A new flap from the dorsum of the first intermetacarpal area: the first dorsal intermetacarpal flap

Soft-tissue reconstruction of the hand still remains a challenge for plastic and reconstructive surgeons. Several flaps have been described to cover soft-tissue defects of the digits and the hand. In the first web region, there are some communications between the intermediate artery arising from the dorsal branch of the radial artery and the volar arteries of the thumb and the index finger. Depending on these communications, a new distally based flap is raised from the first dorsal intermetacarpal area. This flap has been used to cover various defects of the thumb in four patients and the distal radial side of the palmar area in one patient. Donor sites have been closed primarily except in one patient. There were no complications, and the results show that this flap is useful to cover soft-tissue defects of the thumb and proximal phalanx of the index finger as well as the radial side of the palmar and dorsal surfaces of the hand.     

Toe-to-finger transfer combined with wrap-around flap: a new technique for four-finger amputation

Doctor Felipe Castillo, head of the Hospital de San Pablo during the cholera epidemic of 1850, used "Salty water" as treatment for the patients who attended the hospital. The etiology and pathogenesis of this sickness were unknown in those days, so Castillo's conduct was surprising. This study is based on an unpublished report, classified as anonymous, that Castillo gave to the Governor of Mexico City during the cholera epidemic.     

Bulbocavernous myocutaneous flap: a new technique in repair of recurrent urethrovaginal fistula

This paper describes the case of a recurrent post-partum urethrovaginal fistula. The extent of the vaginal tissues loss and the perilesional scarring made the direct closure of the defect non practicable. After suturing the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Nineteen months after surgery the flap healed well without peri urethral suffusion.     

A case report of acute aortic dissection with aortic regurgitation and cardiac tamponade: intimal tear just above commissure of right coronary cusp and left coronary cusp

A 57-year-old man with acute dissecting aneurysm of the ascending aorta underwent immediate operation. Preoperative study showed aortic regurgitation and cardiac tamponade. The intimal tear originated just above commissure of right coronary cusp and left coronary cusp. The procedure was a combination of direct closure of the entry and dissecting space and resuspension of native aortic valve. It was preferential of simple intervention limited to the ascending aorta without using prosthesis. There was no complication such as aortic valve regurgitation, enlargement of the ascending aorta, or persistent of dissection during follow-up period of 12 months.     

Double-lumen aortic arch by persistence of fifth aortic arch: A new case associated with coarctation

Adrenodoxin reductase is an essential component of the mitochondrial monooxygenase systems that are involved in the synthesis of steroid hormones and related compounds. After removing by mutagenesis a secondary ribosome binding site and an mRNA loop formed between the gene and the vector, large amounts of the enzyme could be produced in Escherichia coli by coexpression with the HSP60-chaperone system. The purified protein was homogeneous enough for reproducible crystallization. The crystals diffracted X-rays isotropically beyond 1.7 A resolution permitting a structure analysis.     

A new technique of dural closure--experience with a vicryl mesh

Treatment of postoperative dural CSF leaks following posterior fossa surgery remains a difficult and often perplexing problem. Their management includes either non-operative management or surgical re-exploration. In order to avoid CSF leaks we developed a simple but effective method using a well-cut sheet of a vicryl-poly-p-dioxanone mesh (Ethisorb) covering the whole defect of the craniectomy. This paper presents our technique of dural closure, experiences with and advantages of the vicryl mesh in comparison with conventional procedures using muscle patches in combination with fibrin sealant or fibrin glue alone. Attention is focused upon the frequency of postoperative complications, in particular infection rate and CSF leaks. Furthermore, histomorphological observations after implantation of a vicryl mesh are demonstrated. In conclusion, due to its specific qualities we consider the vicryl mesh as a suitable dural substitute with potential advantages over currently used material.     

A new technique of posterolateral thoracotomy with preservation of the latissimus dorsi muscle

The authors present a new posterolateral thoracotomy technique, preserving the integrity of the latissimus dorsi muscle, which in split in the direction of its fibres instead of being sectioned transversely. The exposure is sufficient for all forms of lung resection and pleural surgery and the incision is easily and rapidly repaired. After describing the technique, the authors review their first 70 patients operated via this incision, which was always sufficient to allow the planned operation. Healing was satisfactory and, in the long-term, the functional and painful sequelae appeared to be less than with the classical Crafoord posterolateral thoracotomy, which could be replaced by this new incision.     

A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.     

