Open abdomen and VAC® in severe diffuse peritonitis.

BACKGROUND: Currently, the open abdomen technique is the widely recognised method for treatment of life-threatening trauma, intra-abdominal sepsis, abdominal compartment syndrome and wound dehiscence. The techniques for temporary closure using negative pressure have gained increasing popularity. Although negative pressure wound therapy has been proved as an effective method in trauma, the results in diffuse peritonitis are contradictory. METHODS: Overall, 108 patients with diffuse peritonitis and open abdomen were prospectively enrolled from January 2006 to December 2013--69 treated with mesh-foil laparostomy without negative pressure and 49 with vacuum-assisted closure (VAC(®)) The primary endpoints were the rate of primary fascial closure and mortality. The secondary outcomes were the rate of complications--enteroatmospheric fistulas, intra-abdominal abscesses, wound infection and necrotising fasciitis, intensive care unit (ICU) and overall hospital stay. RESULTS: VAC was associated with higher overall (73% vs 53%) and late primary fascial closure rates (31% vs 7%), lower rates of necrotising fasciitis (2% vs 15%, p=0.012), intra-abdominal abscesses (10% vs 20%), enteroatmospheric fistulas (8% vs 19%), overall mortality (31% vs 53%, p<0.05), shorter ICU (6.1 vs 10.6 days, p=0.002) and hospital stay (15.1 vs 25.9 days, p=0.000). CONCLUSIONS: The results clearly suggest the obvious advantage of VAC in comparison to the temporary abdominal closure without negative pressure in the cases with severe diffuse peritonitis. However, to a large extent, our results might be attributed to the combination of VAC with dynamic fascial closure.

Incarcerated Spigelian hernia in morbidly obese patients: the role of intraoperative ultrasonography for hernia localization.

BACKGROUND: Spigelian hernias are uncommon and their diagnosis can be difficult. Ultrasonography is, as a rule helpful in making the diagnosis, but extensive exploration is sometimes needed to locate the defect. METHODS: Two patients are described in whom the diagnosis was made preoperatively by ultrasonography, but intraoperative location of the hernias proved extremely difficult because of the patients' obesity. RESULTS: In the first patient, the hernia was located by means of intraoperatively performed ultrasonography. In the second patient, ultrasonography was combined with intraoperatively insufflated pneumoperitoneum and this proved successful in identifying the position of the sac. CONCLUSION: Intraoperative ultrasonography is a valid option for accurate localization of Spigelian hernias, especially in obese patients; extensive intraoperative dissection, distortion of tissue planes, and associated morbidity risks may be avoided.

Gastrointestinal 'crosses'. A new shade from an old palette.

BACKGROUND: We present our experience with an as yet undescribed type of intentionally ingested metallic foreign body that was specially designed to arrest in its passage and cause perforation of the gastrointestinal tract. The two halves of a standard paper clip are tied crosswise with a rubber band, forming an elastic "cross." With its branches squeezed to lie parallel, the cross is wrapped into a small strip of paper and ingested. After being released from its wrapper, the branches of the cross spring back to their original position and cause perforation of the bowel wall. DESIGN: Case series. SETTING: University hospital, Bulgaria. PATIENTS: Five male prisoners from the same jail undergoing laparotomy for foreign body removal during 1 week in January 1994. INTERVENTIONS: Laparotomy, removal of the foreign bodies through incisions of the bowel wall, immediate restoration of the gastrointestinal tract continuity, and peritoneal lavage and drainage. OUTCOME MEASURES: Morbidity and mortality. RESULTS: Two of the patients were initially observed but subsequently underwent surgery for perforations of the gastrointestinal tract. Three of the patients underwent immediate operative treatment. There were 20 total crosses ingested; all foreign objects impacted and perforated the stomach (50%), first duodenal portion (25%), and fourth duodenal portion (20%). There was no morbidity or mortality among the five patients treated. CONCLUSIONS: Because ingested crosses that have been released from their wrappers never move distally, the only definitive solution is to operate early.

Rectal "oven mitt": the importance of considering a serious underlying injury.

A 20-year-old man presented with a rectal "oven mitt," which was removed transanally. Rigid proctosigmoidoscopy revealed no apparent perforation, but subsequent contrast enema using meglumine diatrizoate demonstrated an extraperitoneal rectal perforation, which was probably caused by a wooden stick used to forcefully introduce the glove through the patient's anus. Thus, rectal injuries may be caused not by the foreign object itself, but by another object used as an introducer.

Hydatid cysts of the liver: TN(R)C classification.

