Anatomy theaters in the history and teaching of surgery.

The study of anatomy has played a large part in the progress of scientific observation throughout the centuries and was pivotal in elevating anatomy from the magical thinking of the Hippocrates era and freeing it from subservience to medicine which was all-powerful in the past. Anatomy theaters appeared in Northern Italy in the 14th century and developed in Western Europe from the early 16th century to the beginning of the 19th century. Anatomy theaters lived their golden age in France during the 18th century when the Royal Academy of Surgery (Académieroyaledechirurgie) was created in 1743. These theaters were open to the public, and therefore offered the double vocation of teaching and public entertainment: they were used to teach anatomy and surgery to students and surgeons and offered distraction for the well-informed public that was fascinated by death, ever-present and familiar to all. Anatomical dissection accomplished a double ritual: the "profane" ritual of valorization of scientific knowledge and the "sacred" ritual, where mankind, obsessed with death, respected the human body considered as a divine image. Anatomy theaters declined as they became overshadowed by progress in anatomical teaching using well-illustrated works in well-equipped medical schools while exhibition of anatomic oddities for public amusement was relegated to fairs and circus sideshows. Nonetheless they opened the way to modern anatomo-clinical methods and surgery.

Preoperative evaluation of the probability of common bile duct stones. French Association for Surgical Research.

BACKGROUND: This study was done to determine if certain criteria could predict the presence of common bile duct stones in patients with symptomatic gallstones. It was hoped that patients could be identified in whom intraoperative cholangiography was unnecessary. STUDY DESIGN: One hundred seventy-five patients, from 15 surgical centers, were prospectively enrolled. For each patient, the preoperative score (Huguier score) previously published was calculated according to clinical and ultrasound data: age, diameter of the common bile duct, diameter of the smallest gallstone, history of biliary colic, and acute cholecystitis. All patients underwent an open cholecystectomy and an intraoperative cholangiography. The absence or presence of a common bile duct stone was evaluated during the operation, if necessary, after an instrumental investigation of the common bile duct. RESULTS: Ultrasound was not interpretable in eight (5 percent) of 175 patients. Final analysis was made from the charts of the 167 remaining patients. Thirty (18 percent) had common bile duct stones. When the score was equal to or greater than 3.5, the risk of having a common bile duct stone was 24 percent (27 of 111). When the score was less than 3.5, this risk was 5 percent (three of 56). CONCLUSIONS: Huguier's score is well assessed and can be safely used. Intraoperative cholangiography could be avoided in 33 percent of patients when the score is less than 3.5 (56 of 167).

Inguinal hernia: a patch covering only the myopectineal orifice is effective.

A large mesh in the preperitoneal space, spread on iliac vessels and bladder, can cause future difficulties in a case of urogenital or vascular disease. Since all recurrences are located in the area of the myopectineal orifice, a mesh covering only this area, as in the Rives procedure, is effective and avoids these drawbacks. However, the Rives procedure is demanding, which is why we tried to simplify the technique. A mesh 8-10 cm long and 6-7 cm wide was spread in the preperitoneal space using the inguinal approach, without any fixation or with only a few stitches; the fascia was then simply approximated over the mesh without tension. A total of 161 hernias (99% Nyhus type III and IV) were repaired using this technique. Only six benign complications (3.7%) occurred. With a median follow-up of 63 months (range, 18-94 months), only one recurrence occurred (0.7%), due to misplacement of the mesh, eight patients complained of mild pain, and no late complications were observed. In conclusion, placement of a small mesh covering only the myopectineal orifice using the inguinal approach is effective and is associated with a low risk of drawbacks and complications.

[Feasibility and short-term results of the "plug" technique in inguinal hernia. A prospective evaluation]. / Faisabilité et résultats à court terme de la technique du "plug" dans la hernie inguinale. Evaluation prospective.

