Ipsilateral pedicled TRAM flaps: the safer alternative?

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has become a commonly performed procedure in the 1990s. The original description of the procedure was that of an ipsilaterally based pedicle procedure. Concerns about potential folding of the pedicle with possible compromise of the vascular supply led many surgeons to prefer the contralateral pedicle. Subsequently, there have been several large clinical series of pedicled TRAM flaps showing a relatively high complication rate related to flap vascularity problems. Partial flap necrosis rates in pedicled TRAM series range from 5 to 44 percent. These findings resulted in many centers favoring free TRAM flap breast reconstruction, despite an increase in resource use and negligible differences in complication rates. Ipsilateral pedicle TRAM flap breast reconstruction is not a commonly reported procedure and is reserved for cases for which scars preclude use of the contralateral pedicle. Simplicity and versatility of flap shaping, improved maintenance of the inframammary fold, and lack of disruption of the natural xiphoid hollow give ipsilateral TRAM flaps further advantages. This study reports on a series of 252 consecutive ipsilateral TRAM flap reconstructions in 190 patients. The majority of patients underwent muscle-sparing procedures with preservation of a medial and a lateral strip of rectus muscle. Immediate reconstruction was done in 104 of the 190 patients. Skin-sparing (69 patients) or skin-reduction procedures (21 patients) were used in 90 of the 104 patients (87 percent) undergoing immediate reconstruction. Complication rates were comparable to those of series reported for contralateral TRAM flaps, except that partial flap necrosis (2.0 percent) was less in this series. Risk factors were analyzed with regard to the most common complications seen in this study. Ipsilateral TRAM flap breast reconstruction is our preferred method, if available, because we believe that it has several advantages over the contralateral pedicled TRAM and this report suggests a lower partial flap necrosis rate than previously reported.

Analysis and treatment of severe trigonocephaly.

A retrospective analysis of seven patients with clinically severe trigonocephaly was performed, including a review of preoperative and postoperative computed tomography scans. A method of analyzing the trigonocephalic deformity was developed. This is based on determination of the angular severity of the forehead (110 +/- 4 degrees) and the length of half of the supraorbital bar (40 +/- 3 mm). This central angle was found to be relatively constant in this population. Using simple trigonometric relationships, a rationale for the alternative method of reconstruction used in these patients is presented. This technique is based on transverse expansion of the supraorbital bar, transposition of the lateral orbital rim, expansion of the temporal fossa, and recontouring the orbital aperture. As a separate consideration and step, the bony interorbital distance is widened.

Thoracoscopic vagotomy as a safe adjunct to remedial gastric surgery.

Patients who have had prior subdiaphragmatic dissection with an incomplete vagotomy or Nissen fundoplication present added challenges when they require vagotomy and gastric resection. In this setting, thoracoscopic vagotomy offers significant advantages. A second attempt at vagotomy in a previously dissected field can be prolonged and frustrating. In addition to these concerns, repeat dissection can also lead to failure to find the vagal trunks, perforation of the esophagus, hemorrhage, and/or splenic injury. In our experience, three patients requiring gastrectomy or resection of a marginal ulcer have undergone thoracoscopic vagotomy at the time of transabdominal gastric surgery. The thoracoscopic approach avoided either a thoracoabdominal incision or combined thoracic and abdominal incisions while allowing dissection of the vagal trunks to be performed in normal tissue planes. The minimally invasive approach afforded decreased postoperative pain and excellent clinical results. Thoracoscopic vagotomy offers a welcome alternative to re-exploration of a previously dissected distal esophagus in search of vagal trunks, especially when they have been missed at the time of the first operation. Further application of this approach is recommended.

Palliative gastric transposition following pharyngolaryngoesophagectomy.

