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PubMed1997

[The use of mesh in abdominal wall defects].

Today abdominal wall defect repair can't prescind from the use of prosthetic materials. Inguinal, femoral and incisional hernias represent more frequent events in which, only using prosthetic materials is it possible to perform "tension-free" repair. Prosthetic repairs "agree with" abdominal, wall physio-pathology, guarantee results and prevent recurrences. Permanent biomaterials like polypropylene and dacron mesh deserve special attention for their distinctive features are suitable for abdominal wall defect repair. Selection of material is an important step according to surgical technique and to avoid complications; the most alarming of which is a possible infection. However the average incidence of infection on prosthesis is about 0.5%. While infection risk is really scarce, the benefits of prosthetic repairs are clear: the recurrence rate of traditional hernia repairs is about 33% and 0-0.7% in prosthetic repairs. Likewise the recurrence rate for traditional incisional hernia repair is between 14% and 50%, whereas in prosthetic repairs it is 0-4.5%. Therefore it is necessary to use prosthesis for the following two reasons: firstly to avoid tension on the suture line, the prime cause of recurrence, and secondly to increase formation of collagen fibres on the transversalis fascia that appears histologically and biochemically altered. The authors report their experience of 660 prosthetic repairs, 600 for hernia and 60 for incisional hernia, performed, in the period April 1992-December 1994, at the General Surgery Department in San Giovanni Valdarno Hospital. The surgical techniques used were "tension-free" and "sutureless" and the prosthesis laid down always a polypropylene mesh. Complications only occurred in 33 patients, particularly 4 cases of infection (0.6%) however mesh remove was not required. The follow-up until today evidenced only two early recurrences owing to our technical mistakes in the beginning of our experience. For incisional hernia repair we laid down a giant dacron mesh on preperitoneal space. No complications were registered. The average stay in hospital was 5 days and follow-up showed no recurrence. The use of prosthetic materials in abdominal wall defect repair expressed large benefits with evident and clear reduction in recurrence rate. Traditional techniques produce tension on the suture line and high percentage of early and late recurrences since an essential surgical principle is transgressed. In fact traditionally repair has been accomplished by approximation of anatomical structures, that are not normally in apposition and by utilization of defective tissue. Metabolic alteration involving collagen turnover is evident in these patients. The answer to this problem is prosthetic repair. At present there is no ideal prosthesis, however the surgeon can use several suitable synthetic materials. The selection of prosthetic materials is a fundamental step also considering the possible infection; that however develops rarely. In conclusion the authors think that mesh repairs represent an overcoming of traditional surgical techniques in abdominal wall defect repair.

Abdominal Muscles↗

PubMed1998

A new anastomotic technique in renal transplants reduces warm ischemia time.

The cause of allograft dysfunction following renal transplantation has not yet been fully determined. However, one of the principal factors known to cause dysfunction in renal transplantation is warm ischemia. A new vascular anastomosis technique that reduces anastomotic time and the amount of warm ischemia time during the implantation phase was tested. A retrospective review compared 21 consecutive sutureless renal transplants with 31 consecutive suture transplants using a new technique performed by the same surgeon in the previous 12 months. The results showed the warm ischemia time was reduced by 51% (from 42.4 min to 24.04 min) with the new anastomotic technique, and with few complications. Initial experience with the new anastomotic technique is favorable. Further experience is needed to fully evaluate the complications and long-term outcomes using this technique.

Adult↗

PubMed1997

[Choice of the site of incision for cataract surgery without suture according to preoperative astigmatism].

PURPOSE: To compare surgically induced astigmatism, postoperative astigmatism and uncorrected visual acuity after cataract surgery depending on the site of a 4 mm sutureless incision (superior scleral or corneal temporal) and on the preoperative astigmatism. METHODS: According to preoperative astigmatism and to the site of incision 4 groups have been distinguished. Group I: with-the-rule preoperative astigmatism and superior scleral incision, group II: with-the-rule preoperative astigmatism and corneal temporal incision, group III: against-the-rule preoperative astigmatism and superior scleral incision, group IV: against-the-rule preoperative astigmatism and temporal incision. The patients had a preoperative and postoperative (Day 1, 8, 30, 180, 360) keratometry. Surgically induced astigmatism, preoperative and postoperative astigmatism have been expressed according to Naeser method. The uncorrected visual acuity at Day 30 has been compared in each group. RESULTS: Preoperative astigmatism was similar in the four groups. Surgically induced astigmatism was -0.18 diopter (D) at day 30 and -0.41 D at day 360 for the scleral incisions and +0.60 D at day 30 and +0.33 D at day 360 for the temporal incisions. The postoperative astigmatism was +0.5 D at day 30 and +0.27 at day 360 for the group I and +1.22 D at day 30 and +0.95 D at day 360 for group II. There was no statistical difference in the uncorrected visual acuity. Postoperative astigmatism was -0.8 D at day 30 and -1.03 D at day 360 in group III and -0.04 D at day 30 and -0.31 D at day 360 in group IV. The visual acuity was significantly better in group IV than in group III. CONCLUSION: In cases of preoperative with-the-rule astigmatism < or = 0.75 D the two sites of incisions are possible. In cases of WTR astigmatism over 0.75 D we perform a superior scleral approach. In cases of against-the-rule astigmatism the temporal incision is the only one to consider.

