Interrupted Nonabsorbable Sutures Research Articles

OC-089 A CHALLENGING REPAIR OF RECURRENT VENTRAL HERNIA IN A PATIENT WITH A PREVIOUS INTRAPERITONEAL MESH AND ABDOMINOPLASTY

Abstract Aim To understand the challenges faced in repair of recurrent ventral hernia in a patient with a previous intraperitoneal mesh and abdominoplasty. Introduction Ventral hernias still represent a great challenge for surgeons, especially if they are recurrent. We present a 54-year-old overweight female with complex surgical history and a recurrent incisional hernia. She had a laparoscopic cholecystectomy and port site hernia which was repaired without a mesh. She later underwent a Roux-en-Y Gastric bypass for obesity and developed another port site hernia in lower epigastrium. The incisional hernia was repaired with an intraperitoneal mesh. Finally, she had an abdominoplasty for cosmetic reasons. She presented to our surgical clinic with a clinically palpable recurrent large incisional hernia. Methods The repair was carefully planned with a CT abdomen confirming a 6 cm defect in the upper midline and a large intraperitoneal mesh with multiple metallic tacks. The surgical procedure was as follows: Midline incision and careful dissection of the sac. The intraperitoneal mesh was identified and removed carefully keeping the posterior rectus sheath and peritoneum intact. A posterior component separation technique was performed. Posterior rectus sheath was closed with interrupted absorbable sutures. A tailored polypropylene mesh was placed in retro-rectus space. The anterior rectus sheath was closed with non-absorbable interrupted sutures. Patient had an uneventful postoperative period and was discharged on the third postoperative day. Conclusion Careful patient selection, detailed preoperative planning and expertise in abdominal wall reconstruction result in a successful repair of complex ventral hernias.

V-037 LAPAROSCOPIC REPAIR OF FORAMEN OF WINSLOW HERNIA CONTAINING THE RIGHT COLON

Abstract Aim A 74-year-old woman with hypothyroidism, dyslipidaemia and past abdominal surgeries presented with severe abdominal pain, nausea, bloating and anorexia. On clinical examination, the abdomen was soft with tenderness on palpation in the epigastrium. The laboratory workup revealed leukocytosis. Abdominal CT showed the caecum, the ascending colon, and the hepatic flexure herniated in the lesser sac through the Foramen of Winslow. Even though the initial plan was conservative management, the hernia was persistent and not resolving in the repeat CT scan. A decision was made to proceed with laparoscopic exploration. We aim to present a video of a laparoscopic repair of a Foramen of Winslow hernia. Material and methods Laparoscopy revealed free intrabdominal fluid and part of the right colon in the lesser sac. The hernia was reduced manually, and the colon was inspected, revealing no signs of ischemia. As the caecum was very mobile, a caecopexy was performed by suturing the cecum and the ascending colon to the lateral abdominal wall using non-absorbable interrupted sutures. The operation was performed with three ports, a 10 mm infraumbilcal port for the scope and two 5 mm ports in the right lower quadrant of the abdomen. Results Recovery was uneventful, and the patient was discharged the following day. In follow-up, pain and bloating had completely resolved, and her quality of life was significantly improved. Conclusions This was a challenging case from the technical and the decision-making point of view, with a good outcome and no complications.

Closure of skin with simple interrupted Prolene suturing versus subcuticular continuous Monocryl suturing after ORIF of distal radius fractures

Objectives: The aim of the study was to assess the effects of subcuticular absorbable versus interrupted nonabsorbable sutures for skin closure after distal radius fracture (DRF) fixation surgery in adults on post-operative pain, hand function, scar satisfaction, wound inflammation, and adverse events. Methods: A retrospective study was conducted with 65 patients undergoing DRF surgical treatment between March 2022 and December 2022. Patients were divided into two groups: Traditional interrupted suture with Prolene® (n = 27) and subcuticular continuous suture with Monocryl® (n = 38). Pain intensity, complications, and cosmetics were evaluated. Results: Subcuticular continuous suture with Monocryl® was superior to traditional interrupted suture with Prolene® in terms of the number of complications and esthetic and functional outcomes. Conclusion: This study concluded that the subcuticular suturing with absorbable monofilament Monocryl® proved advantageous compared to simple interrupted suturing with Prolene® because it presented better results regarding pain intensity and esthetic results, with fewer complications.

