Formal Repair Research Articles

PMO-065 Repair of fractured central venous catheters for parenteral nutrition: techniques and risk of infection

IntroductionTunnelled central venous catheters (CVCs) are the best method of vascular access for long-term parenteral nutrition. Failure of intravenous access can necessitate emergeny admission. Removing and replacing CVCs is painful,...

Thickness of Orbicularis Oris Muscle in Unilateral Cleft Lip

Our protocol for closure of unilateral complete or severe incomplete cleft lip begins with active dentofacial orthopedics (Latham device) followed by nasolabial adhesion and alveolar gingivoperioplasty. We have observed that preliminary adhesion provides more orbicularis oris muscle for the second-stage labial repair. A quantitative prospective assessment of all patients undergoing nasolabial adhesion by the senior author between November of 2009 and July of 2010 was undertaken to assess whether there is an increase in lateral orbicularis oris muscle mass by the time of formal repair. Standard anthropometric points were placed before nasolabial adhesion and again at the second-stage closure. Ultrasonographic measurements of orbicularis muscle thickness were made on both lateral labial elements along a line drawn between sbal and cphi. The mean interval increase in thickness of lateral orbicularis oris was determined. Sixteen patients underwent nasolabial adhesion during the study period. Four patients with asymmetric bilateral cleft lip patients and 2 patients who did not have a second ultrasonographic study were excluded. The remaining 10 patients in the study had a nasolabial adhesion at a mean age of 3.9 months (range, 3.1-4.3 months). Mean orbicularis oris thickness before adhesion was 0.7 mm on the cleft side and 1.2 mm on the noncleft side. The increase in orbicularis thickness after the mean interoperative interval of 2.9 months (range, 2.6-3.5 months) was calculated. On the cleft side, there was 0.8 mm (138%) mean increase in orbicularis oris muscle thickness compared with 0.4 mm (32%) mean increase on the noncleft side. Labial adhesion in preparation for repair of unilateral complete or severe incomplete cleft lip results in a measurable increased thickness of lateral orbicularis oris. This additional muscular bulk is useful in construction of the philtral ridge.

Intraperitoneal Rupture of the Bladder

Computed tomographic cystography is an accurate method for diagnosis of bladder rupture. Sagittal and coronal reformation may be helpful in identifying most sites of bladder rupture. Intraperitoneal bladder rupture must undergo formal repair and suprapubic tube drainage.

Management of the Bladder During Surgical Treatment of Enterovesical Fistulas from Benign Bowel Disease

Management of the bladder in enterovesical fistulas from benign bowel disease is not well described in the literature and there is no clear consensus. A retrospective chart review was done of all patients with benign bowel disease and an enterovesical fistula who underwent definitive surgical management between January 1993 and December 2005. Patients were excluded if they had any history of abdominal cancer or pelvic radiation. Surgical management protocol for enterovesical fistulas included a period of perioperative bowel rest, surgical exploration, separation of the fistulized bowel from the bladder, resection of the diseased bowel segment, and Foley catheter placement for 1 week. Seventy-four patients were eligible for the study. The average patient age was 54.3 years (range 19 to 88 years old). Twenty-six women and 48 men underwent celiotomy and segmental resection of the offending bowel and bowel side of the fistula. The bladder side of the fistula was managed by Foley catheter alone in 68% and by surgical repair in 32%. Fifty-two patients had diverticulitis (70.3%) and 22 had Crohn's disease (29.7%). Mean followup was 26.4 months, and median followup was 6.45 months. One patient developed a colocutaneous and vesicocutaneous fistula after celiotomy. The remaining bladder defects healed within 1 week. Successful surgical management of most enterovesical fistulas from diverticulitis or Crohn's disease requires only resection of the diseased bowel, with minimal need for repair or resection of the bladder side of the fistula. Indwelling Foley catheter placement alone is typically sufficient for bladder healing. Only when there are overt defects into the bladder should formal repair be undertaken.

Vaginal Evisceration: A Late Complication of Multiple Vaginal Prolapse Operations

Spontaneous transvaginal small bowel evisceration is uncommon and is distressing to a patient. To date it has been reported in less than 100 cases worldwide. It often occurs in older women with previous vaginal surgery and is often associated with other perineal conditions. This case reports on an elder lady who presented to the emergency room with spontaneous atraumatic small bowel evisceration with a history of multiple transvaginal prolapse repairs. Initial management involved active resuscitation and protection of eviscerated bowel. A perineal/transvaginal repair should be attempted first and is usually successful. Formal repair is to be delayed and the type of operation advocated should be tailored to patient health status, psychosocial need, and potential complications.

