Incidence Of Dehiscence Research Articles

Treatment of axillary bromhidrosis through a mini-incision with subdermal vascular preservation: a retrospective study in 396 patients.

Axillary bromhidrosis is a condition presenting as malodor caused by an interaction between the discharge of apocrine glands and bacteria. Topical agents, liposuction, and elective surgery are currently the main therapeutic modalities. However, the efficiency of these treatments and incidences of side effects are various and frequent, and depend on patient characteristics, surgical technique, and other unknown factors. We report a retrospective study of outcomes in 396 patients treated by mini-incision with subdermal vascular preservation. At 2 years postoperatively, 87.1% of patients had achieved very satisfactory results. Short-term side effects included hematomas, epidermal erosions, infections, necrosis, incision dehiscence, and skin ripples. Long-term side effects comprised comedones, epidermoid cysts, relapsing cyst infections, skin gauffers, scars, keloids, and persistent malodor. Some patients reported unsatisfactory cosmetic results, including skin gauffers, scars, or epidermoid cyst formations. Two discrete aspects of the procedure that must be considered are the extent of apocrine gland clearance, which must be thorough in order to achieve the resolution of malodor, and the maintenance of an intact subdermal vascular plexus to support the regrowth of skin flaps after surgery and to avoid the occurrence of severe side effects.

Periodontal Effects of a Transposed Versus a Conventional Flap in Mandibular Third Molar Extractions

The aim of this study was to compare a transposed with a repositioned flap by assessing the periodontal effects on the second molar and primary healing after extraction of partially impacted lower third molars. A total of 24 patients requiring partially impacted mandibular wisdom tooth removal were enrolled in the study. The test group (n = 12) underwent a transposed flap procedure, whereas the control group (n = 12) underwent a repositioned flap procedure. Plaque index, probing depth, bleeding on probing, and width of keratinized tissue were recorded the day of surgery (T1) and after 60 days (T4). Wound dehiscence was assessed on the mesio-distal and bucco-lingual directions at days 2 (T2), 7 (T3), and T4. No significant differences have been observed in the periodontal parameters between the groups at T1 and T4 (P > 0.05). Similarly, no difference was found at T2, T3, and T4 in wound dehiscence incidence (P > 0.05). To date, no data exists on the use of transposed flaps in third molar surgery; thus a comparison of results cannot be done. Further studies with larger population are needed to investigate the potential advantages of this type of flap.

Prolonged Negative Pressure Wound Therapy Followed by Split-Thickness Skin Graft Placement for Wide Dehiscence of Clamshell Incision After Bilateral Lung Transplantation: A Case Report

Clamshell incision is a standard approach for bilateral lung transplantation, providing a good operative field; however, once wide dehiscence occurs, its management is sometimes difficult because of intense immunosuppression and malnutrition of the recipient. A 22-year-old man with idiopathic pulmonary arterial hypertension underwent cadaveric bilateral lung transplantation through a clamshell incision using standard cardiopulmonary bypass. He developed wound dehiscence on postoperative day (POD) 20 that resulted in exposure of the bilateral fifth ribs and open pneumothorax. Considering the extreme malnutrition and emaciation of the recipient, we avoided initial closure of the dehiscence. After the debridement of necrotic tissue, negative pressure wound therapy was initiated on POD 25 and was continued for approximately 6 months with trafermin spray application. Eventually, the wound, including the fifth ribs, was completely covered with granulation tissue except for the wire tying the sternum. On POD 217, the patient underwent removal of the sternal wire followed by split-thickness skin grafting. His wound was successfully closed and he was discharged without activity limitation on POD 265.

Risk factors for the perineal incision complications after abdominoperineal excision for rectal cancer

