Local flaps, including pedicled perforator flaps: anatomy, technique, and applications.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Discuss the types of local flaps. 2. Analyze the advantages, disadvantages, and applications for each kind of flap. 3. Perform appropriate design and dissection techniques of local flaps. 4. Describe appropriate design and dissection techniques of local perforator and propeller flaps. SUMMARY: The purpose of this article is to comprehensively review the topic of local flaps. Local flaps are those that are elevated nearby and then transferred to an adjacent wound. Options include geometric local flaps, axial pattern local flaps and a new exciting group of flaps, local perforator flaps. The principles, advantages, disadvantages, and applications for each are carefully analyzed. Local perforator flaps can be harvested virtually anywhere in the body and represent a significant clinical advance, as these can solve a wide variety of clinical challenges. These flaps do require gentle microsurgical dissection technique with careful handling for inset of the flap and simultaneously provide the same advantages of other types of local flaps because they also use nearby tissues with a similar color match, thickness, and texture, with primary donor-site closure possible. Local perforator flaps are another very useful option that undoubtedly will become more popular as more surgeons become more familiar with their use and advantages.

[Association between wound size after open cholecystectomy with severity of iatrogenic biliary tract lesions]. / Efecto del tamaño de la incisión en la gravedad de la lesin de la vía biliar iatrogénica posterior a colecistectomía abierta.

BACKGROUND: Transoperative biliary tract injury during open or laparoscopic cholecystectomy is a catastrophic event associated with significant morbidity and mortality. Our objective was to determine if wound size during open cholecystectomy is associated with more complex biliary tract injuries. METHODS: Prospective cohort study performed between March 2006 and February 2007. Sixty-six patients with biliary tract injuries after open cholecystectomy were included. Wound size was analyzed. RESULTS: Sixty six patients were included, 70% were female with a median age of 44. Seventy four percent were treated for acute cholecystitis. Most participants were overweight or had various degrees of obesity. Biliary tract injuries were not recognized during the primary surgical procedure in 76% of cases. All patients with severe biliary tract injuries (Strasberg E-3 and E-4) had a wound size less than 10 cm in length. Wound size was associated with unrecognized injuries (p=0.000), as well as with injury severity (p=0.000). We were notable to demonstrate a statistically significant association between biliary tract injuries and elective or emergency surgical procedures and midline or subcostal surgical incision for cholecystectomy. CONCLUSIONS: Our findings suggest that minor surgical access during open cholecystectomy may constitute a risk factor since smaller incisions were associated with more severe biliary tract injuries and an inability to observe this damage during the surgical procedure. We suggest to adhere strictly to the guidelines of an adequate surgical exposure during open cholecystectomy to prevent biliary tract injuries.

Efecto del tamaño de la incisión en la gravedad de la lesin de la vía biliar iatrogénica posterior a colecistectomía abierta / Association between wound size after open cholecystectomy with severity of iatrogenic biliary tract lesions

Antecedentes: La lesión transoperatoria de la vía biliar durante la colecistectomía abierta y laparoscópica es un evento catastrófico que se asocia con morbilidad y mortalidad significativas. El objetivo fue documentar si el tamaño de la incisión en colecistectomía abierta está asociado a lesiones más complejas de la vía biliar. Métodos: Estudio de cohorte prospectivo de marzo de 2006 a febrero de 2007. Se incluyeron 66 pacientes con lesiones de la vía biliar posterior a colecistectomía abierta. Se analizó el tamaño de la incisión. Resultados: Se incluyeron 66 pacientes, 70% del sexo femenino, con un promedio de edad de 44 años. El 70% fue tratado por colecistitis aguda. La mayoría tuvo sobrepeso o sufría diferentes grados de obesidad. En 76% de los casos, la lesión no fue advertida durante el procedimiento quirúrgico primario. Todos los pacientes con lesión de vía biliar grave (Strasberg E-3 y E-4) tuvieron incisiones menores a 10 cm de longitud. El tamaño de la incisión se asoció con lesiones inadvertidas (p=0.000), así como con el grado de lesión (p=0.000). No pudo demostrarse asociación estadísticamente significativa entre lesiones de la vía biliar y colecistectomía electiva o urgente, e incisión quirúrgica media o subcostal para la colecistectomía. Conclusiones: Nuestros hallazgos sugieren que el acceso quirúrgico menor durante la colecistectomía abierta puede ser un factor de riesgo, ya que incisiones pequeñas se asociaron con lesiones de la vía biliar más graves e imposibilidad para reconocer este daño durante el procedimiento. Sugerimos cumplir estrictamente los principios quirúrgicos de una adecuada exposición durante la colecistectomía abierta como medida para prevenir lesiones de la vía biliar.

BACKGROUND: Transoperative biliary tract injury during open or laparoscopic cholecystectomy is a catastrophic event associated with significant morbidity and mortality. Our objective was to determine if wound size during open cholecystectomy is associated with more complex biliary tract injuries. METHODS: Prospective cohort study performed between March 2006 and February 2007. Sixty-six patients with biliary tract injuries after open cholecystectomy were included. Wound size was analyzed. RESULTS: Sixty six patients were included, 70% were female with a median age of 44. Seventy four percent were treated for acute cholecystitis. Most participants were overweight or had various degrees of obesity. Biliary tract injuries were not recognized during the primary surgical procedure in 76% of cases. All patients with severe biliary tract injuries (Strasberg E-3 and E-4) had a wound size less than 10 cm in length. Wound size was associated with unrecognized injuries (p=0.000), as well as with injury severity (p=0.000). We were notable to demonstrate a statistically significant association between biliary tract injuries and elective or emergency surgical procedures and midline or subcostal surgical incision for cholecystectomy. CONCLUSIONS: Our findings suggest that minor surgical access during open cholecystectomy may constitute a risk factor since smaller incisions were associated with more severe biliary tract injuries and an inability to observe this damage during the surgical procedure. We suggest to adhere strictly to the guidelines of an adequate surgical exposure during open cholecystectomy to prevent biliary tract injuries.