Transverse Abdominal Incision Research Articles

Application of Stoppa approach in periacetabular osteotomy for treatment of hip dysplasia

Objective To evaluate the safety and effectiveness of Stoppa approach combined with iliac incision in periacetabular osteotomy for treatment of hip dysplasia.Methods From September 2011 to July 2012,18 patients (20 hips) with hip dysplasia were performed periacetabular osteotomy through Stoppa approach combined with iliac incision.There were 15 female patients with 17 hips and 3 male patients with 3 hips.The average age was 29 years old (range 19 to 35).The surgical incision included two parts with the abdominal transverse incision (Stoppa approach) and the iliac incision (the lateral window of ilioinguinal approach).The duration of surgery,length of incision,intraoperative blood loss,and amount of allogeneic blood transfusion were measured.The clinical function,radiographic parameters,and operative complications were analyzed at 12 months follow-up.Results The mean operation time was 145 min (range,125-180 min).The mean incision length of Stoppa approach was 7 cm (range,5-10 erm) for the abdominal part and 6 cm (range,4-8 cm) for the iliac part,and the average of total incision length was 13 cm (range,12-16 cm).The mean blood loss during operation was 800ml (range,500-1 600 ml).The mean amount of allogeneic blood transfusion was 1 161 ml (range,400-2 400 ml).The mean duration of follow-up was 19.6 months (range,14-22 months).Compared to the preoperative data,both postoperative Harris hip score and center-edge angle improved significantly,with a mean increase of 13.2±6.0 and 22.5°±4.5° respectively.The mean Harris hip score improved form 80.3±8.5 preoperatively to 93.5±5.2 postoperatively at the time of 12 months follow-up.The average center-edge angle improved from 7.5°±5.4° preoperatively to 30.0°±4.6° postoperatively.All of the osteotomies except two pubic osteotomies healed at the time of three months follow-up.The two pubic osteotomies were treated with protected weight bearing and had a delayed union until the six months follow-up.The mean time of osteotomies union was 3.3 months.Complications included three transient]ateral femoral cutaneous nerve palsies which completely resolved within three months after oral medicine therapy.There were no major neurovascular complications,no infection,no incision hernia or any other surgical complications.Conclusion Stoppa approach combined with iliac incision is a safe and effective approach for periacetabular osteotomy.It is an alternative to conventional ilioinguinal approach for treatment of mild hip dysplasia. Key words: Hip dislocation, congenital; Acetabulum; Osteotomy

Carboxymethylcellulose adhesion barrier placement at primary cesarean delivery and outcomes at repeat cesarean delivery.

To assess associations of a commercially available carboxymethylcellulose adhesion barrier placed during primary cesarean delivery with clinical outcomes of repeat cesarean deliveries. We performed a retrospective cohort study of women undergoing primary cesarean delivery on or after January 1, 2008, and first repeat cesarean delivery in one of four hospitals in the same system by June 30, 2011. Women were included if both deliveries were live singletons at 34-42 weeks of gestation delivered through transverse abdominal incisions and the first hysterotomy was low transverse. Exclusion criteria included intervening delivery; puerperal infection, bowel injury, or bladder injury at primary cesarean delivery; uterine incision or laparotomy (except primary cesarean delivery) before repeat cesarean delivery; and use of another adhesion barrier at primary cesarean delivery. As a surrogate for adhesion grading, the primary outcome was time from skin incision to neonate delivery at repeat cesarean delivery. We also assessed total operative time and rates of selected surgical complications. There were 517 women who met criteria; 248 received the adhesion barrier during primary cesarean delivery and 269 did not. There were no demographic differences between groups except delivery hospital. In the adhesion barrier and no adhesion barrier groups, respectively, mean±standard deviation times to delivery at repeat cesarean delivery were 6.1±3.0 compared with 5.8±2.5 minutes (P=.25), and total operative times were 31.2±10.6 compared with 31.8±11.6 minutes (P=.56). Surgical complications were not different between groups. Placing a commercially available carboxymethylcellulose adhesion barrier at primary cesarean delivery is not associated with decreased time to delivery, total operative time, or complications during repeat cesarean deliveries. II.

