use of intraperitoneal mersilene in the management of large ventral hernias

Large ventral hernias usually require prosthesis for a successful repair. Many prosthetic techniques have been described with extra-fascial, sub-fascial, and intra-peritoneal positioning. The present study was conducted to asses the value of Mersilene mesh intra-peritoneal placement in the management of large ventral hernias. This study included 15 female patients with large ventral hernias [myo-apponeurotic defect >/= 10cm in diameter]. Their ages ranged from 30 to 62 years with a mean of 42.8 years. Twelve patients had an incisional hernia, following midline incision [n=6], right subcostal incision [n=3], paramedian incision [n=2], and Mc Burney's incision [n=1]. Three patients had a huge paraumblical hernia. All patients were clinically evaluated, investigated and had their respiratory function tests assessed both pre-and post-operatively. Hernias were repaired using the intra-peritoneal technique of mesh [30x30 cm Mersilene] positioning with placement of the greater omentum between the mesh and the bowel whenever possible. Patients were followed-up for a mean of 11.5 months [range 8-18 months]. The size of the hernia defect at surgery ranged from 10x13 cm to 22x25 cm with a mean of 13x14 cm. The mean hospital stay was 8.5 days [range 7-10 days]. Post-operatively, one patient developed superficial wound infection and another developed a seroma. Both resolved spontaneously on conservative measures. None of the patients developed post-operative respiratory distress. No recurrence was encountered during the follow-up period. The technique of intra-peritoneal Mersilene mesh fixation in the treatment of large ventral hernias a'ppears to be simple, adequate and safe. It does not cause post-operative respiratory distress and does not necessitate dissection of the intermediate planes thus minimizing hematoma and seroma formation and the risk of sepsis

Anterior abdominal wall fistula: a clinicopathological challenge

Aim of the work was to study the anterior abdominal wall fistulae connected to the gut from etiological, clinical and therapeutic aspects regarding their incidence, presentations, response to conservative or surgical treatment and final outcome. This study was carried out on 30 patients with external fistulae connecting the anterior abdominal wall and Originating from the intestine, biliary radicles and the pancreas. All patients were admitted to Department of Surgery, Main Alexandria University Hospital There were 18 males and 12 females, the age ranged from 12 to 65 years with a mean value of 48.15 +/- 3.24 years. Eleven patients [36.7%] were of high output fistulae, 4 patients [13.3%] were of moderate output fistulae and 15 patients [50%] were of low output fistulae. The complications were sepsis in 10 patients [33. 3%], fever in 10 patients [33.3%], electrolyte depletion and weight loss in 4 patients [13.3%] and skin complications in 22 patients [73.3%]. Abdominal ultrasound and CT scans were done in all cases and revealed internal collection in 7 patients [23.3%], fistulogram was done in 7 cases [23.3%] and endoscopic retrograde cholangiopancreatography [ERCP] in one case. The origin of fistulae was the small intestine In 10 patients [33.3%], the colon in l6 patients [53.3%], from biliary- enteric anastomosis in 3 patients [10%] and from pancreatic duct in one patient [3.3%]. The etiological factors were gut carcinoma in 8 patients [26.7%], hernia repair in 10 patients [33.3%], neglected appendicitis in 3 patients [10%], post Whipple operation in 3 patients [10%], post pancreatic necrosectomy in one case [3.3%], iatrogenic trauma to sigmoid colon during gynaecological surgery in 2 cases [6.7%], rupture sigmoid diverticulitis in 2 patients [6.7%] and one case [3.3%] following typhoid perforation. Spontaneous closure was achieved in 25 patients [83.3%] by conservative treatment which included total parenteral nutrition, enteral nutrition, somatostatin analogue and antibiotics. Surgical intervention was required in spatients [16.7%] in the form of resection of the fistula- bearing segment and anastomosis of the two healthy ends. Five fistulae [16.7%] closed between 2 and 4 weeks, 8 fistulae [26.67%] between 4 and 8 weeks, 9 fistulae [30%] between 6 and 8 weeks and 8 fistulae [26.7%] closed after more than 8 weeks. Only one patient [3.3%] died from sepsis and multiple organ failure. spontaneous closure is depending on a number of factors which include anatomical site, distal obstruction, presence of inter current disease and whether or not the fistulous track is simple or complex. Sepsis in the peritoneal cavity is the major cause of mortality. The use of octreotide is highly recommended as It definitely converts high output to low output fistulae. The enterocutaneous fistulae that fail to resolve within 4 to 6 weeks under conservative treatment require surgical intervention

role of CT guided fine needle aspiration biopsy in the management of intra-abdominal masses

The evaluation of deep non-palpable abdominal masses or focal lesion is often difficult. Distinction between malignant and non-malignant lesions and particularly inflammatory lesions is vital for patient management, and is often suspected from imaging techniques; the diagnosis requires confirmation by biopsy. Fine needle aspiration cytology [FNAC] is a well established diagnostic technique. This study aimed at evaluation of CT guided FNAB in diagnosis of intra-abdominal masses and its impact on treatment planning. The study was conducted on thirty patients with intra-abdominal masses [clinically or radiologically diagnosed] admitted to the Department of Surgery, Faculty of Medicine, the Main University Hospital. FNAs were performed at the Radiology unit in the Main University Hospital with the pathologists assistance. Patients were subjected to surgical exploration according to the findings, aiming at resection of the mass. The impacts of CT and FNAB on the surgical decision were recorded The pathological findings of FNAB were compared with the final histo-pathological findings of the specimen. The study was carried but on 30 patients who had abdominal mass or masses. Each patient was subjected to CT guided FNAC. The age of the patients ranged between 18-70 years, with a mean of 48.57 +/- 13.69 years. with a male to female ratio 1:1. The Sensitivity for CT was 76% and for FNAB was 89%. Specificity for CT was 100% and for ENAB was 100%. Positive predictive value for CT was 90% while it was 95% for FNAB. Negative predictive value was 18% for CT and 40% for FNAB. CT guided FNAB is a relatively painless procedure. It is a safe method for obtaining a pathologic diagnosis. The overall accuracy of the CT guided FNA in intra-abdominal masses was 73.3%. CT guided FNAB helped in avoiding surgery in patients with metastatic or irresectable tumors. The accuracy was 100% in hepatic, pancreatic and pelvic masses. while it was less accurate in retroperitoneal and gastrointestinal masses. This accuracy increased with adenocarcinomas and benign tumors, but decreased with lymphomas, smooth muscle tumors, inflammatory and fibrotic lesions