HIV infection amongst leprosy patients in south India

We use the trapezoidal lamellar incision as standard construction for sutureless self-sealing wound closure in our clinic: a 7 mm incision for phacoemulsification and implantation of a 6.5 mm optic diameter PMMA posterior chamber less (PCL) and an incision up to 11 mm for ECCE with standard PCL. The operation can be performed in a nearly closed system because of the self-sealing wound construction. Experiments in cadaver eyes showed that the wound closure of a 7 mm incision with the no-stitch technique ruptured at a pressure five times greater than the cross-stitch-sutured corneoscleral incision and in an 11 mm incision four times greater (602 +/- 149 mmHg and 150 +/- 29 mmHg). Due to the high stability of the wound closure, no sutures are necessary. Complications arising in connection with sutures are therefore avoided. Clinically, two typical postoperative complications were observed: hypotony occurred in 1% and anterior chamber hemorrhage in 5%. These complications are exclusively caused by imperfection of the internal corneal opening.     

A prospective study of closure techniques of abdominal incisions in infants and children

In a prospective study of layered versus mass closure of abdominal incisions in infants and children, 34 cases underwent wound closure by layered and mass closure technique on an alternate basis. All the patients were assessed for their nutritional status and haemoglobin level pre-operatively, and wound complications were compared with respect to closure technique, nutritional status and normal haemoglobin level. Presence of protein energy malnutrition and anaemia did not increase the risk of wound complications with either of the technique.     

Rotation fasciocutaneous flap for neglected club feet--a new technique

Skin necrosis and wound problems complicate surgical release of severe neglected clubfoot. This is primarily due to excessive tension on the skin edges and a poor understanding of abnormal vascular anatomy in clubfoot. We report a technique of primary skin closure using a local rotation fasciocutaneous flap using the conventional posteromedial skin incision (Turco). Primary uncomplicated wound healing was achieved within 2 weeks in all 16 rigid and neglected clubfeet (1-7 years) operated by this technique. This flap is scientifically logical, technically easy and ensures primary wound healing.     

The utilization of a biological adhesive for wound treatment: comparison of suture, self-sealing sutureless and cyanoacrylate closure in the tensile strength test

We produced a measurement apparatus for testing the tensile strength of wounds during cataract surgery, and tested the tensile strength of treated wounds including wounds sutured with various methods, non-sutured and wounds treated with various bio-tissue adhesives. METHODS: In cataract surgery on white rabbits eyes, a corneoscleral incision 5 mm in length was made 2.5 mm from the limbus corneae, and entry into the anterior chamber was obtained 0.5 mm to the clear cornea. After treatment for closure, the corneoscleral piece was subjected to the tensile strength test. RESULTS: The tensile strengths just after surgery were (1) 0 gf/mm2 after self-sealing sutureless closure; (2) 114 gf/mm2 after vertical suture closure (one stitch with 10-0 nylon); (3) 125 gf/mm2 after horizontal suture closure (one stitch with 10-0 nylon); (4) 143 gf/mm2 after infinity suture closure (with 10-0 nylon); (5) 112 gf/mm2 after fibrin glue (Beriplast P) application (instilled on the surface of scleral incision); (6) 121 gf/mm2 after fibrin glue application (glued on corneoscleral wound); (7) 131 gf/mm2 after cyanoacrylate closure (instilled on the surface of scleral incision); (8) 139 gf/mm2 after cyanoacrylate closure (glued on corneoscleral wound). The respective strengths at four days after surgery were: (1) 86; (2) 131; (3) 137; (4) 175; (5) 109; (6) 43; (7) 138; and (8) 108 gf/mm2. At 28 days after surgery, the respective strengths were (1) 164; (2) 167; (3) 184; (4) 209; (5) 322; (6) 195; (7) 251; and (8) 175 gf/mm2. CONCLUSION: The use of fibrin glue in treatment of a wound in cataract surgery is beneficial in assisting this treatment.     

