Open extraperitoneal mesh repair for abdominal wall hernias in females.

OBJECTIVE: To determine the outcome of treatment in terms of infection and recurrence using open extraperitoneal mesh repair technique. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: The department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment, from February 2006 to November 2008. METHODOLOGY: Female patients with abdominal wall hernias with defect of 4 cm or more were studied. A history of previous surgery along with clinical findings on examination like size of defect and previous scar were noted. At surgery, hernial sacs were carefully opened and omental and intestinal adhesions were carefully separated. Polypropylene mesh was placed over extraperitoneal space and secured with interrupted vicryl 2/0 sutures. Redivac drains were placed over the mesh and the fascial repair. The patients were discharged on the 3rd - 4th postoperative day and were followed-up at 3 monthly intervals for postoperative sequelae like seroma, haematoma, infection and recurrence. RESULTS: There were 32 cases with a mean age of 41.25 + or - 10.79 years. The mean follow-up period was 15.78 + or - 9.02 months. Previous abdominal surgical intervention was found in 16 (50%) cases. Out of those, 14 (43.7%) had defects through the previous scar. A history of multiple caesarean sections alone, or in combination with either hysterectomy or laparotomy in the last 5 years was present in 7 patients. There were 12 (37.5%) cases of paraumbilical hernia, 4 (12.5%) of a recurrent paraumbilical hernia, 5 (15.6%) epigastric hernia, 2 (6.2%) mix hernia, 7 (21.8%) incisional hernia and 1 (3.1%) each of Spigelian hernia and postlaparoscopic cholecystectomy portal (paraumbilical) hernia. The mean size of the defect was 4.9 cm in primary paraumbilical hernias and 7.2 cm in recurrent paraumbilical hernias. The mean size of the defect in incisional hernias was 9.4 cm, larger than all other types. Superficial wound infection was seen in only 1 morbidly obese (BMI > 30) patient. No case of seroma, haematoma, deep seated abscess or recurrence was noted in the follow-up period. CONCLUSION: Abdominal wall hernias are common in female patients, especially those with previous surgical intervention. Open extraperitoneal mesh repair with placement of redivac drains is an effective method for the management of abdominal wall hernias with a smaller complication rate and less recurrence.

Combined urethrolithotomy with vesicolithotomy in an 18-months old boy.

We present a case of 18 months old male child who reported with acute urinary retention. He had a urethral calculus along with a vesical calculus. He was subjected to combined external urethrotomy and open vesicolithotomy in one sitting. The patient made a smooth post operative recovery and was followed up for 6 months.

Retroperitoneal masses: different clinical scenarios.

We present two cases of retroperitoneal masses with different presentations and outcomes. The first case was a 22 years old primigravida lady who underwent emergency caesarean section for preterm premature rupture of membranes with breach. On the operating table, a large retroperitoneal mass was identified and the biopsy confirmed Burkitt's lymphoma. Post operative chemotherapy did not have a favourable result and the patient had a fatal outcome. The other case was a 15 years old boy who had a progressively increasing retroperitoneal mass. Exploratory laparotomy revealed a hard, fixed, unresectable tumour extending into the mesentery of the small gut, biopsies were taken which showed tuberculosis. Post operative antituberculosis treatment had a marked response and the tumour disappeared after 6 months.

Multiple perineal sinuses in non-hodgkin's lymphoma.

A 60 years old male presented with a 10 years history of chronic discharging perineal sinuses with inguinal lymphadenopathy. Biopsy of the inguinal lymph node revealed follicular B-cell non-Hodgkin's lymphoma while the biopsy of the sinuses was non-specific. It was diagnosed as a case of primary nodal NHL with secondary cutaneous manifestations of multiple perineal sinuses (paraneoplastic dermatosis). After two courses of chemotherapy, the discharge from the sinuses disappeared and the lesions healed by scarring.

Use of amnion in vaginoplasty for vaginal atresia.

A 25 years old lady with vaginal atresia, secondary to a mismanaged spontaneous vaginal delivery, underwent vaginoplasty using human amnion. The amnion was kept in its place using a 60cc syringe as a mould. For the next three months, dilatation by soft mould was followed by regular intercourse. Alongwith the restoration of normal coital function, she also conceived and was delivered by planned caesarean section at 38 weeks.

Torsion of appendix of testis.

An case of torsion of the appendix of testis is described in a 10 years old boy. He presented with sudden onset of severe pain in the left testis of 3 days duration. Emergency exploration of the left testis revealed a gangrenous appendix of the left testis. The appendix of the testis was excised and the wound was closed. The patient made a smooth post-operative recovery.