The aim of this prospective study was to assess the feasibility and postoperative outcome of the "plug" technique in inguinal hernia. One hundred and forty-six consecutive patients were operated for 151 hernias. A plug was applied in 131 cases (86.8%). The Lichtenstein technique was used in 20 cases (13.2%) because of a wide weakness of the posterior wall. Eleven (7.3%) postoperative benign complications occurred. No severe complications were observed and no patient was reoperated. The mean duration of oral analgesia was 2.7 (0-10) days. Mean durations of postoperative hospital stay, time off work and cessation of normal activities were 1.2 (0-4) days, 18.1 (1-37) days and 5.8 (1-18) days, respectively. In conclusion, the "plug" technique is feasible in a wide range of hernias and allows a short hospital stay and an early return to normal activity.

[Treatment of inguinal hernia in the adult: results of tension-free procedures]. / Traitement de la hernie inguinale de l'adulte: résultats des réparations sans tension.

OBJECTIVES: The aim of this study was to verify, by a prospective multicenter evaluation, if the results attributed to tension-free procedures were obtained in current practice. PATIENTS AND METHODS: From 1994 to 1997, 398 patients were operated on by three surgical teams. There were 357 men and 4 women (mean age: 58.5 years, range: 25-90). The hernia was bilateral in 37 patients and 435 hernias were treated by Perfix plug (n = 322), Gilbert plug (n = 76) or by Lichtenstein procedure (n = 37), according to the choice of the surgeon. In tension-free procedures, sutures under tension were replaced by a mesh or a plug without any approximation of the margins of the hernial orifice. The procedure was performed under local (n = 316), epidural (n = 94), or general (n = 25) anesthesia. RESULTS: There were no postoperative deaths. There were 19 postoperative benign complications (4.4%). The duration of analgesics consumption, postoperative hospital stay, cessation of normal activities and work (mean [SD] [range]) were 3.3 days ([3.9] [0-60]), 1.3 day ([1.1] [0-16]), 4.5 days ([3.1] [0-34]) and 15.4 days ([10.2] [0-60]) respectively. With a mean follow-up of 36 months ([14] [6-67]), 423 hernias (97.2%) were assessed. Two (0.5%) recurrences occurred. Twenty three patients had secondarily troubles (5.8%): 21 patients complained of chronic pain, one had testis atrophy and one plug had to be removed. CONCLUSION: These results confirm that tension-free procedures are minimally invasive, induce few benign postoperative complications and low pain, allow early return to normal activity, and are followed by few recurrences.

[Tension-free procedures: progress in the treatment of inguinal hernia]. / Les procédés sans tension: un progrès dans le traitement de la hernie inguinale.

OBJECTIVE: Tension-free procedures are aimed to minimize post-operative pain and rate of recurrence, by replacing sutures under tension by a mesh without any approximation of the margins of the hernial orifice. Moreover they offer the advantage of being performed under local or epidural anesthesia. The aim of this study was to verify, by a prospective multicentre evaluation, if the results attributed to these procedures are obtained in current practice. RESULTS: Evaluation involved 435 hernias, treated by Lichtenstein procedure, Gilbert plug and Perfix plug. There were 19 postoperative benign complications (4.4%). The durations of analgesics consumption, post-operative hospital stay, cessation of normal activities and time off work [mean, [(SD), (extremes)]] were 3.3 days [(3.9) (0-60)], 1.3 days [(1.1) (0-16)], 4.5 days [(3.1) (0-34)] and 15.4 days [(10.2) (0.60)] respectively. With a mean follow-up of 36 months [(14) (6-67)], 423 hernias (97.2%) were assessed. Two (0.5%) recurrences occurred. Twenty three patients had secondary troubles (5.8%): 21 patients complained of chronic pain, one had atrophy of the testis and one plug had to be removed. CONCLUSION: Our results confirm that tension-free procedures are minimally invasive, induce few benign postoperative complications, low pain and allow early return to normal activity.