V1-02 AUTOLOGOUS TRANSOBTURATOR MID-URETHRAL SLING FOR FEMALE STRESS URINARY INCONTINENCE

You have accessJournal of UrologyFemale Pelvic Medicine & Reconstructive Surgery1 Apr 2014V1-02 AUTOLOGOUS TRANSOBTURATOR MID-URETHRAL SLING FOR FEMALE STRESS URINARY INCONTINENCE Brian Linder and Daniel Elliott Brian LinderBrian Linder More articles by this author and Daniel ElliottDaniel Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.596AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present a video of a novel transobturator approach to autologous urethral sling placement. METHODS A 55-year old female presented with worsening pure stress urinary incontinence. She had significant bother from her leakage and after discussion of potential management options preferred an autologous urethral sling, however did not want an intra-abdominal portion of the procedure. Thus, we utilized a transobturator approach to autologous urethral sling placement. Following hydrodissection with injectable saline a midline incision was made in the anterior vaginal wall. Dissection was carried to the obturator foramen bilaterally. Next, a transverse abdominal incision was made and an 8cm x 1cm strip of rectus fascia was harvested and prepared with two stay sutures on each lateral end of the fascial sling. A small incision was made in the medial thigh bilaterally and dissection carried to the obturator foramen. A helical trocar was passed twice through each obturator foramen and the stay sutures retracted through the incision. The sling was secured proximally and distally with interrupted sutures. Careful attention was paid to tensioning the sling, which was left flush with the urethra. The stay sutures were then tied down and cut at the skin level. The anterior vaginal wall and skin incisions were then closed. RESULTS The patient had an uncomplicated postoperative course and was able to spontaneously empty her bladder with low post-void residual. She was seen back 2 weeks following her procedure noting no leakage, requiring zero pads and subjectively pleased with her outcome. CONCLUSIONS Given this result, a transobturator approach to urethral sling placement appears technically feasible in appropriately selected candidates. Longer follow up and larger case series will be needed to validate this finding. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e292 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Brian Linder More articles by this author Daniel Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical experience of J‐VAC drain for skin closure in the laparotomy of obstetrics and gynecology

The frequency of wound dehiscence after abdominal surgery has been reported to be approximately 4-29%, and that of surgical site infections is said to be of about 20%. We examined the effectiveness of the subcutaneous J-VAC drain (JVD) in the drainage of bleeding and exudates from surgical wounds. The study was conducted on 192 patients who underwent abdominal surgery from October 2009 to February 2011, and in whom indwelling JVD were placed. During the study period, JVD (10-Fr) were placed subcutaneously on the anterior surface of the fascia in all patients. We examined the frequency of surgical wound complications. A longitudinal incision was used in 101 patients, and a transverse abdominal incision was used in 91 patients. Subjects with a subcutaneous fat thickness of 2 cm or thicker accounted for 115 patients. Subcutaneous hematoma was present in three patients, but only two patients (1%) showed dehiscence that required treatment. This study revealed that subcutaneous JVD is useful for the closure of surgical incisions in gynecology and obstetrics, and that there are no limitations to their applicability.

Postoperative continuous transversus abdominis plane block vs continuous wound infusion of levobupivacaine in females undergoing open gynecologic procedures

IntroductionTransversus abdominis plane (TAP) block is used as a part of multimodal analgesia in decreasing pain of lower abdominal wall incision. Local anesthetic instillation of wounds through subcutaneous or subfascial catheters is used to treat postoperative pain in different types of surgery. The aim of this randomized controlled trial was to study the opioid-sparing effect of these two techniques (if any) compared to placebo in women undergoing gynecologic procedures through transverse lower abdominal incisions.MethodsSeventy-eight ASA I–III patients planned to undergo gynecologic procedures through a transverse lower abdominal incision were randomly divided into three equal groups: Control (C) group (n = 26), Continuous Wound Infusion (CWI) group (n = 26), and continuous transversus abdominis plane block (TAP) group (n = 26). After standardized general anesthetic and before extubation, the patients were given the allocated treatment. A morphine patient-controlled analgesia (PCA) was started postoperatively alongside with the local anesthetic (or placebo) infusion. Cumulative dose of morphine PCA in the first postoperative 48 h was the primary outcome. Secondary outcomes included visual analog pain score (VAS) at rest and on movement and complications of morphine PCA.ResultsThe cumulative dose of morphine PCA in the first postoperative 48 h was higher in control group than in groups CWI and TAP (P < 0.001). However, no significant difference was found between groups CWI and TAP. No significant differences were found among the three groups regarding VAS during rest but TAP group showed less pain scores than groups C and CWI on movement. The three groups were similar regarding morphine side effects.ConclusionContinuous bilateral TAP block and CWI can decrease PCA morphine consumption in the first postoperative 48 h when compared to placebo in women undergoing gynecologic surgery through transverse lower abdominal incision. Continuous TAB block might give better analgesia with movement than CWI.