Does primary closure of direct inguinal hernia defect during laparoscopic mesh repair reduce the risk of early recurrence?

Hernia recurrence is an important complication following inguinal hernia repair. Primary closure of ventral hernia defects laparoscopically has been shown to reduce the risk of recurrence and seroma formation. The results for ventral hernias may potentially be applied to direct inguinal hernias. Our aim was to evaluate the value of primary closure of direct defects during laparoscopic inguinal hernia mesh repair in reducing the incidence of early recurrence. A retrospective, single-center cohort study was conducted on cases performed from August 2016 to February 2018. Patients with direct inguinal hernias undergoing elective laparoscopic mesh repair were included. When performed, the direct hernia defect was primarily closed with extracorporeal non-absorbable interrupted sutures followed by standard placement of a lightweight mesh covering myopectineal orifices. Early recurrence was defined as occurring within 1year of surgery. A total of 75 direct inguinal hernias in 53 patients who underwent surgery and completed at least 1year of follow-up were analyzed. The mean age of patients was 63years (range 44-82years); with majority of patients being male (98.1%). There were no significant differences observed between the two patient populations in terms of demographics, mean operative time and risk factors. In 9 (16.9%) patients, the direct hernias were recurrent hernias and all underwent open mesh repair during the index hernia surgery. The majority of hernia repairs (63 hernias in 45 patients, 85%) were performed via the totally extraperitoneal (TEP) approach. 19 patients (35.8%) with 28 direct inguinal hernias underwent primary closure of the direct defect prior to mesh placement; while, 34 patients (64.2%) with 47 direct hernias did not undergo primary closure. There were 3 direct hernia recurrences (6.4%) at 1year post-operatively, and all occurred in the non-closure group. In comparison, there were no recurrences in the closure group; however, this difference was not statistically significant (p = 0.289) in our study due to the small sample size. Closure of direct inguinal hernia defects during laparoscopic mesh repair has been shown to reduce the incidence of early hernia recurrence in our retrospective study but future randomized controlled trials with large numbers would enable us to draw more robust conclusions and perhaps change the way we perform laparoscopic inguinal hernia repair.

Patellar Bone-Grafting for Severe Patellar Bone Loss During Revision Total Knee Arthroplasty

Treatment of severe patellar bone loss during revision total knee arthroplasty (TKA) is difficult. Patellar bone-grafting is a simple procedure that can improve patient outcomes following revision TKA. The patient is prepared and draped in the usual sterile fashion. The previous longitudinal knee incision is utilized for exposure. Scar tissue is excised from the medial gutter. However, tissue in the lateral gutter is largely maintained. An assessment of the surrounding quadriceps and patellar scar tissue ensues. This tissue can be utilized to create an envelope for holding the bone graft in place. If insufficient tissue is present, fascia from the iliotibial band or vastus medialis, allograft fascia, or synthetics can be used.A careful assessment of component fixation and rotation is critical to the success of patellar bone-grafting. Component revision for aseptic loosening or malrotation should be performed in the usual fashion. During component revision, it is recommended to preserve any additional bone as autograft for the patellar bone-grafting procedure. Common sites of autograft harvest include the femoral box cut and proximal tibial resection.The patella is then addressed by carefully removing the previous implant to avoid additional bone loss. This step is performed with a combination of an oscillating saw, osteotomes, and high-speed burr. The retropatellar bone is then prepared by debriding excess soft tissue, cysts, or cement. A high-speed burr is then utilized to produce a punctate bleeding surface for bone-graft incorporation.The harvested tissue is closed around the perimeter of the patella with use of interrupted nonabsorbable sutures, leaving a window to pack in the bone graft. The bone graft (allograft and autograft) is morselized and place through the window.The optimal patellar thickness is variable. After packing the bone graft through the soft-tissue window, the thickness is measured with a caliper. It is recommended to acquire a thickness of >20 mm because bone-graft resorption and remodeling occur with knee range of motion. The remaining soft-tissue window is closed with use of nonabsorbable sutures. The knee is cycled through a range of motion to ensure optimal patellofemoral tracking. If necessary, a lateral release or medial soft-tissue advancement can be performed to ensure patellofemoral tracking is adequate. Finally, the wound is irrigated and closed in layers. Nonsurgical:Patellar knee braceHinged knee braceSurgical:Gull-wing osteotomyPatellar resurfacing with biconvex patellaBulk allograft reconstructionPartial or complete patellectomyPatelloplastyInterpositional arthroplastyTantalum metal-backed reconstruction. There is a myriad of surgical options for severe patellar bone loss following TKA. Patellar bone-grafting is simple, reproducible, and relatively cost-effective1,2, and avoids the need for the amount of bone for reconstruction that may be required for metal-backed or biconvex patellar implants3,4. The procedure allows for the restoration of the quadriceps lever arm, which may not be restored with other techniques, such as gull-wing osteotomy or patellectomy5. Patellar bone-grafting avoids the cost and risks of disease transmission associated with allograft reconstruction6. Finally, the procedure provides excellent long-term survivorship and patient-reported outcomes. Following this procedure, patients should experience a reduction in knee pain and improved patient-reported outcomes2,6, with a prior study showing that the percentage of patients reporting anterior knee pain decreased from 51% to 27% following patellar bone-grafting. Patients also demonstrated an improvement in knee range of motion, with a mean increase in knee flexion of 7o and knee extension of 2o1. Complications related to this procedure are minimal. Bone stock restoration can be utilized for patellar resurfacing in the future1. Radiographically, patellar bone resorption, loss of patellar height, and patellar remodeling do occur; however, despite these radiographic changes, Knee Society scores increased from 50 to 85 at the time of the latest follow-up. Careful preoperative physical examination should document range of motion, areas of pain, and patellofemoral tracking and/or instabilityBe prepared to revise the femoral and/or tibial components if malrotated in order to optimize patellofemoral trackingRetain any autogenous bone harvested during component revision to use as patellar bone graftEnsure that allograft bone is available to ensure sufficient restoration of patellar thicknessConsider having allograft tissue available in the event that scar tissue in situ is not adequate to create an envelope for packing the bone graftA bleeding retropatellar surface prepared with a high-speed burr will increase the chance of bone incorporationA watertight closure of the soft-tissue envelope is critical to avoid loss of bone graft during knee range of motion.