[Partial traumatic rupture of the common bile duct]. / Rupture traumatique partielle de la convergence biliaire.

Partial rupture of the common bile duct was treated successfully in one case by direct suturing. Anatomical, physiopathological, clinical and therapeutic aspects of this rare type of lesion are discussed.

[Primary double infected aneurysm of upper limb (author's transl)]. / Double anévrysme artériel infectieux primaire du membre supérieur.

The authors report a rare and striking case of primary double infected aneurysm of the left upper limb successfully treated by resection and obliterative endoaneurysmorrhaphy. This opportunity is taken to review the particular physiopathological, anatomical, diagnostic and therapeutic characteristics of this particularly grave type of aneurysm.

[Attempt at cost evaluation of the prevention of parietal infection in abdominal surgery. Retrospective study of 1100 patients surgically treated over 4 years]. / Tentative d'évaluation du coût de la prévention de l'infection pariétale en chirurgie abdominale. Etude rétrospective portant sur 1100 opérés en quatre ans.

Justification for prevention of parietal infection in abdominal surgery was evaluated by a retrospective study of 1100 patients operated upon between 1981 and 1984. Rate of infection in class I was 0.5% and in class IV 8%. Comparison of costs of prevention, and of treatment of declared infection, demonstrated a sum of 280 French francs per case, this representing the allowed outlay in this field. Preventive measures should continue to be applied, this type of expenditure being perfectly justified by the economy obtained through shortening of hospital stay and the inestimable improvement in patients' comfort.

[Progress in the treatment of inguinal hernia]. / Progrès dans le traitement de la hernie inguinale.

The aim of surgical treatment of inguinal hernia is to a) reduce post-operative pain and discomfort to a minimum allowing patients to return to the activities as rapidly as possible, and b) hold the recurrence rate under 1%. The Shouldice technique remains the gold standard; its real recurrence rate is about 5%. Applying a mesh in the retroperitoneal space by laparoscopy is a good approach and can theoretically reach both aims. In current practice however, laparoscopy is not always favorable: general anesthesia is mandatory, technical pitfalls lead to morbidity and later to recurrences. Tension-free procedures would provide the best compromise for achieving the two advantages of: a) reducing pain, discomfort and recurrence risks by eliminating tension and, b) local and or loco-regional anesthesia.

[Pulmonary embolism, an unrecognized risk of post-traumatic arterio-venous fistulae of the hepatic veins (1 case)]. / L'embolie pulmonaire, un risque méconnu des fistules artério-sus-hépatiques post-traumatiques (1 cas)

A stab wound of the right lobe of the liver, initially treated by suture, led to the development of a large arterio-venous fistula with hemobilia. Re-operation on the 23rd day in order to carry out right hepatectomy, was rapidly followed by a massive and recurrent pulmonary embolism. A Trendelenburg operation associated with right hepatectomy did not prevent the patient's death. This risk of pulmonary embolism during post-traumatic hematoma of the liver is not fully recognised and the authors suggest, in cases of arterio-venous fistula of the hepatic veins, primary vascular exclusion of the supra-hepatic vena cava.

[Surgical treatment of aneurysms of the celiac trunk. Apropos of a case]. / Traitement chirurgical des anévrismes du tronc coeliaque. A propos d'un cas.

On the basis of one personal case and 63 cases reported in the literature for patients operated from 1958 onwards, the authors assess the surgical treatment of aneurysms of the celiac trunk. These are rare (4% of all visceral aneurysms), often latent (41.3% of cases) or without any specific symptoms (36.2% of cases), and have an atheromatous (51.8% of cases) or dysplasic (38.8% of cases) origin in most cases. They mainly affect men (68.4% of cases) after 40 years of age (72.2% of cases). They are rarely identified during the clinical examination, but are detected by ultrasound and confirmed by computed tomography and/or angiography (51.8% of cases). They are often small, less than 50 mn, and their size is a criterion for the approach, which usually remains abdominal. Resection is a routine operation (84.3% of cases), but the continuity of the artery is restored in 78.3% of cases only, due to the good-quality replacement provided by the superior mesenteric artery. The operative mortality rate is 7.8%. There are 96.2% good results (2 recurrences), but the average lapse in time is only 15.75 months.

