Basic Surgical Principles Research Articles

A New Dimension in Vesicovaginal Fistula Management: An 8-year Experience at Ramathibodi Hospital

Vesicovaginal fistula is mostly iatrogenic in origin and causes devastating medical, social, psychogenic and hygienic consequences. The aetiology has changed since the nineteenth century, becoming more associated with hysterectomy rather than other obstetric procedures, which were common in the past. We studied the causes, clinical presentations and management of vesicovaginal fistula in our institute during 1998 to 2005. From 1998 to 2005, 45 patients were treated in our hospital, of whom 35 were referred from other hospitals after failed surgery. All the medical records were reviewed. Fistulae, clinical presentation, clinical findings, means of treatment and clinical outcome as well as complications were noted. The most common cause of a fistula in our study was post laparoscopic hysterectomy that comprised 28 cases (62.2%). Transabdominal hysterectomy caused fistula in 10 cases (22.2%) and vaginal hysterectomy only four cases (8.8%). Most cases of vesicovaginal fistulae after laparoscopic hysterectomy presented with early urinary leakage, of which 35.7% presented within 1 week and 50% in the second week. Most of the patients after transabdominal hysterectomies (90%) had leakage in the second week. All patients were treated with surgical repair, 19 cases by a transvaginal approach and 26 cases by a transabdominal repair. Seventeen cases in the transvaginal group and 25 cases in the transabdominal group were dry after the first operation. The rest of both groups were dry after the second operation. After 38 months of follow-up, no complication or incontinence was noted. Vesicovaginal fistula is still a serious iatrogenic consequence and causes suffering in the physical, emotional and social functioning of patients. The study found that the condition is now more frequently associated with laparoscopic hysterectomy. Successful closure of the fistula requires an accurate and timely repair using procedures that exploit basic surgical principles. With the appropriate surgical expertise, all patients can be cured of this distressing condition.

Vesico‐uterine fistula: report of 14 cases

To analyse the indications, diagnosis, major causes and basic principles of surgical treatment of vesico-uterine fistulas (VUF). From 1970 to 2006, 14 patients underwent surgical repair of VUF in two Belgrade hospitals. The most common cause of a fistula was previous Caesarean section (13/14). The mean (range) age was 27 (22-38) years. Five women underwent transvesical fistula suture, and nine underwent a transperitoneal surgical approach with the interposition of a tissue flap; an omental flap in five and a peritoneal flap in four. The mean (range) duration of surgery was 85 (70-120) min. The mean hospital stay was 14 (12-22) days. The urethral catheter was removed 10 days after surgery. One woman with no tissue flap repair relapsed and none of the women with a tissue flap repair relapsed. After surgery, eight patients became pregnant and underwent Caesarean section. Successful closure of VUF requires accurate diagnostic evaluation, appropriate repair using techniques that utilize basic surgical principles, and the careful application of interposing tissue flaps.

Postburn contracture treatment: A healthcare project in Bangladesh

Over the last 6 years, a health care program aimed at the surgical correction of postburn contractures has taken place in Faridpur, Bangladesh. People in this rural region are very poor and often cannot afford medical treatment. Often secondary flexion contractures of the face and chin as well as the upper and lower extremity impede daily functioning and have an enormous psycho-social impact. The application of basic plastic surgical principles such as local transposition of skin flaps as well as skin grafts restores function dramatically and results in stable skin cover. It is quite challenging – both for the surgeon and the anaesthesiologist – to perform these operations within a rather limited infrastructure. In Bangladesh, there is a monumental need for correction of postburn contractures for the social needs of the patient as well as for functional purposes. Future actions should be directed to the training of surgeons and the development of specialized hospitals to demonstrate social as well as political commitment to health care programs.

Genital foreign bodies: more than the eye can see

Genital foreign bodies constitute a diverse but surprisingly common means of presentation to emergency departments. Although the presentation usually means the initial diagnosis is easily made, we present a case here that stresses the importance of attention to history, clinical examination and radiological investigation. A 44-year-old gentleman presented with a history of pain and discharge from a self-inflicted scrotal wound. Further questioning revealed a history of genital foreign bodies, but the full extent of his condition was not apparent until plain pelvic radiographs were obtained. The initial management of genital foreign bodies follows basic surgical principles. Constricting bands must be removed, devitalized tissues debrided and the surgical field extensively irrigated. Underlying psychiatric illness may be present and a high index of suspicion is required in the initial assessment of such patients. A plain pelvic radiograph is recommended to fully identify all foreign bodies present.