IBS26.03 Surgical Technique of Pleurectomy/Decortication

IBS26.03 Surgical Technique of Pleurectomy/Decortication

Small refinements in breast reconstruction: a technique for inframammary fold creation.

In breast reconstructive surgery, the inframammary fold (IMF) is an essential component of breast identity. The lack of the IMF following previous mastectomy requires restoration. We have developed a new IMF reconstruction technique using the posterior sheet (PS) of the expander capsule. This article presents our 10-year experience of performing this original technique during two-stage breast reconstruction. Preoperatively, the midline, lateral, and medial borders (MBs) of the implant pocket and the new IMF line were marked. After extracting the expander, the anterior sheet of the expander capsule was removed with the exception of its lowest 2-cm portion. Two needles were placed at the intersection of the new IMF line with the lateral border (LB) of the implant pocket and its MB. Within the pocket, horizontal dissection of the PS of the capsule was performed from one needle to another, after which the sheet was mobilized downward. The mobilized free border of the PS was pulled upward until the inframammary crease was at the new marked location, and then fixed with non-absorbable interrupted sutures to the underlying tissues. An implant was placed over this layer. The covering tissues were then closed. A total of 321 patients were included. The median age was 38 years (range, 18-58 years). No serious wound complications were observed. Breast-thoracic angle decreased in 21 patients (6.5%), and the distance from the IMF to the lower border of breast segment III was greater than that of the contralateral breast in 14 patients (4.4%). This technique provides a well-defined IMF without indentations or retraction. The results are stable on long-term follow-up and provide a sharp breast-thoracic angle, which is crucial in creating natural-looking ptosis of the reconstructed breast.

Diagnostic Laparoscopy for Right Hemidiaphragm Rupture With Laparotomy Repair: A Case Report

Post-traumatic hemidiaphragm rupture is a rare occurrence with a high mortality rate. The gold standard for diagnosis is exploratory laparotomy, which itself carries a high mortality rate in the emergent setting, as is commonly the case following blunt or penetrating abdominopelvic trauma. In this case, a 31-year-old patient with no significant medical history, who presented following an automobile accident with shoulder and gluteal pain with negative radiologic findings, was discussed. The goal of this case was to increase awareness of a possible alternative to the exploratory laparotomy for hemidiaphragm rupture in the emergent setting associated with lower mortality due to the operation. In this case, diagnostic laparoscopy was performed, and right hemidiaphragm was diagnosed. Repair was made via laparotomy with incorporation of the laparoscopic port incisions into the laparotomy incision. Repair was made using 2-0 interrupted non-absorbable sutures with both the anterior and posterior flaps of the hemidiaphragm supported with large pledgets. The patient tolerated the operation well, and has since recovered completely. This case demonstrates the possibility of utilizing minimally invasive techniques for the diagnosis of isolated diaphragm injury. Additionally, this case highlights the inadequacies of modern imaging technologies for the diagnosis of diaphragm injury, and supports the need of improvement in this technology or an alternative modality with increased sensitivity to rule out diaphragmatic injury. J Curr Surg. 2016;6(1):33-36 doi: http://dx.doi.org/10.14740/jcs298w

