Intraoperative measurement of suture forces in Shouldice repair of primary inguinal hernias

A special instrument was developed in order to quantify intraoperatively the traction forces which are employed during Shouldice repair of a primary inguinal hernia while adapting the lateral edge of the rectus sheath and the iliopubic tract. Further investigations were performed under the Valsalva manoeuvre and simultaneous measurement of the intra-abdominal pressure. In 25 patients an average increase in traction forces of 3.62 +/- 0.60 N was registered when the hernial gap was decreased to 0.3 cm. By applying the Valsalva manoeuvre with an average increase of 32 mm Hg in intra-abdominal pressure, traction was increased by a further 1.67 +/- 0.20 N on average. Hernia repair, tensing of the abdominal muscles and increasing the intra-abdominal pressure, however, have a small effect on the traction forces affecting the edges of the hernial gap. It may therefore be concluded that these factors, frequently believed causal for early hernia recurrence, are actually less influential as the force vector stressing the repair zone points in a different direction.     

Ventrolateral hernias of the abdominal wall. The anatomicopathologic, clinical and therapeutic considerations]

Ventral lateral hernias of the abdominal wall are rare. On the basis of their location we can classify them as follows: hernias of the aponeurosis of the transversus muscle, hernias of the rectal sheath and transmuscular hernias of the iliac region. In a group of 3134 hernias of the abdominal wall observed in a period of 16 years, 11 ventral lateral hernias have been encountered (0.3%). The diagnosis often presents great difficulties as the symptoms and the clinical findings are not typical. They must be differentiated from hematomas of the rectus sheath, abscess or intra-abdominal processes. Echography and Computed Tomography have an important role in their detection. Nevertheless in some patients the true diagnosis is reached only intraoperatively. The treatment generally consists in surgical correction by layer closure of the fascial or muscular defect. In selected cases the use of prosthetic material and video laparoscopic repair are indicated.     

Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen

BACKGROUND: Diagnostic peritoneal lavage (DPL) is used to diagnose intra-abdominal injury in patients with stab wounds and blunt trauma. Because exploratory celiotomy is routinely performed on patients with gunshot wounds to the abdomen, DPL is rarely employed. However, several studies have questioned routine exploration and have drawn attention to the associated morbidity of negative celiotomy. Diagnostic peritoneal lavage is an easily performed and inexpensive test that may be useful in this situation. OBJECTIVE: To evaluate the performance of DPL in the diagnosis of intra-abdominal injury in hemodynamically stable patients with gunshot wounds to the abdomen. DESIGN: A prospective clinical trial. SETTING: Two urban trauma centers. PATIENTS: Patients with gunshot wounds to the abdomen and a systolic blood pressure of at least 90 mm Hg. INTERVENTIONS: Clinical predication of intra-abdominal injury in the emergency department and DPL performed in the operating room before the initiation of celiotomy. Injuries found during the celiotomy were recorded. MAIN OUTCOME MEASURES: The results of the clinical evaluation and DPL were compared with the findings of the celiotomy. RESULTS: Forty-four patients were enrolled into the study. Intra-abdominal injury was present in 32 (73%) of these patients. The senior surgery resident correctly predicted the presence of intra-abdominal injury in 36 (82%) of the patients (sensitivity = 90.0%, specificity = 58.3%, positive predictive value = 85.3%, negative predictive value = 63.6%, phi = 0.52, P < .01) in the emergency department before DPL and celiotomy were performed. Diagnostic peritoneal lavage correctly identified the presence or absence of intra-abdominal injury in 40 (91%) of the patients (positive predictive value = 96.7%, negative predictive value = 78.6%, phi = 0.79, P < .01). CONCLUSIONS: Clinical judgment is highly accurate in separating patients with tangential gunshot wounds to the abdomen from those with intra-abdominal injury but may miss patients with intra-abdominal hemorrhage. Diagnostic peritoneal lavage is highly predictive of the presence of intra-abdominal injury. The return of gross blood on aspiration or a lavage red blood cell count greater than 10 x 10(9)/L should prompt an urgent celiotomy. Missed injuries are rare and most likely to be bowel perforations. Diagnostic peritoneal lavage is an objective test that may augment clinical judgment in selecting hemodynamically stable patients with potential tangential gunshot wounds for observation and is especially useful in identifying intra-abdominal hemorrhage.     