Orifice-view aortography in patients with congenitally deformed aortic valves: determination of aortic valve area

Reports from the United States and around the world have marked a steadily rising cesarean section rate. Although the indications that account for the increase are generally agreed upon (previous cesarean section, dystocia, fetal distress, and malpresentation), the benefits derived from the liberalized use of cesarean section to deal with these diagnoses have not been carefully documented. In an attempt to determine if the cesarean section rate could be lowered with no adverse effect on neonatal outcome, 105,848 deliveries at Downstate-Kings County Hospital from 1961 through 1977 were reviewed. The 9727 cesarean sections performed were evaluated to determine the reasons for the increasing rates and the effect on perinatal outcome. It was concluded that by the use of fetal scalp blood sampling in cases of fetal distress, the use of internal pressure transducers in patients who fail to progress in labor, and allowing selected patients with previous sections to labor, the cesarean section rate might be substantially lowered. The maternal morbidity and mortality were also analyzed.     

A patient with aortic dissection and abdominal aortic aneurysm with fistula

Aneurysm of the abdominal aorta is not uncommon in later life. The frequency of aneurysm rupture varies with aneurysm diameter. In rare cases, the aneurysm may rupture intra-abdominally into surrounding structures and give rise to a fistula. When blood vessels are involved, the commonest form is aortocaval fistula, the presenting symptoms being those of severe right-ventricular heart failure. Although thoracic aorta dissection may be made manifest in acute intense chest pain, it is asymptomatic in up to 50 per cent of cases. The article consists in a case report of asymptomatic thoracic aorta dissection occurring concomitantly with a ruptured abdominal aneurysm the symptoms of which were severe right ventricular heart failure due to an aortocaval fistula causing increased pressure, and severe bilateral oedema of the legs. If the rare complication of an aortocaval fistula could be detected earlier, it might be possible to prevent progression to refractory cardiac failure. The possibility of a fistula should be borne in mind if haematuria is present in a case of abdominal aneurysm or a pulsatile abdominal mass is present in conjunction with a murmur.     

Traumatic aortic transections: eight-year experience with the "clamp-sew" technique

BACKGROUND: Because traumatic aortic transection is associated with high mortality rates, great debate exists about the appropriate operative technique for treatment of patients who have acute traumatic aortic transection. METHODS: To determine the safety and efficacy of the "clamp-sew" method, we retrospectively reviewed our 8-year experience treating 75 patients who had aortic injuries secondary to blunt trauma. Seventy-one of these patients were treated surgically. The clamp-sew method was used in all of these operations. RESULTS: Aortic cross-clamp time averaged 24 minutes (range, 14 to 36 minutes), with 4/71 having times in excess of 30 minutes. One patient (clamp time, 28 minutes) became paraplegic. Significant associated injuries were seen in 51/75 patients (48/71 patients with operation), including intrathoracic (35 patients), orthopedic (28 patients), intraabdominal (24 patients), and central nervous system (17 patients) damage. No patient died within 24 hours of operation. Overall 30-day mortality was 12% (9/75), with 7/9 having two or more aforementioned associated injuries. Of these 7, 5 had central nervous system injuries. Two of 9 died within 30 days without two or more associated injuries: 1 Jehovah's Witness of low hemoglobin, and 1 patient of sepsis. CONCLUSIONS: Although any of several maneuvers may be appropriate in managing traumatic aortic injuries, the simple "clamp-sew" technique is a safe and effective method for the treatment of traumatic aortic transections.     

A new technique for determining the denture tooth bond

As we learn more about hypertension, it is becoming increasingly apparent that conventional blood pressure measurements are fraught with potential error. Noninvasive ambulatory blood pressure monitoring is proving to be extremely valuable in both diagnosis and treatment. Advancing medical technology has provided small, noninvasive, reliable systems what are well tolerated by patients. The commercial availability of these systems facilitates their use in both clinical practice and in research. There have been legitimate concerns that continuous blood pressure monitoring may add considerably to the costs of diagnosing and treating hypertension. These worries, however, may be misplaced. If there are indeed as many patients being treated unnecessarily as has been suggested by many studies, then the money saved on drugs may well cover the costs of prolonged blood pressure monitoring. Moreover, many subjects can be spared unnecessary therapy. Although much work needs to be done with larger groups of patients followed over longer periods of time, the early experiences with 24-h ambulatory blood pressure monitoring have been extremely encouraging. These procedures have added to our understanding of hypertension and of the agents used in its treatment and are rapidly assuming an increasing importance in overall management.     