Gold weight implants for management of thyroid-related upper eyelid retraction.

To evaluate the use of gold weight implantation in the upper eyelid in the treatment of upper eyelid retraction caused by thyroid ophthalmopathy as regards the cosmetic and functional results and the safety of the procedure. This is a surgical intervention case series study. The study was carried out in Ophthalmology Department in El-Minya University Hospital between January 2013 and January 2014. The study was approved by the ethical committee board of El-Minya University. Test weights were applied to the skin of the upper eyelid using special adhesive tape in the sitting position to determine the suitable implantable weight. Three interrupted nonabsorbable sutures (5/0 Dacron) were used to secure the gold weight to the tarsus. The orbicularis was closed using interrupted 6/0 vicryl sutures. The skin was closed using interrupted 6/0 nylon sutures. As regards the postoperative results, by the end of the follow-up period, improvement of eyelid retraction was present in all cases. Normal upper eyelid margin position (covering 2 mm of the cornea) was attained in 10 eyelids (76.92%). Undercorrection was observed in 3 eyelids (23.07%). Two eyelids covered 1 mm of the cornea, and 1 eyelid rested at the upper limbus. All patients (100%) were satisfied as regards the cosmetic results, with the degree of satisfaction ranging between very good for 3 patients and excellent for 4 patients. One patient had bilateral brick-shaped appearance. Gold weight implantation for treatment of thyroid-related upper eyelid retraction markedly improves the cosmetic appearance of the patient and, to a lesser extent, improves the manifestations of exposure with high patient satisfaction, and it is a relatively easy and safe procedure.

Kyste bronchogénique diaphragmatique : une localisation exceptionnelle

A 64-year-old man complained of persistent dyspnea and bilateral basi-thoracic pain with shoulder irradiation. Chest computed tomography revealed a heterogeneous left diaphragmatic mass, while magnetic resonance imaging showed hypo-T1 and hyper-T2 signal. Positron-emission tomography did not show any hypermetabolism. Video-assisted thoracic surgery was decided. At inspection, tumour appeared within the posterior costal part of the diaphragmatic muscle. Tumour resection was extended to a 8-cm-long portion of the lumbar part of diaphragm. Diaphragm was repaired with non-absorbable interrupted sutures. Postoperative course was uneventful. Final pathology revealed an intra-diaphragmatic bronchogenic cyst, which is an exceptional condition. Primary diaphragmatic tumours are very rare and preoperative diagnosis cannot be affirmed. Embryologic hypotheses (migration along the oesophagus or envelopment within diaphragmatic precursors of an abnormal supernumerary lung bud) including recent molecular findings of deregulated pathways (fibroblast growth factor-10 and NOTCH) are discussed.

Spigelian hernia showing itself as a left lower abdominal mass

Summary Spigelian hernia is a rare type of hernia. It can be congenital or acquired. Patients usually have a painful mass in the mid-to-lower abdomen, which is sometimes reducible in the supine position. Because of its high rate of incarceration, surgery should be performed as soon as a Spigelian hernia is diagnosed. We report a male patient with a palpable mass in his left lower abdomen; Spigelian hernia was diagnosed by means of ultrasound and computed tomography (CT). He underwent surgery soon after the diagnosis was made. The hernia defect was closed by interrupted nonabsorbable sutures without a mesh. He was discharged a few days later and recovered uneventfully.