Successful twin pregnancy and delivery following free rectus abdominis muscle flap at 15 weeks gestational age

Although a vertical rectus abdominis flap would not have been selected for reconstruction of the patient's defect had her pregnancy been detected preoperatively, the present case does demonstrate the remarkable resiliency and integrity of the anterior abdominal wall after rectus abdominis muscle flap surgery. Meticulous closure of the abdominal wall is of utmost importance in maintaining abdominal wall competence. Although the merits of muscle splitting techniques and the use of mesh are beyond the scope of this report, there is no evidence that modification of technique should be performed in the patient considering future pregnancy. Our case supports other reports that rectus abdominis flap surgery is not a contraindication to future pregnancy. Intuitively waiting at least 1 year, as recommended by Chen et al., seems reasonable, although the present case demonstrated a successful pregnancy and delivery of twins after a vertical rectus abdominis flap was harvested during pregnancy.     

Modifications to the technic of cesarean section after Stark

BACKGROUND: As the operating births (caesarean section) increase, many surgical equipes have been compelled to revise operating techniques in order to reduce fetus extraction times and the whole expense of operation without renouncing, at the same time to beauty advantages. With Stark technique, that we have modified, we have obtained all these aims, improving at the same time patients' postoperative course as well succeeding to extract the fetus in about five minutes. In the '70 Cohen explained the utility of a transiliac incision allowing the access to abdominal cavity with rectus muscles unsticking in an area in which these muscles should present a less adhesiveness. METHODS: Since 1988 Stark has used Cohen's technique changing however uterus closing times, peritoneal membranes and abdominal walls. Our technique is different since we performed the incision according to Pfannestiel. RESULTS: The times are considerably reduced to 4.8 minutes for fetus extraction and in postoperative time the complications are drastically reduced too (infection, pain, hematoma, adhesions). CONCLUSIONS: Therefore we can surely say that this kind of technique can be used with success in all gynaecological surgery, in extrauterine pregnancies and adnexial tumefactions (not malignant). Personal opinion is that spinal anesthesia is the best analgesic technique.     

Delayed onset of hand tremor related to cerebellar hemorrhage

Spontaneous hematomas are rare and can present with acute or chronic symptoms. Our patient presented with deep vein thrombosis of the lower extremity associated with a spontaneous pelvic hematoma. This lesion was radiologically and clinically indistinguishable from a soft-tissue neoplasm. The case of a spontaneous pelvic neoplasm in an otherwise healthy young man is presented and the literature reviewed regarding issues of differential diagnosis and clinical management.     

Enterocytozoon bieneusi infection and diarrheal disease in patients who were not infected with human immunodeficiency virus: case report and review

Spontaneous spinal epidural hematoma is a rare condition that usually requires surgical evacuation of the hematoma. We report a case of spontaneous spinal epidural hematoma that was probably associated with aspirin intake. The initial clinical signs and symptoms included sharp, left-sided neck pain and weakness of the left arm. The initial magnetic resonance image showed a spinal epidural hematoma extending from C2 to C6, with compression of the myelon. This case is remarkable for dramatic clinical improvement within 12 hours and the magnetic resonance imaging documentation of complete resolution within 3 days. For each patient with a stable or improving neurological status, conservative management monitored by magnetic resonance imaging might be the treatment of choice.     

