Vertical rectus abdominis myocutaneous flap cover for lower abdomen, chest wall, groin and thigh defects following resection of malignant tumours.

Vertical rectus abdominis mycutaneous (VRAM) flap provides a reliable flap cover for large soft tissue defects of chest wall, torso, groin, perineum and thigh. It has been mainly used in trauma and benign conditions. Between January 1994 through January 1999, eight patients with locally advanced malignant tumors underwent radical resection and reconstruction using pedicled VRAM flap. Inferiorly based VRAM flap was used in five patients and superiorly based VRAM flap in three patients. Defect size ranged from 144 to 900 CM2. (mean 386 cm2). Average blood loss for combined resection and reconstruction was 600ml. (range 400-800 ml.) Primary closure of both donor and recipient sites achieved in all patients. There was no wound infection, flap necrosis or abdominal hernia. There patients received postoperative radiotherapy and chemotherapy and two patients received radiotherapy only. All the the patients are alive and free of local recurrence at mean follow up 32 months. Results of our study shows that VRAM flap is versatile and sturdy flap with a wide are of rotation and it can reach diverse anatomical sites like torso, chestwall, thigh and perineum to cover large defects following radical resection for tumors.

Symptomatic outcome after laparoscopic cholecystectomy.

AIMS: Patients with gallstones often present with multiple complaints. We wanted to study the major complaints of our patients undergoing laparoscopic cholecystectomy and the symptomatic relief afforded by the operation. METHODS: We studied 113 patients with symptomatic gallstone disease who underwent laparoscopic cholecystectomy in a single surgical unit. Patients with proven common bile duct stones, obstructive jaundice, cholangitis, present or past associated abdominal pathology or cholecystoenteric fistula were excluded from the study. The mean follow up period was 18 months (range 10-22 months). A detailed account of the symptoms of gallstones, length of post-operative stay, persistence of symptoms, development of fresh symptoms and resumption of fat containing diet were assessed. RESULTS: The male to female ratio was 1:4. Common presenting symptoms were abdominal pain (96%), flatulence or feeling of fullness of abdomen (85%), heartburn (66%), belching (62%), sour eructation (52%), vomiting (48%) and nausea (45%). Mean postoperative hospital stay was 28 hours (range 9-68 hours). Biliary pain was relieved in 99% of patients after laparoscopic cholecystectomy (p < 0.001). The non-pain symptoms which are relieved significantly (p < 0.001) included nausea (98%), vomiting (96%) and sour eructation (92%) had better outcome than belching (64%) flatulence (61%) and heart burn (59%). None of the patients developed jaundice after cholecystectomy. Fresh symptoms that developed after laparoscopic cholecystectomy were heart-burn (6%), belching (3.5%), sour eructation (1%) and vomiting (0.5%). Post-cholecystectomy post-prandial diarrhoea occurred in 20% of the patients. The patients' appreciation of a satisfactory cosmetic result of operation scars was 100 percent. Fifteen female patients (13.5%) complained of increased weight gain of more than 5 kg after laparoscopic cholecystectomy [(p > 0.05; not significant (NS)]. CONCLUSION: Laparoscopic cholecystectomy significantly relieved symptoms of gall stone disease. Biliary pain, nausea, vomiting and sour eructations had better outcome compared to belching, flatulence and heartburn, which are also relieved in majority. Postcholecystectomy post-prandial diarrhea was a significant new symptom after cholecystectomy. Pre-operative flatulence and heartburn are risk factors for poor symptom relief. All patients should be pre operatively counselled about the risk of persistence of some non-pain symptoms after laparoscopic cholecystectomy.