Use of modified tension band sutures for fingernail disruptions

A series of 66 patients, aged between 1 and 70 years, with 70 disruptive injuries to finger nails was reviewed. The injuries were treated by cleaning of the finger, evacuation of haematoma and anatomical replacement of the nail plate, or a substitute, which was secured with a modified dorsal tension band suture without formal repair of the nail bed. K-wire fixation of the distal phalanx was employed only in the event of displaced fracture of the distal phalanx, complete absence of the nail plate and laceration extending to the distal pulp. This simple method, which bypasses the injured and friable, but vital nail structures resulted in uncomplicated re-formation of the normal nail plate in all of the cases. Removal of the nail plate and formal repair of the nail bed is not necessary in any age group with finger nail disruptions.

Recurrence of Pseudomyxoma Peritonei within the Inguinal Canal

Tumor appearing in an inguinal hernia sac indicates widespread carcinomatosis with ascites. A new onset hernia is a common clinical presentation of pseudomyxoma peritonei syndrome arising in an appendiceal mucinous tumor. Recurrence of pseudomyxoma peritonei within the inguinal region was previously reported in only a single patient. We present five patients with a recurrence of pseudomyxoma peritonei tumor nodules in the inguinal region following cytoreductive surgery and attempt to understand the etiology of this treatment failure. From a database of 910 patients with mucinous appendiceal tumors with peritoneal dissemination who had definitive treatment, five patients who had disease recurrence within the inguinal region were identified. The clinical histories were studied and presented in order to make future recommendations regarding the management of these patients. Five patients with ages ranging 39 to 67 years had a mucinous tumor in the inguinal region as a recurrence after a previous cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. One of them had separate recurrence in both right and left inguinal regions. All these patients were made disease-free by the reoperative surgery with a sacrifice of the testicle in four. None have evidence of a recurrence of an inguinal hernia despite the lack of formal repair. At the time of initial cytoreductive surgery the surgeon should be aware of the inguinal region as a possible site of relapse. This may be more problematic in patients who have had prior surgery with mucoid fluid in a hernia as the presenting sign of pseudomyxoma peritonei. Inguinal recurrences should be removed with clear margins even if orchiectomy is required.

Sequelae of traumatic laryngotracheal separation: the need for individualized long term treatment plan

Laryngotracheal separation is a rare variant of laryngeal trauma. However it is life threatening and potentially fatal. Patients with this injury usually succumb at the site of the accident itself. Here we present two cases of laryngotracheal separation of different etiology and of different outcomes. The treatment advocated for laryngotracheal separation is initially airway stabilization followed by formal repair of the transected trachea. However both our cases illustrates that the outcomes can be different and that a long term treatment plan should be individualized to each patient.

Penetrating injuries of the chest

A penetrating chest injury is one of the more frightening situations facing a trainee surgeon in an accident and emergency department. The more experienced surgeon realises that such patients have already selected themselves as potential survivors and there is only a limited number or procedures that can be done in such a situation, but that more than at any time in surgery, a rapid but orderly approach is necessary. Emergency thoracotomy, relief of tamponade and control of haemorrhage may be lifesaving even when performed by the inexperienced surgeon. More formal repair, drainage and closure can be performed by the specialists when they arrive, but those initial minutes can be the difference between a neurologically impaired or a fully functioning patient. Surgical exploration is needed often in penetrating chest trauma than blunt trauma. However, where in the past a thoracotomy may have been necessary for full diagnosis, in the stable patient, judicious use of spiral CT, ultrasound and angiography may avoid unnecessary thoracotomy. Techniques of damage control surgery, permissive hypotension and minimally invasive thoracoscopy reflect progress in the management of chest trauma but their role in the emergency department has yet to be fully defined. With ongoing changes in surgical training it is increasingly likely that penetrating chest injuries will present to a non-cardiothoracic trained resident who will be required to initiate the necessary surgery. It is therefore encumbent on all residents in such a position to familiarise themselves with the indications, the timing and the approaches to emergency surgery of the chest.

Rectocele: pathogenesis and surgical management.

Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty. The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation. The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.

Simple laparoscopic gastropexy as the initial treatment of paraoesophageal hiatal hernia.