To evaluate the factors affecting perineal incision complications after abdominperineal excision(APE) for rectal cancer. This was a retrospective study of 167 patients with rectal cancer undergoing APE at Peking University People's Hospital between October 1998 and December 2013. Chi-square test and multivariate Logistic regression analysis were used to identify risk factors. The overall rate of perineal incision complication was 24.6%(41/167) including 7 cases of incision infection, 10 cases of incision fat liquefaction, 21 cases of poor wound healing, 2 cases of incision fistula, 1 case of incision dehiscence. In univariate analysis, the risk factors associated with perineal incision complication were operating time≥280 minutes(P=0.005), blood loss≥350 ml(P=0.017) and the protective factors associated with perineal incision complication were the procedure of APE (P=0.048), intraperitoneal chemotherapy with 5-FU sustained release (P=0.014), lymph node metastasis (P=0.006), while gender, age, BMI, ASA score, other complications, distance from distal tumor to anal verge, preoperative radiochemotherapy, postoperative stay in ICU, total drainage volume 3 days before operation, tumor differentiation, and postoperative TNM staging were not associated with perineal incision complication(all P>0.05). Multivariate logistic regression analysis identified two independent risk factors: operating time≥280 minutes(OR=5.217, 95% CI:1.250 - 6.234, P=0.000), intraperitoneal chemotherapy with 5-FU sustained release(OR=3.284, 95% CI:1.156 - 9.334, P=0.026). Operating time≥280 minutes and intraperitoneal chemotherapy with 5-FU sustained release are independent risk factors for perineal incision complications after APE for rectal cancer. For patients receiving APE procedure, intraperitoneal chemotherapy with 5-FU sustained release should be used with caution, and the operative time should be reduced when possible.

Application of Computer-Assisted Design and Manufacturing–Fabricated Artificial Bone in the Reconstruction of Craniofacial Bone Defects

The purpose of this study was to evaluate the clinical application of individual craniofacial bone fabrications using computer-assisted design (CAD)-computer-assisted manufacturing technology for the reconstruction of craniofacial bone defects. A total of 8 patients diagnosed with craniofacial bone defects were enrolled in this study between May 2007 and August 2010. After computed tomography scans were obtained, the patients were fitted with artificial bone that was created using CAD software, rapid prototyping technology, and epoxy-methyl acrylate resin and hydroxyapatite materials. The fabrication was fixed to the defect area with titanium screws, and soft tissue defects were repaired if necessary. The fabrications were precisely fixed to the defect areas, and all wounds healed well without any serious complications except for 1 case with intraoral incision dehiscence, which required further treatment. Postoperative curative effects were retrospectively observed after 6 to 48months, acceptable anatomic and cosmetic outcomes were obtained, and no rejections or other complications occurred. The use of CAD-computer-assisted manufacturing technology-assisted epoxy-methyl acrylate resin and hydroxyapatite composite artificial bone to treat patients with craniofacial bone defects could enable the precise reconstruction of these defects and obtain good anatomic and cosmetic outcomes.

Ankle fusion with a retrograde locked intramedullary nail for sequela of lower extremity compartment syndrome

ObjectiveTo assess the value of ankle fusion with a retrograde locked intramedullary nail in the treatment of sequela of lower extremity compartment syndrome. MethodsThirty-five cases of equinus deformity following tibiofibular compartment syndrome treated by means of ankle fusion with a retrograde locked intramedullary nail from January 2001 to December 2010 were retrospectively reviewed. The complications, the time needed for bony fusion of the ankle joint assessed by anteroposterior and lateral X-ray photographs as well as patients’ subjective evaluation were recorded and analysed. ResultsAmong the 35 patients, 15 had previously undergone surgical treatment twice on the same limb, 13 had thrice and 7 had to be operated on four times before ankle fusion. An anterior midpoint approach to the ankle joint was adopted in 29 cases, while anterior midpoint approach plus a small incision on the posterior ankle joint was made in 17 cases, whereas lateral approach in 6 cases. Tarsus joint fusion was performed on 4 cases. The follow-up period ranged 6-124 months, averaged 40.6 months. Bone grafting was not performed in this series. Preoperative tibial shaft fracture occurred in one patient and was healed after conservative treatment. Incision dehiscence located at previous Achilles tendon incision was found in two patients. As a result, one received an intramedullary nail emplacement at calcaneoplantar part while the wound at anterosuperior part of the other one was healed by dressing change. Two patients failed to bony union 5 months postoperatively, in which one healed 10 weeks after retrieval of proximal tibial nail and another by iliac grafting. Terminal necrosis of the toe due to blood supply dysfunction was not found in this series. All the patients were satisfied with the ankle joint function postoperatively. The time for bony union on X-rays was 9.8 weeks on average. Except for one patient who demanded removal of intramedullary nail, all the intramedullary nails were not retrieved at the end of follow-up. Nail breakage happened in one patient and no other breakage or backing out of the nail was found. ConclusionsLower extremity compartment syndrome and residual ankle deformity often extremely impact ambulation and are hard to deal with because several pathologic phenomena might exist in these patients, for instance, poor skin conditions due to repeated preexisting surgery; poor perfusion in distal limbs following blood vascular injury; reflux limitation and long-term limb swelling due to muscle strength disturbance; osteoporosis as a result of long-term immobilization or limb disuse. Ankle fusion with a retrograde locked intramedullary nail is an optimal protocol to solve these clinical symptoms and rather ensures a definite fusion and firm fixation to these patients with simple manipulation and few complications.