Sensitivity of fluorochrome microscopy for detection of Mycobacterium tuberculosis versus nontuberculous mycobacteria

BACKGROUND: Sternal wound infection is a relatively rare but potentially devastating complication of open heart operations. The most common treatments after debridement are rewiring with antibiotic irrigation and muscle flaps. Here we present the results of a prospective trial to determine the appropriate roles of closed-chest catheter irrigation and muscle flap closure for sternotomy infection and to assess the effect of internal mammary artery bypass grafting on the outcome of each treatment modality. METHODS: Between 1990 and 1994, 5,658 sternotomies were performed at the University of Washington Medical Center. Sternal dehiscence occurred in 43 patients, 25 of whom had infection (overall incidence, 0.44%). Because of the infrequency of this complication, a prospective, randomized trial was developed in which the initial approach to sternal dehiscence was rewiring and catheter irrigation. Muscle flaps were used as the primary treatment if the sternum could not be restabilized or as secondary treatment if catheter irrigation failed. Wound resolution, length of hospital stay, and complications were evaluated. RESULTS: Sterile dehiscences were successfully closed with irrigation in 17 of 18 patients; the other patient required flap closure. Of the 25 patients with infection, 19 had irrigation and 6, closure with flaps primarily. In the group of infected patients, 17 of the 19 who received irrigation also had internal mammary artery bypass grafting. Irrigation failed in 15 (88.2%) of these 17 patients, and salvage was accomplished with muscle flap closure. All 6 patients with infection who were closed primarily with muscle flaps had a successful outcome. Hospitalization averaged 10.2 days when muscle flaps were used primarily and 14.3 additional days for unsuccessful irrigation. When irrigation was successful, the hospital stay averaged 11.2 days. CONCLUSIONS: Catheter irrigation should be reserved for patients without infection or patients with infection but without internal mammary artery bypass grafts in whom dehiscence occurs less than 1 month after sternotomy. All others should have closure with muscle flaps.     

Pitfalls in the management of preauricular sinuses

A total of 159 operations for the excision of a preauricular sinus carried out in 117 patients over an 8-year period were reviewed. Previous excision, the use of a probe to delineate the sinus and operating under local anaesthesia all increased the chance of recurrence. The condition recurred more often in patients who developed post-operative wound sepsis than in those who healed primarily. Means of decreasing the recurrence rate include: (1) meticulous dissection of the sinus by an experienced head and neck surgeon under general anaesthesia; (2) the use of an extended preauricular incision; (3) clearance down to the temporalis fascia to ensure complete removal of all epithelial components; (4) avoidance of sinus rupture; and (5) closure of wound dead space.     

Combined use of single and double-cross steel wires for closure of midline sternotomy

BACKGROUND: We describe an improved technique for sternal closure which is performed using combined single and double-cross steel wires. We made a mechanical study of these single and double-cross shapes considering the effects of applied transverse and longitudinal shearing forces. METHODS: We used this technique in 80 patients who underwent coronary surgery with the use of bilateral internal mammary arteries. RESULTS: Among them no major wound complications occurred, and in all cases a firm stabilization of the sternum was achieved. CONCLUSIONS: We therefore consider this technique of sternal closure easy, safe and effective, also in patients considered at risk for sternal dehiscence.     

Coronary artery operation in patients after breast cancer therapy

OBJECTIVE: The purpose of this investigation was to retrospectively study the outcome of patients undergoing coronary artery operation who were previously treated for breast cancer. METHODS: Between July 1992 and December 1996, 28 patients with a history of breast cancer underwent coronary artery bypass graft operation and were randomly matched against a noncancer group of similar size (n = 36) to allow for comparison of their preoperative characteristics, operative course, and postoperative outcome. RESULTS: The incidence of sternal wound infection was significantly higher in the cancer group than in the control group (25% versus 6%; p = 0.027). Postoperative noncardiac chest pain occurred more frequently in the cancer group than in the control group (52% versus 31%; not significant). In the study group, radiotherapy and recent myocardial infarction were the only two independent factors associated with sternal wound complications. Patients with a less than 17-year interval between the breast cancer therapy and the coronary artery operation had a higher incidence of sternal wound infection (46%) as opposed to patients with a longer time interval (7%; p = 0.028; odds ratio = 12). Sternal wound complications were more frequent in patients with a history of right-sided breast cancer (50%) compared with left-sided lesions (12.5%; p = 0.068; odds ratio = 7). CONCLUSIONS: Coronary artery operation in patients after breast cancer therapy may be associated with an increased sternal wound infection rate. To decrease this risk of infection, an approach through a right thoracotomy, minimally invasive techniques, the use of skeletonized internal mammary artery, and broad spectrum antibiotic therapy may be considered.     

Pressure-guided method for identification of the epidural space in children

Total aortic replacement is preferably performed by staged operations, and reports of a simultaneous operation are few. In these reports, both a median sternotomy and a thoracoabdominal incision are employed. We report a patient who successfully underwent simultaneous total aortic replacement without a sternotomy incision. The technique and the feasibility of the operation are discussed.     