In Reply

We thank Dr. Harper for his comments and interest on our recent study published in Anesthesiology.1We fully agree with the author that complete compliance with the enhanced recovery after surgery recommendations would have involved absence of mechanical bowel preparation (MBP) in left-sided colonic surgery. Nevertheless, the largest systematic review on the role of MBP in colonic surgery (including approximately 5,000 patients) failed to demonstrate harmful effects of MBP in terms of anastomotic leakage.2 In addition, two large-scale randomized controlled trials3,4 suggested more deep intraabdominal abscesses in the absence of MBP and a significant benefit in patients who had MBP. It has also been shown that preoperative MBP is useful when intraoperative colonoscopy is required to precisely locate small tumors. Finally, although MBP has adverse physiologic effects attributed to dehydration, omission of preoperative fasting and use of individualized goal-directed fluid administration may easily and effectively compensate for this.We respectfully disagree with the author when stated that midline incision may not represent current daily for colorectal surgery. To the best of knowledge, current recommendations do not advocate use of transverse or oblique incisions for open colorectal surgery. Since the publication of the Cochrane review, the Postsurgical Pain Outcome of Vertical and Transverse Abdominal Incision randomized controlled trial5 has shown no relevant difference in pain scores and postoperative morbidity between incision types after major abdominal procedures, whereas more wound infections were seen after transverse incisions. Although problematic, these concerns are not the most important ones. Indeed, as a possible clinical benefit of wound catheters placement in oblique and/or transverse incisions has never been explored during colorectal surgery, any comparison between continuous wound analgesia, as an interventional treatment group in this setting, and epidural analgesia would have been only speculative.Until more thorough studies addressing the question have been carried out, our opinion is that there is no sufficient evidence to shift from epidural analgesia to continuous wound infiltration of local anesthetics in elective open colorectal surgery. We are convinced that the soon-to-be-published Dr. Harper’s study will help provide answers to the many remaining questions regarding the optimal analgesic regimen in open colorectal surgery.

Mini-Laparotomy Versus Laparoscopy for Gynecologic Conditions

Study ObjectiveTo compare conversion rates, operative time, and estimated blood loss in patients undergoing mini-laparotomy (<4 cm vertical or transverse abdominal incision) versus laparoscopy for treatment of benign gynecologic conditions. DesignRetrospective study (Canadian Task Force classification II-2). SettingAcademic medical center. PatientsWomen who underwent laparoscopy or mini-laparotomy for treatment of gynecologic conditions from January 2002 to March 2011. Patients who underwent hysterectomy as part of the surgery, cancer staging procedure, pregnancy-related procedure, or diagnostic surgery alone were excluded. InterventionsMini-laparotomy or laparoscopy. Measurement and Main ResultsPrimary outcomes were operative time and estimated blood loss. Secondary outcomes were hospital readmission, repeat operation, overnight hospital admission, emergency room visits because of surgery-related signs or symptoms, and wound complications. Of 950 medical records examined, 493 patients (52%) met the inclusion criteria, of which 141 (29%) underwent mini-laparotomy and 352 (71%) underwent laparoscopy. The groups had similar indications for surgery and level of surgical assistant. Patients who underwent mini-laparotomy were older than those who underwent laparoscopy. In patients who underwent mini-laparotomy, mean operative time was significantly shorter (49.3 versus 91.5 minutes; p = .003), and estimated blood loss was less (20 versus 32 mL; p = .001). The cumulative secondary outcome rate was not statistically different between the 2 groups (15% versus 16%). When each secondary outcome (conversion, repeat operation, overnight hospital admission, readmission to the hospitalization, emergency department visit, and wound complication) was examined independently, only the wound complication rate was significantly higher in the mini-laparotomy group compared with the laparoscopy group (5 of 141 patients versus 1 of 352 patients; p = .008). ConclusionsMini-laparotomy is a safe alternative to traditional minimally invasive approaches in gynecology and offers the additional benefits of shorter intraoperative time and less blood loss; however, it is associated with a significantly higher rate of major wound complications. Mini-laparotomy is an important surgical approach and should be included in gynecologic surgical training.