Efficacy of cyanoacrylate glue in operative wound closure

Background: Amongst all the causes wound disruption, suture material plays a very significant role and the surgeon’s interest therefore in this subject is obvious. In surgery the choice of suture material has been largely empirical. One learns the art and craft of surgery from one’s chief and tendency is to use the suture material used by him. The objective of the study was to study the efficacy of cyanoacrylate glue in operative wound closure. Methods: This comparative study of efficacy of cyanoacrylate glue in operative wound closure was carried out at S. R. T. R. Government medical college, Ambajogai, Maharashtra, India for a period of two years. The study consisted of 100 patients all of whom underwent elective surgical procedures. They were divided into two groups: in group I patients (n = 50) cyanoacrylate glue was used for wound closure and in group II patients (n = 50) the wound was closed with interrupted silk sutures. Results: 54 were males and 46 were females. The most common operative procedure in this study was appendicectomy (28%). Maximum numbers of patients i.e. 42 were seen in the age group of 21-30 years. Time taken in the closure of wound by cyanoacrylate in group I was considerably lesser than the time taken in the closure of wound by silk suture in group II. The incidence of wound infection or dehiscence was also significantly lower in group I. The incidence of dehiscence in group I was 4% compared to 8% in group II. Conclusions: Use of cyanoacrylate glue was found to be more effective and conventional suturing.

Evaluation of Risk Factors of Surgical Wound Dehiscence in Adults After Laparotomy.

Objectives:The percentage of patients with difficult and prolonged healing of the wound is still high, while the immediate complications such as wound dehiscence occurs in up to 3 % of all treated patients in abdominal surgery. The aim of study was to analyze the risk factors and comorbidities in the group patients undergoing laparotomy and associated with early postoperative wound dehiscence.Methods:The retrospective study included all patients treated surgically at Clinic of General and Abdominal surgery, Clinical Center of the University of Sarajevo in the period from January 1, 2013 until January 1, 2016, with clinically verified surgical wound dehiscence.Results:The results showed statistically proportion of male patients (70%) compared to female (30%). The largest number of respondents were in age group 71-80. Surgical wound infection was evident in 61% of patients, malignant staining in 52%, hypoproteinemia was found in 50% of patients, anemia in 43%, peritonitis in 36% and diabetes in 14% of respondents. Of the total respondents with surgical wound dehiscence, 30 (68%) had comorbidities present. By analyzing the prevalence of comorbidity and risk factors recorded in relation to comorbidity, it was noted that hypertension is most often associated with hypoproteinemia (X2=4.399; p=0.036), wound infection (X2=4.112; p=0.043) and malignant diseases (X2=4.016; p=0.045). The frequency of the anemia, peritonitis and diabetes in the sample was not different in relation to the comorbidity conditions (p >0.05).Conclusions:The risk factors occurrence of surgical wound dehiscence in our study were identified as hypoproteinemia, malignant disease, anemia and peritonitis. The highest incidence of dehiscence was in patients operated on in medical emergencies, and in patients with malignant disease.

Type IV Cell-Mediated Hypersensitivity Reaction Caused by Titanium Implant Following Medial Displacement Calcaneal Osteotomy and First Metatarsal-Cuneiform Arthrodesis

INTRODUCTION AND OBJECTIVES: Due to its inert character and desired biocompatibility, titanium (Ti) implants have been universally accepted as safer alternatives to the previous conventional orthopedic hardware implants. However, a recent emergence of Type IV hypersensitivity reactions to Ti have displayed symptoms that include eczema, contact dermatitis, prolonged fever, sterile osteomyelitis, and impaired fracture and wound healing. The following case presents a patient with postoperative incision dehiscence and devascularization of cortical surfaces in contact with Ti hardware after undergoing a medial displacement calcaneal osteotomy and a first metatarsal-cuneiform arthrodesis. To our knowledge, this is the only reported case of an allergic reaction to a Ti implant in the foot or ankle in the United States. METHODS: Diagnostic tools to confirm a Ti hypersensitivity reaction include a patch test and lymphocyte transformation test. The lymphocyte transformation test can be utilized if a false negative patch test is suspected. Potential treatment options include immunosuppressants, removal or substitution of the Ti hardware, and external fixation. RESULTS: In this case, the patient's allergy to Ti was confirmed with a patch test, and all hardware was subsequently removed with no other complications. CONCLUSIONS: A hypersensitivity reaction to Ti should remain a differential diagnosis for a patient presenting with symptoms such as prolonged fever, contact dermatitis, sterile osteomyelitis, and impaired wound healing. Preoperative diagnostic tools, such as the patch test, can be utilized to prevent allergic reactions from occurring. Treatments for Ti hypersensitivity should be tailored to fit the patient's needs and can include removal or substitution of the Ti hardware, external fixation, and immunosuppressants.