Facial flaps for facial skin lesions

This article covers basic surgical principles for the use of local flaps in facial skin reconstruction. Some surgical details of commonly used flaps are included, but detailed classification of facial flaps is not covered. Readers are referred to standard texts for more detail of individual flap design and use.

Mini Incision: Occasionally Desirable, Rarely Necessary: In the Affirmative

Exposure is a crucial issue in total knee arthroplasty, and the basic surgical principles of exposure apply to the knee just as to other operations. The skin and muscle must not be stretched, and the surgeon must have an excellent view and access to the knee structures. Stretching of the skin or muscles causes damage, hurts the patient, and predisposes to infection. There is no discernable advantage to compromises on exposure to avoid incising the muscle or skin. Many of the advantages credited to smaller skin incisions likely are because of improvements in pain management. Infiltrating with local anesthetics and using shorter tourniquet times may help the patient recover more quickly. Inadequate exposure does not.

The use of prophylactic antibiotics in head and neck oncological surgery

An overview of best evidence-based current practice in the use of prophylactic antibiotics in elective oncological head and neck surgery is presented. Patients undergoing head and neck oncological surgery are at great risk of developing complications following surgery. The incidence of wound infection has been reported to be as high as 87%, often with devastating effects. Prophylactic antibiotics have helped to reduce significantly the risk of infection; however, clinicians managing these patients should also have a thorough understanding of the risk factors leading to postoperative infections and should apply the most basic surgical principles at all times, to minimize infection rates. Prophylactic antibiotics usage in clean-contaminated major oncological head and neck surgery is mandatory to reduce the risk of infection. In clean major oncological head and neck surgery their use is also advisable but there is no evidence that in clean surgery for benign disease it offers any advantage. Short antibiotic regimes of four doses per 24 h are as effective as prolonged courses regardless of the complexity of the procedure. A combination of antibiotic agents covering aerobic, anaerobic and Gram-negative bacteria is superior to single agents. High-risk patients should be also given short regimes, as there is no evidence that prolonged courses are of more benefit in these patients. Methicillin-resistant Staphylococcus aureus infection can have devastating consequences for patients undergoing major head and neck surgery. Protocols of prevention and treatment should be in place in all institutions treating patients with head and neck cancer. Close collaboration between surgical, microbiology and infection-control teams is essential.

Prognostic factors of recurrence after vesicovaginal fistula repair

We evaluate the prognostic factors of recurrence in patients after the surgical repair of vesicovaginal fistula. From 1985 to 2002, 73 women with vesicovaginal fistula underwent late (> 3 months) surgical repair. A multivariate analysis of the data was performed with the EPI-INFO software. All P-values were two-sided, with odds ratio and 95% confidence intervals. A total number of 73 patients underwent 97 procedures with a mean rate of 1.38 procedures/patient. The overall surgical success rate was 86.7%. Multivariate analysis demonstrated that recurrence was statistically significant for multiple fistulas (single vs two or more), fistula size (>10 mm), fistula type (Type I vs Type II), fistula etiology (obstetrical vs non-obstetrical) and the presence of urinary tract infection before the repair. Recurrence risk was fivefold higher for both the size and the type of the fistula, threefold higher for obstetrical etiology and 4.5-fold higher for multiple fistula. The interposition of flaps was a protective factor for recurrent cases. The surgical approach was not a significant prognostic factor of recurrence. Successful closure of a vesicovaginal fistula requires an accurate and a timely repair using procedures that exploit basic surgical principles. Multiple fistula, size and type of the fistula, and obstetrical etiology were the recurrence risk factors. We recommend in all patients with multiple risk factors for recurrence, the interposition of flaps.

