Fascia lata onlay patch for repairing infected incisional hernias.

Abdominal incisional hernias represent the most common wound complication after abdominal surgery and infected abdominal incisional hernias are difficult to manage. We describe a simple, safe and effective method of using a free fascia lata patch to repair a large infected incisional hernia. This procedure involves the following steps: incising the skin and subcutaneous tissue and identifying the edges of the hernia defect; incising each anterior rectus sheath and completely suturing the medial edges of the fascia with 0 polypropylene; creating a fascia lata patch; and overlapping the defect in the anterior rectus fascia with the fascia lata patch as an onlay graft to reinforce the fascial closure. Five patients with infected hernias underwent this procedure, and all postoperative outcomes were satisfactory.

Molecular factors of failure in incisional hernia surgery.

Incisional hernias occur as frequent as they did 20 years ago even if we use modern technologies in terms of suture. Sutures techniques, either primary repair or applied after failure of primary repair are characterized by high rates of recurrence. Using the hernia mesh has become mandatory in repairing of all types of hernias - inguinal, ventral or incisional. Implantation of the mesh is a relatively well-coded surgical procedure. But surgery is only the first step in the process of healing. Implantation starts a strong response with haematological mechanisms: protein absorption, complement activation, coagulation, platelet activation, neutrophil activation and tissue mechanisms: proliferation, adhesion, fibrosis. Recurrence rates are consistently lower when replacement meshes are used and a variety of meshes have been developed for this purpose. How the mesh is embedded by the human body and how the biomechanical limits of the abdominal wall are restored is still a subject of debate for surgeons. Histopathological studies and progress in design and materials are the only keys to solve this problem. Also pathological studies should determine the right material for personalized repair according to each patient's biology. This paper attempts to analyze the molecular failure factors in incisional hernia surgery, different from errors in surgery procedures. Complications can be avoided or reduced by an appropriate selection of the type of place in a particular case, and by performing a meticulous technique. Incisional hernias are considered at this moment a biological progressive phenomenon, and not only a strictly technical one, a "simple hole in the abdominal wall" that has to be firmly sutured.

Closed non-suction drain placement as haematoma and seroma formation preventive measure post-nylon darn surgery for inguinoscrotal hernias in adults.

PURPOSE: Inguinal hernia is a common male surgical disease. Intervention carries a wide range of complications such as scrotal haematoma and seroma which may require surgical re-intervention or predispose patients to developing infections, pains or feeling of mass. This could lead to long hospital stay. Scrotal tamponade by bandaging or wearing of tight pants and elevation are practiced to reduce bleeding and haematoma formation. These methods require prolong use. Closed suction drains are scarcely used in resource-deprived communities due to high cost and non-availability. AIM: This study was to determine the effectiveness of a closed non-suction drain in preventing scrotal collection requiring further surgical intervention and the predisposition to developing surgical site infection following nylon darn repair of inguinoscrotal hernia. METHODS: Forty (40) participants were recruited for a preliminary study and assigned into control and interventional groups (CG, IG) for purposes of inserting flexible feeding tube (FFT) wound drain after nylon darn (ND) repair. Daily measurement of drained scrotal collection was carried out in the IG till the day drainage was zero. Residual volumes in IG and wound collection in the CG who were not candidates for re-intervention were determined at 14th and 28th post-operative days using ultrasound scan. Data were analyzed using SPSS version 25. RESULTS: Three (3) patients (15.8%) in the CG required re-intervention. Surgical site infection rates for the CG and IG were, respectively, 2/19 versus 0/21 (ρ = 0.134).There was a numerical significant difference in the mean volumes of scrotal collections between the control (0.95 ± 0.42 ml) and the intervention group (0.44 ± 0.33 ml) [p value of 0.041] but with no clinical impact. CONCLUSION: Simple inexpensive flexible feeding tube placement significantly reduced scrotal collection which forms a base for larger sample size in subsequent studies. This could reduce the feared risk of re-intervention, wound infection and long hospital stay post-operative.

Antibacterial prophylaxis in dermatologic surgery: an evidence-based review.

Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs. Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.

Polymethyl Methacrylate Cement Fill as a Definitive Treatment for Massive Bone Defect After Infected Internal Fixation in Bicondylar Tibial Fracture: A Case Report.

