Transperitoneal exclusion: a simple third world solution for abdominal aortic aneurysm

We present an operation never described before for dealing with abdominal aortic aneurysms by exclusion via a midline trans-abdominal approach. This breakthrough holds many advantages over conventional aneurysmorrahphy and requires further clinical trials (AU)

Cartoid endarterectomy under local anaesthesia: the technique of choice for developing countries

Cartoid endarterectomy is frequently performed in the United States of America and the United Kingdom. Although this operation is done to prevent strokes, in the earlier period it was associated with a stroke rate of about 15 percent and a mortality of 7 percent. Improvements in surgery, anaesthesia and monitoring techniques have significantly reduced morbidity and mortality to less than 4 percent each. Because most of these procedures are done under general anaesthesia various monitoring techniques are used to assess cerebral ischaemia during cartoid clamping. These include electroencephalography, distal stump pressure, transcranial Doppler, and evoked potential monitoring. However, in addition to being expensive and cumbersome, no individual technique is perfect.(AU)

Minilaparotomy ureterolithotomy: the third world treatment of choice for ureteric calculi? - abstract

Since the development of stone shattering and endourological techniques for the management of renouretic calculi, open surgery has been replaced as a first time treatment option in major urological centres. However, there are significant economic implications for these advantages and also many Caribbean countries cannot offer specialist urological services. Minimal access surgery has been shown, in other situations, to result in minimal metabolic disturbance, little pain, short hospital stay and early return to work. We developed a minilaparotomy muscle-splititng incision to achieve these results in ureteric stones and studied it prospectively in consenting patients. We reported 82 manilap ureterolithotomies with a 4-7 cm skin incision, mean operating time 28 minutes (10 - 44) and a mean hospital stay of 42 hours (24 -72). Because a muscle splitting technique is used pain is minimal and time to resumption of work averaged 16 days (8 - 35). We believe that manilap ureterolithotomy offers significant advantages over many currently employed techniques. These include reduced cost, operating time and duration of postoperative recovery, no need for specialist operative training and equipment and improved cosmetic results. We recommend it as the treatment of choice for ureteric calculi in most Caribbean territories. (AU)

Minilaparotomy cholecystectomy: the Third World solution for gallstones - abstract

Although many authors view laparoscopic cholecystectomy as the treatment of choice for gallstones there is evident that it has probably caused more deaths and major postoperative morbidity than open cholecystectomy. The Medical Defence Union has reported increased claims for bile duct injury from laparoscopic cholecystectomy (LC). The technology is expensive and not readily available in third world countries. Because minilaparotomy cholecystectomy (MC) also minimally invasive and offers similar advantages to LC we studied it prospectively and report our experience. MC was performed in 160 consecutive patients through a 4.8 cm (3 - 6 cm) incision, with operating time of 35 minutes (18 - 80 ). No major ductal injury and no reoperation occurred. Patients were discharged after 38 hours (range 16 - 60 hours). The operating time is much shorter, hospital stay and postoperative morbidity similar to LC. Review of the world literature shows no clear advantage of LC over MC. Because MC is cheap, effective, requires no specialised training or expensive equipment and can be done by any competent surgeon in most hospitals in the developing world, we recommend it as treatment of choice for gall stones in the third world. (AU)

Sutureless closure of traumatic wounds - abstract

Traumatic wounds are one of the commonest problems presenting to Accident and Emergency Departments. The most popular method of skin closure is suturing. However, this requires suture material, sterile equipment, operating room, cleaning solution, local anaesthesia and an assistant. In the Third World Accident and Emergency Departments setting these may not be readily available. Because of our chance observation that tape closure without cleaning and anaesthesia produced good healing in traumatic wounds we subjected the technique to a prospective analysis in consenting patients. A total of 147 lacerations, 8 cm long (range 2-17 cm) were closed with adhesive tape without cleaning the wounds. Wounds with obvious gross contamination and particulate matter were excluded. On follow up visits at 5 and 10 days, the sepsis rate was 1.36 percent and overall complication rate 2.7 percent. Patient satisfaction was excellent as they had a very short wait for treatment, no injections or suturing and no need for suture removal. Tape closure is associated with less wound sepsis than suturing. As we found, the results compare favourably with suturing. Because it is cheaper, quicker, requires no instruments or special facilities we recommend it for the treatment of traumatic wounds. (AU)

Foot revascularisation in the diabetic with severe tibial artery disease - abstract

It is commonly believed that diabetics have "small vessel" disease causing severe ischaemia and gangrene foot. This is supported by the fact that, often enough, such patients have a popliteal pulse. In most centres world-wide, these patients are not offered revascularisation options and lose their limbs. Recently, there have been a few reports supporting the value of tibial artery bypass in diabetes with infrapopliteal arterial disease. We have used short vein bypasses in 12 diabetic patients with a palpable popliteal pulse, no distal pulses and limb-threatening ischaemia in the foot. Bypasses were done to the dorsalis pedis, plantar arteries or posterior tibial at the ankle using the popliteal or posterior tibial as the inflow source. Eleven of the 12 limbs were salvaged in the immediate post-operative period and another graft occlusion at 18 months resulted in below-knee amputation. We recommended that diabetics with limb-threatening foot ischaemiaand a palpable popliteal pulse should be carefully investigated by arteriography and Doppler, and distal bypass should be performed whenever possible. Because of the large diabetic population in the Caribbean and because of the morbidity and mortality of major amputations we feel that, wherever possible, limb salvage efforts should be made. Infrapopliteal vascular reconstruction in the diabetic can certainly save many limbs currently amputated because of tibial artery disease. (AU)

Compartment syndrome due to reperfusion injury

Theorectically, tisue oedema due to reperfusion injury may be severe enough to cause compartment syndrome. One such rare case is presented. (AU)

Compartment syndrome due to reperfusion injury

Theorectically, tisue oedema due to reperfusion injury may be severe enough to cause compartment syndrome. One such rare case is presented.

Hartmann's operation: does it still have a place? - abstract

In 1923 Hartmann described an operation where, for an advanced rectal carcinoma, he completely excluded the rectum and brought out an end sigmoid colostomy. Since then, this procedure has been widely used for cases where rectal anastomosis is regarded as unsafe. In 23 consecutive cases in which Hartmann's operation was indicated (gangrenous sigmoid volvulus 3, trauma 6, pelvic sepsis 9, tumour 6) the authors elected to do an "unsafe" anastomosis with a totally defunctioning proximal colostomy. Only two (2) cases developed complications (minor). Hartmann's operation should only be done in the situation where there is absolutely no intention to restore gut continuity as pelvic dissection to reconstitute the gut can be very difficult. If rectal anastomosis is regarded as unsafe it should still be carried out and a defunctioning colostomy done since the second stage only involves colostomy closure (AU)

Intussusception in infancy and childhood

Intussusception is the commonest cause of intestinal obstruction in childhood in Trinidad. A review of 94 consecutive cases seen at the General Hospital, Port-of Spain, over a 12 year period (1974-1985) indicates that there had been a very rapid increase in incidence of intussusception in the last 4 years. The majority were under 1 year of age (87 percent) and there was a predominance in the Negro child (62 percent). Male to female ratio was 1.2:1 . A high misdiagnosis rate (55 percent) lead to inappropriate treatment and delay in surgical intervention. This resulted in a high case fatality (6.4 percent) and complication rate. In order to minimize morbidity and mortality from intussusception steps must be taken to ensure earlier diagnosis and treatment. (AU)