Peritoneal fine structure of inguinal hernia: a transmission electron microscope study.

Fine structure of normal human parietal peritoneum served as control data for recording changes in the fine structure of the peritoneum of hernial sacs. In these sacs, mesothelial cells retracted, rounded up and some of them eventually separated altogether to give rise to wide open intercellular spaces thus creating unhindered passageways (stomata) between the subserosal connective tissue and the cavity of the sacs. There was a considerable collagen build-up in the subserosal fibrous tissue of hernial sacs. Occurrence of this fibrosis is at variance with an accepted surgical concept which suggests a defect in collagen synthesis as the cause of herniation. In some sacs mesothelial nodules and/or peritoneal adhesions were present. Certain cytological changes in the mesothelial cells of hernial sacs showed features in common with cells of malignant tumours in general, and features mimicking malignant mesotheliomas in particular. This is in spite of the fact that thorough gross and light microscopic examination of operative specimens and cytological evaluation of peritoneal effusion failed to reveal any evidence of malignancy. Pathologists should be aware of the consummate ability of mesothelial cells to mimic carcinomas in order to avoid possible diagnostic errors. In this report, an electron micrograph of peritoneal adhesion is being published for the first time in the literature. A syncytium-like firm bond between adjoining mesothelial cells constituted the adhesion which is obviously an irreversible process.

Piles and rectoceles.

Symptomatic rectocele is known to contribute to the formation of piles in female patients. This paper describes a subset of women pile sufferers who have occult rectoceles which are asymptomatic, and which are not obvious on routine visual examination, even with the use of the speculum. These patients are multiparous and have sustained perineal damage either from episiotomy or from laceration. They present with symptoms of piles. If treated by conventional pile surgery the postoperative course is bedevilled with difficult defaecation, the patient often needing to insert a finger into the vagina to gain satisfactory evacuation. An accurate case history will show all these patients to have a preoperative story of straining at stool. Anterior rectal wall pressure on rectal examination shows a definite occult rectocele (spinnaker deformity) coupled with a deficient scarred perineum. This paper describes 15 such patients who have been seen over the past 4 years. Treatment has been by either pile surgery and later colpoperineorrhaphy (four cases), by combined colpoperineorrhaphy and pile surgery (eight cases), or by surgical correction of the rectocele alone (three cases).

Peritoneal fine structure of inguinal hernia: a scanning electron microscope study.

Mesothelial cells of the normal human peritoneum of the anterior abdominal wall are covered with numerous surface microvilli. These cells become partially denuded inside the sacs of direct and indirect inguinal hernias and so lose the protective property the microvillar covering may impart on them. These mesothelial cells of hernial sacs also acquire an extensive surface coat of fibrin-like material, presumably due to the loss of that protective property, which may as a result subject them to adhesions. There is a considerable collagen build-up in the subserosal fibrous tissue of sacs of both direct and indirect inguinal hernias. Such a build-up is at variance with the accepted current surgical concept which suggests a defect in collagen synthesis, rather than a build-up, as the cause of direct hernia.

Heterotopic periarticular ossification in burns.

The pathogenesis of this rather rare complication of burn injury is discussed. Injury and bleeding as a result of enthusiastic physiotherapy are usually incriminated as the major cause of such bone formation. More recent work is quoted which suggests that increased nutritional support regimes, particularly in respect of protein, cause a calciuretic response in burn patients. This iatrogenic mobilization of calcium, together with the increased levels of calcium due to injury and bed rest, may precipitate this complication. The periarticular location usually seen in burns, as compared with the heterotopic sites in muscle following other forms of injury, is noted. Although spontaneous resolution can sometimes occur, an active approach, with surgical excision being early rather than deferred, is advocated.

The management of deep thermal burns to the head.

The management of severe thermal burns of the head with associated bone destruction is discussed, and two patients in this category who were successfully treated by decorticating the dead bone with the high-speed dental drill are presented. The burns in both cases had defied management with alternative techniques, and both patients achieved satisfactory skin coverage five weeks after dental burring.