CASE: A 62-year-old woman sustained a bicondylar proximal tibial fracture. She had a deep infection after open reduction and internal fixation resulting in massive metaphyseal bone loss. Because only subchondral bone was left, the cavity was filled with cement after pins were used to support the proximal tibia. Then, a hinged knee-spanning external fixator (EF) was applied. After the removal of the EF, the patient was almost pain free and tolerated full weight-bearing, and no further surgeries were needed. CONCLUSION: The cemented wires technique proved to be a good short-term and possibly a reasonable long-term treatment approach for infected nonunion with massive bone loss still maintaining lower leg alignment.

Risk factors for postoperative hemorrhage in patients with oral squamous cell carcinoma: A retrospective study.

BACKGROUND: Postoperative hemorrhage is one of the life-threatening complications of oral cancer surgery. The purpose of this study was to identify the risk factors in a large cohort. PATIENTS AND METHODS: Patients with oral squamous cell carcinoma who had received surgery were enrolled. The variables between patients with and without postoperative hemorrhage were compared using univariate and multivariate models. RESULTS: Of the 1513 patients (or 1581 cases) enrolled in the study, 34 patients suffered from postoperative hemorrhage. In the univariate analysis, cigarette, and alcohol consumption, floor of mouth tumors, T4 classified tumors, flap reconstruction, surgical site infection, and flap necrosis were risk factors for postoperative hemorrhage. In the multivariate model, flap necrosis and surgical site infection were independent risk factors for postoperative hemorrhage. CONCLUSIONS: The patients with surgical site infection or flap necrosis should be closely monitored in order to avoid postoperative hemorrhage.

Staged reconstruction of large skull defects with soft tissue infection after craniectomy using free flap and cranioplasty with a custom-made titanium mesh constructed by 3D-CT-guided 3D printing technology: Two case reports.

RATIONALE: A craniectomy, which results in a large skull defect, is performed to decrease the intracranial pressure under conditions such as intracranial hemorrhage and ischemic stroke. When the patient's condition is stabilized, autologous cranioplasty using the bone flap previously removed in the craniectomy is performed. Bone flap infection after the autologous cranioplasty is not uncommon and is difficult to treat. After the infection is controlled, cranioplasty is needed to improve the head deformity and neurologic function. Cranioplasty with a titanium mesh can result in aesthetic improvement and a low infection rate. Using 3-dimensional computed tomography (3D-CT) and 3D printing, titanium mesh is manufactured to fit perfectly on the patient's skull defect. PATIENT CONCERNS: Two patients with large skull defects in the right temple area due to previous craniectomy were referred to our department for reconstruction. They had histories of recurrent infections at the operation site even after removal of the autologous bone flap that had been used for the cranioplasty. DIAGNOSIS: Preoperative computed tomography (CT) showed 12×16 cm and 8×8.3 cm skull defect on right temporal area, respectively. INTERVENTIONS AND OUTCOME: The infection was controlled by well-vascularized free flap coverage. After the surgery, cranioplasty with custom-made titanium mesh was performed to improve the aesthetic and functional problems of the patients. The contour of the temporal area was symmetric. The patients were satisfied with the results. LESSONS: Staged reconstruction of large skull defects with soft tissue infection after craniectomy using free flap followed by cranioplasty with titanium mesh on can lead to safe, aesthetic, and satisfactory result.

Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008.

BACKGROUND: Antibiotic prophylaxis is an important component of dermatologic surgery, and recommendations in this area should reflect the updated 2007 guidelines of the American Heart Association, the American Dental Association with the American Academy of Orthopaedic Surgeons guidelines, and recent prospective studies on surgical site infection. OBJECTIVE: To provide an update on the indications for antibiotic prophylaxis in dermatologic surgery for the prevention of infective endocarditis, hematogenous total joint infection, and surgical site infection. METHODS: A literature review was performed, expert consensus was obtained, and updated recommendations were created, consistent with the most current authoritative guidelines from the American Heart Association and the American Dental Association with the American Academy of Orthopaedic Surgeons. RESULTS: For patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, prophylactic antibiotics are recommended when the surgical site is infected or when the procedure involves breach of the oral mucosa. For the prevention of surgical site infections, antibiotics may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease. LIMITATIONS: These recommendations are not based on multiple, large-scale, prospective trials. CONCLUSIONS: There is a strong shift away from administration of prophylactic antibiotics in many dermatologic surgery settings, based on updated authoritative guidelines. These recommendations provide guidance to comply with the most current guidelines, modified to address dermatology-specific considerations. Managing physicians may utilize these guidelines while individualizing their approach based on all clinical considerations.