Numerous PCR-RFLPs within the porcine CYP21 (steroid 21-hydroxylase) gene

Mesenteric cysts are rare intra-abdominal tumors with an incidence around one case per 100,000 hospital admissions. The clinical presentation is variable; patients may be asymptomatic or present with either acute or chronic abdominal pain. Physical examination commonly demonstrates a smooth, round and mobile abdominal mass. Differential diagnosis includes any abdominal cyst or tumor. Laboratory tests are usually helpless. Ultrasonography and CT scans are the best diagnostic tools. The treatment of choice is the total resection of the cyst, which is regularly performed by open surgery. This paper reports a case of a mesenteric cyst successfully resected by laparoscopy, and addresses the possible uses of this approach.     

Late tamponade with mechanical circulatory support

BACKGROUND: Circulatory support with mechanical devices often leads to bleeding and tamponade. METHODS: We report a series of three patients that required mechanical circulatory support for postcardiotomy ventricular dysfunction. RESULTS: Late tamponade occurred in each patient with different clinical presentations. Early postoperative bleeding occurred in 2 patients. There was no active bleeding in any of the 3 patients. Transesophageal echocardiography was not helpful in making the diagnosis. CONCLUSION: Late tamponade, which may be the result of hematoma with earlier bleeding, can present as dyspnea, hypoxia, or forms of hemodynamic collapse. Exploratory media sternotomy is required to definitively make the diagnosis and to evacuate the hematoma.     

Interhemispheric subdural hematoma in adults: case reports and a review of the literature

The interhemispheric subdural hematoma is a relatively uncommon type of subdural hematoma, especially seen in patients with blood clotting disturbances. When its mass becomes sufficiently large, specific neurological abnormalities such as hemiparesis and signs of the falx syndrome are seen. Treatment can consist of conservative observation or craniotomy and is dictated by the clinical course. Conservative management is the treatment of choice for patients without disturbances of consciousness and for patients with stable clinical conditions. Surgical treatment is necessary in patients with progressive deterioration. Three case reports are presented, as well as a review of 64 cases described in the literature. The salient aspects of this clinical entity are discussed.     

Interhemispheric subdural hematoma

The interhemispheric subdural hematoma (ISH) is a special subdural hematoma with regard to both location and symptomatology. The most widely described clinical signs and symptoms associated with an ISH are a lucid interval and the falx syndrome. The latter is featured by a contralateral hemiparesis that is accentuated in the lower extremity but spares the face. Minor head trauma or a preexisting coagulation disorder are also often found. Nonsurgical treatment should be chosen in patients with little neurologic dysfunction and a stable clinical course. Patients with progressive neurologic deterioration and focal neurologic deficits should be operated on without delay. This article provides a review of 99 published cases of ISH and adds 3 cases to the existing literature.     

Increasing irritability with sudden onset of flaccid weakness

Spontaneous spinal epidural hematoma (SSEH), is a rare and potentially fatal condition that responds favorably to early surgical intervention and should be considered in the differential diagnosis of spinal cord compression. There are few reported cases in children. We present a case of spontaneous spinal epidural hematoma in an 18-month-old child and review the literature.     

Chronic subdural hematoma associated with middle meningeal arteriovenous fistula treated by a combination of embolization and burr hole drainage

A rare case of chronic subdural hematoma associated with a middle meningeal arteriovenous fistula was treated by a combination of embolization and burr hole drainage. This clinical situation might be missed in this era of computed tomography, when cerebral angiography is seldom indicated for the diagnosis of neuro-traumatic diseases. We should bear in mind the possibility of this clinical situation of a chronic subdural hematoma associated with a linear skull fracture crossing the middle meningeal groove in order to avoid possible hemorrhagic complications during surgery for chronic subdural hematoma.     

