Modification Of Surgical Technique Research Articles

Overcoming Challenges in the Management of Critical Events During Cardiopulmonary Bypass

Critical events during cardiopulmonary bypass (CPB) can challenge the most experienced perfusionists, anesthesiologists, and surgeons and can potentially lead to devastating outcomes. Much of the challenge of troubleshooting these events requires a key understanding of these situations and a well-defined strategy for early recognition and treatment. Adverse situations may be anticipated prior to going on CPB. Atherosclerosis is pervasive, and a high plaque burden may have implications in surgical technique modification and planning of CPB. Hematologic abnormalities such as cold agglutinins, antithrombin III deficiency, and hemoglobin S have been discussed with emphasis on managing complications arising from their altered pathophysiology. Jehovah's witness patients require appropriate techniques for cell salvage to minimize blood loss. During initiation of CPB, devastating situations leading to acute hypoperfusion and multiorgan failure may be encountered in patients undergoing surgery for aortic dissection. Massive air emboli during CPB, though rare, necessitate an urgent diagnosis to detect the source and prompt management to contain catastrophic outcomes. Gaseous microemboli remain ubiquitous and continue to be a major concern for neurocognitive impairment despite our best efforts to improve techniques and refine the CPB circuit. During maintenance of CPB, adverse events reflect inability to provide optimal perfusion and can be ascribed to CPB machine malfunction or physiological aberrations. We also discuss critical events that can occur during perfusion and the need to monitor for organ perfusion in altered physiologic states emanating from hemodilution, hypothermia, and acid-base alterations.

A study of complications during cataract surgery in patients with pseudoexfoliation syndrome

Aim: Pseudoexfoliation (PXE) is a common and clinically important systemic condition that affects elderly people, who are also likely to undergo cataract surgery. It can cause serious complications during cataract surgery due to the pupillary rigidity and zonular weakness and instability. The purpose of this study was to study the frequency and types of complications of small incision cataract surgery (SICS) and phacoemulsification surgery in patients with cataract and PXE. Materials and Methods: This cross-sectional descriptive study was carried out on 52 eyes of 52 patients with cataract and PXE who underwent SICS or phacoemulsification surgery in a tertiary care hospital. Their perioperative and post-operative complications were documented and analyzed through statistical package for social sciences version 15.0 (IBM). Results: Poor pupillary dilatation in spite of use of standard mydriatic drops and non-steroidal anti-inflammatory drugs was the most common finding. This single factor made subsequent steps of surgery very difficult due to poor peripheral visualization. Pupillotomy was done in 25% cases. Other problems encountered were accidental iridodialysis, posterior capsule rupture, vitreous loss, retained cortical matter, decentered intraocular lens and zonular dialysis. Conclusion: Presence of associated PXE in cataract patients significantly increases the risk of vision threatening complications. Use of flexible iris hooks for small pupils and for capsular stability, capsular tension rings and high viscosity viscoelastics are useful modifications of surgical technique for good visual outcome.

