Groin pain in athletes is a difficult problem requiring a multidisciplinary approach to diagnosis and treatment planning. Endoscopic preperitoneal herniorrhaphy is an effective treatment for obscure groin pain when the pain is associated with an inguinal hernia and allows for a short recovery time back to full athletic activity.

Laparoscopic herniorrhaphy has been criticized because of the need for general anesthesia. The endoscopic preperitoneal approach allows the use of epidural anesthesia, obviating the potential complications and side effects seen with general anesthesia. The purpose of this study was to determine the efficacy of epidural anesthesia for preperitoneal herniorrhaphy. Fifty-two patients underwent repair of a total of 80 hernias over a 6-month period. Thirty-six patients underwent their repairs with the use of epidural anesthesia with the goal of a T-4 sensory level. A tension-free prosthetic repair was performed in all patients. Seventeen patients had unilateral repairs and nineteen had bilateral repairs under epidural, while seven patients had unilateral repairs and nine patients had bilateral repairs under general anesthesia. There were no significant differences in patient demographics. All herniorrhaphies were electively performed on an outpatient basis by a single surgeon (A.L.S.) in a teaching setting. There were no significant differences for unilateral and bilateral repairs when type of anesthesia was compared. There was only one conversion from epidural to general anesthesia, secondary to poor sensory blockade first noticed during creation of the preperitoneal space (97% success rate). Seven patients receiving epidural anesthesia experienced pneumoperitoneum during the procedure. This did not effect the ability to perform the hernia repair successfully. There were no complications related to the epidural anesthetic. Endoscopic preperitoneal herniorrhaphy can be performed effectively under epidural anesthesia, obviating the need for general anesthesia.

The incidence and significance of bile leak after open cholecystectomy have been studied. The purpose of this study was to determine the incidence and significance of postoperative bile leak associated with both emergent and elective laparoscopic cholecystectomies. One thousand four hundred patients undergoing laparoscopic cholecystectomy from July 1990 to January 1995 were retrospectively reviewed. Twenty-seven percent of laparoscopic cholecystectomies were performed urgently for acute cholecystitis. Diisopropyl-iminodiacetic acid (DISIDA) scan was used to determine the presence of a bile leak or obstruction. Also, a subgroup of 63 patients from March to May of 1992 was studied in a nonblinded prospective fashion to determine the rate of asymptomatic bile leak. The incidence of bile leak in the subgroup of 63 patients was 4.7% (n = 3). All of these bile leaks were asymptomatic and of no clinical significance. The incidence of bile leak in the remaining 1337 was 0.14% (n = 2). These bile leaks were discovered by DISIDA scan following a workup of atypical abdominal pain following laparoscopic cholecystectomy. Both of these patients underwent ERCP with papillotomy. There were no ductal injuries in the entire series. Symptomatic bile leaks following laparoscopic cholecystectomy are rare. Asymptomatic bile leaks occur infrequently and are of no clinical significance.

A case of gasless laparoscopic esophagogastric myotomy for achalasia is presented. The technical aspects of the technique as well as the benefits of this approach are reviewed.