Histochemical and immunohistochemical studies on the origin of the blue marlin heater cell phenotype

The superior rectus muscle fibers of marlins, swordfish, sailfish and spearfish are modified for heat production at the expense of contractile ability. Although 'heater cells' are a muscle derivative (Block, 1986, 1991), the myoblast origin and developmental pathway of these thermogenic cells is unknown. To gain insight into heater cell origins, we characterized blue marlin superior rectus muscle and its heater tissue derivative with histochemical and immunological techniques. We specifically employed myosin ATPase and succinate dehydrogenase histochemical assays, and myosin heavy chain immunohistochemistry. Results revealed that marlin superior rectus muscles contain at least six distinct fiber types, and suggested the presence of both twitch and tonic fibers. Immunological results indicate that myosin is present within the thermogenic cells but not in myofibrillar lattices. The antibodies that recognized myosin in heater cells also labeled myosin in the twitch fibers of swimming muscle. In contrast, antibodies that labeled histologically defined tonic fibers did not label heater cells. These results suggest that heater cells and twitch fibers express the same myosin isoform, and establish a phenotypic connection between heater cells and twitch fibers. This conclusion is discussed in the context of the muscle-to-heater trajectory and the muscle fiber-type origin of heater cells.     

The diagnosis and treatment of abduction deficiencies

Deficient abduction can be due to both innervational deficiencies and/or mechanical restrictions. Innervational deficiencies include lateral rectus weakness or paralysis, myasthenia gravis, progressive external ophthalmoplegia nd Duane's syndrome with aberrant innervation to the lateral rectus muscle. Mechanical causes include restrictions on the medial side of the globe (a tight medical rectus due to endocrine ophthalmopathy, a contractured medial rectus muscle as a result of a lateral rectus paralysis, excessive resection of the medial rectus muscle, scarring and hemorrhage due to multiple previous operations upon the medial rectus), as well as a posteriorly inserted lateral rectus. This latter condition may result from a traumatically disinserted lateral rectus muscle, an excessively recessed lateral rectus muscle or a lateral rectus that has slipped from its attachment following strabismus surgery. Insufficient force for full abduction is caused by posterior insertion of the lateral rectus. The diagnosis of these various conditions is considered with reference to the forced duction, force generation and saccadic velocity tests. The treatment of these different causes of abduction deficiency is discussed noting that the approach to treatment depends upon the etiology of the abduction deficiency.     

Chlamydia pneumoniae and cardiovascular disease

Oculomotor organization in elasmobranch fish (sharks, skates, and rays) differs from that in other vertebrates in that the medial rectus muscle is innervated by contralateral rather than ipsilateral motoneurons. Distinguishing whether this innervation pattern is unique to the elasmobranchs, or is the ancestral pattern for cartilaginous fishes, requires examination of a representative of the sister group to the elasmobranchs, the holocephalans (ratfish). In the present study, the innervation pattern of the medial rectus was examined in a ratfish, Hydrolagus colliei, by using biotinylated dextran amines (BDA, 3,000 MW). Labeled cells were revealed in the contralateral oculomotor nucleus. Therefore, an innervation pattern in which the medial rectus muscle is innervated by contralateral motoneurons is the primitive condition for cartilaginous fishes.     

Sliding myofascial flap of the rectus abdominus muscles for the closure of recurrent ventral hernias