Adjuvant intraperitoneal 5-fluorouracil in high-risk colon cancer: A multicenter phase III trial.

OBJECTIVE: To evaluate the results of a prospective multicenter randomized study of adjuvant intraperitoneal 5-fluorouracil (5-FU) administered during 6 days shortly after resection of stages II and III colon cancers. SUMMARY BACKGROUND DATA: Systemic adjuvant chemotherapy improves the survival of patients with stage III colon cancer receiving treatment for 6 months. Intraperitoneal chemotherapy theoretically combines peritoneal and hepatic effects. METHODS: After resection, 267 patients were randomized into two groups. Patients in group 1 (n = 133) underwent resection followed by intraperitoneal administration of 5-FU (0.6 g/m2/day) for 6 days (day 4 to day 10). These patients also received intravenous 5-FU (1 g) during surgery. Patients in group 2 underwent resection alone (n = 134). RESULTS: In group 1, 103 patients received the total dose, 18 received a partial dose as a result of technical or tolerance problems, and 12 did not receive the chemotherapy. Rates of surgical death and complications were similar in both groups. Tolerance to treatment was excellent or fair in 97% of the patients and poor in 3%. After a median follow-up of 58 months, 5-year overall survival rates were 74% in group 1 and 69% in group 2; disease-free survival rates were 68% and 62%, respectively. Survival curves were superimposed until 3 years after treatment and began diverging thereafter. Among patients receiving the full treatment, the 5-year disease-free survival rate was improved in the treatment group in patients with stage II cancers but was unchanged in patients with stage III cancers. CONCLUSIONS: Chemotherapy with intraperitoneal 5-FU administered during a short period after surgery was well tolerated but was not sufficient to reduce the risk of death significantly. However, it reduced the risk of recurrence in stage II cancers. These results suggest that it should be associated with systemic chemotherapy to reduce both local and distant recurrences.

Absceso epidural lumbar post hernia discal traumática: caso clínico / Lumbar epidural abscess secondary to traumatic disk herniation: a case report

We report the case of a 42-year-old male patient presenting with trauma history and lumbar spine axial compression which caused a herniated nucleus pulposus at lumbar level, revealed through MRI. After a four-day evolution period, fever and laboratory alterations indicative of an infectious process appear without signs of neurologic involvement. Hemoculture was positive for Staphylococcus aureus and MRI showed the presence of a lumbar spinal abscess secondary to infected epidural hematoma. The patient was treated with antibiotics, being given ceftriaxone, metronidazol, and gentamicin as an initial theraphy switched subsecuently to cloxaciline and cefazoline, He showed a favourable evolution, completing a six-week period of endovenous treatment plus four weeks receiving oral therapy The patient was discharged in good condition with no neurologic deficit.

Se presenta el caso de un hombre de 42 años con historia de trauma y compresión axial de la columna lumbar que originó una hernia de núcleo pulposo a nivel lumbar, demostrada mediante resonancia magnética. Al cuarto día de evolución aparece fiebre y alteraciones de laboratorio concordantes con infección, sin signos de compromiso neurológico. El hemocultivo resulta positivo para staphylococcus aureus. La resonancia magnética demuestra presencia de absceso espinal lumbar, que impresiona secundario a hematoma epidural infectado. El paciente es tratado médicamente, con antibioticoterapia que incluye inicial mente ceftriaxona/ metronidazol/ gentamicina y posteriormente cloxacilina/cefazotina, con buena evolución, completando 6 semanas por vía endovenosa y 4 vía oral. Su evolución fue favorable, siendo dado de alta en buenas condiciones y sin déficit neurológico.