Giant inguinoscrotal hernia repair.

Giant inguinoscrotal hernia is defined as an inguinal hernia extending below the midpoint of inner thigh in standing position. The authors describe giant inguinoscrotal hernia and small umbilical hernia with 12 years history of this uncommon disease. After preoperative evaluation, US and CT examination he was operated on. It was very difficult to return the hernia sac contents back to the abdomen and additional infraumbilical incision was needed. Hernioplasty suo modo without mesh was done. Patient recovered uneventfully. In the discussion the authors present the newer classification of giant inguinal hernia, the current treatment options and known serious complications of surgery. Finally, it indicates that good treatment results can only be achieved by close cooperation of concerned professionals in the treatment and intensive intraoperative and postoperative patient monitoring (Fig. 9, Ref. 31).

Use of intraabdominal VAC (Vacuum Assisted Closure) lowers mortality and morbidity in patients with open abdomen.

OBJECTIVE: Authors compare two groups of patients with open abdomen. The objective is to compare and evaluate two treatment modalities, namely Kern laparostomy and vacuum-assisted closure in terms of mortality, closure of abdominal wound, and fistula management, all these stratified by BMI and CRP. BACKGROUND: Open abdomen can be considered a "patient salvage technique", used in patients with abdominal sepsis, as well as in patients with abdominal compartment syndrome, and in damage control surgery. Various management techniques are known, of which Kern laparostomy is most widely used. Newer techniques using negative pressure have emerged, still waiting for their wider acceptance and use. The authors present their study, in which they compare Kern laparostomy and intraabdominal VAC in patients with open abdomen. MATERIAL AND METHODS: Study consists of 44 patients treated at the authors´ clinics, while group KERN consisted of patients managed by Kern laparostomy, and group VAC was managed by intraabdominal VAC. The groups were compared in terms of mortality, abdominal closure, appearance of enteroatmospheric fistulas, primary closure of fistulas, and possibility of diversion of enteral contents. All outputs were stratified by CRP (C-reactive protein) and BMI (Body Mass Index). RESULTS: In VAC group, a significant decrease in mortality was seen, as well as significantly higher closure of abdominal wall, and significantly higher possibility of diversion of enteral content from fistulas. No statistically significant findings were observed in stratification with CRP and BMI. CONCLUSION: Intraabdominal VAC offers patients lower morbidity and mortality and should be defined as a treatment of choice in patients with open abdomen (Tab. 4, Fig. 3, Ref. 15).

Laparoscopic splenectomy in pregnancy - from contraindication to golden standard.

Laparoscopy has been holding its strong position within visceral surgery for decades. For several diagnoses, laparoscopy became the method of first choice. Laparoscopic splenectomy is a standardized procedure in patients indicated mostly due to haematological disorders. Apart from bleeding disorders, pregnancy used to be recognized as a contraindication to laparoscopic surgery. Splenic cysts are extremely rare during pregnancy; only seven cases have been described in literature. The authors had to deal with a patient treated and observed by haematologist for haemorrhagic splenic cyst and hypersplenism. Because of her low compliance, the patient did not undergo splenectomy in the past. Due to the gradual progression of disease and furthermore because of her pregnancy, the question of splenectomy became semi-urgent. The patient underwent laparoscopic splenectomy in second trimester, while not only the surgery alone, but also her early postoperative period and remaining pregnancy passed off uneventful. The authors suggest that even in pregnancy, the patients suffering from serious haematological disorders necessitating splenectomy could safely benefit from the advantages of laparoscopic approach, which also in these cases could become a gold standard (Fig. 2, Ref. 13).

[Diverticulum of the greater curvature of the stomach as a cause of anaemia]. / Divertikul velkej kurvatúry zalúdka ako prícina anemizácie.

Gastric diverticula represent a rare pathological condition. They are usually asymptomatic and are often found only by accident during radiologic or endoscopic examination, or during autopsy. Their incidence is low and evenly distributed between men and women. Gastric diverticula are most frequently located on the posterior wall of the cardia and on the lesser curvature of the stomach. The authors present a case study of a 58-year-old patient with severe sideropenic anaemia, a marked weight loss and non-specific dyspeptic symptoms. The suspicion of a diverticulum was raised by a gastroenterologist during gastrofibroscopy and confirmed by a radiologist following a dynamic CT examination of the stomach. The diverticulum had an atypical location beneath the cardia on the greater curvature. The patient was indicated for surgery. During conventional laparotomy, resection of the diverticulum was performed using a linear stapler. The postoperative course was uneventful. Histology confirmed a false diverticulum. The patient is doing well, is asymptomatic, has put on 7 kg since the operation and her blood count is normal.