Use of the LAHayeSIK??? Surgical System for Laser In Situ Keratomileusis

Purpose: To describe a new surgical instrument and associated surgical technique to standardize the laser in situ keratomileusis surgical procedure. Methods: Descriptive article providing detailed and step-by-step use of the LAHayeSIK Surgical System. Results: The LAHayeSIK System provides consistent control of the surgical principles, techniques, and environment. The maintenance of an isolated surgical field, secure control of eye position, intraoperative flap management, proximal plume evacuation, even hydration, backwash-free irrigation, automated aspiration, and facilitated flap repositioning and adhesion provided by the single handpiece was found to eliminate extraneous instrumentation and improve operating efficiency while maintaining a consistently clean surgical field. Conclusion: The integration of the LAHayeSIK Surgical System into a refractive practice provides in -depth and comprehensive control of basic surgical principles and techniques that are essential in significantly reducing postsurgical complications, improving outcomes, and reducing retreatments.

Technique of contemporary iliofemoral and infrainguinal venous thrombectomy

Patients with acute deep vein thrombosis involving the iliofemoral venous system experience the most severe postthrombotic sequelae. Treatment designed to reduce or eliminate the postthrombotic syndrome must necessarily remove thrombus to eliminate obstruction. Unfortunately, currently published guidelines do not recommend venous thrombectomy and actually recommend against its use because of the poor results initially reported. However, recent reports of venous thrombectomy and the long-term results of a large randomized trial confirm the significant benefit compared with anticoagulation alone. The technique of contemporary venous thrombectomy follows basic vascular surgical principles and offers patients the opportunity for complete or nearly complete thrombus extraction, thereby avoiding the significant morbidity of their anticipated postthrombotic syndrome. The techniques described herein represent the authors' approach to patients with few alternatives to clear the venous system. Because the patient benefit is well established, vascular surgeons should include contemporary venous thrombectomy as part of their routine operative armamentarium, offering this procedure to patients with extensive deep vein thrombosis involving the iliofemoral venous system, especially if other options are not available or have failed.

The biology of integration of the anterior cruciate ligament

The anterior cruciate ligament (ACL) is a short, stout, intra-articular, extrasynovial structure which acts to control rotational movements and anterior translation of the femur upon the fixed tibia.[1][1] Rupture is a traumatic event, often as a consequence of twisting upon the weight-bearing limb

Long-term Follow-up of a Randomized Trial Comparing the Beger and Frey Procedures for Patients Suffering From Chronic Pancreatitis

To report on the long-term follow-up of a randomized clinical trial comparing pancreatic head resection according to Beger and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy according to Frey for surgical treatment of chronic pancreatitis. Resection and drainage are the 2 basic surgical principles in surgical treatment of chronic pancreatitis. They are combined to various degrees by the classic duodenum preserving pancreatic head resection (Beger) and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy (Frey). These procedures have been evaluated in a randomized controlled trial by our group. Long-term follow up has not been reported so far. Seventy-four patients suffering from chronic pancreatitis were initially allocated to DPHR (n = 38) or LE (n = 36). This postoperative follow-up included the following parameters: mortality, quality of life (QL), pain (validated pain score), and exocrine and endocrine function. Median follow-up was 104 months (72-144). Seven patients were not available for follow-up (Beger = 4; Frey = 3). There was no significant difference in late mortality (31% [8/26] versus 32% [8/25]). No significant differences were found regarding QL (global QL 66.7 [0-100] versus 58.35 [0-100]), pain score (11.25 [0-75] versus 11.25 [0-99.75]), exocrine (88% versus 78%) or endocrine insufficiency (56% versus 60%). After almost 9 years' long-term follow-up, there was no difference regarding mortality, quality of life, pain, or exocrine or endocrine insufficiency within the 2 groups. The decision which procedure to choose should be based on the surgeon's experience.

Laparoscopic Radical Nephrectomy: A Single Center Experience

Renal cell carcinoma has become one of the most important indications for urological laparoscopic surgery. The laparoscopic technique combines the benefits of a minimal invasive approach with basic surgical principles. We report our experience with 52 procedures. Materials and methods Between June 2000 and December 2003 we performed 52 transperitoneal laparoscopic radical nephrectomies for clinical stage T1-T2 renal cell carcinoma. Median age of patients was 59 yrs (range 31–77 yrs). The mean tumor size was 5.4 cm (range 3–12 cm). Results In three patients (5.7%) conversion to open surgery was necessary. The mean operating time was 215 min (150–305 min). Post-operative hospitalization was 5.1 days (3–11 days). Median follow-up was 19.5 months (3–36 months). No cases of local recurrence or port metastasis occurred during observation. Conclusions In our center, a transperitoneal laparoscopic approach with the removal of intact specimens in endobags has become the standard treatment for stage T1-T2 N0 M0 renal cell carcinoma.