Prosthetic repair of incisional hernia combined with elective bowel operation.

BACKGROUND AND AIMS: Incisional hernia repair with mesh is considered a clean operation and it is not recommended to be perfomed at the same time with a potentially contaminated operation. The aim of this study is to assess the short-term results of a group of patients who underwent a colon operation and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. PATIENTS AND METHODS: From Novemberto June 2006, 19 patients underwent incisional hernia repair with polypropylene mesh, with simultaneous colonic operation. In 13 patients reestablishment of bowel continuity after a Hartmann procedure was done, whereas in four patients a loop colostomy was closed. Two patients underwent colectomy for cancer. RESULTS: Post-operatively one patient had a seroma and two others had wound infections which required mesh removal. The mean follow-up was 70.15 +/- 48.40 months (range 3 to 142 months). During this period five patients died, four from progression of malignancy and one from myocardial infarction. Three patients (15.78%) developed recurrence, two patients with previous Hartmann's operation for complicated diverticulitis and wound infection and the third patient due to inappropriate mesh fixation with buttonhole hernia development. CONCLUSION: Prosthetic repair of incisional hernias can be safely performed simultaneously with a colonic operation, with an acceptable rate of infectious complications and recurrence. It is unjustifiable to avoid the use of mesh in a potentially contaminated field when an appropriate technique is used.

Risk of plate removal in free flap reconstruction of the mandible.

OBJECTIVES: To evaluate the factors associated with need for removal of fixation plates in mandibular free flap reconstruction. METHODS: This retrospective cohort analysis reviews patients undergoing mandibular free flap reconstruction at a tertiary care center from 2005 to 2016. Patients requiring removal of fixation plates were identified through electronic medical records. Factors including demographics, adjuvant therapy, surgical site infection (SSI) and fistula rates were compared. Removal rates based on flap type were determined. RESULTS: Between 2004 and 2016, 307 patients underwent osteocutaneous mandibular free flap reconstruction. 83 required removal of their fixation plates (27%). Age, tobacco use, and BMI were similar between patients requiring removal versus not requiring removal. Primary indications for removal were plate exposure (n = 41), and/or chronic drainage (n = 31), infection (n = 25), and pain (n = 17). Patients undergoing removal were significantly more likely to have had adjuvant radiation therapy (OR 2.09, CI 1.82-3.81), surgical site infection (OR 13.9, CI 5.15-43.2), and post-operative fistula (OR 13.0, 6.85-24.8). 35% of all fibula flaps (n = 52), 21% of osteocutaneous radial forearm (n = 21), and 11% of osteocutaneous scapular flaps (n = 6) required removal. 90% of patients (n = 75) had resolution of their symptoms following hardware removal. CONCLUSION: Surgical site infection and fistula are strongly associated with the need for plate removal. Fibular free flaps carry the highest rate of plate removal. Plate removal leads to resolution of plate-associated symptoms in a majority of cases.

Pedicled buccal fat pad for the augmentation of facial depression deformity: A case report.

RATIONALE: Tissue augmentation of facial depression deformities can be achieved by volume replacement with autologous fat injection, dermal filler injection, etc. Here, we report a case of tissue augmentation of a facial depression deformity using a pedicled buccal fat pad (BFP). PATIENT CONCERNS: A 64-year-old woman was referred with a chief complaint of facial depression deformity. DIAGNOSES: Her molars had been removed at another hospital 12 years prior to this referral, and the patient suffered from a left cheek depression deformity as a sequela of a postextraction infection. INTERVENTIONS: An incision was made in the left gingivobuccal sulcus under local anesthesia, and BFP was carefully excised from its normal location. The subcutaneous scar tissue was dissected, and a pocket was created via the same mucosal incision. BFP was then pushed into the pocket. OUTCOMES: The depression deformity immediately disappeared postoperatively. The transplanted BFP remained unabsorbed and soft 43 months postoperatively. The patient did not have any complications. LESSONS: This novel procedure has 2 advantages. First, the pedicled BFP is a vascularized tissue and is not absorbed postoperatively; control of contour is easy, and only 1 treatment session is required. Complications associated with fat necrosis can be avoided. Second, only a single intraoral incision is required; the risk of donor-site morbidity is very low, and scar formation does not occur on exposed skin. Third, this procedure can be performed without special instruments and equipment. The main disadvantages are limited rotation arc and volume of pedicled BFP. Despite its limited application, this procedure is simple and useful, with low invasiveness.