On-Q® pain pump versus epidural for postoperative analgesia in children

The On-Q(®) pain pump provides a continuous infusion of local anesthesia for management of postoperative pain. The objective of this study was to assess the efficacy and outcomes of the On-Q(®) pump compared to continuous epidural in children postoperatively. We performed a retrospective review of patients in our hospital who received a postoperative epidural or On-Q(®) pump from 2005 to 2008. Patients were sub-categorized by incision type. Seventy patients received epidural and 66 On-Q(®). On-Q(®) therapy was longer by 1 day (p < 0.0001), but did not affect postoperative length of stay. Patients with On-Q(®) pumps had a decreased rate of Foley catheter placement (p = 0.002) and shorter duration of catheter use by more than a day (p < 0.001). Moderate to severe pain was similar in the two groups on postoperative days 0-5. Supplemental narcotic use was higher in the On-Q(®) group only on postoperative day 1 (p = 0.005) and in patients with midline and transverse abdominal incisions. No differences were seen in time to ambulation or recovery of postoperative ileus. The On-Q(®) pain pump is an effective method for postoperative pain control, without the inherent risks of epidural catheters.

Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, randomised controlled trial

Variations exist in the surgical techniques used for caesarean section and many have not been rigorously assessed in randomised controlled trials. We aimed to assess whether any surgical techniques were associated with improved outcomes for women and babies. CORONIS was a pragmatic international 2×2×2×2×2 non-regular fractional, factorial, unmasked, randomised controlled trial that examined five elements of the caesarean section technique in intervention pairs. CORONIS was undertaken at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Each site was assigned to three of the five intervention pairs: blunt versus sharp abdominal entry; exteriorisation of the uterus for repair versus intra-abdominal repair; single-layer versus double-layer closure of the uterus; closure versus non-closure of the peritoneum (pelvic and parietal); and chromic catgut versus polyglactin-910 for uterine repair. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based number allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. The primary outcome was the composite of death, maternal infectious morbidity, further operative procedures, or blood transfusion (>1 unit) up to the 6-week follow-up visit. Women were analysed in the groups into which they were allocated. The CORONIS Trial is registered with Current Controlled Trials: ISRCTN31089967. Between May 20, 2007, and Dec 31, 2010, 15 935 women were recruited. There were no statistically significant differences within any of the intervention pairs for the primary outcome: blunt versus sharp entry risk ratio 1·03 (95% CI 0·91-1·17), exterior versus intra-abdominal repair 0·96 (0·84-1·08), single-layer versus double-layer closure 0·96 (0·85-1·08), closure versus non-closure 1·06 (0·94-1·20), and chromic catgut versus polyglactin-910 0·90 (0·78-1·04). 144 serious adverse events were reported, of which 26 were possibly related to the intervention. Most of the reported serious adverse events were known complications of surgery or complications of the reasons for the caesarean section. These findings suggest that any of these surgical techniques is acceptable. However, longer-term follow-up is needed to assess whether the absence of evidence of short-term effects will translate into an absence of long-term effects. UK Medical Research Council and WHO.