Technical aspects and early results of robotic esophagectomy with chest anastomosis

Minimally invasive esophagectomy with a chest anastomosis has advantages. We present technical lessons learned and early results. A retrospective review was conducted of minimally invasive laparoscopic and robotic Ivor Lewis esophagectomy. Over 10 months, 22 patients (19 men) underwent laparoscopic gastric mobilization, with robotic esophagectomy. All had the thoracic portion completed robotically and 21 had the stomach mobilized laproscopically. All had esophageal cancer and 20 received neoadjuvant chemoradiotherapy. All had R0 resection with a median of 18 lymph nodes removed and a blood loss of 40 mL. The first 6 patients underwent a stapled posterior and hand-sewn anterior anastomosis; five of these patients experienced a major morbidity, including 1 anastomotic leak and 1 leak from the gastric staple line. The last 16 patients had a 2-layered completely hand-sewn anastomosis, and there were no anastomotic leaks or major morbidities. There were no 30- or 90-day mortalities. Technical improvements included placing a loop around the esophagus in the abdomen for third arm retraction, advancing the gastric conduit into the chest using nonrobotic instruments, using 10-cm nonabsorbable interrupted sutures for the outer layer, and a running 22-cm long absorbable suture for the inner layer. Robotic thoracic esophagectomy using ports only is feasible, safe, and affords R0 resection with thorough thoracic lymph node dissection. It also allows the sewing of a 2-layered chest anastomosis with good early results.

Wound Healing after Open Appendectomies in Adult Patients: A Prospective, Randomised Trial Comparing Two Methods of Wound Closure

The skin is closed in open appendectomy traditionally with few interrupted nonabsorbable sutures. The use of this old method is based on a suggestion that this technique decreases wound infections. In pediatric surgery, skin closure with running intradermal absorbable sutures has been found to be as safe as nonabsorbable sutures, even in complicated cases. Our purpose was to compare the safety of classic interrupted nonabsorbable skin closure to continuous intradermal absorbable sutures in appendectomy wounds in adult patients. A total of 206 adult patients with clinically suspected appendicitis were allocated to the study and prospectively randomized into two groups of wound closure: the interrupted nonabsorbable (NA) suture and the intradermal continuous absorbable (A) suture group. Primary wound healing was controlled on the first postoperative day, at 1 week clinically and after 2 weeks by means of a telephone interview. Follow-up data were obtained from 185 patients (90 in group NA and 95 in group A). Continuous absorbable intradermal suturing was as safe as nonabsorbable sutures in regard to wound infections. Continuous, absorbable sutures can be used safely even in complicated appendicectomies without increasing the risk of wound infection. Considering the benefits of absorbable suturing, we recommend this method in all open appendectomies.

Laparoscopic Repair of an Isolated Congenital Bilateral Lumbar Hernia in an Infant

We describe the laparoscopic repair of an isolated congenital bilateral lumbar hernia in an infant. Initial laparoscopic primary repair with nonabsorbable interrupted sutures resulted in recurrence, but subsequent laparoscopic mesh repair led to satisfying results. A lumbar hernia is defined as the protrusion of an organ or tissue through a defect in the posterolateral abdominal wall. This type of hernia is extremely rare. In 1774, Petit reported a patient with a strangulated lumbar hernia. He also described the anatomical borders of the (inferior) lumbar triangle through which the hernia protruded.1 Although he was not the first to publish on this subject, the inferior triangle and the associated hernia are nowadays associated with Petit. Nearly a century later, in 1866, the existence of a superior lumbar triangle was reported by Grynfeltt.2 The inferior lumbar triangle (Petit) is an upright triangular space. Its boundaries are the posterior border of the external oblique muscle anteriorly, the anterior border of the latissimus dorsi muscle posteriorly and the iliac crest inferiorly. Its roof is the superficial fascia and its floor the internal oblique muscle. The superior lumbar triangle (Grynfeltt) is an inverted triangular space. Its borders consist of the posterior border of the internal oblique muscle anteriorly, the anterior border of the sacrospinalis muscle posteriorly, and the 12th rib and serratus posterior inferior muscle superiorly. The roof is formed by the latissimus dorsi muscle and the floor by the aponeurosis of the transversus abdominis muscle.3 In 2007, Moreno-Egea et al estimated that 300 cases of lumbar hernia, protruding through the inferior or superior lumbar triangles, have been reported in the medical literature.4 Approximately 80% of these hernias are considered to be acquired (i.e., incisional or postinfectious) while 20% are thought to be congenital.5 Consistent with these findings, in 2008, Akcora et al reported that a total of 60 congenital hernias have been described.6 In 20 cases, the congenital hernias were associated with the lumbocostovertebral syndrome.7–9 This syndrome includes hemivertebrae, absence of ribs, anterior myelomeningocele, and abdominal wall muscular hypoplasia. Other abnormalities associated with congenital lumbar hernia have been described as well. However, no additional anomalies were found in our patient. Isolated bilateral congenital hernia and open repair in an infant have been described before for the first and, to our knowledge, only time in 2002.10 Here, we report for the first time the laparoscopic repair of this type of bilateral hernia in a baby.