English

BACKGROUND: Neglected fracture of the lateral condyle of distal humerus in children is very common. Patients with non union of the lateral condylar fracture have pain, instability or a progressive cubitus valgus deformity, condylar prominence. A neglected displaced lateral humeral condyle fracture remains a difficult problem to treat. The bone ends become indistinct and soft tissue becomes contracted; making anatomic reduction difficult. Moreover an attempt to mobilize the fragment by stripping the soft tissues may lead to avascular necrosis. Several authors have recommended operative treatment for such patients, while others do not recommend operative intervention because stiff elbow and AVN are the usual outcomes. The present study was undertaken to assess the results of open reduction and internal fixation in neglected lateral humeral condyle fracture in children. MATERIAL AND METHODS: This is a prospective study carried out between November 2008 and July 2011 in the department of orthopedics at Teerthanker Mahaveer Medical College and research centre, Moradabad. Eighteen patients (14M:4F) with an average age of 7.3years (range 5.5 to 14 years) who had lateral humeral condyle fracture and reported 3 or more weeks after sustaining injury, were included in the study. The fractures were classified according to the Jacobs system. All patients were operated using the lateral approach and fixation was done using K wire or screw with or without bone grafting. The results were graded as excellent, good, fair or poor according to the modified criteria of Agarwal et al. RESULTS: There were 14 males and 4 females with a mean age of 7 years and 3 months (range 4-14 years). Among the nine (50%) patients who presented between 5 to 8 weeks after injury, the results were excellent in 3, good in 4, fair in 1 and poor in 1 patient. Excellent to good results were seen in all the five (27%) patients presenting between 3-5 weeks of injury. Among four (23%) patients out of total 18 patients who presented between 9-12 weeks of injury, 2 had poor results and 1 each had good and fair results. Maximum number of patients had Jacobs type 2 fractures. In our study 25% of these patients had showed excellent results, whereas only 12.5% of patients with type 3 fracture showed excellent results. Fourteen (n=14) patients underwent internal fixation with K wire and in four patients’ fixation was done by cancellous screws. The commonest complication seen was pin tract infection (n=10), followed by occasional pain (n=5) around the elbow. There were no cases of avascular necrosis. CONCLUSION: Satisfactory functional results can be obtained even in late presenting fractures lateral condyles of the humerus in children with modification of surgical technique.

Post-operative steroids in the management of capsulitis following TMJ arthroscopy

Post-operative steroids in the management of capsulitis following TMJ arthroscopy

Use of Surgisis for Abdominal Wall Reconstruction in Children with Abdominal Wall Defects

Abdominal wall defects in children can present a challenge to the pediatric surgeon. Despite the development of new materials and modifications of surgical technique, no single approach has been established. The purpose of this study was to evaluate the authors experience using porcine small intestine submucosa for abdominal closure. A retrospective review of all patients with abdominal wall defects who underwent reconstruction with Surgisis at the authors' institution from 2004 to 2011 was performed. Patient demographics, cause of defect, recurrence, rate of infection, and length of follow-up were reviewed. A total of 24 patients were identified as having Surgisis implanted for abdominal wall defects. The most common etiology of abdominal defect was omphalocele. All patients went on to heal wounds. Four patients developed postoperative seroma formation and another two had wound infection. Two recurrences in the form of incisional hernia were observed. Both resolved spontaneously without intervention during the follow-up. The median follow-up period was 5 years (range 2-9 y). No significant predictors of complications were identified. Surgisis is an effective adjunct in the repair of abdominal wall defects in children. Complication rates remain low. In addition, recurrence may disappear spontaneously as the patch absorbed and replaced by scar tissues. Further studies are warranted.

Praktische Anwendung des „4-Säulen-Konzepts“ der situationsadaptierten Therapie des Hämorrhoidalleidens im alltäglichen Arbeitsfeld einer proktologischen Abteilung

In addition to the stage, several factors influence the treatment of haemorrhoids. The aim of this study was the elaboration of an individual therapy concept which is situation-adjusted. In this context, our own experience and approaches are presented. In the Department of Coloproctology of the Prosper-Hospital Recklinghausen, from January 2009 to August 2012, 903 haemorrhoidectomies (2nd to 4th degree) have been performed. We report our results on the practical implementation of a situation-adjusted treatment of haemorrhoidal disease. In this context we present an overview of effective modifications of surgical techniques. Retrospectively the perioperative course and postoperative outcome were evaluated. Even in a collective with a large number of high-risk patients (26 %) respecting the "four columns" that constitute the fundament of a situation-adjusted treatment of haemorrhoids, high patient satisfaction and good outcome with low complication (7 %) and recurrence (0 %) rates could be attained. The "four columns" (findings of examination, therapeutic options, physician and patient) form the fundament of an effective treatment of haemorrhoidal disease without many complications and guarantee an individually tailored therapy for each patient.

