Annals of Surgical Innovation and Research - Latest Articles

Emergency incisional hernia repair: A difficult problem waiting for a solution

Hasnain Zafar — 2012-01-04T00:00:00Z

Background: Emergency repair of incarcerated incisional hernia with associated bowel obstruction in potentially or contaminated field is technically challenging due to edematous, inflamed and friable tissues with occasional need for concurrent bowel resection and carries high rates of post-operative infectious complications. The aim of this study was to retrospectively assess the wound related morbidity of use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. We also describe a new technique of leaving the mesh exposed to heal by secondary intention with granulation tissue. Methods: Between 2000 and 2010 a total of 60 patients underwent emergency surgery for incarcerated incisional hernia with associated bowel obstruction with placement of permanent prosthetic mesh. The wound was closed after hernia repair in 55 patients while it was left open to granulate in 5 patients. Results: In the group of patients with primary wound closure, 11 patients developed superficial surgical site infection, 5 developed deep wound infection and one patient had cellulitis. These patients were treated with wound debridement and antibiotics. Mesh removal was required in one patient. There were no infections in the group of patients who had their surgical wounds left open. One patient in this group died on the fifth postoperative day from septicemia. Conclusion: Use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. in contaminated field is associated with high risk of wound infection.

At times, myomectomy is mandatory to effect delivery

Rajiv Mahendru — 2011-10-28T00:00:00Z

Background: Excision of a leiomyoma has never been a choice during caesarean section.MethodMyomectomy of a massive fibroid was necessitated prior to delivering the baby. Results: Delivery of a healthy was effected by Classical caesarean section. Conclusion: Leiomyoma in pregnancy is not an unknown entity and is a cause of concern for being a source of excruciating pain, at times, during the ongoing gestation.Although performed rarely, it is sometimes necessary to remove a large myoma to effect delivery of the baby during Cesarean section as is depicted in the case being presented hereunder.

Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case.

Ashraf Helmy — 2011-10-10T00:00:00Z

Background: Biliary tract reconstruction continues to be a challenging surgical problem. Multiple experimental attempts have been reported to reconstruct biliary defects with different materials and variable outcome. Our aim was to evaluate a new method for biliary reconstruction using an isolated pedicled gastric tube in a live animal trial and also to present the first clinical case. Methods: Seven mongrel dogs underwent biliary reconstruction using gastric tube harvested, completely separated from the greater curvature, and based on a vascularized pedicle with the right gastroepiploic vessels. The tube was interposed between the common bile duct (CBD) and the duodenum. Postoperative mortality, morbidity, liver functions, gross and microscopic histological picture were assessed. The first clinical case was also presented where, in a patient with post-cholecystectomy biliary injury, an isolated pedicled gastric tube was interposed between the proximal and distal ends of the CBD. Results: One dog did not recover from anesthesia and another one died postoperatively from septic peritonitis. Five dogs survived the procedure and showed uneventful course and no cholestasis. The mean anastomotic circumference was 4.8 mm (range 4-6) for CBD anastomosis and 6.2 mm (range 5-7) for duodenal anastomosis. Histologically, anastomotic sites showed good evidence of healing. In the first clinical case, the patient showed clinical and biochemical improvement. Endoscopic retrograde cholangiography was feasible and assured patent biliary anastomoses. Conclusion: In mongrel dogs, biliary reconstruction using pedicled gastric tube interposition between CBD and duodenum is feasible with satisfactory clinical results, anastomotic circumference and histological evidence of healing. The technique is also feasible in human and seems to be promising.

Stapler Access and Visibility in the Deep Pelvis: A Comparative Human Cadaver Study between a Computerized Right Angle Linear Cutter versus a Curved Cutting Stapler

Toyooki Sonoda — 2011-08-27T00:00:00Z

PurposeDistal rectal stapling is often challenging because of limited space and visibility. We compared two stapling devices in the distal rectum in a cadaver study: the iDrive™ right angle linear cutter (RALC) (Covidien, New Haven, CT) and the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH). Methods: Twelve male cadavers underwent pelvic dissection by 4 surgeons. After rectal mobilization as in a total mesorectal excision, the staplers were applied to the rectum as deep as possible in both the coronal and sagittal positions. The distance from the pelvic floor was measured for each application. A questionnaire rated the visibility and access of the stapling devices. Measurements were taken between pelvic landmarks to see what anatomic factors hinder the placement of a distal rectal stapler. Results: The median (range) distance of the stapler from the pelvic floor in the coronal position for the RALC was 1.0 cm (0-4.0) vs. 2.0 cm (0-5.0) for the CC, p = 0.003. In the sagittal position, the median distance was 1.6 cm (0-3.5) for the RALC and 3.3 cm (0-5.0) for the CC, p < 0.0001. The RALC scored better than the CC in respect to: 1. interference by the symphysis pubis, 2. number of stapler readjustments, 3. ease of placement in the pelvis, 4. impediment of visibility, 5. ability to hold and retain tissue, 6. visibility rating, and 7. access in the pelvis. A shorter distance between the tip of the coccyx and the pubic symphysis correlated with a longer distance of the stapler from the pelvic floor (p = 0.002). Conclusions: The RALC is superior to the CC in terms of access, visibility, and ease of placement in the deep pelvis. This could provide important clinical benefit to both patient and surgeon during difficult rectal surgery.