Non-Ischemic Remote Cardioprotective Phenomena

Ischemic preconditioning (IPC) is a powerful cardioprotective phenomenon that occurs in several species. IPC means that transient ischemic makes the cardioprotection in the subsequent period of ischemic thus it limits the scope of myocardial infarction. The reports of recent years have obtained the conclusion that this cardioprotection can be also induced by the non-ischemic preconditioning such as metabolic stimulation of myocardial cells and distention of the left ventricle. From the physiological point of view, the protective effect of non-ischemic preconditioning is associated with the higher proportion of myocardial cell metabolism. Remote ischemic preconditioning (RIC) is a therapeutic measure for cardioprotection against the deleterious effect of acute ischemia-reperfusion injury (IRI). And, it’s beneficial effects are also seen in other organs (lung, liver, kidney, brain) and tissues (skeletal muscle). Although the mechanism of RIC has not yet been completely determined, there are several probable hypotheses supporting the cardioprotection induced by RIC, which include the neuronal pathway, humoral pathway, and systemic response. Recently, some researchers have provided experimental evidence for the cardioprotection under non-ischemic trauma at a site from the heart produced by a transverse abdominal incision. This study demonstrated that protection could be elicited by non-ischemic stimulus which they term “remote preconditioning of trauma (RPCT)”. Because of remote preconditioning of trauma, which is produced by an abdominal incision only through the skin, so it means that it’s non-ischemic. Although remote ischemiac stimulus has been shown to elicit cardioprotection against IRI, there are not many reports about the remote non-ischemic stimulus and its mechanism. In this article, we provide a review of cardioprotection, the potential mechanism of RPCT as well as its clinical prospects.

Another case of pediatric cecal diverticulitis

We have recently reported in this journal a report of two pediatric patients with cecal diverticulitis, a 15-year-old female and a 3-year-old female. There have been no documented reports subsequent to ours; however, we have since encountered an additional pediatric patient with cecal diverticulitis to add to this case series. This most recent patient is a 10-year-old female who presented to the emergency department with a 1-day history of worsening abdominal pain. Her parents reported subjective fevers at home, but denied any nausea or emesis. In the emergency department, her vital signs were within normal limits. Physical examination was notable for tenderness to palpation in the right lower quadrant. Her white blood cell count was 12,500 mm with 72 % neutrophils. An abdominal ultrasound was performed which could not visualize the appendix, and did not demonstrate any free fluid. A computed-tomography scan was then obtained which showed a cecal wall diverticulum with wall thickening and adjacent marked inflammatory changes consistent with cecal diverticulitis. The appendix was visualized and appeared normal. Free fluid was present in the right lower quadrant, however, no pneumoperitoneum was present. The patient was started on intravenous piperacillin/ tazobactam. Based on the radiographic findings and a worsening abdominal examination, the decision was made to proceed with operative exploration. Similar to our prior cases, a transverse abdominal incision was made in the right lower quadrant. The cecal wall was found to be thickened and a rubbery mass was palpated within the wall of the cecum. An ileocecectomy was performed. Pathology revealed a perforated ‘‘false’’ cecal diverticulum with organizing serositis. The patient did well postoperatively and was discharged on postoperative day 6. This case is very similar in presentation, operative findings, and pathology results to the two previous cases we have reported. We are seeing an increased incidence of pediatric cecal diverticulitis. Further investigations are necessary to understand the etiology of this disease in the pediatric population, and to clarify the possibility of an increasing incidence in childhood.

Avoiding extraction site herniation after laparoscopic right colectomy

Transverse abdominal wall incisions are favoured as part of enhanced recovery programmes. We explored the use of rectus-preserving extraction site incisions in laparoscopic right colectomy. The approach involved minimal anterior abdominal wall disruption with preservation of the rectus abdominis muscle: the rectus abdominis muscle extraction site (RAMES). In 15 patients, a RAMES was used electively in right colectomy for malignancy. The median wound length was 6cms. There was no clinical or radiological evidence of incisional herniation in the 15 patients at 12-month and in the 12 survivors at 24-month follow-up. An anatomical dissection at specimen extraction site reduces early incisional herniation rates and should be of benefit in the longer term.

The CORONIS Trial: international study of caesarean section surgical techniques

Design CORONIS is a pragmatic multicentre fractional factorial randomised controlled trial and is being conducted in sites in Argentina, Chile, Ghana, India, Kenya, Pakistan and Sudan [1]. Women are eligible if they are undergoing their first or second caesarean section through a transverse abdominal incision. Five comparisons will be carried out using a 2 balanced incomplete block factorial design. Each woman is allocated THREE of the five pairs of interventions using a bespoke secure webbased randomisation system (with 24/7 automated backup telephone system) hosted by the NPEU Clinical Trials Unit. The 5 pairs of interventions are: i. Blunt versus sharp abdominal entry ii. Exteriorisation of the uterus for repair versus intraabdominal repair iii. Single versus double layer closure of the uterus iv. Closure versus non-closure of the peritoneum (pelvic and parietal) v. Chromic catgut versus Polyglactin-910 for uterine repair Primary outcome: death or maternal infectious morbidity (one or more of the following: antibiotic use for maternal febrile morbidity during postnatal hospital stay, antibiotic use for endometritis, wound infection or peritonitis) or further operative procedures or blood transfusion. Sample size required: 15,000 women in total; minimum 9,000 women per comparison pair.

