal hernioplasty.

Purpose: In 2003, a dedicated Dutch committee developed evidence-based guidelines for the treatment of inguinal hernia (IH) in children and adults. The aim of this study was to describe trends in hernia care before and after the publication of the guidelines on IH surgery in The Netherlands., Methods: Originally, a retrospective baseline analysis of IH surgery in 90 Dutch hospitals was performed among patients treated for IH in 2001. The results of this baseline analysis were compared with a recently performed second analysis of patients treated for IH in 2005., Results: In children <4 years of age, the study showed a significant decrease of contralateral explorations. In adults, the study showed that significantly more patients were treated with a mesh-based repair in 2005 (95.9 vs. 78.8%, P < 0.01). Moreover, there was an increase of patients with bilateral hernia treated with an endoscopic technique (41.5 vs. 22.3%, P < 0.01) and more patients were treated in day surgery (53.5 vs. 38.6%, P < 0.01). Lastly, a decline in operations performed for recurrent IH in adults was observed (10.9 vs. 13.3%, P < 0.01)., Conclusion: This study showed that most patients with IH in The Netherlands were treated according to the main recommendations of the Dutch evidence-based guidelines.

Background: Inguinal nerve identification during open inguinal hernia repair is associated with less chronic postoperative pain. However, most Dutch surgeons do not identify all three inguinal nerves when carrying out this procedure. The aim of this study was to evaluate the feasibility of a nerve-recognizing Lichtenstein hernia repair and to measure the extra time required for surgery, Methods: Forty patients with primary inguinal hernia were operated on following the nerve-recognizing Lichtenstein hernia repair by four experienced hernia surgeons from four different Dutch teaching hospitals. The additional time needed to identify each individual nerve was recorded, and iatrogenic nerve injuries and anatomical characteristics were registered., Results: Identification of the iliohypogastric and ilioinguinal nerves was each performed within 1 min. Identification of the genital branch of the genitofemoral nerve was notably more difficult but could usually be performed within 2 min. Identification of the cremasteric vein, running parallel to the genital branch, was less comprehensive. The incidence of major anatomical variations was low. Twenty-five per cent of ilioinguinal nerves, however, could not be identified. In five patients inguinal nerves were damaged iatrogenically during standard manoeuvres of the Lichtenstein hernia repair., Conclusion: Three-nerve-recognizing Lichtenstein hernia repair is feasible and non-time consuming if the surgeon has appropriate anatomical knowledge. In view of the low incidence of major anatomical variations, knowledge of standard inguinal nervous anatomy should be adequate. This procedure could enable the surgeon to prevent or recognize iatrogenic nerve damage and offer an opportunity to perform deliberate neurectomy as an alternative to accidental nerve injury.

Purpose: A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable., Methods: Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias., Results: To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome., Conclusions: A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

Background: The Onze Lieve Vrouwe Gasthuis (OLVG) hospital is a large district teaching hospital with a residency programme for general surgery. Since 1998, inguinal hernia (IH) repairs in this hospital were performed according to the preliminary "evidence-based guidelines" concerning IH repair. The aim of this study was to analyse whether the use of the guidelines improves the quality of IH repair measured by a reduction of the operated recurrences, especially from the patients who underwent the previous repair in this hospital., Methods: A retrospective study was performed which included all male adults (>18 years of age) undergoing IH surgery in the OLVG hospital for a primary or recurrent inguinal hernia from 1994 until 2004., Results: The use of mesh for primary hernia increased significantly from 0.6% in 1994 to 100% in 2004 (P < 0.001). The number of operations performed for recurrent IH fluctuated between 7% and almost 18%. However, the tendency towards a decrease in recurrence is clearly demonstrated by comparing the average recurrence rates of two time periods, namely, 1994-1998 (15.8%) and 2002-2004 (10.6%), proving a significant decrease (P < 0.002). The decreasing portion of recurrences previously operated in the study hospital from 64.3% (1994) to 14.3% (2004) was striking (P < 0.001). The prior operation performed before the recurrence was mesh-based in an average of 42/273 (15.4%) patients and increased each year., Conclusions: Between 1994 and 2004, a significant increase in the use of mesh-based techniques for the treatment of IH, influenced by the Dutch evidence-based guidelines, probably resulted in a significant decrease in the number of operations performed for recurrent IH.