Neck Incision Planning for Total Laryngectomy with Pharyngectomy.

To investigate the effect of skin incision location for total laryngectomy with pharyngectomy (TLP) on postoperative outcomes including wound dehiscence and infection rate. Case series with chart review. Academic tertiary care center. A retrospective analysis was conducted of all patients undergoing TLP with flap closure at Johns Hopkins Medical Institutes between August 2005 and February 2013. The effects of patient characteristics and skin incision technique on postoperative wound dehiscence and infection were analyzed using cross-tabulations and multivariate regression modeling. A total of 49 patients were included in the analysis; 31 received low-neck apron (LNA) incisions with an incorporated tracheostoma, while the remaining 18 had mid-neck apron (MNA) incisions with separate tracheostoma fashioned inferior to their incisions. Of these patients, 17 experienced incisional wound dehiscence (35%), and 18 contracted postoperative infections (37%). Generalized linear regression models demonstrated a significantly increased odds of wound dehiscence for patients with LNA incisions (odds ratio 29.8; 95% CI, 1.4-631.5, P = .029). There were no significant predictive variables for postoperative infection. These results demonstrate that the use of a separately fashioned tracheostoma with MNA incision is associated with decreased rate of wound dehiscence in patients undergoing TLP.

Modified Transverse Thoracosternotomy and Cost-Effective Reinforced Sternal Closure

The bilateral transverse thoracosternotomy clamshell incision provides excellent exposure to the mediastinal structures in double lung transplantation. The use of a modified transverse sternotomy and a figure of 8 configuration with one monofilament metal wire, along with two longitudinal wires across the sternal division, results in greater stability and equally distributed oblique tension. Our described technique was more cost effective and resulted in no incidence of dehiscence. We present our experience using a modified transverse sternotomy and reinforced sternal closure method.

Clinical application of modified skin soft tissue expansion in early repair of devastating wound on the head due to electrical burn

To observe the clinical effect of modified skin soft tissue expansion in repair of devastating wound on the head due to electrical burn in the early stage. Twenty-one patients with partial scalp soft tissue defect accompanying skull exposure and necrosis in different degree due to high-voltage electrical burn were hospitalized from April 2009 to October 2014, with wound area ranging from 7 cm × 5 cm to 15 cm × 13 cm. The wounds were debrided as early as possible, and necrotic skulls were kept in situ and covered with porcine ADM and silver-containing dressing. Bacterial culture of exudate from the residual soft tissue was carried out 3 days after hospitalization. Pertinent antibiotics were applied topically to control infection, and autologous split-thickness skin grafts were transplanted. Two to three weeks after injury when the skin grafts survived, modified skin soft tissue expansion was carried out. The crossbow-form incision was made on the normal scalp 2 cm away from the edge of transplanted skin; a capsule cavity was formed by ladder-like dissection. An expander was inserted with the injection port laying outside. The expander was stretched by inflation and deflation. The incisions were sutured layer by layer. The time of continuing negative pressure drainage in the interval of expansion was extended. Volume of water reaching 2 to 3 times of the capacity of expander was injected for excessive expanding. The expanded skin flap was rotated to repair the wound after expansion was ended. Within 1 week after debridement, 4 kinds of bacteria were detected in the bacterial culture of wound exudate, including 4 cases of Staphylococcus aureus, 5 cases of Staphylococcus epidermidis, 5 cases of Pseudomonas aeruginosa, and 3 cases of Acinetobacter baumannii. A total of 26 expanders were imbedded. No infection or incision dehiscence in the expanding area or cracking and leakage of expander was observed during expanding period. Two to three months after injury, expanded skin flap transplantation was completed, and the wound was repaired. Raw wounds were seen in 4 expanded skin flaps after transfer, and they healed after dressing change. Punctiform ulceration at the seams of 2 flaps was observed one month after the operation, which healed after removing few pieces of sequestra by themselves. The other expanded skin flaps survived well. During the postoperative follow-up for 3 to 12 months, satisfactory appearance and hair growth was observed in the operation area. Repair of the devastating wound on the head due to electrical burn with modified skin soft tissue expansion could achieve the result of early wound covering and cosmetic repair without alopecia in one time.