Procedures and surgeries of the teat

Injuries to the end of the teat are frequent and frustrating to treat. Treatment of these injuries evolved from being aggressive using teat knives to a more conservative approach employing rest nonreactive teat inserts. The process of milking seems simple, but it involves fine-tuned mechanics. Teat fibrosis, even when small, has a disastrous effect on the production life of an animal. There is no place for error; any surgical intervention should be precise and aim for perfection. Medical imaging techniques and minimally invasive surgery help the surgeon to make the best decision. Finally, more investigation is needed to treat varicose veins to understand the origin and develop better treatment. Teat injuries have drawn more attention more recently. Surgical interventions are better planned, and blind treatment with unsuitable teat knives is avoided. Treatment of superficial of full-thickness teat lacerations does not require a high level of anatomic or surgical knowledge, although basic surgical principles should be applied. Hemostasis, delicate débridgement and tissue handling, and appropriate suture materials and patterns are key to success. Appropriate sedation, anesthesia, and analgesia are essential to achieve this goal and should never be neglected.

Combined laparoscopic operation:report of 12 cases

目的 探讨腹腔镜多器官手术的可行性及优越性.方法 12例患者行腹腔镜胆囊切除加阑尾切除术5例,肝囊肿开窗引流术2例,肠粘连松解术4例,单侧卵巢囊肿切除1例.结果 12例多器官手术均获成功无并发症发生.术后住院时间平均为3.5±1.1 d,肠功能恢复时间平均为16.6±7.3 h,下床活动时间平均为20.5±5.6 h,术后疼痛轻微,仅1例使用镇痛剂.结论只要严格掌握手术指征,腹腔镜能安全有效地同时处理两种或两种以上的疾病。

The immediate management of fresh obstetric fistulas

Objective It has been a general rule to wait with the repair of an obstetric fistula for a minimum period of 3 months allowing the patient to become an outcast. In a prospective way an immediate management was studied and antibiotics were not used, all according to basic surgical principles. Methods A total of 1716 patients with a fistula duration of 3 to 75 days after delivery were treated immediately on presentation by catheter and/or early closure. Instead of antibiotics, a high oral fluid regimen was instituted. The fistulas were classified according to anatomic and physiologic location in types I, IIAa, IIAb, IIBa, and IIBb, and according to size in small, medium, large, and extensive. The operation became progressively more complicated from type I through type IIBb and from small through extensive. Results At first attempt 1633 fistulas (95.2%) were closed and another 57 could be closed at further attempt(s), accounting for a final closure in 1690 patients (98.5%); 264 patients (15.4%) were healed by catheter only. Of these 1690 patients with a closed fistula, 1575 (93.2%) were continent and 115 (6.8%) were incontinent. The results as to closure and to continence became progressively worse from type I through type IIBb and from small through extensive. Postoperative wound infection was not noted; postoperative mortality was encountered in 6 patients (0.4%). Conclusion This immediate management proves highly effective in terms of closure and continence and will prevent the patient from becoming an outcast with progressive downgrading medically, socially, and mentally.