Paraoesophageal hiatal hernia is relatively rare compared with sliding hernia but it is associated with serious complications. Its clinical management presents a major challenge since many patients are elderly and unfit for a formal repair. This paper describes a laparoscopic method aimed at reducing the complications of open repair. Thirteen patients treated for symptomatic paraoesophageal hernia were included in the study. Eleven patients successfully underwent a simple laparoscopic modification of the Boerema anterior gastropexy. Two patients required an open anterior gastropexy through a minilaparotomy because of incomplete reduction of the hernia. A five-puncture technique was used. The stomach and any other contents of the sac were reduced into the abdomen and the stomach was firmly fixed to the fascia of the anterior abdominal wall with GORE-TEX sutures tied extracorporeally. There was one postoperative death due to spontaneous intrathoracic perforation of the posterior aspect of the stomach in an elderly woman with severe cardiac disease. There was no postoperative morbidity. Eight of the ten patients who went home following laparoscopic gastropexy have remained asymptomatic on follow-up. In three patients, two in the laparoscopic group and one in the open group, symptoms recurred. While anterior gastropexy has a significant incidence of recurrent herniation, the clinical results of this simple procedure in a high-risk population support its use as the initial surgical option.

Triceps tendinitis

Elbow extension is very critical for the throwing athlete. The extensor mechanism of the elbow is a relativelyuncommon source of clinical dysfunction. However, two primary processes may affect the triceps tendon, triceps tendonitis, and triceps avulsion injuries. Triceps tendonitis, the more common of the two, is manifested by chronic posterior elbow pain with extension activities. It occurs almost exclusively in males, usually in the fourth decade of life, and especially in individuals who perform forceful repetitive extension activities, eg, throwing athletes. Two distinct subsets of patients exist: those with and those without an olecranon traction spur. Conservative management involves avoidance of repetitive forceful elbow extension, nonsteroidal anti-inflammatories, and time. Splinting in 45° of elbow flexion may be useful if tolerated. Counterforce bracing is typically unsuccessful because the cross-section of the arm changes with biceps contraction. Corticosteroid injection is contraindicated. Although conservative management is limited in scope, it is usually successful in triceps tendonitis in the absence of an olecranon traction spur. The presence of an olecranon traction spur is associated with a higher failure rate of conservative treatment necessitating surgical intervention. Surgical management, when required, involves subperiosteal exposure and excision of the spur and the olecranon tip and formal repair of the triceps tendon.

Wound dehiscence at a 7-mm port site closed with tissue adhesive

Objective To describe the herniation of omentum through a 7-mm suprapubic port site, which had been closed with tissue adhesive, following laparoscopic sterilization, requiring repair under general anaesthetic. Setting Minimal access gynaecological surgery unit in a district general hospital. Subject A 26-year-old multiparous woman who presented with abdominal pain and an omental herniation through her suprapubic port site. Intervention The patient required repeat laparoscopy and digital reduction of the hernia with formal repair of the rectus sheath defect. Conclusion This case of herniation through a midline 7-mm port site may have implications for the closure of wounds at laparoscopy. Most gynaecologists do not formally close the rectus sheath at laparoscopic sterilization; however, with the possibility of visceral herniation and vascular compromise, this practice may change in the future. It is not clear whether the tissue adhesive had a role in this complication.

Hybrid total hip replacement

This article reviews the rationale and current knowledge regarding hybrid total hip arthroplasty. Patient selection, preoperative planning, and templating are covered in depth. The authors provide technical pearls regarding the surgical performance of hybrid total hip replacement using a posterolateral approach to the hip. Particular attention is given to acetabular component positioning, seating of the acetabular component, and formal repair of the posterior capsule and short external rotators.

Bladder rupture from external trauma: diagnosis and management.

Rupture of the bladder from external trauma is usually due to a blow to the abdomen when the bladder is distended or associated with a fractured pelvis. The diagnosis is made by performance of a retrograde cystogram and observation of contrast extravasation. An intravenous contrast study is not acceptable. All patients with an intraperitoneal bladder rupture should have formal repair. Extraperitoneal bladder ruptures may be treated with catheter drainage if the urine clears of blood promptly, the catheter drains well, and the bladder neck is not involved in the injury. Otherwise, formal repair is mandatory.