Versatility of the Angularis Oris Axial Pattern Flap for Facial Reconstruction.

To describe the versatility of the axial pattern flap based on the cutaneous perforating branch of the angularis oris artery for reconstruction of large facial defects in dogs, including complications and clinical outcomes. Retrospective clinical case series. Client-owned dogs (n = 8). Facial flaps (n = 9) based at the commissure of the lip with a caudodorsal orientation were utilized, with established anatomical borders. Flaps were elevated deep to the panniculus carnosus in a caudal to rostral direction, preserving the angularis oris artery, its cutaneous perforator, and surrounding cutaneous vasculature. Flaps were rotated dorsally or ventrally to cover the defect. Primary closure of the donor site was by direct apposition in all cases. Angularis oris axial pattern flaps were most commonly used to close large defects of the nasomaxillary area rostral to the eyes (6 dogs), followed by orbital (2) and intermandibular (1) defects. Defects occurred because of tumor resection (6 dogs), trauma (2), and a chronic, non-healing wounding (1). All flaps healed with acceptable functional and cosmetic outcomes without major complications. Followup ranged from 10 days to 16 months. Minor postoperative complications included flap edema (8 dogs), partial incisional dehiscence (3), distal tip necrosis (2), and oroantral fistula recurrence (1). Angularis oris axial pattern flaps provided hirsute, full-thickness skin coverage of a variety of large facial defects with minor complications, and should be considered when restructuring large defects of the rostral face or chin.

Clinical analysis of colon cancer combined with abdominal abscess

Objective To summarize the clinical characteristics, preoperative examinations and therapeutic method of colon cancer combined with abdominal abscess. Methods The clinical data of 41 patients with colon cancer combined with abdominal abscess who were admitted to the First Hospital of Longyan between January 2008 and August 2014 were retrospectively analyzed. All the patients underwent laboratory tests and imaging examinations before operation. According to the principles of operative safety and radical resection of tumor, 41 patients underwent open operation and then received the fluid infusion, antibiotic treatment, parenteral nutrition support and symptomatic treatment after operation. Patients were followed up via telephone interview and outpatient examination till August 2014. Results All the 41 patients had different levels of obstruction and infection at admission, and concomitant diabetes mellitus were detected in 26 patients, essential hypertension in 21 patients, heart diseases in 19 patients and chronic obstructive pulmonary disease in 9 patients. The results of laboratory tests showed that there were 4 patients with hemoglobin (Hb) 90 g/L, 36 patients with albumin (Alb) <30 g/L, 18 patients with increased glycosylated hemoglobin (GHb) , 41 patients with increased serum procalcitonin and 10 patients with increased blood carcinoembryonic antigen (CEA) . Abdominal tumors and intestinal obstructions were detected in 41 patients by thoracic and abdominal enhanced CT, intraluminal tumors in 23 patients by colonoscopy because of unsuccessful placement of colonoscopy in 19 patients, the metal stent endoprosthesis was placed in 2 patients to relieve obstruction. Fifty-nine strains of bacteria were cultured from 41 copies of the pus (28 copies obtained from diagnosistic peritoneocentesis and 13 copies obtained from operation) , and most of them were escherichia coli with a percentage of 61.0% (36/59) and were sensitive to imipenem. All patients underwent open surgery including 33 patients combined wtih enterostomy. The operation time was 150-272 minutes with a median time of 221 minutes. The volume of intraoperative blood loss was 100-800 mL with a median volume of 370 mL. The tumor located at the ileocecal valve was detected in 6 patients and ascending colon in 9 patients, and then palliative or radical right hemicolectomy was performed. The tumor located at the hepatic flexure of colon was detected in 2 patients and then radical extended right hemicolectomy was performed. The tumor located at the splenic flexure was detected in 4 patients and descending colon in 7 patients, and then the radical resection and terminal ileostomy were performed. Among 13 patients with tumor located at the sigmoid colon, 12 patients received radical resection and 1 patient received palliative resection. Eleven patients were complicated with pulmonary infection, 6 patients with infection or dehiscence of incision, 5 patients with anastomotic leakage, 4 patients with ureteral injury, 4 patients with heart failure, 3 patients with paralytic intestinal obstruction, 2 patients with septicemia, 1 patient with renal failure, 1 patient with cerebral infarction and 1 patient with pulmonary embolism. Nine patients died after operation. The diameter of resected tumor was 4.5-15.0 cm with a median diameter of 9.4 cm. High-differentiated tumors were detected in 25 patients, moderate-differentiated tumors in 12 patients and low-differentiated tumors in 4 patients (signet-ring cell carcinoma in 1 patient) . There were 4 patients in the T3 stage of tumor and 37 patients in the T4 or T4b stage. The number of lymph node dissection was 23 (range, 15-35 ) with 18 positive lymph nodes. Six patients had lymph node metastasis. Twenty-eight patients were followed up for a median time of 27 months (range, 3-80 months) . During the follow-up, 16 patients died and 12 patients survived, 10 patients died of tumor recurrence and metastasis, 6 patients died of other diseases, 4 patients had tumor recurrence and metastasis and 8 patients had no recurrence and metastasis. Conclusions Patients with colon cancer combined with abdominal abscess are usually complicated with internal diseases, with a high mortality. Surgical treatment is the only curative treatment option, but an accurate preoperative evaluation is essential and the opportunity of operation should be evaluated before operation, the injury of ureteral , vascular and other surrounding important structures should be avoided during operation, meanwhile, intraoperative application of enterostomy could reduce anastomosis-related complications. After operation, routine peritoneal lavage and antibiotics according to the drug sensitive test are conducted for reducing the postoperative complications and mortality. Key words: Colonic neoplasms; Abdominal abscess; Surgical procedure, operative