The effectiveness of systematic perioperative oral hygiene in reduction of postoperative respiratory tract infections after elective thoracic surgery in adults: a systematic review.

BACKGROUND: Nosocomial infections are a significant contributor to patient morbidity and mortality. Nosocomial infections significantly increase hospital length of stay and total hospital costs. Thoracic surgery, mechanical ventilation and/or admission to an intensive care unit are known to increase patients' risk for nosocomial respiratory tract infection. OBJECTIVES: To identify, appraise and synthesize the best available evidence on the effectiveness of systematic perioperative oral hygiene in the reduction of postoperative respiratory airway infections in adult patients undergoing elective thoracic surgery. INCLUSION CRITERIA: Patients over the age of 18 years who had been admitted for elective thoracic surgery, regardless of gender, ethnicity, diagnosis severity, co-morbidity or previous treatment.Perioperative systematic oral hygiene (such as mechanical removal of dental biofilm or plaques and/or systematic use of mouth rinse) performed by patients themselves or by healthcare staff (such as nurses).Randomized controlled trials and quasi-experimental studies.Nosocomial infections, specifically respiratory tracts infections, and surgical site infections SEARCH STRATEGY: Multiple databases (PubMed, CINAHL, Embase, Scopus, Swemed+, Health Technology Assessment Database and Turning Research Into Practice [TRIP] database) were searched from 1980 to December 2014. Studies published in English, German, Danish, Swedish and Norwegian were considered for inclusion in this review. METHODOLOGICAL QUALITY: Two independent reviewers used the standard critical appraisal tool from the Joanna Briggs Institute to assess the methodological quality of studies. DATA EXTRACTION: The process of data extraction was undertaken independently by two reviewers using tools from the Joanna Briggs Institute. DATA SYNTHESIS: Quantitative results were synthesized in meta-analysis. RESULTS: This review includes six studies: three randomized controlled trials and three quasi-experimental studies.The absolute magnitude of the summary effect sizes were: for nosocomial infections relative risk (RR) 0.65 (95% confidence interval [CI] 0.55-0.78) for respiratory tract infections RR 0.48 (95%CI: 0.36-0.65) and for deep surgical site infections RR 0.48 (95%CI 0.27-0.84). CONCLUSIONS: Systematic perioperative oral hygiene reduces postoperative nosocomial, lower respiratory tract infections and surgical site infections but not urinary tract infections. The effect is statistically, clinically and practically significant.Perioperative decontamination of the nasopharynx and/or oropharynx is a strategy worth pursuing. The intervention is cheap and can easily be carried out by the patients themselves. (Grade A)Studies testing decontamination of the nasopharynx and/or oropharynx have until now only included patients undergoing thoracic surgical procedures. As the interventions are cheap, easy to carry out and have a great impact on the patients' outcome, it is recommendable to carry out more studies involving other type of patients undergoing major surgery with a high prevalence of nosocomial infections, respiratory tract infections and surgical site infections.

Pathogenesis of aortoduodenal fistula: experimental and clinical correlates.

An aortoduodenal fistula (ADF) is believed to stem from erosion of a rigid prosthesis into the fixed retroperitoneal duodenum. Experimental and clinical data do not support a mechanical etiology, but indicate that the pathogenesis is an unrecognized graft infection with pseudoaneurysm formation. A 5 cm segment of Dacron was interposed in the infrarenal aortas of 24 dogs that were divided into four groups of six animals each. In group 1 (control) the duodenum was fixed by sutures to the proximal anastomosis of the Dacron graft. At 6 weeks' follow-up, no ADFs or deaths had occurred among this group. In group 2 the duodenum was fixed to the aortoprosthetic anastomosis and the dogs received an intravenous infusion of 10(8) S. aureus; two of these dogs developed ADF (P less than 0.01). In group 3 the duodenum was incorporated as a patch on the anterior aspect of the aortoprosthetic suture line, creating a false aneurysm; three of these animals died as a result of ADF. A false aneurysm was created in group 4 dogs, as in group 3, but in addition, 10(8) S. aureus was administered intravenously; here five to six animals developed ADF. Clinical and bacteriological evidence of graft infection was present in seven of 11 patients with ADF who were seen over an 18 year period. Five had pseudoaneurysm formation at the proximal anastomosis. Operation was performed in eight patients; three had closure of the aortic leak and repair of the duodenum with omentum interposition. All resulted in recurrent fistula and delayed hemorrhage. Simple graft excision in two patients without reconstitution of peripheral circulation resulted in lower extremity gangrene. The three survivors had graft excision and axillofemoral bypass. These data suggest that the etiology of ADF is primary low-grade infection. Successful operation necessitates excision of the graft, duodenal closure, and an extraanatomical axillofemoral bypass graft.

