MINIMALLY INVASIVE SURGICAL REPAIR FOR ABDOMINAL WALL HERNIAS IN NONHUMAN PRIMATES, TWO CASES IN WESTERN LOWLAND GORILLAS (GORILLA GORILLA GORILLA).

A 33-yr-old female Western lowland gorilla (Gorilla gorilla gorilla) was diagnosed with a congenital umbilical hernia that was reducible and asymptomatic; change in the hernia was noted after parturition and concerns regarding increased risk of bowel incarceration developed. The hernia was successfully repaired with robot-assisted laparoscopic surgery. A 5-mon-old male Western lowland gorilla presented with bilateral inguinal hernias that were repaired via elective laparoscopic repair. In both cases, the gorillas did well without complications and never appeared to acknowledge wounds or exhibit signs of pain postoperatively. A literature review and interinstitutional survey was conducted to determine success rate of minimally invasive versus open repair of hernias in nonhuman primates (NHP). Of the cases identified, recurrence and/or wound morbidity was seen in 0% of laparoscopic repairs and 50% of open repairs. NHP may benefit from elective, minimally invasive surgical techniques that may reduce hernia recurrences and wound morbidity.

Surgeon-directed ultrasound for trauma is a predictor of intra-abdominal injury in children.

This study investigated the efficacy of surgeon-directed focused assessment with sonography for trauma (FAST) in conjunction with physical exam (PEx) as a predictor of intra-abdominal injury in children. Injured children (ages < or = 17) presenting to a level I trauma center with abdominal trauma were evaluated in the emergency department (ED) by the trauma team of surgical attendings and residents. PEx and FAST were performed immediately upon arrival to the ED and results compared to CT, the standard exam for presence of intra-abdominal injury. Data was collected prospectively from July 1, 2000, until April 30, 2002. One hundred and twenty injured children underwent evaluation of abdominal trauma with PEx, FAST, and abdominal CT. Two patients had false-negative CT scans. Bayesian analysis was applied to the results of the remaining 118 patients. FAST compared with CT findings revealed sensitivity 70 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 92 per cent. FAST results were combined with PEx findings such that either suggestive of intra-abdominal injury was regarded as a "positive exam." Sensitivity was 100 per cent, specificity 74 per cent, positive predictive value 53 per cent, and negative predictive value 100 per cent. Surgeon-directed FAST with consideration of PEx is a predictor of intra-abdominal injury in children.

Physical examination as a reliable tool to predict intra-abdominal injuries in brain-injured children.

BACKGROUND: Brain-injured children have been thought to have an unreliable abdominal examination. This study evaluates the reliability of physical examination in the prediction of intra-abdominal injury in brain-injured children. METHODS: Pediatric patients with a traumatic brain injury or Glasgow Coma Scale (GCS) <15 and intra-abdominal organ injuries were selected. Admission data were reviewed, and findings were tabulated. RESULTS: Fifty patients had an abnormal abdominal examination. Nineteen of 71 patients with head injury and intra-abdominal organ injuries required laparotomy. These 19 patients had abdominal tenderness, distention, abrasions, and/or a positive focused abdominal sonography for trauma (FAST) scan. Seven of 19 patients had a GCS of 3. Of the 12 patients requiring surgery with GSC 4 to 14, all patients had abnormal physical examinations. CONCLUSIONS: Patients who required an operation presented with an abnormal examination and/or a positive FAST. These data suggest that examination and/or FAST may reliably identify patients with intra-abdominal organ injuries in need of an operation.

Pediatric major resuscitation--respiratory compromise as a criterion for mandatory surgeon presence.

UNLABELLED: The American College of Surgeons Committee on Trauma has indicated that there are minimum criteria for a trauma surgeon to respond to a major resuscitation (MR) within 15 minutes. These criteria have been required for children without significant data to support their validity. Our hypothesis is that prehospital intubation/respiratory compromise (IRC) as a criterion to define an MR will be an accurate predictor. METHODS: The trauma registry of a level I trauma center was used for data collection of age, injury severity score (ISS), IRC, mortality, hospital days, intensive care unit (ICU) days, and emergency operations. Chi2 with Yates correction and Mann-Whitney rank-sum testing was used for statistical analysis expressed as mean +/- SEM. RESULTS: One hundred eighteen patients were encoded as MR. Forty patients had prehospital IRC and 78 patients did not. There were statistically significant differences seen in ISS, ICU length of stay, and mortality (P < .001). Forty-five percent of patients with IRC died. None of the patients without IRC died. CONCLUSION: Injured children with prehospital IRC are significantly more likely to die, have a higher ISS, and a longer ICU length of stay. Prehospital respiratory distress in injured children in our trauma system is a reasonable criterion to define an MR in children.

Using a bioabsorbable copolymer plate for chest wall reconstruction.

Reconstruction of the chest wall in a child is an uncommon problem for pediatric surgeons. The available material for chest wall reconstruction typically has been borrowed from the adult experience. The authors describe their recent experience with a commercially available bioabsorbable plate in a variety of conditions that require chest wall reconstruction.

The impact of intra-abdominal hypertension on gene expression in the kidney.

BACKGROUND: Intra-abdominal hypertension (IAH) has been recognized as a source of morbidity and mortality in the injured patient. Research concerning this entity has focused predominantly on the pathophysiology. We developed a model of IAH to determine whether gene expression is altered in the presence of this condition. METHODS: Using general anesthesia, adult Sprague-Dawley rats were intubated and instrumented with a carotid and jugular catheter. Three pairs of rats (three control; three IAH 25 mm Hg) were used at each time interval. Continuous measurements of heart rate, blood pressure, cardiac output, and temperature were recorded. Arterial blood gases were measured every 30 minutes. A catheter was placed in the peritoneum and warm saline was infused up to a pressure of 25 mm Hg that was measured through this catheter continuously. At 30 and 60 minutes, the kidneys were harvested and standard protocols were used to extract nucleic acid and perform cDNA microarray analysis screening for 4,000 genes. Each experimental rat was paired with a control rat and each set underwent individual cDNA array analysis. RESULTS: Hemodynamic changes occurred that were consistent with IAH, including depression of cardiac output and acidosis. Although widespread changes in gene expression were identified, only genes that were up-regulated and down-regulated by a ratio of fivefold, a difference in magnitude of 150 molecular dynamic counts, and p < 0.05 were considered significant. When comparing IAH of 25 mm Hg at 30 and 60 minutes, there was a surprising decrease in up-regulated genes from 10 to 1. In addition, there was an increase in down-regulated genes from zero to five genes. CONCLUSION: IAH causes changes in gene up- and down-regulation in the kidney. The number and types of genes change in magnitude and type over time. Further investigation into renal gene expression may offer insight into the molecular pathophysiology of IAH.