A new porto-systemic bypass technique for hepatopancreatoduodenectomy with portal vein resection

When reconstructing the portal vein (PV) following hepatopancreatoduodenectomy (HPD) with PV resection, a new porto-systemic bypass (PSB) technique can be employed to prevent intestinal vascular congestion. The Whipple procedure is performed in a standard manner, as long a portion of the gastrocolic trunk is preserved for insertion of an antithrombogenic catheter (ATC). After harvesting the left external iliac vein and exposing the right great saphenous vein, the end of the ATC is inserted in the superior mesenteric vein via the gastrocolic trunk in the distal direction and the other end of the ATC is inserted in the greater saphenous vein. PSB is achieved as a result of the venous pressure gradient. By employing this technique, an ATC can be inserted without damaging another mesenteric venous branch and with minimal damage to the endothelium, and the small intestine is not exposed in the operative field until enteric reconstruction is started. This technique is a promising option for PSB during HPD with PV resection.     

Coregistration imaging of the foot. A new localisation technique

We describe a new technique, known as coregistration imaging, which superimposes 99mTc isotope bone scans on to plain radiographs. We used the technique selectively in cases in which the nuclear medicine physician, who reported the isotope scan, had difficulty in localising the anatomical site of the abnormality. In the forefoot, coregistration of isotope scans did not help to localise pathology; the scan alone gave sufficient detail. In 17 patients with pain in the hind- and midfoot, isotope scanning identified eight sites of abnormality in those with normal radiographs. In those with more than one abnormality on plain radiographs the isotope scan eliminated 12 sites of suspicion. Coregistration of the images significantly increased the certainty of localisation of disease (p < 0.001). We recommend the selective use of coregistration scanning as a useful technique for investigating patients with pain in the foot and ankle.     

A new and simple technique of total hepatic ischemia in the mouse

BACKGROUND: A model of total hepatic ischemia is currently not available in mice. Models described in rats using portosystemic shunts to achieve total ischemia have been notoriously difficult. In mice, the problem is compounded further when using this type of technique because of the small size of the animal. A new technique is described combining partial hepatectomy with clamping of the remnant liver. METHODS: A partial (30%) hepatectomy is performed with resection of the caudate, right lateral, and quadrate lobes, and papillary process. Vascular microclamps are placed across the pedicles of the median and left lateral lobe at the level of the hilum to achieve total ischemia. Spontaneous portocaval shunts through caudate branches and collateral vessels prevent mesenteric congestion. Animals were studied for survival. RESULTS: The procedure consistently took less than 30 min (25+/-2 min), and no bleeding of the resected tissue was observed. Evidence for total hepatic ischemia and spontaneous shunts was demonstrated by the use of an intraportal dye. All animals survived 60 min of ischemia, whereas all died after 90 min of ischemia. CONCLUSION: This is a technically simple and rapid procedure to perform. In the current environment of multiple knockout mice and bioreagents that are available, a model of this type is essential.     

A new method of covering skin loss of the internal canthus: paralateronasal flap

The author describes a new procedure of coverage of the medial canthus: paralateronasal flap. It is a cutaneous rotation-advancement flap with random vascularisation ensured by the dermal vascular plexus. It is vertical and S-shaped. Its first curve is concave laterally and ascends widely to the lateronasal area, and its second lower curve is concave medially, following the nasolabial fold. This flap has been used 14 times, mostly to repair defects caused by excision of skin cancers of the medial canthus. Mean follow-up is 18 months. The aesthetic results obtained are very satisfactory. The author compares the advantages of the paralateronasal flap with present techniques and thinks that this new flap should find its place in the therapeutic arsenal for repair of the medial canthus.     

A new technique of screening gene mutation--fluorescent fingerprinting

A new classification is substantiated of motor syndromes in patients with hemispheric cerebral insult. The classification is represented by six syndromes, it takes advantage of the degree of upper and lower monoparesis, relation between the two, condition of muscular tone, ability of people to help themselves, to cope in their homes, and other items. Correctness of the classification has been confirmed by the method of correlation analysis and parameters of stimulation electromyography. The use of the classification will, we believe, help in administering the relevant rehabilitative therapy treatments in a more efficient way.     

Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft—a new technique

Long standing oral submucous fibrosis is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. This article introduces a new technique of release of submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft. The surgical technique involves a pre-auricular incision extending into the temporal region with dissection carried out in the sub follicular plane to develop the superficial temporal fascia flap to its maximum extent. The masseter muscle origin is released from the zygomatic arch and the temporalis muscle insertion is released from the coronoid process through an external approach. The entire fibrosed mucosa is released intraorally to create a mucomuscular defect thus achieving full mouth opening. The superficial temporal fascia flap is then brought in and sutured to the intraoral defect, which is then covered with a split thickness skin graft. This procedure is performed bilaterally.A total of five patients were treated with this new technique and all of them showed good mouth opening in long term follow up. There was no donor site morbidity. The incision line is well hidden in the hair bearing area. A well vascularised superficial temporal fascia flap brings in good blood supply to the area of affected muscle and mucosa to improve its function.