PTU-228 Abdominal fascial wound closure with 2–0 sutures does not lead to increased rates of dehiscence or incisional hernia

Introduction Emerging evidence has shown that using smaller more frequent sutures close to the fascial wound edge is associated with a lower incidence of incisional hernia, dehiscence and surgical site infection compared to conventional wound closure. 1 However in implementing this practice we have experienced difficulty due to concerns regarding sutures below 1–0 grade allowing increased rates of early dehiscence and incisional hernia. We sought to demonstrate the safety of this method of wound closure. Method Un-selected patients undergoing abdominal surgery (elective and emergency) were prospectively collected from within the practice of a single surgeon in a regional teaching hospital. All wounds greater than four centimetres (fascia defect length) were included. All patients underwent closure of abdominal fascial wounds using a suture to wound length ratio of at least 4:1. Suture material was 2–0 PDS. Risk of death from surgery was preoperatively calculated using the P-POSSUM score. Initial follow up period was 30 days from procedure. Study end points were length of stay, morbidity and mortality within 30 days, dehiscence and hernia formation rate. Results 34 patients underwent fascial closure as described above, 17 cases were patients undergoing emergency laparotomy. Average fascial defect length was 13.8 cm (median 14.5 cm); average length of suture used was 98.5 cm (median 82 cm). Average ratio of suture length to wound length was 7.5. Mean length of stay in this group was 5.4 days. Average BMI was 28.9; average calculated risk of death was 11.6%. A single patient died from overwhelming sepsis shortly after emergency laparotomy. Three patients developed chest sepsis post operatively (emergency group) and two elective patients were readmitted within 30 days with chest infection and hypocalcaemia respectively. Conclusion We have demonstrated that using a small, frequent suture does not give rise to increased rates of early dehiscence, incisional hernia or major wound complications in the early post operative period. Disclosure of interest None Declared. Reference Israelsson L, Millbourn D. Prevention of incisional hernias. How to close a midline incision. Surg Clin North Am. 2013;93:1027–1040

The biplanar oncoplastic technique case series: a 2-year review.