Use of a radiopaque localizer grid to reduce radiation exposure

Kee Kim — 2011-08-09T00:00:00Z

Background: Minimally invasive spine surgery requires placement of the skin incision at an ideal location in the patient's back by the surgeon. However, numerous fluoroscopic x-ray images are sometimes required to find the site of entry, thereby exposing patients and Operating Room personnel to additional radiation. To minimize this exposure, a radiopaque localizer grid was devised to increase planning efficiency and reduce radiation exposure. Results: The radiopaque localizer grid was utilized to plan the point of entry for minimally invasive spine surgery. Use of the grid allowed the surgeon to accurately pinpoint the ideal entry point for the procedure with just one or two fluoroscopic X-ray images. Conclusions: The reusable localizer grid is a simple and practical device that may be utilized to more efficiently plan an entry site on the skin, thus reducing radiation exposure. This device or a modified version may be utilized for any procedure involving the spine.

Odontostomatologic Management of Patients Receiving Oral Anticoagulant Therapy: A Retrospective Multicentric Study.

Francesco Inchingolo — 2011-07-19T00:00:00Z

IntroductionToday, we frequently find patients taking oral anticoagulant therapy (OAT), a prophylaxis against the occurrence of thromboembolic events. An oral surgeon needs to know how to better manage such patients, in order to avoid hemorrhagic and thromboembolic complications.Materials and methodsA group of 193 patients (119 men aged between 46 and 82 and 74 women aged between 54 and 76) undergoing OAT for more than 5 years were managed with a standardized management protocol and a 2-months follow-up. The aim of the present study was to apply a protocol, which could provide a safe intra- and postoperative management of patients on OAT. Results: Among the 193 patients, only 2 had postoperative complications. Conclusions: We think that the protocol used in the present study can be used for complete safety in the treatment of this type of patients.

Comparing ambient, air-convection, and fluid-convection heating techniques in treating hypothermic burn patients, a clinical RCT

Britt-Marie Kjellman — 2011-07-07T00:00:00Z

Background: Hypothermia in burns is common and increases morbidity and mortality. Several methods are available to reach and maintain normal core body temperature, but have not yet been evaluated in critical care for burned patients. Our unit's ordinary technique for controlling body temperature (Bair Hugger®+ radiator ceiling + bed warmer + Hotline®) has many drawbacks e.g.; slow and the working environment is hampered.The aim of this study was to compare our ordinary heating technique with newly-developed methods: the Allon™2001 Thermowrap (a temperature regulating water-mattress), and Warmcloud (a temperature regulating air-mattress). Methods: Ten consecutive burned patients (> 20% total burned surface area and a core temperature < 36.0°C) were included in this prospective, randomised, comparative study. Patients were randomly exposed to 3 heating methods. Each treatment/measuring-cycle lasted for 6 hours. Each heating method was assessed for 2 hours according to a randomised timetable. Core temperature was measured using an indwelling (bladder) thermistor. Paired t-tests were used to assess the significance of differences between the treatments within the patients. ANOVA was used to assess the differences in temperature from the first to the last measurement among all treatments. Three-way ANOVA with the Tukey HSD post hoc test and a repeated measures ANOVA was used in the same manner, but included information about patients and treatment/measuring-cycles to control for potential confounding. Data are presented as mean (SD) and (range). Probabilities of less than 0.05 were accepted as significant. Results: The mean increase, 1.4 (SD 0.6°C; range 0.6-2.6°C) in core temperature/treatment/measuring-cycle highly significantly favoured the Allon™2001 Thermowrap in contrast to the conventional method 0.2 (0.6)°C (range -1.2 to 1.5°C) and the Warmcloud 0.3 (0.4)°C (range -0.4 to 0.9°C). The procedures for using the Allon™2001 Thermowrap were experienced to be more comfortable and straightforward than the conventional method or the Warmcloud. Conclusions: The Allon™2001 Thermowrap was more effective than the Warmcloud or the conventional method in controlling patients' temperatures.