Management of sternal and abdominal wounds in a pediatric heart transplant patient

A 14-year-old girl with congenital heart disease underwent ventricular assist device placement before cardiac transplantation. The inability to close her abdominal fascia necessitated the placement of Prolene mesh, which subsequently became exposed and contaminated when her incision dehisced. Stable closure was obtained with Vicryl mesh and a rectus abdominis turnover flap. Her posttransplant course was notable for compression of the donor heart, necessitating prolonged open sternotomy. She failed an attempt at delayed sternal closure due to compression of the right ventricle by the sternum. In addition to standard pectoralis advancement flaps, a pedicled osseous sternal flap based on her left internal mammary artery was developed to avoid ventricular compression yet still provide some protection to the mediastinum. Alternative uses of this vascularized bone flap to assist with chest wall reconstruction are discussed.     

Modifications of and special operating tricks in the classical technique of surgery against strabismus

Even nowadays the idea of most of the operations against strabismus is based on myectomy and reposition of the rectus muscles. At the Department of Ophthalmology of the University Medical School of Debrecen we use mainly these two methods of operation. At our Department we performed 1605 operations against strabismus during the last 10 years. 1269 of our patients had convergent, 336 had divergent strabismus. The majority of the operations were performed on patients less than 6 years of age, under general anesthesia. The outcome of the operation is successful if it results in a situation, in which torque affecting the eyeball stabilizes it in the normal position. The advantage of the combined surgical procedure is that the former muscular balance remains intact, and by relatively small intervention good results can be achieved. In the rectus muscles of squint patients anatomical and histopathological changes could be found, especially if they did not receive pleoptic treatment preoperatively. Depending on the direction of the strabismus one of the muscles is thicker, while the other is thinner, due to hyper- and hypofunction. Our surgical experience of many years showed that by modifying the classical technique of the operations with some fine technical tricks it was possible to increase the success rate. In our film we presented the right way of incising and handling the subconjunctival connective tissue (Tenon capsule) thus making it possible to lay it back to its original place at the end of the operation. This way the chance of postoperative scarring is reduced. We demonstrated how to test the contractility of the muscles by using muscle-hooks, that replaces the forceps test. In case of myectomy we demonstrated the tricks of how to handle the easiest and the finest way. In case of retroposition we can achieve perfect reconstruction and wound healing by using the shown simple technique. We also take much care of suturing the conjunctiva during operations performed on infants that is important because of their undisciplined behavior.     

Relationship between the time of day of trauma infliction and the dynamics of endothelial mitotic activity

Endothelial mitotic activity of the rabbit jugular veins depending on the daytime of trauma infliction was studied. In the first series of experiments (I), the operations were performed from 8 to 10 a. m., and in the second (II)-- from 8 to 10 P. M. After the operation one animal was killed every 3 hour, for 5 days. Mitotic activity (MK %) was studied continuously 8 mm from the wound edge in flat film preparations. The data obtained were statistically treated using approximation of the process course by the method of weighed sliding averages. Independently of the time of trauma infliction, the first mitoses in the endothelium appear after 21 h. Further, mitotic proliferation has a wavy character of different intensity in different tissue areas. Lack of similarity in the organism circadiam phase at the time of operation, produces distinct differences in the course of the process which are seen in asynchronity of the daytimes when the rise and recession of mitotic activity occur and in different length of these waves. In I series the length of these waves equals to 36, and in II series-- to 48 h. After the evening operation, 24-hour rhythm superimposed on its aliquat 48-hour activity is slearly seen. After the morning operation, daily rhythm is not observed. After the evening operation the process is more intense and has a greater length along the endothelial layer.     

A study of perineal wound healing after abdominoperineal resection

A comparative study of 53 cases has revealed that a technique of complete primary closure of the perineal wound after abdominoperineal resection of the rectum and anal canal appears to be a superior, more rational approach than other orthodox techniques. (It is unsuitable for any case contaminated with pus or faeces during operation.) Redivac apparatus used through a separate route for continuous drainage from the sacral cavity has made the postoperative care easier for nurses and surgeons and this period more comfortable for the patient. It provides a simple method compared with other suction apparatus used for the same purpose. Of the 53 cases, 12 were operated on using a traditional technique involving the closure of the perineal wound around a tube drain connected to an underwater seal, while in the remaining 41 the approach described here was used. Primary healing of the perineal wound with the later approach was obtained in about 88 per cent. With the other technique the figures were 34 and 66 per cent respectively for early healing within 3 weeks and delayed healing between 3-8 weeks. Primary healing of the perineal wound reduces the total stay in hospital and the morbidity.     