Oncoplastic techniques for breast reconstruction following partial mastectomy are now commonly included in the armamentarium of most reconstructive plastic surgeons. These techniques have been frequently used for women with large breast volume and less frequently used form women with small to moderate breast volume. Most women with smaller breast volumes have been typically considered for mastectomy. As an alternative to mastectomy, the biplanar technique was designed and described as an oncoplastic option. The purpose of this manuscript is to review our 2-year experience using this technique in a series of women with small to moderate breast volume. A retrospective review of patients who underwent oncoplastic surgery from 2011-2012 by the senior authors (RM and MYN) was completed. Ten patients were identified that had the biplanar technique involving glandular tissue rearrangement in conjunction with the immediate placement of a submuscular implant or tissue expander. Patient demographics, perioperative details, and post-operative outcomes were evaluated. The mean age and BMI of the ten patients in the study was 56 years (range, 40-68 years) and 24.1 years (range, 20.3-28.6 years) respectively. The mean resection volume was 76.5 g (range, 25-164 g). Eight patients had placement of a permanent implant and two patients had placement of a tissue expander. The average volume of the implanted devices was 138 cc (range, 90-300 cc). In eight patients, a sheet of acellular dermal matrix was used. Immediate biplanar reconstruction was performed in seven patients and a staged-immediate biplanar reconstruction was performed in three patients. Complications included a positive margin on final pathology requiring mastectomy (n=1), infection (n=1), incisional dehiscence following radiation (n=1), and loss of nipple sensation (n=2). Follow-up ranged from 4.5-27 months (mean of 19.5 months). The biplanar oncoplastic technique may represent a valuable option in women with small to moderate breast volumes that choose to have breast conservation therapy (BCT). This technique has demonstrated success with minimizing contour irregularities and maintaining breast volume. Based on our early experience, patient satisfaction is favorable.

Indications, complications, and outcome of horses undergoing repeated celiotomy within 14 days after the first colic surgery: 95 cases (2005-2013).

To examine factors associated with short- and long-term prognosis for horses undergoing repeated celiotomy within 14 days after the first colic surgery. Retrospective case series. 95 horses that had undergone 2 celiotomies within a 14-day period between 2005 and 2013 at 3 equine referral hospitals. Historical, clinical, and laboratory data were compared between horses that did not survive and horses that did survive to hospital discharge (short-term survival rate) and to > 3 and > 6 months after hospital discharge (long-term survival rates). Strangulating small intestinal lesions were the most common finding during the first celiotomy (60/95 [63.2%]), and persistent gastric reflux was the most common reason for the second celiotomy (56/95 [58.9%]). Reasons for a second celiotomy were not associated with survival rate. For horses that had long-term follow-up, 22 of 92 (23.9%) survived > 6 months after hospital discharge. Two of 13 horses with intestinal resections during both surgeries survived to > 6 months after hospital discharge. Compared with horses not undergoing intestinal resection, significantly fewer horses requiring resection during 1 or both surgeries survived to hospital discharge and to > 3 and > 6 months after hospital discharge. Incisional infections occurred in 68.4% (26/38) of horses that survived to hospital discharge, and 31.6% (12/38) developed incisional hernias or dehiscence. Results indicated that the prognosis for horses undergoing repeated celiotomy is guarded, and intestinal resection negatively affects the long-term survival rate.

The relationship of age and radiographic incidence of superior semicircular canal dehiscence in pediatric patients.

To determine if age affects radiographic incidence of superior semicircular canal dehiscence (SSCD) in pediatric patients. Retrospective case review. Tertiary children's hospital. Patients (0-18 yr) with high-resolution computed tomography (CT) temporal bone scans from April 2001 to February 2013. Diagnostic high-resolution CT temporal bone scans. Findings of dehiscent, thin, or normal SSC on CT scans (including reconstructed Poschl views). Interobserver radiographic interpretation rate between neuroradiologist and otologist. Seven-hundred CT scans (1,400 ears) were reviewed, and 1,188 ears were acceptable for analysis. Twenty-three ears (1.9%) had dehiscent SSC, 185 ears (15.6%) had thin SSC, and 980 ears (82.5%) had normal SSC. Median ages of dehiscent, thin, and normal canals were 5, 7, and 9 years, respectively ( p < 0.05). As age increased, the incidence of dehiscent and thin SCC cases decreased; for example, dehiscent or thin canal existed in 51.4% of children less than 12 months, 17.5% of children between 1 and 2 years, 18.5% of children between 3 and 10 years, and 10.9% of children between 11 and 18 years. The κ value of agreement between neuroradiologist and otologist was 0.814, demonstrating a high value of agreement (p < 0.05). Radiographic SSCD, although uncommon, appears to be more prevalent in younger children, especially infants younger than 12 months. This suggests that the SSC may develop more bony covering with age.

