Upper limb arterial injury: Management and Outcome

In this study we are aiming to document and analyse the roles of arterial damage and associated injuries on long-term functional outcomes after upper extremity arterial trauma. In this retrospective study we reviewed patients who presented with an arterial injury to the upper limb during the period between [2003 to 2006]. The location and management of the arterial injuries, the nature and severity of concomitant nerve injuries and the overall degree of disability in the survivors were determined. 68 patients were included in this study. 34 patients [50%] sustained blunt injuries, 33 [48.5%] were presented with penetrating injuries, and one patient sustained firearm injury. The most common site of arterial injury was the brachial artery 36 patients [52.9%]. The most common method of surgical management was an autogenous vein interposition graft, placed in 24 patients [35.3%]. 28 patients were suffered serious upper limb fractures such as supracondylar fracture humerous. There were 19 nerve injuries. Residual disability was present in 13 patients [19%]. Only 2 patients had complete recovery of the injured nerves. Associated injuries, rather than the vascular injury, are the cause of long-term disability in the multisystem trauma victim who has upper extremity arterial injury

prospective randomized study of subfascial versus prefascial polypropylene mesh reinforcement of midline wound closure after vertical banded gastroplasty in morbid obese patients

Background: Incisional hernia is a common problem following a midline vertical incision in all patients undergoing open bariatric procedures

Patients and methods: The present study was conducted on 30 morbid obese patients who underwent vertical banded gastroplasty [VBG] operation through upper midline incision. The patients were randomly divided into three groups. Group I: Patients for whom the midline abdominal incisions were reinforced by subfascial preperitoneal polypropylene mesh before closure of the linea alba. Group II: The midline abdominal incisions were reinforced by prefascial subcutaneous polypropylene mesh after closure of the linea alba. Group III: The linea alba was closed en-mass with continues polypropylene No 1 sutures [standard closure]

Results: The mean age was 30.4 years. Twenty-four patients were females [80%] and six were males [20%]. The mean body mass index was 45.4kg/m2. The commonest associated medical conditions were, osteoarthritis detected in 18 patients [60%], hypertension in 17 patients [56.7%], type II diabetes mellitus in 15 patients [50%]. Most of the patients presented with more than one associated medical condition as, osteoarthritis 6' hypertension. The mean time of incision closure was 36 minutes in group I, 31 minutes in group II and 15.4minutes in group III. Early postoperative wound complications were, superficial wound infection in one patient of group I [10%], in 3 patients of group II[30%] and in one patient of group III[10%] . Partial wound disruption in 2 patients of group 11[20%] and in one patient of group III[10%]. Subcutaneous seroma in one patient of group I[10%], 3 patients of group II[30%] and one patient of group III [10%]. During the period of follow up [mean of 22 months], chronic pain at the scar site was reported in 2 patients of group 100%], 3 patients of group II[30%] and one patient of group III[10%]. Incisional hernia reported in 3 patients of group Ill [30%]

Conclusion: The subfascial placement of the mesh has many advantages over prefascial position, as, the possibility of bowel obstruction or fistula formation is not present, likewise, the risks of seroma and wound infection were minimized. The subfascial technique also does not initiate adhesions between the subcutaneous tissue and rectus sheath with subsequent difficult dissection during late dermolipectomy if needed. Subfascial placement of the mesh is a very simple technique and is recommended as an ideal method for closure of the midline abdominal incisions in morbid obese patients