Aged↗

PubMed1998

[Treatment of subacute cardiac rupture after myocardial infarction].

Five successfully treated cases of subacute cardiac rupture after myocardial infarction are described. There were 4 men and 1 woman, ranging in age from 51 to 71 years. Two patients had systemic hypertension. Rupture occurred during the first myocardial infarction in all patients. The interval from the onset of myocardial infarction to cardiac rupture ranged from 1 to 6 days (mean 4 days). In one patient, the rupture was repaired under cardiopulmonary bypass using an autologous pericardial patch over the infarcted myocardium. Two patients underwent sutureless repair with fibrin glue; one of them developed a left ventricular pseudoaneurysm 2 years after the operation, requiring resection. These three patients were operated on through a median sternotomy. The remaining two patients were treated for cardiac tamponade by pericardial drainage through a subxiphoid incision; one died 38 days after the operation due to congestive heart failure. The four surviving patients are currently well 22, 39, 41 and 60 months after surgery. In summary, a conservative approach may be effective for treatment of subacute cardiac rupture.

Aged↗

PubMed1998

[Evaluation of astigmatism and blood-aqueous barrier breakdown following procedures in the anterior eye segment].

PURPOSE: The aim of this study was to evaluate the disruption of the blood-aqueous barrier (BAB) and the induced astigmatism following phacoemulsification, trabeculectomy and phacotrabeculectomy. MATERIAL AND METHODS: 141 eyes of patients who underwent different surgical procedures of the anterior segment were examined with the use of computer-assisted videokeratography. All maps were recorded preoperatively, and one and five days after surgery. We also applied a laser flare-meter in 41 eyes in order to quantify aqueous flare following these procedures. RESULTS: The mean surgically-induced astigmatism following conventional trabeculectomy was 2.1 D and 1.4 D one and five days postoperatively, phacoemulsification with sutures 2.7 D and 1.9 D and phacotrabeculectomy 3.0 D and 2.4 D, respectively. Lower values of astigmatism obtained after sutureless phacoemulsification were 0.6 D and 0.3 D one and five days postoperatively, respectively (p < 0.05 vs Phaco+IOL+Trab. group, p < 0.01 vs other groups). It was found that aqueous flare values following phacotrabeculectomy were 58.0 photon counts/milisec.--one day, 39.3--3 days, 24.4--7 days, 20.4--10 days postoperatively. Significantly reduced values were observed after phacoemulsification--27.6 one day after surgery and 17.6--3 days later (p < 0.01 vs Phaco+IOL+Trab.group). CONCLUSIONS: It could be concluded that induced astigmatism and the amount of inflammation were the highest after triple procedure and the lowest after phacoemulsification.

Anterior Chamber↗

PubMed1998

Review of the medical management of postoperative cataract complications.

BACKGROUND: With the increasing number of surgeons using phacoemulsification techniques combined with sutureless scleral tunnel and clear corneal incisions for cataract surgery, the majority of patients will undergo an uncomplicated course of visual rehabilitation requiring no more than standard topical antibiotic and steroid regimen. Occasionally--even with an uneventful surgical course--postoperative complications arise. Many of these postoperative complications can be managed medically, without surgical intervention. Topical and oral glaucoma and nonsteroidal anti-inflammatory agents play an important role in the management of postoperative cataract complications. METHODS: A review of the common postoperative complications and their medical management using topical and oral pharmaceutical agents are presented. Emphasis is placed on current trends in treatment following contemporary cataract surgery. CONCLUSION: Although the complication rate is reduced with modern cataract surgery techniques, the primary care clinician should be prepared to identify and manage the most common clinical conditions. Armed with the proper knowledge of ophthalmic medications and their possible ocular and systemic interactions, optometrists can successfully manage and co-manage many postoperative cataract complications. Common postoperative complications are reviewed, along with current treatment regiments and dosage forms.