Gastrointestinal stromal tumour (GIST) from the point of view of a general surgeon.

Authors present the current knowledge about pathology of gastrointestinal stromal tumours (GISTs), their symptoms and diagnostics. They present data about surgical and biological therapy of GISTs and relation between them based on literature. This work is supplemented with the own group of 16 patients with GISTs, treated on their surgical ward in years 2003-2008. General surgeon meets GISTs in unclear diagnosed tumours and when encountering their complications. Recurrent and metastatic tumours should be treated in centres (Tab. 6, Fig. 1, Ref. 24). Full Text in PDF www.elis.sk.

Sandwich mesh abdominal closure.

The open abdomen carries a high mortality rate and represents a big surgical challenge. The recent introduction of vacuum assisted closure (VAC) introduced new techniques of its management, including STAR--Staged Abdominal Repair, Fabian Protocol, VAC supported with PDS, support with polyglactin mesh and the use of tissue expanders in the staged closure of the open abdomen. One of the methods, SMAC--sandwich mesh abdominal closure, emerged in April 2008 by the clinical group from Germany. The authors present their own modification of SMAC and a case report, where it was used. By current literary research it was the first patient in the Central European hospital managed by SMAC VAC. The authors of the article conclude that SMAC VAC and its modification is highly effective in the management of the open abdomen (Fig. 5, Ref. 4).

Selected indicators of care in patients with acute pancreatitis in the Slovak Republic.

UNLABELLED: The aim of this study was to state the standard of care in patients with acute pancreatitits in the surgical wards in the Slovak republic and compare the results to the European study. We sent out 57 questionnaires to surgical wards and received 34 back (59.65%). RESULTS: Most wards treat 51-60 patients per year (20.59% of wards). C-reactive protein (CRP) was mainly used as a stratification system (85.29%), followed by clinical assessment (79.41%). Only 41.18% of wards use antibiotic prophylaxis and primary CT indicated only 29.41% of the Slovak wards. Non improvement of clinical state is as indication for repeated CT in 100%. Only 11.76% of wards in the Slovak republic use fine needle aspiration (FNA) to confirm infection of pancreatic necrosis. The surgical intervention was mostly (76.47%) indicated in patients with organ dysfunction and sepsis, while according to 38.24% of wards, the optimal time for intervention is between 15th and 21st day after disease onset. 44.12% of wards would treat pancreatic abscess by surgical evacuation and consecutive closed lavage, pancreatic necrosis would treat identically 50% of participating wards (Fig. 6, Tab. 4, Ref. 14). Full Text in free PDF www.bmj.sk.

Significance of MRI in the treatment of perianal fistula.

OBJECTIVES: Objective of the study was to examine patients with fistula preoperatively with MRI and then compare with operative findings. BACKGROUND: Most common cause of perianal suppuration is infection of cryptoglandular origin. This results in simple intersphincteric abscess, or spreading of infection in cranial or caudal direction, horizontally or circulary. To choose the correct surgical therapy, sufficient diagnostic is necessary. This includes clinical examination, endorectal ultrasonography, rectoscopy with fistula injection with hydrogen peroxide or dye. More and more often MRI is used. METHODS: In 2007 19 patients with perianal fistula were operated on. In 14 patients, preoperative MRI was done without contrast dye or probing. Fistulas were classified on 5-grade scale. We treated simple fistulas with fistulectomies, in three cases of complicated fistulas cutting setons were used. RESULTS: We examined 14 patients and confronted preoperative MRI result with operative findings. In 12 patients results matched, in two patients peroperatively diagnosed and treated fistula did not show on MRI. One was transsphincteric fistula with abscess and one was simple transsphincteric fistula.Because of low number of patients, statistical interpretations are not significant. CONCLUSIONS: Results are preliminary, we continue in prospective analysis. MRI may be useful for successful treatment by correct assessment of the extent of disease. It is necessary to consider cost-effectiveness when indicating MRI (Tab. 6, Fig. 3, Ref. 11). Full Text (Free, PDF) www.bmj.sk.