Abdominal Surgical Incision Induces Remote Preconditioning of Trauma (RPCT) via Activation of Bradykinin Receptors (BK2R) and the Cytochrome P450 Epoxygenase Pathway in Canine Hearts

Recently, a novel observation was made in which nonischemic trauma at a site remote from the heart produced by a transverse abdominal incision resulted in a marked reduction of infarct size (IS) in the mouse heart via activation of sensory nerve fibers in the skin and subsequent activation of bradykinin 2 receptors (BK2R). This phenomenon was termed remote preconditioning of trauma (RPCT). Since RPCT may have potential clinical implications we attempted to confirm these findings in a large animal model, the dog. The epoxyeicosatrienoic acids (EETs) have also recently been shown to be antinociceptive and have been shown to mimic ischemic preconditioning (IPC) and postconditioning (POC) in dogs, therefore, we tested the role of the EETs in RPCT. Anesthetized adult mongrel dogs of either sex were subjected to 60min of left anterior descending (LAD) coronary artery occlusion followed by 3h of reperfusion. In all groups except the controls (no slit), a transverse slit (9cm) was applied to the abdominal wall of the dog being careful to only slit the skin. Subsequently, 15min after the slit the heart was subjected to the ischemia/reperfusion protocol. In the control dogs, the IS as a percent of the area at risk (AAR) was 22.5 ± 2.4%, whereas in the dogs subjected to the slit alone the IS/AAR was reduced to 9.2 ± 1.2% (*P < 0.01). The BR2R blocker, HOE 140 (50ug/kg, iv) given 10min prior to the slit, completely abolished the protective effects of RCPT as did pretreatment with 14,15-EEZE, a putative EET receptor blocker or pretreatment with the selective EET synthesis inhibitor, MSPPOH. These results suggest that BK and the EETs share cardioprotective properties in a large animal model of RPCT.

A comparison of circumumbilical and transverse abdominal incisions for neonatal abdominal surgery

Purpose Although neonatal bowel surgery traditionally involves a transverse abdominal incision, several authors have reported that the circumumbilical incision is effective and cosmetically appealing. We report the first study comparing the circumumbilical incision to the transverse abdominal incision for a variety of neonatal abdominal operations. Methods Retrospective cohort analysis comparing the circumumbilical incision to the transverse abdominal incision for neonates who underwent surgical repair of malrotation, duodenal atresia/web, or intestinal atresia/web was performed between 1999 and 2009. Results One hundred thirty-two patients underwent a laparotomy through a transverse abdominal incision (n = 106) or a circumumbilical incision (n = 26). Baseline characteristics between groups were similar. No differences were found when comparing operative time, postoperative days on a ventilator, narcotic infusion, time to full feeds, length of hospital stay, incidence of surgical site infection, and bowel obstruction. Although more incisional hernias occurred in the circumumbilical incision group (38%) than the transverse abdominal incision group (6%), all hernias in the circumumbilical group resolved without intervention, whereas 33% required surgical repair in the transverse abdominal group. Conclusions Because of its cosmetic advantages and similar outcomes to the transverse abdominal incision, the circumumbilical incision should be considered as an alternative to the transverse abdominal approach in neonatal surgery.