2-Octyl Cyanoacrylate Skin Adhesive for Topical Skin Incision Closure in Female Pelvic Surgery

Background: 2-octyl cyanoacrylate (2OCA) high viscosity tissue adhesive (Medline Industries, Inc., Mundelein, IL) is a liquid topical skin adhesive. 2OCA offers the same design features and clinical utility in terms of flexibility, strength, and low complication rate as the commercially available 2OCA tissue adhesives. Additionally, 2OCA features high viscosity allowing for better control during the application process, polymerization without the use of an external activator, and a distinctive violet color for ease of application visualization. Objective: The aim of this prospective case series is to descriptively report clinical data with the application of 2OCA as a topical incision closure system in female pelvic surgery. The primary outcomes included: incisional pain, incisional dehiscence, and post-operative bleeding. The secondary outcome included drying times of the adhesive with regard to incision length. Methods: A prospective open-label observational case series study was conducted to evaluate the use of 2OCA in surgical wound closure of the topical skin in adult patients undergoing gynecologic surgical procedures. A total of 50 adult women undergoing gynecologic surgery were enrolled. 2OCA was applied only by surgeons who had undergone product training to the incisions in a standardized, protocol-defined fashion. Drying times for the adhesive and photography were recorded intraoperatively. Post treatment follow-up was conducted with queries of pain level, incisional dehiscence, and incisional bleeding immediately post-operatively, 48 hours, 5 - 10 days and 14 days post-treatment. Adverse events were documented. Results: 2OCA was applied to a total of 154 incisions from the 50 patients enrolled to the study. The procedures included: 16 laparoscopic total hysterectomies, 4 diagnostic laparoscopies, 2 laparoscopic myomectomies, 2 laparoscopic bilateral or unilateral salpingo-oophorectomies, 5 total robotic-assisted laparoscopic surgeries (2 total hysterectomies, 1 supracervical hysterectomy, 1 sacrocolpopexy, and one excision of endometriosis), 7 sacral neuromodulation procedures, and 18 midurethral slings. The overall rate of incisional dehiscence was 3% (4/154). The rate of reported incisional bleeding was 3% (4/154). There was 1 incisional infection. The pain reports based on a 10-point scale had a mean of 4.96 immediately post-operatively, which decreased to a mean score < 1 (0.2) by post-op day (POD) 14. The mean drying times for the various lengths of incisions included the following: 1.28 minutes for incisions ≤ 5 mm, 1.53 minutes for 6 - 8 mm, 1.66 minutes for 10 mm - 20 mm, and 1.57 minutes for the 40 - 50 mm incisions. In 23% (36/154) of incisions 2OCA was the sole method of skin closure. Conclusion: This study demonstrates that 2OCA is safe to use in gynecologic surgical incisions with low rates of post-operative incisional bleeding and incisional dehiscence. Post-operative reports of pain maintained expected levels for recovery. 2OCA is a practical alternative or augmentation to traditional suture closure of skin incisions at the time of gynecologic surgery.

Combined approaches for fixation of Schatzker type II tibial plateau fractures involving the posterolateral column: a prospective observational cohort study.

This study aimed to investigate the surgical techniques and the clinical efficacy of combined approaches for the treatment of Schatzker type II tibial plateau fractures involving the posterolateral column [lateral and posterolateral columns (LPCs) fractures] in a prospective cohort. From January 2007 through December 2010, a total of 65 patients with LPCs underwent dual-plate fixation via a combined anterior and posterior approach. The anterior and posterior approaches were the conventional anterolateral approach and a posteromedial inverted L-shaped approach, respectively, with the patients in a floating position. Ultimately, 41 patients were followed up for a mean period of 52.5months. All fractures healed. The mean time to radiographic bony union was 15.2weeks and the mean time to full weight-bearing was 18.7weeks. No parameter associated with knee alignment changed significantly between immediately postoperation and 2years postoperation. No collapse of the reduced articular surface was detected. Two years postoperation, the mean Hospital for Special Surgery score was 92.3; the mean Short Form-36 score was 90.1, and the mean range of knee motion was 1.7°-123.6° (extension-flexion). Two patients suffered dehiscence of the anterolateral incision and another suffered partial necrosis at the margin of the posteromedial incision postoperatively. All healed in response conservative treatment. Another two patients experienced numbness in the posteromedial inferior region of the calf. No implant loosening, breakage, fixation failure, or other complication was observed during follow-up. LPCs are not uncommon. Careful preoperative analysis of computed tomography images and impeccable preparation are necessary to avoid neglecting a posterolateral column fracture. It is inappropriate to generalize one scenario for all Schatzker type II fractures: a single approach cannot address all subtypes of these fractures. Dual-plate fixation via a combined approach is an effective treatment for LPCs.