Injuries of the intraabdominal organs at patients with polytrauma.

The authors analyse group of 77 patients with several injuries of the intraabdominal organs by polytrauma and intraabdominal continuing bleeding. The injuries were classified in compliance with the classification of the American Association for the Surgery of Trauma (AAST), 1994. At hemodynamically stable patients, the authors accept selective non-operative forms of treatment, however are aware of the risk of delaying the therapy of severe polytrauma. (Tab. 4, Fig. 2, Ref. 3.).

Current palliative treatment of malignant jaundice.

When selecting the most suitable palliation of malignant jaundice, the following factors are to be considered: 1) patient's overall condition, 2) presumption of patient's survival, 3) technical, personal, and economic factors, 4) effectiveness of procedure, 5) morbidity and mortality of palliative treatment. (Tab. 2, Ref. 3.).

Stabilisation of thoracic wall in patients with chest injury.

The authors analyse a group of 38 polytraumatised patients with unstable thoracic injury who were subdued to internal surgical stabilisation of the thoracic wall during the period from 1st October 1994 to 30th September 2001. The average period of controlled pulmonary ventilation (CPV) was 3 days and the average period of hospitalisation at the Anaesthesiology and Intensive Care Department (AICD) was 10 days. In indicated cases, the authors recommend an active surgical approach in the treatment of patients with unstable thoracic injuries. (Tab. 2, Fig. 2, Ref. 3.).

[The current approach to liver injuries]. / Súcasný prístup k poraneniam pecene.

PURPOSE OF THE STUDY: The authors analyze their own three-year material within the treatment (both surgical and conservative) of the injury of liver. MATERIAL: During the given period 18 patients with the injury of liver were treated, of which 15 (83%) surgically and 3 (17%) conservatively. The group included 13 men (72%) and 5 women (28%), the average age at the time of injury was 30 years (range, 19-44 years). Ten patients (56%) suffered a blunt injury and 8 patients (44%) a penetrating injury, of which in 5 patients it was the case of a stab wound and in 3 patients a gunshot wound. METHODS: Indicated to operation were patients with a continuous intraabdominal bleeding, multiple organ injury of the abdominal cavity, simultaneous injury of diaphragm and gunshot wounds in the abdominal cavity. The method of treatment of the liver was determined by the extent of the injury. The authors accept the selective non-surgical treatment of hemodynamically stabilized patients which was developed on the basis of modern imaging methods. The condition of patients is also limited by the extent and severity of associated injuries. Hepatic injuries were classified according to American Association for the Surgery of Trauma, 1994. RESULTS: The average amount of hemoperitoneum in the patients operated on amounted to 1 550 ml. (200-4000) of blood, the average number of transfusion units 9 (4-20), the average duration of hospitalization at the intensive care unit was 7 (1-44) days and at the surgical department 10 (1-24) days. The average amount of hemoperitoneum according to Federle classification in the nonoperated on patients was 250 ml (200-375), the average number of transfusion units was 1.2 (1-2) of erythrocyte mass, the average duration of the stay in the intensive care unit of the surgical department was 2.3 (2-3) and at the surgical department 6.9 (6-8) days. Complications were recorded in 5 (28%) patients. During resuscitation 6 patients (33%) died due to hemorrhagic shock and in 2 (11%) patients we introduced during the resuscitation intracaval shunt. DISCUSSION: Non-surgical treatment has become a standard method of the treatment of a blunt hepatic, injury in the adult population and it is used in the extent of 50-82%. Failure of conservative treatment at present leads to a surgical intervention. Surgery is indicated in patients which continuously require transfusions, whose vital indicators have deteriorated and where there are evident growing signs of peritoneal irritation. CONCLUSION: Non-surgical treatment of blunt hepatic injuries should be initial in all patients with a secured hemodynamic stability. As it is impossible to find out in which patients non-surgical treatment will fail, the initial period of observation at the intensive care unit is a guarantee of a selective approach. If all its principles are observed the percentage of success of this treatment should exceed 90%.