Ranking of patient and surgeons' perspectives for endpoints in randomized controlled trials—lessons learned from the POVATI trial [ISRCTN 60734227

Surgical trials focus mainly on mortality and morbidity rates, which may be not the most important endpoints from the patient's perspective. Evaluation of expectations and needs of patients enrolled in clinical trials can be analyzed using a procedure called ranking. Within the Postsurgical Pain Outcome of Vertical and Transverse Abdominal Incision randomized trial (POVATI), the perspectives of participating patients and surgeons were assessed as well as the influence of the surgical intervention on patients' needs. All included patients of the POVATI trial were asked preoperatively and postoperatively to rank predetermined outcome variables concerning the upcoming surgical procedure (e.g., pain, complication, cosmetic result) hierarchically according to their importance. Preoperatively, the surgeons were asked to do the same. One hundred eighty two out of 200 randomized patients (71 females, 111 males; mean age 59 years) returned the ranking questionnaire preoperatively and 152 patients (67 females, 85 males; mean age 60 years) on the day of discharge. There were no differences between the two groups with respect to the distribution of ranking variables (p > 0.05). Thirty-five surgeons (7 residents, 6 fellows, and 22 consultants) completed the same ranking questionnaire. The order of the four most important ranking variables for both patients and surgeons were death, avoiding of postoperative complications, avoiding of intraoperative complications, and pain. Surgeons ranked the variable "cosmetic result" significantly as more important compared to patients (p = 0.034, Fisher's exact test). Patients and surgeons did not differ in ranking predetermined outcomes in the POVATI trial. Only the variable "cosmetic result" is significantly more important from the surgeon's than from the patient's perspective. Ranking of outcomes might be a beneficial tool and can be a proper addition to RCTs.

Clinical pattern and management outcome of uterine fibroids seen in a private specialist hospital in southeast Nigeria.

BackgroundUterine fibroid is the commonest tumour affecting women of reproductive age in our locality. Owing to the significant role played by privatehealth facilities in healthcare delivery in the developing countries, most of these cases will be handled at the private facilities. Therefore aconstant review of pattern of presentation and treatment outcome in these hospitals is necessary to improve on the efficiency of the diagnosis andtreatment of this common condition.Objective: To ascertain the pattern of clinical presentation, findings at surgery and treatment outcome of cases of uterine fibroids managed byabdominal myomectomy in Private Specialist Hospital in Southeast Nigeria, over a 5-year period.Setting: Grace Specialist hospital Onitsha, South East of Nigeria.Materials and methods: This prospective descriptive study was carried out between 1st January 2003 and 31st December 2007. Patients whowere booked for myomectomy on account of uterine fibroids were recruited for the study. The diagnosis of uterine fibroids was made bothclinically and use of ultrasound. Biodata, clinical presentation, findings at surgery, complications following surgery and duration of hospital staywere recorded. The data was analyzed with the epi info statistical package, version 2006.Result: The mean age of the patients was 32.9±6.5 years. Majority of the patients were nulliparous (7.0%). The commonest presenting symptomwas menorrhagia (44.40%) and majority (54.2%) of the women had medium sized fibroids (uterine size 12-16weeks).The total number of fibroid nodules ranged from 1-148(mean= 11) with weight varying between 25g to 3850g. Most (68.1%) of the patients had a combination ofintramural, subserous, submucous fibroids and intraligamentary fibroids. The transverse abdominal incision was used in majority (51.4%) of thepatients. The estimated mean blood loss was 500±150mls, with a mean drop in haemoglobin concentration of 1.4 +0.6g/dl. 22.20% of thepatients received blood transfusion intraoperatively. Postoperative complications were encountered in 11.80% of patients and constitute mainly of febrile morbidity (5.6%) and wound infection (2.8%). The mean hospital stay was 9.1=3.6 days. No mortality was recorded.Conclusion: Most of the women managed for uterine fibroids were nulliparous and presented mainly with menorrhagia and multiple fibroidsnodules. Myomectomy as a form of treatment is safe but may be attended by a high level of blood transfusion. Efforts should be made to reduceintraoperative blood loss by the use of tourniquet and the gonadotrophin releasing hormone analogues.

Triclosan-coated sutures reduce wound infections after hepatobiliary surgery—a prospective non-randomized clinical pathway driven study