Early experience with thoracoscopic repair of congenital diaphragmatic hernias in pediatric age group: results and lessons learned

To describe the surgical technique, initial results, and overview indications of thoracoscopic repair of congenital diaphragmatic hernia. A retrospective review was undertaken of patients with CDH who underwent thoracoscopic repair from January 2006 to July 2010, in department of pediatric surgery in a tertiary care institute in India. Patients underwent surgery under general anesthesia. Reduction of the hernia contents was carried out using one trocar for telescope and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 6-10 mmHg. The hernia defect was repaired using nonabsorbable interrupted sutures. There were 17 patients, including 12 boys and 5 girls. Among 12 infants, there were 6 patients younger than 30 days. The other 5 patients were older than 1 year. The hernia was located in the left side in 14 patients and in the right side in 3 patients. The mean operative time was 110 min. Conversion was required in three patients. There were one recurrence and one postoperative death. Thoracoscopic repair is feasible and safe for children with CDH, including selective newborn. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery.

Thoracoscopic Repair for Congenital Diaphragmatic Hernia: Experience with 139 Cases

To analyze indications and to present details of surgical technique and outcomes of thoracoscopic repair for congenital diaphragmatic hernia (CDH) in 139 patients. We reviewed medical records of all patients with CDH who underwent thoracoscopic repair by the same surgical team from June 2001 to October 2009. Patients were placed in the lateral decubitus position. The operations were performed using three trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2-6 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extracorporeal knots. A prosthetic patch was used when direct closure of the hernia defect was not feasible. There were 139 patients, including 91 boys and 48 girls. Seventy-five patients were newborns, and 64 were infants or children. The hernia was located on the left side in 113 patients (81.3%) and on the right side in 26 patients (18.7%). The mean operative time for thoracoscopic approach was 66 ± 27 minutes. Conversion was required in 11 patients (7.9%) from 2001 to 2007. There were no conversions in 2008 or 2009. A prosthetic patch was used in 7 patients. There were 14 postoperative deaths (10%). Follow-up was obtained in 114 patients, ranging from 1 to 84 months (mean 26.3 ± 24.7 months). Five patients had recurrence (3.6%). Thoracoscopic repair is feasible and safe for children with CDH, including newborns. The conversion rate decreased, and indications increased with surgical team experience.

Video Demonstration of the Technique of Laparoscopic Gastrophrenopexy for the Treatment of Symptomatic Primary Organoaxial Gastric Volvulus

The aim of this work was to demonstrate the technique of laparoscopic gastrophrenopexy performed for intermittent partial organoaxial volvulus. Two pediatric patients, with an initial presentation of postprandial epigastric discomfort, were investigated by upper gastrointestinal contrast meal. These investigations revealed the presence of a rare variant of primary organoaxial gastric volvulus. Both patients underwent a laparoscopy, which confirmed gastromegaly with redundant gastrophrenic and gastrolienal ligaments. A gastrophrenopexy was performed with initial pexy of, principally, the fundus to the left hemidiaphragm, using interrupted nonabsorbable sutures. The gastrophrenopexy was performed without an esophagocardiopexy or an anterior gastropexy. A video demonstrates the technical aspects of the procedure, and the associated pre- and postoperative imaging for both patients will be presented. Both procedures were accomplished laparoscopically in less than 60 minutes, with no immediate postoperative complications. The patients were discharged the following day after a period of observation. Symptom resolution occurred with both patients. One patient underwent a repeat upper gastrointestinal contrast study 4 years post intervention, which demonstrated an intact gastropexy. Laparoscopic gastrophrenopexy may be utilized for this rare variant of gastric organoaxial volvulus. This technique is durable over the medium term and is, therefore, recommended as the primary intervention in symptomatic pediatric patients.