Current management of peripheral trigeminal nerve injuries

Current management of peripheral trigeminal nerve injuries

A decision tree for bone graft success

Successful bone grafts to the maxillomandibular complex depend upon an understanding of basic bone biology, appropriate surgical technique, evaluation of recipient and donor sites, and knowledge of bone graft materials.This lecture presents the protocol for bone graft success and discusses the reasons that affect success and/or failure. Particular attention is directed to evaluation of the recipient site and specifically the quality and quantity of cancellous and cortical bone. This evaluation combined with an understanding of basic surgical principles aids the clinician to decide not only on appropriate surgical procedure, but upon the use of autogenous bone versus allogeneic or alloplastic grafts. This lecture guides the clinician to answer specific questions of when to use an onlay bone graft, a split cortical graft, the sandwich graft, the sinus graft, ridge preservation, socket grafts, particulate grafts with titanium or membrane stabilization.Autogenous bone has been considered the “gold standard” as the most predictable graft. However, harvesting autogenous bone requires a second surgical site, increased surgical and healing time, and increase morbidity. Is there an alternative to autogenous grafts? This lecture also discusses when autogenous grafts are absolutely indicated and when alternative graft materials are successful as well as when they fail to produce predictable success.ReferencesRoberts E, et al: Bone physiology and metabolism. Calif Dent Assoc J October:54, 1987Reddi AM, Wientroub S, Muthukumaran N: Biological principle of bone induction. Orthop Clin North Am 18:207, 1987Wittbjer J, Palmer B: Osteogenetic activity in composite grafts of demineralized compact bone and marrow. Clin Orthop 173:229, 1983 Successful bone grafts to the maxillomandibular complex depend upon an understanding of basic bone biology, appropriate surgical technique, evaluation of recipient and donor sites, and knowledge of bone graft materials. This lecture presents the protocol for bone graft success and discusses the reasons that affect success and/or failure. Particular attention is directed to evaluation of the recipient site and specifically the quality and quantity of cancellous and cortical bone. This evaluation combined with an understanding of basic surgical principles aids the clinician to decide not only on appropriate surgical procedure, but upon the use of autogenous bone versus allogeneic or alloplastic grafts. This lecture guides the clinician to answer specific questions of when to use an onlay bone graft, a split cortical graft, the sandwich graft, the sinus graft, ridge preservation, socket grafts, particulate grafts with titanium or membrane stabilization. Autogenous bone has been considered the “gold standard” as the most predictable graft. However, harvesting autogenous bone requires a second surgical site, increased surgical and healing time, and increase morbidity. Is there an alternative to autogenous grafts? This lecture also discusses when autogenous grafts are absolutely indicated and when alternative graft materials are successful as well as when they fail to produce predictable success. References Roberts E, et al: Bone physiology and metabolism. Calif Dent Assoc J October:54, 1987 Reddi AM, Wientroub S, Muthukumaran N: Biological principle of bone induction. Orthop Clin North Am 18:207, 1987 Wittbjer J, Palmer B: Osteogenetic activity in composite grafts of demineralized compact bone and marrow. Clin Orthop 173:229, 1983

Combined procedures in laparoscopic surgery.

With advancements in minimal access surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies at the same surgery. In our center, we performed 145 combined surgical procedures from January 1999 to December 2002. Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures. The combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy, ovarian cystectomy, tubal ligation, urological procedures, fundoplication, splenectomy, hemicolectomy, and cystogastrostomy. In the same period, 40 patients who had undergone laparoscopic cholecystectomy and 40 patients who had undergone ventral hernia repair were randomly selected for comparison of intraoperative outcomes with a combined procedure group. All the combined surgical procedures were performed successfully. The most common procedure was laparoscopic cholecystectomy with another endoscopic procedure in 129 patients. The mean operative time was 100 minutes (range 30-280 minutes). The longest time was taken for the patient who had undergone laparoscopic splenectomy with renal transplant (280 minutes). The mean hospital stay was 3.2 days (range 1-21 days). The pain experienced in the postoperative period measured on the visual analogue scale ranged from 2 to 5 with a mean of 3.1. Of 145 patients who underwent combined surgical procedures, 5 patients developed fever in the immediate postoperative period, 7 patients had port site hematoma, 5 patients developed wound sepsis, and 10 patients had urinary retention. As long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery. Minimal access surgery is feasible and appears to have several advantages in simultaneous management of two different coexisting pathologies without significant addition in postoperative morbidity and hospital stay.

Recurrent Undescended Testes

Failure of primary orchiopexy for undescended testis is a relatively uncommon occurrence. Redo orchiopexy is a technically challenging procedure with a high rate of success. Prevention of recurrent undescended testis can be achieved with the application of the basic surgical principles of (1) extensive proximal cord mobilization, (2) careful inguinal dissection, and (3) secure intrascrotal gonadal fixation without tension. Secondary or redo orchiopexy requires an experienced pediatric subspecialty surgeon (pediatric or urologic), detailed anatomic knowledge, meticulous operative technique, magnification and delicate instrumentation, injury-free cord dissection, full proximal retroperitoneal cord mobilization, and tension-free intrascrotal fixation. En bloc cord dissection, cord transposition below the deep inferior epigastric vessels, and inguinal cordopexy are helpful adjuncts to reoperative orchiopexy. Successful correction of recurrent undescended testis should approach 95%.