Open Aortic Arch Repair: State-of-the-Art and Future Perspectives

Surgical procedures for the treatment of complex aortic arch pathology remain among the most challenging cardiovascular operations, incurring considerable risk for death and stroke. The purpose of this article is to describe the evolution of our approach to open repair of the aortic arch. Our arterial cannulation strategy has shifted from femoral and direct aortic to right axillary and more recently innominate artery cannulation. This transition has facilitated the administration of continuous antegrade cerebral perfusion and more moderate levels of hypothermia during complex repairs. Modifications in surgical technique, including arch reconstruction with the trifurcated graft, and the classical and frozen elephant trunk techniques have simplified the conduct of the operation. Experimental and clinical research supporting the evolution of our approach is discussed in this paper.

Abordaje posterior de tobillo para la artrodesis tibioastragalocalcánea con clavo intramedular retrógrado: Modificación de la técnica quirúrgica

IntroductionTibioastragalocalcaneal arthrodesis is a salvage procedure in cases where there is serious injury to the hind foot and ankle with a tibiotalar and subtalar joint involvement, which cannot be controlled with conservative methods or isolated tibiotalar arthrodesis. Materials and methodsWe describe a modification of the traditional surgical technique of posterior approach for tibio-talo-calcaneal with retrograde intramedullary nail. ResultsBeing a modification of a surgical technique results are not presented. DiscussionThe posterior approach of the ankle and hind foot allows a very good view of the tibiotalar and subtalar joint surfaces, access to both malleoli if their osteotomy is necessary, correct existing deformities, and solve previous canal syndromes, as well as the use of bone graft.

Better Quality of Life After Medial Versus Lateral Unicondylar Knee Arthroplasty

The number of unicompartmental knee arthroplasties (UKAs) is growing worldwide. Because lateral UKAs are performed much less frequently than medial UKAs, the limited information leaves unclear whether UKAs have comparable survival and health-related quality of life (HRQoL) of the lateral UKA to medial UKAs. We therefore compared the (1) survivorship and (2) HRQoL after lateral versus medial cemented mobile-bearing UKAs and (3) determined whether there is an association of survival to modifications of surgical technique in one of three phases. We retrospectively reviewed 558 patients who underwent mobile-bearing UKAs from 2002 to 2009. From the records we determined revision of the joint for any reason and revision for aseptic loosening. Patients reported their physical function, pain, and stiffness as measured by the WOMAC, SF-36 physical-component summary (PCS), and Lequesne knee score. Information regarding implant survival was collected for 93% of the patients. We analyzed the patients separately by three phases based on surgical changes associated with each phase (1: initial technique; 2: improved cementing; 3: additional bone resection to ensure backward sliding of the inlay without impingement). The minimum followup was 2.1 years (mean, 6 years; range, 2.1-9.8 years). Implant survival was 88% at 9 years. We found similar implant survival rates for medial (90%) and lateral UKAs (83%). In all HRQoL measures, patients receiving a medial UKA had better mean scores compared with patients who had a lateral UKA: WOMAC physical function (23 versus 34, respectively) and pain (21 versus 34) and SF-36 PCS (41 versus 38). There were no survival differences by surgical phase. Our observations suggest a medial UKA is associated with superior HRQoL when compared with a lateral UKA, although implant survival is similar.

Improving bronchial stump necrosis outcomes with the use of platelet-poor plasma?

DOI of original article: 10.1016/j.jss.2012.1 * Corresponding author. Indianapolis, IN 462 E-mail address: meddoc22@yahoo.com. 0022-4804/$ e see front matter a 2014 Elsev http://dx.doi.org/10.1016/j.jss.2013.02.046 Despite many advances and modifications in surgical technique, the development of postoperative bronchopleural fistula (BPF) following pulmonary resection remains a dreaded complication. Morbidity and mortality following BPF development can be exceptionally high [1,2]. Consequently, renewed efforts are being directed toward preemptive strategies to minimize the risk of BPF formation. Although several proposed risk factors have been identified, necrosis and/or the presence of vascular ischemia following surgery seems to play a prominent role in the development of BPFs [3,4]. Consequently, attention has focused on the intracellular milieu and role of cytokines, growth factors, and local hemostatic mechanisms in tissue necrosis and wound healing. The use of platelet-rich plasma (PRP) has been utilizedwith growing success in a number of clinical applications [5e7]. From these studies, PRP appears to play a crucial role in modulating local wound inflammation, hemostasis, and tissue remodeling. Paradoxically, in contrast to these studies, in a paper recently published in the Journal of Surgical Research, Santana-Rodriguez et al. reported a significant decrease in bronchial stump necrosis using local application of plateletpoor plasma (PPP) following pneumonectomy [8]. Whereas