Serous Lined Extramural Tunnel Principle in the Creation of a Catheterizable Channel in Bladder

Purpose To evaluate the versatility of this principle and its aptness to various situations in pediatric reconstructive surgery providing a video showing the fine technical details. Material and Methods Over the past 9 years, the principle was used in 11 patients (mean age 11years). Indications were: 2 conversions from ileal conduit to continent cutaneous (1 PUV, 1 pelvic rhabdomyosarcoma) and 9 creations of catheterizable channel in bladder augmentation (1 PUV, 3 spina bifida, 5 bladder-exstrophy). Associated procedures were (1 BN closure, 2Sling, 5 Mitchell BNR, 2 MACE). Appendix was used as an outlet in 7 and Monti in 4. Results In all, the stoma was successfully matured to the umbilicus. There were no postoperative complications or difficult catheterization. In the first 3months all were continent. Three-6months later, 3/11(27%) developed secondary incontinence (Injection was tried unsuccessfully). Surgical revisions showed de-ssusception of the tunnel in each (each had Monti outlet). Eight/11(73%) remained continent (mean follow up of 2.4years postoperatively). Conclusions This technique is versatile. Can be used as primary or salvage surgery. The stoma can always be brought to the umbilicus. The appendix is the preferred continent outlet. Fine surgical details as fixation of the outer pouch wall of the tunnel to the inner anterior abdominal wall and the use of interrupted non-absorbable sutures in the tunnel floor are crucial for the success. One disadvantage is that bulking agent injection is not useful to treat secondary incontinence

Laparoscopic-assisted repair of Morgagni hernia in children

Purpose Morgagni hernia is a rare entity that accounts for less than 6% of all surgically treated diaphragmatic hernias in pediatric age group. They are mostly asymptomatic and discovered incidentally. Open surgical repair has been the gold standard in all cases once diagnosed. However, since the introduction of minimal access surgery, different laparoscopic techniques of Morgagni hernia repair have been reported in the literatures. Most of them are reporting on few cases and the immediate outcomes. Herein, we report the largest experience to date assessing the safety and efficacy of laparoscopic-assisted full-thickness anterior abdominal wall repair of Morgagni hernia in children with more emphasis on the short-term outcomes, such as the recurrence and the fate of the hernia sac. Methods Fifteen children with Morgagni hernias underwent primary laparoscopic repair by placement of interrupted nonabsorbable sutures through the full thickness of the anterior abdominal wall, incorporating the hernia sac, the posterior rim of the defect, and returning back out through the anterior abdominal wall with the sutures tied in the subcutaneous tissue. Result Between January 2004 and January 2008, 15 children with Morgagni hernia were treated laparoscopically in our institution-affiliated hospitals. Male-female ratio was 2:1. Mean age was 21.7 months. The average operative time was 42.6 minutes. Average time to full feed was 22.9 hours. Postoperative analgesia requirement was minimal. The average hospital stay was 24 hours. All operations were completed laparoscopically. None of the patients developed intraoperative or postoperative complications. The maximum follow-up was 48 months (mean, 20 months). All patients are in good health without recurrence or significant sac residual. Conclusion Laparoscopic-assisted Morgagni hernia repair is a safe and effective modality of treatment. It is well tolerated and gives all the advantages of minimal access surgery, without adverse effects from leaving the sac plicated in place.

Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients

A retrospective study aimed to analyze our experience in 46 patients with blunt traumatic diaphragmatic rupture (BTDR) admitted to our tertiary hospital from 1995 to 2007. Charts, chest roentgenograms (CXR), and computed tomography (CT) scans were carefully reviewed. The mean age was 36.5+/-10.1 years, 36 (78.3%) were males. The etiology was a traffic accident in 36 (78.3%) patients. BTDR was left-sided in 34 (73.9%) and right-sided in 12 (26.1%) patients. CXR was diagnostic in 26 (56.5%) and CT in 12 (26.1%) patients. Associated injuries included lung 12 (26.1%), liver 10 (21.7%), spleen 24 (52.2%) and bowel 2 (4.2%) patients. BTDR was approached through thoracotomy 26 (56.5%), laparotomy 16 (34.8%), and combined approach 4 (8.7%) patients. The repair was primarily with interrupted non-absorbable sutures in 42 (91.3%) and by prosthetic mesh in four patients. Complications developed in 20 patients. Mortality was observed in 2 (4.3%) patients. We concluded that BTDR is a common lesion in young adult males on the left side caused by a traffic accident. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis. Associated injuries represent the main prognostic factor affecting morbidity and mortality. Thoracotomy and primary repair is adequate surgical treatment.