Minimally Invasive Surgery - Maximal Exposure To Research

Ronald Matteotti — 2011-06-25T00:00:00Z

Annals of Surgical Innovation and Research enters its fourth year as an open access, fully on-line journal. In the last few years we witnessed dramatic changes in the world of science, clinically and from a research point of view. Social media and the ever growing world wide web became an integral part of science groups and discussion forums. These new technologies allow for a wide and fast dissemination of cutting edge research, clinical findings and are capable of incorporating audio-visual content unlike any other form of scientific publication, in our fast paced environment an important point not to underestimate. Its big advantage is the open access policy which allows everyone to see your research and dynamic manuscript immediately upon acceptance. With incorporating an unlimited number of dynamic manuscripts we take the forefront in 'multimedia-publishing'. This new concept is especially useful in the field of minimally invasive surgery, robotic surgery and newer technologies, like NOTES, involving endoscopic devices where visual content is more important than a plain manuscript. Scientists still fear to publish open access because of its costs and still not wide acceptance.

Mandibular reconstruction using an axially vascularized tissue-engineered construct

Ahmad Eweida — 2011-03-20T00:00:00Z

Background: Current reconstructive techniques for continuity defects of the mandible include the use of free flaps, bone grafts, and alloplastic materials. New methods of regenerative medicine designed to restore tissues depend mainly on the so-called extrinsic neovascularization, where the neovascular bed originates from the periphery of the construct. This method is not applicable for large defects in irradiated fields. Methods: We are introducing a new animal model for mandibular reconstruction using intrinsic axial vascularization by the Arterio-Venous (AV) loop. In order to test this model, we made cadaveric, mechanical loading, and surgical pilot studies on adult male goats. The cadaveric study aimed at defining the best vascular axis to be used in creating the AV loop in the mandibular region. Mechanical loading studies (3 points bending test) were done to ensure that the mechanical properties of the mandible were significantly affected by the designed defect, and to put a base line for further mechanical testing after bone regeneration. A pilot surgical study was done to ensure smooth operative and post operative procedures. Results: The best vascular axis to reconstruct defects in the posterior half of the mandible is the facial artery (average length 32.5 ± 1.9 mm, caliber 2.5 mm), and facial vein (average length 33.3 ± 1.8 mm, caliber 2.6 mm). Defects in the anterior half require an additional venous graft. The defect was shown to be significantly affecting the mechanical properties of the mandible (P value 0.0204). The animal was able to feed on soft diet from the 3rd postoperative day and returned to normal diet within a week. The mandible did not break during the period of follow up (2 months). Conclusions: Our model introduces the concept of axial vascularization of mandibular constructs. This model can be used to assess bone regeneration for large bony defects in irradiated fields. This is the first study to introduce the concept of axial vascularization using the AV loop for angiogenesis in the mandibular region. Moreover, this is the first study aiming at axial vascularization of synthetic tissue engineering constructs at the site of the defect without any need for tissue transfer (in contrast to what was done previously in prefabricated flaps).

Syringe Micro Vibrator (SMV) a new device being introduced in dentistry to alleviate pain and anxiety of intraoral injections, and a comparative study with a similar device

Amir Hashem Shahidi Bonjar — 2011-01-07T00:00:00Z

Background: Neurologically, it is proven that stimulation of larger diameter fibers - e.g. using appropriate coldness, warmth, rubbing, pressure or vibration- can close the neural "gate" so that the central perception of itch and pain is reduced. This fact is based upon "Gate-control" theory of Melzack and Wall.Presentation of the hypothesisSyringe Micro Vibrator is a new design being introduced for the first time in the field of Dentistry. This device is a promising breakthrough in pain and anxiety management and may deliver solution for clinicians plagued with patient pain phobia. It has an off-set rotating micro vibration creator with ultra high frequency and ultra low altitude that can be easily placed on any standard dental syringe and some disposable syringes. This device was registered as an invention in dentistry and received Iran National Patent number of 63765.Testing the hypothesisBy creating micro vibration, this device would be effective in reducing the pain and anxiety confronted with most types of intraoral injections as palatal, mandibular block, intraligamental and local infiltration. From the aspect of the patient pain management, this device contributes both physiologically (based on Gate Control Theory of pain) and psychologically (based on the device function as will be explained by dentist to the patient as a modern pain reducing technology). From the aspect of clinician, SMV motor provides vibrations with ultra high frequency to alleviate pain, but since it has ultra low vibration altitude, it has no adverse effect on the clinician dexterity and accuracy during injection and it does not interfere with pin point localization of injection site.Implications of the hypothesisUpon mounting on a conventional dental anesthesia injection syringe, SMV is switched on and the clinician then uses normal injection technique to administer the anesthetic. This device is not only a useful accessory device for ordinary patients, but also more useful for pediatric patients and those who have a phobia of intraoral injection or pain.