Two male patients, aged 37 and 56, suffered from neuralgic pain after a Lichtenstein procedure for inguinal hernia repair using prosthetic reinforcement. Since mesh-based repair techniques have decreased the recurrence rate, postoperative inguinal pain has become a major complication of these operations. Three months after surgery, 20% of the patients experience some pain. In 12% of the patients this pain limits daily activities and 1-3% of the patients are invalidated by neuralgic pain. Preventing damage to sensory nerves during the operation is one way of preventing neuralgic pain. Damaged sensory nerves should be excised. Neuralgic pain after the operation may be alleviated by tricyclic antidepressants, opioids or antiepileptic drugs. In selected patients with neuralgic pain neurectomy is indicated. In one of the patients presented the neuralgic pain disappeared after neurectomy of the ilioinguinal nerve. Triple neurectomy in the other patient, however, was unsuccessful.

Objective: To investigate the factors that contribute to surgical delay and whether this delay can be associated with post-operative complications., Design: Retrospective cohort study., Method: Patients admitted with a hip fracture between 1 January 2001-31 December, 2003 to the Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands, were included. The delay before surgery was recorded in 446 patients who underwent surgical treatment for a hip fracture. As possible predictors of delay before surgery, the following factors were investigated: demographic and other patient information, pre-operative medication, co-morbidities, pre-operative acute co-morbidities, classification according to the American Society of Anesthesiologists (ASA) and whether or not the patient had already had surgery to the same hip. To measure the effect of delay before surgery, we investigated post-operative complications like: delirium, decubitus ulcers, urinary tract infections, pulmonary infections, pulmonary embolism, deep vein thrombosis, wound infection, failure ofosteosynthesis and in-hospital mortality., Results: In total, 446 patients, 98 male and 348 female, with a mean age of 82.2 years met the inclusion criteria. Distinct predictors of delay before surgery were: ASA-classification, pre-operative urinary tract infection, pre-operative chest infection, pre-operative delirium, pre-operative anaemia and re-operation. There was no significant association between delay of surgery and the occurrence of post-operative complications., Conclusion: Presence of a pre-operative medical condition has an important effect on surgical delay for a hip fracture. The assumption of the Dutch Healthcare Inspectorate that delay of surgery for hip fracture causes more complications could not be confirmed.

Late into the 19th century, treatment for inguinal hernias consisted of repositioning the hernia with trusses or using 'softening agents' such as warm herbal baths and moist bandages. Surgical resection or cauterisation, often combined with hemicastration, was only considered for cases ofstrangulated hernia that could not be repositioned. Bassini (1844-1924) is credited with developing the precursor to the modern inguinal hernia operation at the end of the 19th century. Bassini's essential discovery was that the transverse fascia plays a key role in the pathophysiology of inguinal hernias. Bassini's operation, consisting of complete incision of the transverse fascia and reconstruction of the inguinal floor, was considered the gold standard for nearly a century. One problem with the conventional Bassini operation was the tension applied to tissues, which led to a high rate of recurrence. Although Bassini's operation has now become obsolete, current surgical approaches still centre on fortification of the inguinal floor. This tension-free repair now uses synthetic mesh that is positioned using an open anterior approach, laparoscopic surgery, or a preperitoneal technique.

Background: Morbidity associated with open inguinal hernia repair (IH repair) mainly consists of chronic pain. The aim of this study was to identify possible disparities between state-of-the-art Lichtenstein repair, and its application in general practice., Methods: A questionnaire was mailed to all surgeons and surgical residents (n = 1,374) in the Netherlands in February 2005. The objective was to determine the state of general practice with respect to technical steps during the Lichtenstein repair that are suggested to be involved in the development of chronic pain, as recently updated by Lichtenstein's successor, Amid., Results: More than half of the respondents do not act according to the Lichtenstein guidelines with respect to surgical steps that are suggested to be involved with the origin of chronic pain of somatic origin. Compliance with Amid's guidelines with respect to the handling of the nerves is variable. Surgeons conducting high numbers of IH repair are more likely to operate according to the key principles of the state-of-the-art Lichtenstein repair., Conclusion: There is a substantial disparity between the state-of-the-art Lichtenstein repair and its application in general practice with respect to steps that are suggested to play a role in the origin of chronic groin pain.