The double dermal keyhole pattern for breast reduction

A small contribution is made to the dependable keyhole pattern in breast reduction. A double dermal modified keyhole closure is described. It is a simple, versatile, and adaptable method of closure regardless of the pedicle technique used for reduction mammaplasty. A triangular flap (skin and dermis) is incorporated on the medial keyhole flap. A deepithelialized dermal flap is created on the lateral keyhole flap. In the final closure of the wound, the medial triangular flap is sutured over the lateral deepithelialized dermal flap. A double dermal closure at the inverted T region is thereby created. The frequency of occurrence of wound spread and early postoperative wound dehiscence is decreased by this closure, which provides cosmetic improvement and wound support where it is needed the most.     

Clinical experience with the video-assisted saphenectomy procedure for coronary bypass operations

BACKGROUND: Leg wound complications after saphenectomy are frequent after coronary bypass operations and have a detrimental effect on postoperative quality of life and treatment cost. To reduce morbidity, we evaluated a new technique of video-assisted vein harvest. METHODS: Between March 1996 and October 1996, 50 patients had video-assisted saphenectomy (VAS) and 40 patients had the standard open technique (control group). An additional 13 patients had both procedures (hybrid group). Level of pain, edema, and wound complications were evaluated at discharge and at 2, 4, and 6 weeks postoperatively. RESULTS: The mean operating time for VAS patients was slightly higher than for control (60.6+/-24.7 minutes versus 53.2+/-21.1 minutes; p > 0.05). The average incision length in VAS patients was 13.8+/-8.8 cm for an average of 3.3 grafts per patient. Three VAS procedures were aborted, two because of time constraints, and one because of bleeding, and a segment of vein was lost to injury. The VAS group had considerably less early postoperative pain than the control group (1.7+/-1.2 versus 4.1+/-1.4 [1 = mild, 10 = severe]; p < 0.005) and edema was similar for both groups. Patients in the hybrid group reported less pain in the VAS-operated leg. Serious wound infection occurred in 4 patients, with 2 patients in the control group requiring reoperation for drainage and flap reconstruction. CONCLUSIONS: Based on this initial experience, VAS harvesting, although initially more time consuming, is a rapidly mastered technique, results in shorter overall incision length, and is associated with considerably less postoperative pain than the standard open technique.     

The association of intra-abdominal infection and abdominal wound dehiscence

Concurrent infection is a risk factor for abdominal wound dehiscence. We reviewed our experience with fascial dehiscence to determine the incidence and to identify prognostic factors for associated intra-abdominal infection. Over a 7-year period, 107 patients with abdominal wound dehiscence were identified. Seventeen were managed nonoperatively, and 90 underwent exploratory laparotomy, 43 of whom had no intra-abdominal pathology and 47 of whom had intra-abdominal infections. Demographic factors, comorbid diseases, and potential indicators of systemic infection did not distinguish patients with intra-abdominal infection from those without. Patients with an intra-abdominal infection were more likely to have undergone an emergency operation (74% vs 48%; P < 0.02), an operation on the colon (55% vs 25%; P < 0.005), or an operation with a higher wound classification (P < 0.02). Mortality was higher in patients with intra-abdominal infection than in those without (44% vs 20%; P < 0.02). Wound dehiscence after emergent operations, and operations with a higher wound classification, especially those involving the colon, should raise concern for intra-abdominal infection. Thorough abdominal exploration should be performed at the time of dehiscence repair. Before nonoperative management is chosen, intra-abdominal infection should be excluded.     