BACKGROUND: Liver hydatid disease remains a serious public health problem. Its incidence is increasing but still there is no standardised protocol for assessment of the severity of the disease or for classifying the lesion in each individual case. OBJECTIVE: To construct a new and maximally descriptive classification system that could help in better assessing the extent of the disease, both in primary and recurrent cysts. DESIGN: Description of a newly created classification system. SETTING: University hospital. METHOD: Review of the literature and own observations. RESULTS: Classification system describing T (topography of the cyst), N (natural history of the cyst), R (recurrent cyst) and C (complication of the cyst). CONCLUSION: Consideration is given to almost all aspects of classifying liver hydatid cysts. A new concept for classification is presented which can become the basis for further multi-institutional comparison of data.

Application of a new water jet apparatus in open hepatobiliary surgery: hepatic resection, cholecystectomy, common bile duct lavage.

The presently accepted technologies for hepatobiliary surgery have some limitations and disadvantages. Use of water jet dissection is rapidly spreading and its indications are continuously being widened. In 1988 we developed a new bimodular jet-cutter "Parenchimotom-01". After the experimental application on 110 dogs, the apparatus was introduced into clinical practice. Between 1992-1995 we have successfully performed 11 liver resections, 14 cholecystectomies, and 2 lavages of the common bile duct on 25 patients. Marked decrease in blood loss, operative time, rate of complications, and length of hospitalization were noted. We suggest the water jet dissection to be a sophisticated and maximally effective instrumental technology that offers numerous advantages over the other techniques so far commonly accepted in hepatobiliary surgery and which may improve the treatment and prognosis in patients with different hepatobiliary disease entities.

The Lichtenstein open tension-free inguinal hernia repair using a new prosthetic mesh-Bulgarian irresorbable ampoxen.

The routine use of mesh for repair of inguinal hernia has been popularized by Lichtenstein and coworkers. We adopted this technique and performed it widely using a mesh unknown in the Western world. Ampoxen [multifilamented polycaproamide, impregnated with 5-Nitro-8-Hydroxyquinolinum (Nitroxolinum, DCI), MEDICA, SA, Sandanski, Bulgaria] was discovered in 1975 and proved to be an excellent prosthetic material for replacement of attenuated or destroyed abdominal wall; furthermore, this mesh is very cheap and became widely applicable in our country. This report describes our experience with the first 846 adult inguinal hernia repairs under local anesthesia using Ampoxen. All 846 patients had excellent results, without recurrence. There were nine wound infections (1.1%), 16 testicular oedemas (1.9%), no seromata and no deaths. In no patient was the prosthetic mesh removed. There were no complications related to the use of Ampoxen; this mesh is permanent, has a great degree of fibrous tissue reaction, and wide spectrum antimicrobic activity. We advocate the Lichtenstein technique using irresorbable mesh (particularly Ampoxen) for all adult groin hernias except Types 1 and 2 (according to Nyhus' classification), and for all adult recurrent groin hernias.

Meckel's diverticulum duplication. Case report.

Meckel's diverticulum is the most common congenital abnormality of the small intestine. A case of Meckel's diverticulum duplication is described, believed to be the first report of this kind in the literature.

Life-threatening streptococcal myonecrosis complicating primary wound closure after pilonidal sinus excision.

We describe a case of anaerobic streptococcal myonecrosis as a rare complication after pilonidal sinus excision with primary closure. The recognition of the disease in any patient who has early septic deterioration after a surgical procedure requires aggressive management for survival.

Stercoral perforation of the colon.

An elderly man presented with abdominal pain and signs of peritonitis. Emergency laparotomy was performed and a stercoral perforation of the cecum was found with a large scybalum plugging the defect. The patient was treated with right colectomy and a stoma was formed from the terminal ileum and transverse colon. Stercoral perforation of the colon is extremely unusual and carries high morbidity and mortality. The etiology, diagnosis and treatment of the condition are briefly discussed.

Perforated nonspecific ulcer of the sigmoid colon: four cases in one year.

During 1993, four consecutive adult male patients underwent emergency surgery for free perforation of nonspecific sigmoid colon ulcers. All four patients presented with peritonitis and in each patient the Hartmann's procedure was performed. In each patient there was a single perforation but two of the patients presented with multiple erosions and ulcerations, and the other two- with solitary ulcers. All patients survived and had uneventful postoperative course. Three of them underwent uncomplicated restorations of the bowel continuity. Colonoscopy should be attempted in every suspicious case to confirm or to exclude the presence of nonspecific colon ulcers that could threat patient's life.