Approaches to repair of ventral hernia and full-thickness losses of the abdominal wall.

This article describes the causes, course, and treatment options for surgical repair of umbilical epigastric and incisional hernias. Special attention is paid to the full-thickness abdominal wall defects, which are particularly difficult wounds to close. A method of closure with Marlex mesh, followed by myocutaneous flap coverage, is discussed.

Compression sutures in the management of corneal transplant wound infections.

PURPOSE: To report the usefulness of compression sutures in the management of three cases of bacterial wound infections in corneal transplants. METHODS: Interventional case series. RESULTS: All three cases of wound dehiscence and perforation resulting from bacterial wound infections were successfully treated with placement of compression sutures with concurrent topical antibiotic treatment. CONCLUSION: The placement of compression sutures is a successful surgical technique to reestablish corneal transplant wound integrity compromised by infection.

The two-stage concept with temporary subcutaneous implantation of a vacuum sealing system: an alternative surgical approach in infected partial abdominal defects after lapratomy or abdominoplasty.

BACKGROUND: Infected abdominal defects after laparatomy or abdominoplasty may present serious complications. The management of a progressive infection in the abdominal region with partial necrosis -without peritoneal irritation - is treated variously. Multiple revisions due to re-infection or seroma are often necessary. The different surgical treatment options almost always necessitate an extended immobilisation and hospitalisation of the patient. PATIENTS AND METHODS: In five patients with infected partial abdominal defects after abdominoplasty (n = 3) or laparatomy (n = 2) successful management of infection was achieved in a two stages with temporary subcutaneous implantation of a polyurethane foam, combined with a vacuum assisted wound closure device, followed by secondary wound closure. In the first step a debridement, subcutaneous implantation of the foam, combined with intermittent subathmospheric pressure through a V.A.C. device was performed. In the second step an explantation of the foam, re-debridement and secondary wound closure was possible over 2 - 4 drains. RESULTS: In all patients - after a temporary immobilisation of 5 days, and systemic antibiotic administration - wound healing was achieved. In one diabetic patient another single revision was necessary, because of the necrosis of a distal wound edge. The mean hospitalisation after application of these procedures was 15 days (12 - 19). CONCLUSIONS: The surgical treatment of infected partial abdominal defects after laparatomy or abdominoplasty - performed in a two-stage procedure with temporary subcutaneous implantation of a V.A.C.-system, and secondary wound closure, offers a high level of safety, and presents an useful alternative tool in the difficult management of these patients.

Calcium sulfate as a mandibular implant.

Mandibular reconstruction has posed significant problems, particularly when dealing with loss of mandibular substance. Various implant substances have been utilized in attempts to repair mandibular defects. These have included metals, synthetic material, and organic substances. All have posed significant problems, particularly with rejection and inability of the implant to develop a stable fusion with the surrounding bone. Recently, calcium sulfate has been successfully used as an implant in frontal sinuses, mastoid cavities, and, in one report, as a mandibular implant. The present study looks at the ability of calcium sulfate to induce osteoneogenesis in canine mandibles with and without the presence of a periosteal covering around the implant. Infection somewhat limited the success of the study, but in those animals without major infections, successful replacement of the calcium sulfate by normal bone occurred both with and without the presence of periosteum.

Acceleration of capsule formation around silicone implants by infection in a guinea pig model.

Fibrous capsules surrounding silicone implants were investigated in a new guinea pig model to delineate some of the factors leading to capsular contracture. Both the implant surfaces and tissue capsules were examined by light and scanning transmission electron microscopy (STEM + SEM) with x-ray energy spectroscopy (XES). The capsular tissues were qualitatively similar to those recovered clinically, showing dense parallel collagen deposits, fibroblasts, myofibroblasts, macrophages, and foreign-body giant cells. Silicone was positively identified within intercellular vacuoles and the rough endoplasmic reticulum of macrophages by XES. Tissue recovered from the capsules that surrounded implants that were contaminated with S. aureus presented a qualitatively similar histologic spectrum. The contaminated specimens did show an accelerated response. SEM showed a cellular invasion of the silicone envelopes. We conclude that the model accurately simulates the clinical situation and suggests that immune mechanisms may play a key role in capsular contracture.