Cataract Extraction↗

PubMed1998

[Surgery of mechanical complications of acute myocardial infarct].

Reviewed are the current surgical methods for the treatment of mechanical complications after an acute myocardial infarction, specially the subacute ventricular rupture, the most frequent complication, and in which we have the greatest experience in the world. Mechanical complications constitute the second cause of death after myocardial infarction, following pump failure. The most frequent mechanical complication is ventricular rupture, which is the cause of death in 26% of the cases of acute myocardial infarction. The setting of solid diagnostic tools, with the association of echocardiographic and hemodynamic criteria, has permitted the identification of a large number of patients with subacute ventricular rupture before death, and has allowed them to be treated surgically. The surgical techniques have evolved to more conservative methods and, nowadays, nearly all the patients can be operated on without extracorporeal circulation and using sutureless techniques. The results is greater surgical survival with satisfactory functional status at follow up. The incidence of septal and papillary muscle rupture is considerably less frequent, but of great interest. The surgical results have been improved on the basis of early diagnosis, aggressive surgical attitude, and better reparative and myocardial protection techniques.

Heart Rupture, Post-Infarction↗

PubMed1998

Covering the "open abdomen": a better technique.

"Damage control" in severe abdominal trauma, abdominal compartment syndrome, necrotizing fasciitis of the abdominal wall, and necrotizing pancreatitis often preclude closure of the fascia after laparotomy. Many techniques have been reported for temporary coverage of the exposed viscera, but most have had documented problems. We report the successful use, since 1989, of a temporary sutureless coverage. The viscera are covered with omentum when possible, then with a clear plastic sheet. Sump drains are placed over this layer. The entire abdomen is then covered with two layers of iodophor-impregnated adhesive plastic drape. The last 50 patients managed with this technique are reported. The most common indication (27 patients) was for treatment of severe abdominal trauma. There were no wound infections, fasciitis, or bowel obstruction. Eighteen patients died; no deaths were related to abdominal closure. Temporary abdominal covering with adhesive plastic sheeting is a rapid, safe, and readily available method for managing the open abdomen. This technique provides a physiologic milieu for the abdominal viscera, simplifies nursing care, and promotes safe closure of the abdomen at a later time.

Abdomen↗

PubMed1998

Corneal topography after cataract surgery using a clear corneal incision closed with one radial suture.

BACKGROUND AND OBJECTIVE: To determine whether corneal topography and visual recovery are affected by suturing a temporal, clear corneal incision for cataract surgery. PATIENTS AND METHODS: Forty-one consecutive phacoemulsification patients (39 eyes) had a 3.2-mm incision sutured with one 10-0 nylon, radial suture removed after 1 postoperative week. Visual acuity (VA) and corneal topography, including best fit sphere (BFS), best fit cylinder (BFC), principle meridian, topographic irregularity (TI), and vector-corrected astigmatism (VCA), were measured preoperatively and 1 day, 1 week, and 1 month postoperatively. Two-tailed t tests and Pearson correlations were calculated. RESULTS: From the preoperative measurement to 1 week postoperatively, VA improved, BFS (P = .005) and TI (P = .033) increased, and VCA shifted with-the-rule. From 1 week to 1 month postoperatively, BFS (P = .012) and TI (P = .002) decreased. BFC and its direction did not change. Almost all measures were significantly correlated. CONCLUSION: The benefits of sutureless surgery on corneal topography and visual recovery are not degraded by using a suture to prevent wound leakage.

Aged↗

PubMed1998

[Treatment of undeveloped intestinal fistulas in purulent peritonitis].

For treatment of two consecutively opened into abdominal cavity perforating fistulas of small bowel in conditions of purulent peritonitis the author successfully used funnel-shaped obturators by Kolchenogov. In the same patients in later adhesive intestinal obstruction, which could not be eliminated by common surgical mode, continuous introduction of semifluid food and intestinal chyme collected from enterostoma (located above the obstruction) were carried out through enterostoma located above the obstruction. After resorption of inflammatory infiltrate bowel continuity was restored. Based on favourable results of treatment for perforation fistulas opening into free abdominal cavity, the author more than once in conditions of purulent peritonitis successfully applied sutureless suspending enterostomies on the catheter of Petzer, which principally is an analogue of the obturator by Kolchenogov, using the same method as in perforation fistulas. Inflamed bowel wall thus is well accreted with abdominal wall, and after withdrawal of catheter by Petzer the developed tubular bowel fistula is rapidly healing spontaneously.

Adult↗