Multi-resistant tuberculosis of fatal outcome in a patient without HIV infection

Fifty six patients with typhoid enteric perforation who underwent operative treatment were randomly assigned to 2 groups. Twenty seven patients in group A underwent laparotomy via the Rutherford-Morrison incision while 29 patients in group B underwent the same procedure via a right paramedian incision. Surgical treatment consisted of two layer closure of the perforation with peritoneal lavage and tube drainage in all cases. Mean operating time in group A and group B was 45 +/- 10 minutes and 73 +/- 6 minutes respectively (p < 0.001). Postoperative wound dehiscence in group A and group B was observed in 2 and 11 cases respectively (p < 0.001). Incisional hernia developed in 8 patients in group B and none in group A (p < 0.01). Two patients in group A and 10 in group B developed adhesion-obstruction (p < 0.05). Differences in wound sepsis, pelvic abscess and mortality were not significant. Mean hospital stay in groups A and B was 12.4 days and 16.8 days respectively (p < 0.001). We conclude that in the presence of a confirmed preoperative diagnosis of typhoid enteric perforation, laparotomy via the Rutherford-Morrison incision may significantly reduce postoperative wound complications and morbidity without significantly altering the overall outcome.     

Surgery in patients with HIV infection: indications and outcome

We reviewed the records of 12 patients with HIV infection (one stage I, three stage II, two stage III, six stage IV) who received 15 surgical procedures under general or lumbar/epidural anesthesia. We discussed surgical indications, their poor wound healing and precautions for preventing the risk of transmission of HIV to health care workers. Six emergency and nine elective operations were performed. Postoperative complications developed after three emergency and three elective operations. Ten patients showed delay of wound healing which was not directly correlated with the CD4+ cell count. No operative deaths occurred. In any stage of HIV infection, not only palliative but also curative operations can be performed as long as HIV infection, opportunistic infections and HIV-related neoplasms can be controlled. Late stage wound healing is poor, but the wound will heal without keloid formation, although it takes two to three times longer than usual. For operating on patients with HIV infection precautions for preventing needle sticks, sharp injuries and blood exposure should be learned and used by health care workers. As a result, surgical staff members will be able to perform operations safely on HIV-infected patients to improve both quality of life and the prognosis of their disease.     

Valve operations through a minimally invasive approach

BACKGROUND: We analyzed in-hospital results of 87 patients undergoing minimally invasive valvular operations (right parasternal incision through third and fourth cartilages). METHODS: Age was 21 to 84 years (mean, 56.2 +/- 16); 45 patients (51.7%) were female. Five (5.7%) had a previous valvular operation and 8 (9.2%) had severe left ventricular dysfunction. Valve diseases were as follows: aortic in 35 patients (40.2%), mitral in 44 (50.5%), double in 5 (5.7%), tricuspid regurgitation in 2 (2.2%), and mitral periprosthetic leak in 1 (1.1%). RESULTS: Nineteen mitral repairs (21.9%), 22 replacements (25.3%), 1 leak closure (1.1%), 1 tricuspid repair (1.1%), and 1 replacement (1.1%) were performed. Thirty-one patients (35.7%) underwent aortic replacement, 2 (2.3%) aortic decalcification, 1 (1.1%) subaortic membrane resection, 4 (4.6%) a double-valve procedure, and 5 (5.7%) a single-valve operation combined with myocardial revascularization. In-hospital mortality was 5.7% (5 patients). Univariate analysis was significant for previous operation, New York Heart Association class IV and severe ventricular dysfunction. Multivariate analysis was significant for previous operation and severe ventricular dysfunction. Atrial fibrillation (12.6%) was the most frequent complication. Postoperative stay was 6.5 +/- 6 days. CONCLUSIONS: The minimally invasive approach is a useful technique in valvular surgery. Patients with a previous valvular operation, severe ventricular dysfunction, and New York Heart Association class IV dyspnea have higher in-hospital mortality.     

Use of tissue meshing technique to facilitate side to side closure of large defects

BACKGROUND: Primary closure of a large wound usually needs flaps of sophisticated design or skin grafts, both require more skill and wound care. Motley and Holt first reported the use of meshed advancement flap, a relative simple technique to close large defects of the lower leg in five patients. OBJECTIVE: To report the use of tissue meshing technique to close large wounds with significant tension on various sites of the body. METHODS: Six patients with large benign or malignant neoplasms at various sites of the body were included. Tissue meshing technique was used to facilitate wound closure after elliptical excision of the tumors at office visits. RESULTS: The wound defects, ranging from 3.0-3.5 cm in width, were closed with satisfactory cosmetic results, except for the occurrence of transient small hypertrophic scars in one patient. There was no complication of wound dehiscence, ischemia, infection or hematoma. CONCLUSION: Tissue meshing technique is a simple procedure and appears to be a satisfactory alternative to facilitate the closure of large wounds under tension. This technique is suitable for most body sites excluding central face and neck because there may be a stippled appearance in the area of meshing.