[Abdominal unplanned reoperations in the Service of General Surgery, University Hospital of Puebla]. / Reintervenciones quirúrgicas abdominales no planeadas en el Servicio de Cirugía General del Hospital Universitario de Puebla.

INTRODUCTION: The reoperation is considered as the access to the abdominal cavity before complete healing of the surgical wound from a previous operation within the first 60 days after the first procedure. It occurs in 0.5 to 15% of patients undergoing abdominal surgery and generates significant increase in morbidity and mortality in patients undergoing abdominal surgery. OBJECTIVES: Identify the number of unplanned abdominal surgical reoperations and identify the causes of these unplanned reoperations were performed in our department. METHODOLOGY: This is a retrospective study conducted at the University Hospital of Puebla in the period between April 2009 to February 2012, a total of 1,709 abdominal surgeries performed by the Service of General Surgery were included. RESULTS: Ninety-seven cases of reoperation of which 50 cases were not planned surgery cases were identified; 72% (36 cases) from emergency operations, and 28% of elective surgery. CONCLUSIONS: The incidence found in our study is low compared to similar studies. Prospective studies and focus on risk factors and causes of unplanned reoperations are required, in order to know them in detail and, consequently, reduce its incidence and morbidity and mortality they add.

[Blunt chest trauma with pneumomediastinum and pneumoperitoneum secondary to Macklin effect. Case report]. / Trauma contuso de tórax con neumomediastino y neumoperitoneo secundario a efecto Macklin. Reporte de un caso.

BACKGROUND: Pneumomediastinum is the presence of free air around mediastinal structures, which may be spontaneous or secondary, and can occur in 10% of patients with blunt chest trauma, with the Macklin effect being its main pathophysiology. CLINICAL CASE: A 21 year old male, hit by motor vehicle, with alvéolopalatal fracture and blunt chest trauma, who, 72 hrs after admission, shows subcutaneous emphysema in the anterior chest. A simple tomography of the chest and abdomen was performed, finding a pneumomediastinum, bilateral pulmonary contusions and pneumoperitoneum. Oesophageal, tracheobronchial or intra-abdominal viscera injuries were ruled out, establishing the cause of pneumomediastinum and pneumoperitoneum due to the Macklin effect. This required conservative management in intensive care unit, with a favourable clinical course and discharged after a 10 day hospital stay. DISCUSSION: Macklin effect is caused by dissection of air medially along the bronchoalveolar sheath (interstitial emphysema), secondary to alveolar breakdown and extending into mediastinal and other anatomical structures (pneumoperitoneum). It has been documented in blunt trauma, as well as in acute asthma, positive pressure ventilation, or after Valsalva manoeuvres. The imaging method of choice is computed tomography, and its characteristic findings, interstitial emphysema adhering to a bronchus and pulmonary blood vessel. CONCLUSIONS: In the presence of pneumomediastinum and pneumoperitoneum is necessary to rule out oesophageal and tracheobronchial injury before establishing the Macklin effect as its cause. The diagnosis is made with computed tomography and managed conservatively.

[Type IV paraesophageal hernia with 60% of gastric necrosis. Case report]. / Hernia paraesofágica tipo IV con necrosis gástrica del 60 por ciento. Reporte de un caso.

BACKGROUND: Paraesophageal hernias are rare and, when associated with symptoms, the risk of complications increases, becoming a surgical emergency. CLINICAL CASE: We report a case of a 53 year-old female with 3 weeks of clinical evolution including abdominal pain, nausea and occasional vomiting; 24 h prior to admission she presented intestinal occlusion. Radiographic and tomographic findings showed a paraesophageal hernia, requiring exploratory laparotomy, which demonstrated a 9 cm paraesophageal diaphragmatic defect with a hernia sac containing transverse colon, omentum, fundus and body of the stomach (this last one presented ~60% of necrosis), performing nonanatomic gastrectomy and simple diaphragmatic reconstruction. The patient had a complicated postoperative period requiring two additional surgeries attempting to correct gastrectomy dehiscence and ending with a third procedure for cervical esophagostomy and Witzel jejunostomy. CONCLUSIONS: Elective repair is recommended in all patients with asymptomatic paraesophageal hernia in order to avoid possible complications. The approach method is dependent on the surgeon's experience and the conditions of the hernia and involved structures at the time of diagnosis.

Antecedentes: las hernias paraesofágicas son de baja incidencia y generalmente asintomáticas; sin embargo, cuando provocan síntomas, el riesgo de complicaciones se incrementa y se convierten en una urgencia quirúrgica. Caso clínico: mujer de 53 años de edad, con cuadro clínico de tres semanas de evolución, caracterizado por dolor abdominal, náusea y vómito ocasionales, a lo que se agregó oclusión intestinal 24 horas antes de que acudiera a consulta. En la valoración radiográfica y tomográfica se observó una hernia paraesofágica que requería laparotomía exploradora. Se encontró un defecto diafragmático paraesofágico de 9 cm, con un saco herniario de contenido del estómago, colon transverso y epiplón, con necrosis gástrica de 60% (en el fondo y el cuerpo). Se le practicó una resección gástrica no anatómica y plastia diafragmática. El periodo postoperatorio fue complicado porque se le hicieron otras dos intervenciones quirúrgicas por dehiscencia de gastrectomía y una más por esofagostomía cervical y yeyunostomía tipo Witzel. Conclusiones: se recomienda la reparación electiva en todos los sujetos asintomáticos con hernia paraesofágica, con el fin de evitar las posibles complicaciones. El método de abordaje depende de la experiencia del cirujano y de las condiciones en que se encuentre la hernia y las estructuras involucradas al momento del diagnóstico.