Background: Pain syndromes of somatic and neuropathic origin are considered to be the main causes of chronic pain after open inguinal hernia repair. Nerve-identification during open hernia repair is suggested to be associated with less postoperative chronic pain. The aim of this study was to define clinically relevant surgical anatomical zones facilitating efficient identification of the three inguinal nerves during open herniorrhaphy., Method: Through dissection of 18 inguinal areas of embalmed and unembalmed human cadavers, identification zones were developed for the inguinal nerves (in particular for the genital branch of the genitofemoral nerve)., Results: The iliohypogastric nerve was identifiable running approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm (range 2.5-5.5 cm) cranially from the external ring. When present, the ilioinguinal nerve was identifiable running ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle. Identification of the genital branch of the genitofemoral nerve was more comprehensive. The course of the genital branch is laterocaudal at the level of the internal inguinal ring., Conclusion: Based on the newly defined identification zones, peroperative identification of all inguinal nerves is possible. Further research is warranted to assess clinical feasibility of these zones and to evaluate the influence of (facultative) division, preservation or omittance of the identification of inguinal nerves on the incidence of chronic pain.

Background: Inguinal hernias are a common entity with nearly 31,000 repairs annually in The Netherlands and over 800,000 in the USA. The aim of the present study is to determine whether a laparoscopically diagnosed patent processus vaginalis (PPV) is a risk factor for the development of groin hernia., Methods: The study population was originally composed of 599 consecutive cases (189 male, 32%) of laparoscopic transperitoneal surgery for different indications performed in 4 teaching hospitals in The Netherlands between November 1998 and February 2002. During laparoscopy, the deep inguinal ring was inspected bilaterally. The PPV group was compared with the obliterative processus vaginalis (OPV) group., Results: After a mean follow-up of 5.5 years, the studied population consisted of 337 cases (94 male, 28%). In this study 12% of the studied population appeared to have PPV in adult life. The percentage PPV of our study group is much higher than the percentage of hernia repairs performed in the Dutch population. A greater proportion (12%) of hernia repairs in the PPV group was found as compared with the OPV group (3%). The chance of developing an inguinal hernia within 5.3 years is four times higher in the group with PPV. No significant correlation between age and the prevalence of PPV was observed., Conclusion: This study demonstrates that PPV is an etiologic factor and a risk factor for acquiring an indirect inguinal hernia in adults.

Objective: To determine whether a randomised clinical trial in general hospitals can be performed in a reliable way without financial support., Design: Descriptive., Method: The trial involved 1040 patients in whom an inguinal hernia had been corrected with a propylene mat in the period 1998-2003. They were randomised to either a single dose of prophylactic antibiotics or a placebo. The primary outcome measure was 'wound infection during the 3 months after the operation'. The audit concerned 98 patients, chosen at random, for whom 3 investigators from an independent bureau collected data from the patient charts and study forms during 3 clinic visits in the period 2000-2003. Whether various quality criteria had been fulfilled was assessed on the basis of these data., Results: In all 4 participating clinics, approval of the medical ethics assessment committees had been obtained. The trial protocol corresponded to the consent form. A proper informed consent was obtained from 63/98 patients (64%). The last (third) follow-up was missed in 23/98 patients (23%). During the trial, the patients who had missed this follow-up were contacted by telephone, which succeeded in 98%. The status and trial forms had been filled out completely and correctly with regard to the peroperative randomisation forms in 90% of the cases and with regard to the follow-up in 75% of the cases. The trial protocol was adhered to on almost every point., Conclusion: The data collection in the studied, not financed trial was adequate, probably as a result of the relatively simple questions posed, the easily determinable outcome measure and the efforts expended above and beyond the protocol.

Background: The aim was to determine whether systemic antibiotic prophylaxis prevented wound infection after repair of abdominal wall hernia with mesh., Methods: This was a systematic review of the available literature identified from multiple databases using the terms 'hernia' and 'antibiotic prophylaxis'. Randomized placebo-controlled trials of antibiotic prophylaxis in abdominal wall mesh hernia repair with explicitly defined wound infection criteria and a minimum follow-up of 1 month were included. After independent quality assessment and data extraction, data were pooled for meta-analysis using a random-effects model., Results: The search process identified eight relevant trials. Two papers on umbilical, incisional or laparoscopic hernias, and six concerning inguinal and femoral (groin) hernias were suitable for meta-analysis. The incidence of infection after groin hernia repair was 38 (3.0 per cent) of 1277 in the placebo group and 18 (1.5 per cent) of 1230 in the antibiotic group. Antibiotic prophylaxis did not significantly reduce the incidence of infection: odds ratio 0.54 (95 per cent confidence interval 0.24 to 1.21); number needed to treat was 74. The number of deep infections was six (0.6 per cent) in the placebo group and three (0.3 per cent) in the antibiotic prophylaxis group: odds ratio 0.50 (95 per cent c.i. 0.12 to 2.09)., Conclusion: Antibiotic prophylaxis did not prevent the occurrence of wound infection after groin hernia surgery. More trials are needed for complete evidence in other areas of abdominal wall hernia., (Copyright 2005 British Journal of Surgery Society Ltd.)