TREATMENT RESULTS USING A MIXED FIBER MESH IN PATIENTS WITH GRADE IV CYSTOCELE

Purpose We determined the efficacy of a modification of the 4-corner bladder and bladder neck suspension procedure using mixed fiber mesh to correct grade IV cystocele. Materials and Methods We evaluated 15 women with a mean age 67 years who had severe anterior vaginal wall prolapse, of whom 3 had concurrent enterorectocele. Previously 5 patients had undergone repair of anterior vaginal wall prolapse and 2 had undergone procedures for stress urinary incontinence. In 10 patients type II stress urinary incontinence was diagnosed with urethral hypermobility and abdominal leak point pressure greater than 90 cm. water. No patients with intrinsic sphincter deficiency were enrolled in the study. A mixed fiber mesh was positioned using a modification of the 4-corder bladder and bladder neck suspension technique. Patients with concurrent enterorectocele underwent simultaneous formal repair of the posterior descensus. Results All patients were available for postoperative pelvic examination at 3-month intervals. Mean followup was 23.4 months (range 18 to 39). Of the 15 women 13 were continent (dry) at followup. No recurrent cystocele was evident, except in 1 patient who presented with segmental posterior bladder prolapse. In 2 patients new onset enterorectocele developed 6 months after mesh implantation. Conclusions Our study confirms that the addition of mesh to the classic 4-corner bladder base and neck suspension procedure effectively treats incontinence and cystocele. We recommend this method for cases in which traditional techniques have previously failed and when the quality of suspending tissue is poor or defective, as in connective tissue disease. However, the risk of worsening enterorectocele or its new onset must be considered.

Reduction of early posterior dislocation following posterolateral approach in primary total hip replacement by formal posterior capsule repair

Reduction of early posterior dislocation following posterolateral approach in primary total hip replacement by formal posterior capsule repair

Management of gunshot injuries to the penis and anterior urethra.

To verify the appropriate methods of diagnosis and treatment of gunshot injuries to the penis and anterior urethra. Retrospective study. Fourteen patients presented over 5 years with gunshot wounds to the male genitalia with injuries involving the penis and or the anterior urethra. All patients underwent a full physical examination and retrograde urethrogram to fully stage suspected injuries. Of the nine patients sustaining penile wounds, four were superficial, requiring only debridement, and five involved the corpus cavernosum, necessitating formal repair. Physical findings of an expanding hematoma, a palpable corporeal defect, and excessive bleeding via the wounds were indicative of cavernosal injury and warranted a penile exploration. All patients were potent in follow-up, although two patients with extensive injuries did complain of curvatures. Retrograde urethrograms noted anterior urethral injuries in eight patients, three of whom also had sustained cavernosal injuries. Five were repaired primarily, and three were treated by urinary diversion via a suprapubic tube. Three patients developed urethral strictures: one in the primary repair group and two in the diversion group. The preferred method of handling low-velocity gunshot wounds to the penis and anterior urethral includes debridement of superficial wounds, repair of cavernosal defects, and primary repair of urethral injuries wherein tissue loss is not extensive to result in high-potency rates and lower rates of urethral stricture disease.

Bile duct injury during laparoscopic cholecystectomy: a report of the Standards Sub-committee of the Victorian State Committee of the Royal Australasian College of Surgeons.

A survey of Victorian surgeons performing laparoscopic cholecystectomy was carried out. This report discusses the bile duct injuries identified in the survey. Twelve injuries were recorded, a rate of 0.2%. Three of the 12 required formal repair, the other 9 being treated by T-tube alone. Possible mechanisms of these injuries, the experience of the surgeon, the role of operative cholangiography and delays in recognition of the injury are discussed.

Surgical management of large paraesophageal hernia with complete intrathoracic stomach.

AbstractBetween 1971 and 1986, the author operated on 30 patients, 23 women and 7 men, with large paraesophageal (PE) hernias and complete intrathoracic stomach. The average age of the patients was 70 years. Thirteen patients required urgent repair because of incarceration causing complete obstruction, bleeding, and, in one instance, perforation. Only 2 patients had a prior history of esophageal reflux. Surgery, always transabdominal, included excision of the sac, closure of the defect with pledgetted sutures, and anterior gastropexy. Four extremely poor‐risk patients underwent anterior gastropexy alone under local anesthesia. Two other patients underwent anterior gastropexy alone for different reasons. There were no deaths or major complications and no recurrences. The author's experience suggests that: (a) an abdominal approach is preferable to a transthoracic repair; (b) ancillary antireflux surgery, such as fundoplication, should be used only when indicated on the basis of a prior history of reflux esophagitis, which was the case in only 2 of our patients; (c) because the symptoms and complications of PE hernias result from the gastric volvulus rather than from the hernia per se, formal repair of the defect is not always necessary. Thus, patients whose general condition does not permit a major abdominal operation under general anesthesia can be completely relieved of their symptoms by an anterior gastropexy done under local anesthesia; (d) a PE hernia is a life‐threatening condition and elective repair should be recommended once the diagnosis is made.