Despite a reported incidence of up to 11 percent of incisional/ventral hernias following celiotomies, there is no universally applicable preventive or reconstructive technique in practice. Among patients undergoing repair of ventral incisional herniation, the reported recurrence rates are typically in the 30- to 50-percent range. This study concentrates on the patient with a large, recurrent abdominal incisional hernia in whom conventional surgical repair has failed. We report our recent 4-year experience with the use of "components separation" of the myofascial layers of the abdominal wall for repair of these recurrent herniations. During 4-year period, 35 patients with large, recurrent ventral hernias underwent repair by the same surgeon (J. H. M.) using the method described below. Abdominal defects as large as 875 cm2 were repaired, with a median defect size of 255 cm2. The repair was based on the compound flap of the rectus muscle with its attached internal oblique-transversus abdominus muscle with advancement to the midline to recreate the linea alba. Any repairs that were attenuated were supported with either ePTFE (8.6 percent) or Vicryl mesh (34 percent). The study group consisted of 35 patients, 34 percent male and 66 percent female; mean age was 55 years. Length of follow-up ranged from 1 to 43 months, with a mean follow-up of 22 months. Overall recurrence rate for herniation was 8.5 percent (3/35). Additional complications, namely seroma, wound infection, and hematoma, occurred at rates of 2.8, 5.7, and 5.7 percent, respectively. There were no mortalities. The compound flap of the rectus and internal oblique-transversus can be advanced medially to recreate the linea alba to provide dynamic, stable support for defects as large as 875 cm2. A recurrence rate of 8.5 percent was achieved in a relatively high-risk population with acceptable morbidity and no mortalities. In our 4-year experience, the sliding rectus abdominus myofascial flap has proved to be a safe and effective tool for dealing with patients in whom conventional means of repair have failed.     

Contribution of IL-1 beta to the enhancement of Campylobacter rectus lipopolysaccharide-stimulated PGE2 production in old gingival fibroblasts in vitro

Campylobacter rectus is associated with adult periodontitis. We previously reported that C. rectus lipopolysaccharide (LPS)-stimulated prostaglandin E2 (PGE2) production in old cells of human gingival fibroblasts (HGFs) is higher than that in young cells. The present study examined whether an enhancement of C. rectus LPS-stimulated interleukin (IL)-1 beta production in old HGFs contributed to the increased production of PGE2. LPS was prepared from C. rectus ATCC33238. HGFs were established from healthy gingiva in three patients, aged 10-12 years. Cellular aging in culture was determined with increasing doubling. The cultured cells were treated with LPS (0.01-10 micrograms/ml), and the amount of IL-1 beta in the medium was measured after a 24 h incubation. The LPS-stimulated IL-1 beta production in each old cell (corresponding to 57-67% of complete life-span) was increased (1.6-2.6 times) compared to that in the young cells (corresponding to 17-20% of the life-span). The IL-1 beta mRNA synthesis in the presence of LPS in the old cells was higher than that in the young cells. The enhancement of LPS-stimulated PGE2 production was inhibited by anti-IL-1 beta antibody and by IL-1 receptor antagonist. These findings suggest that the greater ability of old cells to produce PGE2 in response to C. rectus LPS is due to their greater level of IL-1 beta.     

Indications for thoracotomy following penetrating thoracic injury

The treatment of penetrating thoracic injuries has been reviewed in both civilian and military series. Although most surgeons agree that closed that closed thoracostomy drainage is the initial treatment of choice, the timing of early thoracotomy and perhaps cardiorrhaphy upon patients with penetrating thoracic injuries remains controversial. The purpose of this study was to determine which patients will require immediate thoractomy or cardiorrhaphy following penetrating chest injury. Over a two-year period 190 patients with penetrating thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Seventy-nine patients required laparotomy for associated intra-abdominal injuries. The mortality rate was related to exsanguinating hemorrhage or postoperative intra-abdominal sepsis. Cardiopulmonary complications were rare in the absence of intra-abdominal sepsis and could not be attributed to the thoracic injury or thoracotomy. Indications for immediate cardiorrhaphy or thoracotomy are: 1) location of the entrance wound (70% in upper mediastinum); 2) blood pressure on admission less than 90; 3) initial thoracostomy blood loss greater than 800 cc; 4) radiographic evidence of retained hemothorax; and/or 5) clinical evidence of pericardial tamponade.     

Magnetic resonance imaging of penile rupture: aid to diagnosis

We report on a patient with atypical clinical findings in whom magnetic resonance imaging confirmed the suspicion of penile rupture. The tear appeared as an obvious discontinuity of the low signal intensity of the tunica albuginea and was associated with a hematoma. We conclude that magnetic resonance imaging is useful for confirming the diagnosis of penile rupture when clinical findings are atypical, indicating surgical repair.