The 'Inguinal hernia' guideline was written over a period of two years by nine surgeons (including one epidemiologist) from all regions of the Netherlands with demonstrable clinical and scientific expertise in the area of inguinal surgery after a training course on 'The development of evidence-based guidelines'. A draft of the guideline was on the website of the Association of Surgeons of the Netherlands for a period of three months, during which time the members of the society could comment on its contents interactively. The guideline comprises chapters on risk factors and prevention, diagnostics, indications for treatment, treatment, day surgery, antibiotics, thrombosis prophylaxis, training, anaesthesia, postoperative pain control, complications, costs, aftercare, and specific aspects of inguinal hernia in children. For the treatment of adult patients a mesh technique is recommended. The Lichtenstein technique is recommended as the first choice for uncomplicated primary inguinal hernia. Laparo-endoscopic techniques can be used by trained teams for specific indications. Other techniques have not been compared with the current methods of treatment sufficiently. It is recommended that the operations be carried out in daycare and that the use of local anaesthesia should be considered more often. The diagnosis of inguinal hernia in a child is based on the physical examination. It is recommended that the surgeon should not rely solely on the history but confirm the presence of a hernia personally. The treatment of a paediatric inguinal hernia is always operative. Generally, the younger the child, the more urgent the operation because of the increased risk of incarceration in infants, particularly premature babies. There is no indication for routine exploration of the contralateral groin. If an incarcerated hernia cannot be reduced, emergency operation is necessary and referral to a paediatric surgical centre must be considered. The implementation and effectiveness of the guideline will be measured by taking an inventory of all inguinal hernia operations performed in the Netherlands before and after its publication.

Objective: To determine prognostic factors associated with mortality in patients aged 80 years and over who were treated at the Department of Surgery within a one-year period., Design: Prospective., Method: The following items from the complications register were investigated: degree of mobility prior to the operation and the housing circumstances, presence of comorbidity in the case history (heart disease, lung disease, diabetes mellitus, dementia, urgency of admission and operation (elective, urgent, acute)), and the surgical subspecialism (gastroenterology, traumatology, vascular surgery and general surgery). The number of postoperative complications was also examined. Statistical analyses were performed using the chi 2 test and multiple logistic regression analysis., Results: A total of 179 patients were included: 53 men and 126 women, with an average age of 85 years and 86 years respectively. The overall mortality was 11%: 39% in acutely presented patients and 8% in subacute patients. None of the electively operated patients died. The following factors were significantly associated with mortality: subacute presentation (odds ratio 8.5; 95%-CI: 2.8-27), acute presentation (odds ratio 72; 95%-CI: 8-737), cardiological evaluation without further measures was associated with less mortality (odds ratio 0.13; 95%-CI: 0.02-0.85)., Conclusion: The risk of mortality increased with the urgency of presentation. A cardiological evaluation in which the patient, without the need for further additional measures, was found to be in an optimal condition was associated with a relatively low risk of mortality.