Intraoperative floppy iris syndrome (IFIS) in patients receiving tamsulosin or doxazosin—a UK-based comparison of incidence and complication rates

The association between intraoperative floppy iris syndrome (IFIS) and tamsulosin has been well-described. The rate of IFIS in association with other α-1 antagonists needs further clarification. The objective of this study was to determine the incidence of IFIS and associated cataract surgery complications in patients taking tamsulosin or doxazosin. Patients receiving tamsulosin or doxazosin, and an equivalent number of controls, were identified using the electronic patient record for cataract surgery performed over 2 years. The presence of IFIS and intraoperative complications were ascertained. Modifications of surgical technique in the form of preoperative 1 % atropine, intraoperative diluted phenylephrine, iris hooks, or highly viscous viscoelastic materials were recorded. Of the 2,785 cataract operations performed in 2,028 patients, 52 cases (1.9 %) were on tamsulosin and 109 were on doxazosin (3.9 %). In the doxazosin group (excluding three cases with incomplete data), significantly more eyes (17 of 106 eyes, 16 %) showed at least one IFIS characteristic than controls, six eyes (6 %) required adjustment of surgical technique, and intraoperative complications occurred in two eyes (1.9 %). In the tamsulosin group, significantly more eyes (25 of 52 eyes, 48 %) demonstrated at least one IFIS feature than control or doxazosin eyes; 18 eyes (35 %) needed adjustment of surgical technique, and seven (13.5 %) suffered intraoperative complications. Incidence of IFIS was significantly higher in tamsulosin and doxazosin patients. The presence of IFIS was associated with a significantly higher complication rate. We would advise that all patients receiving α1 antagonists (not only those receiving tamsulosin) should be identified preoperatively, receive appropriate modifications in preparation, and have alternative techniques and a senior surgeon available at the time of surgery.

Improving outcomes of living-donor right hepatectomy

Complication rates of living-donor right hepatectomy remain a matter of major concern. The aim of this study was to achieve near-zero morbidity for living-donor right hepatectomy in a single centre. All living donors who underwent right hepatectomy between January 2005 and September 2011 were enrolled in this retrospective study. During this interval, modifications in surgical technique and management included upper midline laparotomy, use of wound protectors, hanging manoeuvre during parenchymal transection using Glisson's approach, no intraoperative cholangiography, no intensive care unit stay after surgery, no central venous catheterization, and reduction in systemic heparin dose before graft removal. Donor characteristics, operative outcomes and complications graded according to Clavien's classification were recorded. A total of 300 donors were enrolled and these were divided into three groups of 100 operated on in consecutive time periods. Groups were comparable with regard to donor characteristics. The overall complication rate was 16·0 per cent, with no deaths. From group 1 to group 3, the duration of operation (P < 0·001), length of hospital stay (P < 0·001), and rate of overall (P < 0·001) and grade IIIb (P = 0·019) complications decreased significantly. In the most recent group, the morbidity rate was 3·0 per cent without any major complications, reoperation or blood transfusions. All donors recovered completely. This study suggests that near-zero morbidity may be reached after right hepatectomy in carefully selected living donors by continuous refinement of surgical technique and management.