Penetrating cardiac injury.

Penetrating cardiac injury is still a diagnostic problem at this time. The authors want to show the breadth of problems on the case histories of two patients. It is important to classify the patients according to their risk group, and then to proceed. In each suspicion of cardiac injury we started with thoracotomy. It is an important "life endangering thoracotomy in emergency room". The hypotension with abdominal symptoms was started with laparotomy. Transdiaphragmatic pericardiotomy is a helpful adjunct in the decision as to whether proceed to median sternotomy. (Tab. 2, Fig. 3, Ref. 7.)

[Resuscitation operations in patients with multiple injuries]. / Resuscitacné operácie u polytraumatizovaných pacientov.

The authors analyze a group of 15 patients with polytrauma during a 4-year period. The patients had the clinical signs of severe bleeding. Despite the complex resuscitation care, the patients died due to consequences of haemorrhagic shock already during the operation or very soon after operation. All patients were after initial resuscitation and diagnostic procedures (apparatus breathing, aggressive volumotherapy, proved continuous bleeding) performed for the use of further resuscitation actions, namely surgical control and stoppage of bleeding, surgical indications. This pathophysiological consideration is reflected also in the title of this study. The study further discusses the modern injury conception of resuscitation at a operating theatre which in frame of surgical intervention attempts to achieve homeostasis. At the same time, the surgical approach frequently must prefer the methods which enable the physiological stability on the behalf of incomplete solution of post-traumatic anatomic integrity. The definite solution can be possibly performed by subsequent operation. (Ref. 5.)

[Significance of monitoring of intracranial pressure in craniocerebral injuries.]. / Význam monitorovania intrakraniálneho tlaku pri kraniocerebrálnych poraneniach.

The authors extend the analysis of the previously published group of 26 patients with a craniocerebral injury during a 20-month period of monitoring of intracranial pressure by means of epidural approach by new techniques. Since 1996 they have implanted a technically upgraded intracranial pressure censor intraparenchymatosely and since 1998 intraventricularly in total in 27 patients with craniocerebral injury during 36-month period. The significance of continuous monitoring of intracranial pressure in indicated cases consists in the prevention and treatment of intracranial hypertension (medicaments, ventilation regimen, nursing care) as in craniocerebral injuries ther does not develop a direct relationship between the disorder of conscience and intracranial pressure. Key words: craniocerebral injuries, monitoring of intracranial pressure, intracranial hypertension.

[Aortoesophageal fistulae as a cause of fatal hemorrhage]. / Aortoezofágové fistuly ako zdroj fatálneho krvácania.

Aortoesophageal fistula is a rare cause of upper gastrointestinal bleeding, ranging from 0 to 2.3% in literature. The authors studied a group of 266 patients with upper gastrointestinal bleeding during the period of three years (1996-1998). According to two patient cases and the data from literature diagnostic methods, causes of aortoesophageal fistulas are analysed and the necessity of urgent closure of the fistulas is stressed. (Tab. 2, Fig. 2, Ref. 15.)

[Carcinoids--personal experience with surgical therapy]. / Karcinoid--nase skúsenosti s chirurgickou liecbou.

The authors retrospectively studied a group of 8 patients in the period of 7 years (1990-1997). Most frequent surgical procedure performed was appendectomy (4 cases), right-sided hemicolectomy (2 cases), gastric resection (1 case) and small intestine resection (1 case). The most frequent side of carcinoid localization was appendix followed by small intestine. In 3 cases the tumours were macroscopically detectable, the remaining only histologically. Patients were without clinical manifestations of carcinoid syndrome. (Tab. 1, Ref. 9.)

[Injuries of diaphragm in our group of patients.]. / Urazy bránice v nasom klinickom materiáli.

In thoracic and abdomen surgeries the injury of diaphragm is often neglected. Clinical symptoms vary and in patients with polytrauma they are usually disguised. The authors analyze a group of 9 patients with polytrauma with the injury of diaphragm during a five-year period (from 1 September 1993 to 31 August 1998) specifying diagnostic possibilities and stressing the necessity to revise the diaphragm in laparotomy or thoracothomy for associated injuries. The prognosis of the injury is given by associated injuries. Key words: injury of diaphragm, polytraumatic patient.