The development of indirect inguinal hernias in infants is caused by a patent processus vaginalis (PPV). Consequently, this type of hernia is cured by simple herniotomy. In adults, however, herniotomy alone is accompanied by a high recurrence rate. This indicates that additional factors play a part in the development of indirect inguinal hernias in adults. The aim of this study was to determine the etiology of the development of an indirect hernia in adult life. Also, the prevalence of a PPV without clinical evidence of a hernia was determined and related to age. From November 1998 until February 2002, 599 patients from four different teaching hospitals, who underwent abdominal laparoscopy for various pathologies, were included. During laparoscopy, the deep inguinal ring was bilaterally inspected. Patients undergoing laparoscopy for inguinal hernia repair were excluded. Mean age was 45 years (range 8-89 years). Thirty-two percent (189/599) were male. Twelve percent (71/599) had PPV, all without clinical symptoms. Fifty-five percent (39/71) with PPV were male (P<0.0001). Fifty-nine percent (42/71) with PPV were right-sided, 29% (21/71) with PPV were left sided, and 12% (8/71) were bilateral (P=0.01). The prevalence of PPV in patients under 20 years was 22%. Of those between 20 and 30 years of age, 6% had PPV. Of those between 30 and 50 years, 24 patients (11%) had PPV. Of patients over 50 years, 33 (14%) had PPV. No significant differences between ages were observed. It is concluded that asymptomatic patent processus vaginalis frequently exists in adult life. The prevalence of PPV does not increase significantly with age. Assuming that indirect hernias start with asymptomatic peritoneal protrusion that can be observed laparoscopically, the incidence of PPV, like the incidence of adult indirect hernias, should increase in case of acquired etiology. Such an increase of incidence with age was not confirmed by our results. It is concluded that the etiology of indirect inguinal hernia in adults, as in infants, is congenital.

Objective: To gain insight into the nature and magnitude of drug-related problems in the emergency department (ED) of a hospital (Onze Lieve Vrouwe Gasthuis) in Amsterdam, the Netherlands., Design: Prospective, observational., Method: During the period from June through to November 2000, the following data were recorded for all patients visiting the ED with drug-related problems: age, sex, nationality, form of presentation, presenting complaint, drugs used, diagnostics performed, treatment in the ED and clinical course leaving the ED., Results: During the study period, 214 (1%) patients were seen with drug-related problems. The largest group consisted mainly of young, foreign occasional users of soft drugs (117 patients, 55%). Their complaints were aspecific and harmless. The need for additional diagnostics was limited, with no additional diagnostic tests being carried out in 178 patients (83%). Treatment consisted of reassurance (50 patients, 23%), observation (123 patients, 58%) and medication (85 patients, 40%). Nineteen patients (9%) needed additional treatment (suturing, plastering, etc.). Ten patients (5%) were admitted to the hospital. Reasons for admission were psychotic episodes, prolonged unconsciousness or respiratory problems., Conclusion: The magnitude of the drug problem in an emergency department in the centre of Amsterdam and the use of medical resources were limited. The nature of the problem consisted mainly of mild symptoms following the use of soft drugs, usually by young, foreign occasional users.

In the Netherlands, approximately 30,000 inguinal hernia repairs are performed yearly. At least 15% are for recurrence. New procedures are being introduced creating discussion on which technique is the best. Currently it is not possible to choose on evidence alone because of the long follow-up that is needed. In 1996 an inventory was taken of all inguinal hernia repairs that were performed in the Amsterdam region (9 hospitals). These results were compared with the results from a similar study performed in 1994. Major changes in treatment strategy were noted. The Bassini repair was replaced by Shouldice and Lichtenstein techniques. There was a significant increase in the use of prostheses for both primary and recurrent inguinal hernias. There was no significant decrease in the percentage of operations performed for recurrent hernia from 19.5% to 16.8%. However, there was a significant decrease in operations performed for early recurrences (5.1%-3.4%) (p = 0.05). These results suggest that the Shouldice and Lichtenstein repairs may be superior to the Bassini repair in terms of early hernia recurrence.

Investigators have shown that significant segmental motion occurs in patients immobilized in halo vests. One cadaver study showed that this is decreased with a posterior pad added to the construct. To improve nonoperative care of patients with cervical trauma, segmental cervical motion was evaluated in normal volunteers immobilized in a halo vest with and without a posterior pad. Two commonly used methods to measure sagittal angulation were used. Thirty normal volunteers were placed in halo vests by using positioning pins on the cranium. A sphygmomanometer attached to the posterior uprights of the vest inflated to 40 mm Hg was used as a posterior pad at the greatest visible lordosis. Lateral radiographs of the cervical spine were taken with volunteers in the upright and supine positions with and without the posterior pad inflated. Radiographs were randomly sorted and were each read twice by 3 readers. Measurements of the posterior atlantodental interval, sagittal displacement, and sagittal rotation were recorded using 2 different methods: the Buetti-Bauml method, which uses lines drawn along the posterior vertebral bodies, and the method of White and colleagues, which uses lines drawn along the inferior vertebral bodies. Inflation status of the pad showed no statistically significant difference in any of the measured variables. This was true for both methods of measurement. Application of a posterior pad to the halo vest did not show any change in the segmental motion of the cervical spine in normal volunteers.