Matching donor to recipient in liver transplantation: Relevance in clinical practice

Achieving optimum outcomes after liver transplantation requires an understanding of the interaction between donor, graft and recipient factors. Within the cohort of patients waiting for a transplant, better matching of the donor organ to the recipient will improve transplant outcomes and benefit the overall waiting list by minimizing graft failure and need for re-transplantation. A PubMed search was conducted to identify published literature investigating the effects of donor factors such as age, gender, ethnicity, viral serology; graft factors such as size and quality, recipient factors such as age, size, gender and transplant factors such as major or minor blood group incompatibility and immunological factors. We also report technical and therapeutic modifications that can be used to manage donor-recipient mismatch identified from literature and the authors' clinical experience. Multiple donor and recipient factors impact graft survival after liver transplantation. Appropriate matching based on donor-organ-recipient variables, modification of surgical technique and innovative peri-transplant strategies can increase the donor pool by utilizing grafts from marginal donors that are traditionally turned down.

Technical Learning Points for Robotic Prostatectomy: Video Assessment of Positive Margins at the Prostate Base in Two Cases

Introduction: Surgical technical error is a modifiable cause of positive surgical margins (PSMs) for robot-assisted laparoscopic prostatectomy (RALP). Retrospective intraoperative video review has the potential to evaluate technique. Gross pathology can be used to identify PSMs, which can then be correlated with the retrospective video review to identify where in the operation the positive margin took place. Technical errors, however, have not been well published. We present a 6:48 minute video comparing whole-mount pathology to surgical technique for RALP with a specific focus of evaluating the technical error of each operation at the prostate base. Materials and Methods: We reviewed the patients with PSMs who had video recordings for a single surgeon at our institution (P.M.) at our institution from 2008–2011. Results: We identified two patients with a PSM at the prostate base after RALP at our institution. Both operations utilized the posterior approach for clinical T2 disease. The whole-mount pathology was reviewed and then compared to the dissection of the prostate base. In both videos, we were able to identify the disruption of the prostate due to technical error. The first patient had a PSM at the left posterior base that occurred during dissection of the posterior lateral pedicle. Upon review, we believe that this could have been avoided by opening Denonvillier's fascia before dissecting the posterior lateral pedicles. The second patient had a positive margin was at the right posterior base that occurred at the junction of the seminal vesicle and prostate. This area was exposed during division of the bladder neck. Upon review, we believe that this could have been avoided by extending dissection along the lateral seminal vesicle until the prostate base was established. Conclusions: Video review has the potential to standardize training, improve surgical technique, and ultimately reduce technical error. Touijer et al evaluated positive margins in 12 cases and identified that technical error resulted in 8 positive margins. As a result, their group eliminated blunt teasing of the neurovascular bundles and instead controlled the capsular vessels by dividing them after the dissection plane was defined as well as control the prostatic pedicle higher on the prostate base to better delineate the limits of the neurovascular bundles and prostate. This resulted in a lower PSM rate in the next 90 patients.1 Open prostatectomy has also been evaluated with retrospective video. Walsh et al. retrospectively blinded reviewers to 62 videos and was able to identify four key steps that correlated with the recovery of sexual function. Ultimately, this exercise resulted in modification of surgical technique used by their institution.2 Simulation and video have already been integrated in many teaching programs and has been found to be successful.3,4 At our institution, we hope to improve upon simulation and use retrospective evaluation of robotic prostatectomy to improve resident teaching and outcome. For these two reviewed cases, surgeon technical error resulted in PSMs. A better understanding of previous errors will hopefully decrease future PSMs at this critical step. The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article. Runtime of video: 6 mins 48 secs

Complications of Suture Button Ankle Syndesmosis Stabilization with Modifications of Surgical Technique