Wound infections after abdominal surgery are still frequent types of nosocomial infections. Suture materials might serve as a vehicle for mechanical transport of bacteria into the surgical wound. To reduce bacterial adherence to surgical sutures, triclosan-coated polyglactin 910 suture materials with antiseptic activity (Vicryl plus®) were developed. The aim of this prospective non-randomized clinical pathway driven study was to ascertain if the use of Vicryl plus® reduced the number of wound infections after transverse laparotomy. Between October 2003 and October 2007, 839 operations were performed using a transverse abdominal incision. In the first time period, a PDSII® loop suture was used for abdominal wall closure. In the second time period, we used Vicryl plus®. Risk factors were collected prospectively to compare the two groups. Using a PDSII® loop suture for abdominal wall closure in the first time period, 9.2% of the patients developed wound infections. In the second time period, using Vicryl plus®, the number of wound infections decreased to 4.3% (p < 0,005). Both groups were comparable regarding risk factors despite no other changes in protocols of patient care. Antiseptic-coated loop Vicryl suture for abdominal wall closure can be superior to PDSII sutures in respect to the development of wound infections after a two-layered closure of transverse laparotomy.

Preemptive analgesic efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing gynecologic surgery via a transverse lower abdominal skin incision

BackgroundThe transversus abdominis plane block is recently described peripheral block to providing analgesia to the anterior abdominal wall. The goal of this study is to evaluate the analgesic efficacy of the ultrasound-guided transversus abdominis plane block (US-TAP block) in patients undergoing gynecologic surgery via a transverse lower abdominal skin incision.MethodsThirty-two patients undergoing gynecologic surgery were randomized to undergo standard care such as PCA, or to receive additional US-TAP block with standard care. After general anesthesia induction, a bilateral US-TAP block was performed using 0.375% ropivacaine 20 ml on each side. Postoperative demand of rescue analgesics in PACU and ward were recorded. Each patient was assessed postoperatively by a blinded investigator in the postanesthesia care unit (PACU) and at 2, 6, 10, 24, 48 hr postoperatively to investigate pain, drowsiness, nausea and itch.ResultsThe US-TAP block reduced pain intensity compared to standard care in the PACU (5.2 ± 3.1 vs 8.4 ± 1.3) and at 2, 24 postoperative hours (3.0 ± 2.4 vs 5.2 ± 2.4, 0.9 ± 1.5 vs 2.2 ± 1.9). Fentanyl requirements in PACU was reduced (20.3 ± 20.9 vs 62.5 ± 35.4 µg, P < 0.05). In ward, pethidine requirements was reduced (21.9 ± 28.7 vs 56.3 ± 34.8 mg, P < 0.05).ConclusionsThe US-TAP block with standard care provide more effective analgesia after gynecologic surgery via a transverse lower abdominal skin incision.

Keyhole Approach for Repair of Congenital Duodenal Obstruction

We report on our experience of repair of congenital duodenal obstruction using a circumumbilical incision. The aim of this report is to describe how a Bianchi approach provides a safe and invisible alternative to transverse abdominal incision for the repair of duodenal atresia. Between January 2005 and December 2009, we treated 13 cases with congenital duodenal obstruction using a circumumbilical incision (Group I) and 14 cases with this condition repaired using a standard transverse right upper abdominal incision (Group II). Surgical procedures included a diamond-shaped duodenoduodenostomy as originally described by Kimura and standard duodenal web excision. The circumumbilical incision utilized at our institution is a classic Bianchi procedure. The 2 groups were compared with regard to patient demographics, operative reports and postoperative outcomes. There were no differences in preoperative parameters such as gestational age, age at surgery, or body weight at operation between the 2 groups. The circumumbilical cohort and transverse incision cohort had similar rates of congenital anomalies (61.54% vs. 64.29%), Kimura diamond-shaped anastomosis (61.54% vs. 64.29%) with only a slight female predominance in Group I. The mean operating time in Group I was 65.0 min while mean duration of the operation in Group II was 64.64 min. The difference between groups was statistically not significant (p>0.05). The mean time to full enteral feeding for patients with an umbilical incision was significantly shorter (p<0.0001) compared to patients with a standard incision (6.92 days vs. 11.86 days). Mean postoperative hospital stay was longer for patients in Group II (19.71 days vs. 12.38 days; p<0.0001). The postoperative course was uneventful for all patients. There were no intra- or postoperative complications. We report on a first series comparing umbilical and transverse right upper abdominal incision for the treatment of congenital duodenal obstruction. Our results suggest that an umbilical incision offers all the benefits of a minimal access approach, including earlier feeding and shorter times to discharge. We consider our approach an intermediate step, with laparoscopy likely to become the "gold standard" for the treatment of congenital duodenal obstruction.