Objective: To assess the value of a written questionnaire in the follow-up of patients after inguinal hernia repair., Design: Prospective study., Setting: University and two district hospitals. The Netherlands., Subjects: 314 patients with 362 inguinal hernias., Main Outcome Measures: Correlation between answers to questionnaire and clinical examination in the diagnosis of recurrent hernias., Results: 13/24 recurrences (54%) after a mean follow-up of 33 months with a follow-up rate of 93% were not diagnosed by the questionnaire., Conclusion: Follow-up after hernia repair must be by physical examination.

Objective: To make an inventory of inguinal hernia repairs performed in one year, and to analyse the number of and origin of recurrent hernias., Design: Retrospective., Setting: Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands., Method: Analysis of all hernia operations performed in Amsterdam and Amstelveen in 1994 in male patients over 18 years of age. Request of national data, computer data from the hospitals, hand count of all operation reports and investigation of patient files., Results: In 1994, 1108 patients were operated for inguinal hernia on one or two sides. In 216/1108 (19.5%) cases recurrent hernia was involved. According to national statistics this occurred in 175/1123 (15.6%). In the two University hospitals 25.7% of all repairs were for a recurrent hernia, in the two hospitals with a surgical training programme this proportion was 17.9% and in the five hospitals without a training programme it was 18.6%. Of the early recurrences (within two years) 82.5% (47/57) were reoperated in the same hospital as before but of the late recurrences (more than 10 years) this proportion was only 26.8%. Only 16.6% (36/216) of the patients with a recurrence were reoperated by the same surgeon who had performed the prior operation. Most popular method for repair was a Bassini (59%). In the training hospitals more early recurrences were repaired than in the non-training hospitals., Conclusion: The percentage of hernia repairs for recurrent hernia is higher than national statistics suggest and higher than expected. Surgeons have little insight into their performance as many recurrences are repaired by another surgeon and many recurrences occur after ten years. Better training and more use of modern techniques may improve results.

The Shouldice technique for inguinal hernia repair has been suggested by some authors as the best conventional method against which other methods using prostheses should be compared. The paper which follows is a systematic review involving a comprehensive search of the medical literature to identify all clinical trials (article or abstract) evaluating the Shouldice repair. After assessment of certain quality criteria, the best studies were pooled in a meta-analysis. Nine publications were found with 11 study arms. In ten studies the results of the Shouldice technique were better than the results of the control arm. Six studies could be pooled in a meta-analysis of 2500 patients; Shouldice was significantly better than control methods (relative risk 0.62 (95 per cent confidence interval 0.45-0.85)). In spite of possible bias caused by different variables (modifications in operative technique, suture material, level of surgeon, follow-up methods and outcome measurement), the results of this systematic review suggest that the Shouldice method is the best current conventional technique for inguinal hernia repair.

Objective: To assess the operative methods used in Dutch surgical practice to repair the inguinal floor of the primary hernia., Design: Survey by questionnaire., Setting: University department of Surgery, The Netherlands., Subjects: All Dutch Surgeons., Outcome Measures: Answers to questions about the methods of repair used, specific surgical options, and materials. Comparison of training hospitals and district hospitals., Results: Replies were received from 145/155 departments (94%), but from only 448/774 individual surgeons (58%). 192 (43%) used one method alone (Bassini 71, Shouldice 49, McVay 36, Griffith 24 and others 12) and 256 (57%) of surgeons used combinations of 11 different methods. Only 9 used a prosthetic mesh and 7 laparoscopic repair. The Shouldice method was significantly more popular in training hospitals compared with non-training hospitals (36%) (71/199) compared with (20%) (48/249) (p < 0.05). There were many modifications to accepted methods. Only 78% (94/121) of surgeons who said that they did a standard shouldice repair incised the transversalis fascia. 64% (287) of surgeons said that they modified their technique to suit individual patients., Conclusion: In the Netherlands there is no standard technique of inguinal hernia repair.

The 'exulceratio simplex Dieulafoy' is an uncommon and probably underdiagnosed cause of upper gastrointestinal haemorrhage. The bleeding is intermittent and even endoscopically often missed. In this article the pathogenesis, diagnostic methods, clinical presentation and therapy are discussed. We present one case treated in our hospital.