The TightRope® is a relatively new device designed to stabilize ankle syndesmotic injuries. There are no studies evaluating the clinical effectiveness of this technique and few reports addressing complications and potential modifications to the surgical technique reported in this article. A retrospective review of 102 cases of traumatic ankle syndesmotic stabilization using the TightRope device is presented. Patients were followed up for a median of 85 days after surgery. Eight patients subsequently had the TightRope removed. This was performed for four reasons: osteomyelitis surrounding the implant, painful aseptic osteolysis surrounding the implant, failed stabilization of the syndesmosis, and unexplained pain. On the basis of experience, the authors recommend meticulous attention during the surgical technique. To prevent skin irritation and stitch abscess formation leading to osteomyelitis, the FiberWire loop is best cut with a knife at least 1 cm beyond the knot, allowing the sharp end of the FiberWire to lay flat adjacent to the fibula. Painful aseptic osteolytic reaction to the TightRope necessitates removal. To prevent rediastasis, a small medial incision is recommended for endobutton positioning directly abutting the tibial cortex without soft tissue interposition. Inserting the TightRope through a fibula plate prevents lateral button pull-through and rediastasis.

PS126. Influence of Obesity on Groin Surgical Site Infections after Vascular Surgery

Surgical site infections are a significant risk after vascular surgical procedures and can be due to a multitude of contributing factors. The purpose of this study was to examine the effect of obesity on the infection rates of vascular surgery patients undergoing groin incisions and evaluate other confounding factors. A single center retrospective cohort study was undertaken to examine all vascular surgery patients undergoing groin incisions for femoral artery vascular procedures from February 2007 through August 2008. Patient demographics, characteristics, including BMI, and potential confounding variables of diabetes, hypertension, smoking, renal insufficiency, coronary artery disease, cerebrovascular disease, pulmonary disease, and hyperlipidemia were recorded. All patients were monitored for infection for 30 days and those having a prosthetic implant were monitored for one year. A total of 451 patients were included in this study. 6% (n=29) of the patients developed groin wound infections diagnosed by clinical (NSQIP criteria) or microbiologic wound culture criteria. The most common causative organism was MRSA (n=9). Patients with surgical site infections had statistically higher BMIs (30 vs. 27, P = .016). Further analysis demonstrated that the surgical site infection group had a higher percentage of obese individuals than did the infection-free group (45% vs 26%, P = .009). Of the other variables examined, only diabetes was associated with increased surgical site infections (P = .007). Obesity, as defined by a BMI greater than 30, and the presence of diabetes independently increase the chance of post operative groin wound infections in the vascular surgery patient population. These patients may warrant better pre-op preparation, closer post-operative care, and modification of surgical technique in order to avoid an infectious complication.

Postoperative Assessment of Laryngopharyngeal Dysfunction in Neonates After Norwood Operation

The purpose of this study was to evaluate the incidence of vocal cord (VC) and swallowing dysfunction in infants after the Norwood operation and to examine the relationship between laryngopharyngeal dysfunction and postoperative outcomes. We conducted a retrospective review of 63 infants who underwent routine postoperative fiberoptic endoscopic evaluation of swallowing function and vocal cords after a Norwood operation at our institution during a recent 6-year period (2003-2009). The overall incidence of VC dysfunction after the Norwood operation was 58.7%. After a modification of the aortic arch dissection technique in 2007, the incidence of VC dysfunction decreased significantly from 79.5% in 2003 through 2006 to 25% in 2007 through 2009 (p<0.001). The incidence of swallowing dysfunction also decreased from 23.1% in 2003 through 2006 to 4.2% in 2007 through 2009 (p=0.07). Swallowing dysfunction was more common in patients with VC dysfunction (21.6%) as compared with patients without VC dysfunction (7.7%; p=0.18). Patients with VC dysfunction were more often discharged home on tube-only feeding regimens compared with infants without VC dysfunction (46% versus 26.9%). In infants with both VC and swallowing dysfunction, 75% were discharged exclusively to have tube feeding. Median hospital length of stay tended to be longer in infants with swallowing dysfunction (31 days) than in infants without swallowing dysfunction (23 days; p=0.16). Vocal cord and swallowing dysfunction are common in infants after the Norwood operation and may increase the need for tube feeding regimens. Modification of surgical techniques for dissection and mobilization of the aorta can significantly reduce the incidence of these adverse outcomes.

Cardiopulmonary Bypass Surgery in Children - Minimizing the Incidence of Postoperative Junctional Ectopic Tachycardia after Surgical Technique Modification

Background: Mechanical injury to tissues in and surrounding the Atrioventricular node is considered a major factor in the aetiology of postoperative Junctional Ectopic Tachycardia (JET). Objectives: The study aims to evaluate the effect of retractor modification used during cardiopulmonary bypass surgery and the incidence of postoperative JET in children. Material & Methods: The study involves retrospective chart review of all pediatric patients who had undergone cardiopulmonary bypass surgery in Children Hospital of Eastern Ontario, Canada, between 1993 and 1996. Patients treated between 1993 to 1994 with wide eyelid retractor (depth 23mm; width 18 mm) were classified as Group A, and the patients treated with narrow retractor (depth 10 mm; width 8 mm) between 1995 to 1996 were classified as Group B, respectively. Results: Of the study subjects, Group A had 209 while Group B had 186 subjects. The age and weight of group A subjects was “mean ± standard deviation” (4.4±4.1 year and 17±12 kg), while that of Group B was (4.7±4.7 year and 20±15 kg). The overall incidence of postoperative JET and mortality was lower in Group B than Group A (2% vs. 10%; p=0.0008; 0% vs. 21%; p<0.05, respectively). Conclusion: A decrease in the incidence of JET and mortality was noticed after the use of narrow retractor.

Total Hip Replacement after Failed Femoral Head and Neck Excision in Two Dogs and Two Cats

To document outcome in 2 dogs and 2 cats after conversion of femoral head and neck excision (FHNE) to total hip replacement (THR). Case series. Dogs (n = 2) and 2 cats. For 1 dog and 2 cats, THR was performed using cemented acetabular and femoral components. Noncemented acetabular and cemented femoral components were used in 1 dog. All animals presented with severe hip pain and chronic lameness after unsuccessful FHNE. Potential causes of suboptimal outcome after FHNE were incomplete resection of the femoral neck (n = 3) and fibrous adhesions involving the sciatic nerve (n = 2). Post-FHNE remodeling of the proximal femur and acetabulum necessitated unconventional modifications of surgical technique. In all 4 cases, final clinical outcome and radiographic reassessment were satisfactory. Aseptic loosening of the acetabular bone-cement interface necessitating surgical revision was the only complication noted in 1 cat. Despite severe preoperative pain and chronic functional impairment in all cases, conversion of FHNE to THR produced marked clinical improvement including return to unrestricted exercise within 12 weeks of surgery.

Initial experience of double-layer tension free reconstruction of abdominal wall defects with porcine acellular dermal collagen implant and polypropylene mesh

Various techniques have been proposed for the repair of abdominal wall defects (AWD) with varying rates of success. Despite the development of new materials and modifications of surgical technique, no single approach has emerged as the optimum way to close large AWD. We report a method for repairing large incisional and recurrent abdominal wall hernias using a double-mesh technique. The defect is closed using an underlay biological implant and an onlay synthetic mesh, which is 'quilted' to the underlying abdominal wall and biological implant. The current study reports our initial experience with this approach in ten consecutive patients operated on for large AWD. In this prospective observational study the following data were collected: age, gender, previous surgery, co-morbidities, situation and size of the defect, antibiotic therapy, hospital stay, postoperative complications and bacteriology in case of infection. The patients were reviewed at 1, 3 and 6 months, and 1-year postsurgery. Overall all ten AWD of ≥ 75 cm(2) were reconstructed successfully using the quilting technique. Median age of patients was 61 years (range 47-73 years); male:female ratio was 3:2 and median weight was 107.5 kg. Two patients developed a wound infection and were treated successfully with antibiotics. At median follow-up of 15.5 months (range 6-29 months) there was no case of recurrence. The use of double-layer of porcine acellular dermal collagen implant and polypropylene mesh in reconstruction of AWD can be considered a safe and effective treatment. The early short-term results are encouraging with few complications.