Extensive extirpative resection of advanced head and neck tumors followed by functional reconstruction is a formidable undertaking. Poor long-term survival and substantial morbidity and mortality have often conferred a nihilistic approach toward these patients. We reviewed our experience with transhiatal gastric transposition with pharyngogastric anastomosis for reconstruction of pharyngoesophageal defects to assess the value of undertaking such a formidable surgical intervention. A retrospective analysis (1990-1994) of 20 consecutive patients with advanced head and neck tumors who underwent pharyngolaryngoesophagectomy followed by transhiatal gastric transposition with pharyngogastric anastomosis was performed. Morbidity was 35 per cent; mortality was 10 per cent. Pharyngogastric leaks occurred in 10 per cent of patients. The median postoperative stay was 19 days. Ninety-four per cent of patients had good to excellent palliation. Follow-up averaged 14.3 months. Late stricture occurred in two patients that was easily amenable to dilatation. Tumor recurrence caused dysphagia in one patient; otherwise, all patients are swallowing well or have died without dysphagia. Gastric transposition without thoracotomy is a versatile and reliable method for reconstruction of large pharyngoesophageal defects and is associated with an acceptable morbidity and mortality, thus allowing good palliation in a patient population with an extremely poor prognosis and an otherwise poor quality of life.

Complications of laparoscopic cholecystectomy: the experience of a university-affiliated teaching hospital.

BACKGROUND: In most published reports on laparoscopic cholecystectomy, the cases have been accrued from small community hospitals in a multicenter fashion. The purpose of this study was to compare the rate of complication following laparoscopic cholecystectomy performed at a single university-affiliated teaching hospital to those quoted in the literature. STUDY DESIGN: A retrospective review of the first 1300 laparoscopic cholecystectomies performed at the Videoscopic Surgery Center at Pennsylvania Hospital from May 1990 through January 1994 was undertaken. Complications were classified as those related to creation of the initial pneumoperitoneum and those related to cholecystectomy. RESULTS: A 3% conversion rate to open cholecystectomy (n = 40) was noted due to the presence of dense adhesions, gangrenous cholecystitis, or difficult anatomic relationships. There were 18 complications (1.4%) related to creation of the initial pneumoperitoneum and 14 complications (1.1%) related to cholecystectomy. Complications related to laparoscopy included bleeding from the abdominal wall (n = 2), trocar site hernia (n = 11), hollow viscus injury (n = 1), and wound infection (n = 4). Complications related to cholecystectomy included unanticipated retained CBD stone (n = 5), symptomatic bile leak (n = 6), hollow viscus injury (n = 1), intraabdominal abscess (n = 1), and a retained portion of gallbladder (n = 1). There were no perioperative deaths related to laparoscopic cholecystectomy, and the overall morbidity was 2.4%. Long-term follow-up revealed no cases of benign biliary strictures. CONCLUSIONS: With attention to anatomy, technique, and meticulous dissection, laparoscopic cholecystectomy can be safely performed in a university-affiliated teaching hospital setting.

Endoscopic preperitoneal herniorrhaphy in professional athletes with groin pain.

INTRODUCTION: Surgical exploration of the groin with subsequent herniorrhaphy has been recommended for obscure groin pain in athletes. The purpose of this study was to evaluate the efficacy of endoscopic preperitoneal herniorrhaphy and, if indicated, contralateral groin exploration in professional athletes with groin pain. PATIENTS AND METHODS: Eight professional athletes presented with groin pain and underwent endoscopic preperitoneal herniorrhaphy between February 1994 and May 1996. All athletes were male with a median age of 25.1 years (range: 22-30). Seven of the athletes complained of unilateral groin pain while one patient had bilateral pain. Seven had undergone previous conservative treatment without success. Despite multiple examinations, only two patients had been diagnosed with hernias prior to referral to the surgeon. Of the remaining six patients, all were found to have small inguinal hernias in the symptomatic groin. Seven of the patients were noted to have bilateral pathology. RESULTS: Operative time averaged 55.3 min. All patients were ambulatory without significant difficulty within the first 24 h, discontinued oral narcotic use within 72 h of surgery, and were back to recreational activities within 1 week. Aerobic conditioning was resumed within a maximum of 2 weeks. Full conditioning and/or return to full competition occurred within a 2- to 3-week period. At the time of 4 week follow-up, all athletes reported no more than minimal postexertional discomfort, with near total relief of early postoperative symptoms. No athletes noted any impairment in their ability to perform at peak levels. CONCLUSIONS: Groin pain in athletes is a difficult problem requiring a multidisciplinary approach to diagnosis and treatment planning. Endoscopic preperitoneal herniorrhaphy is an effective treatment for obscure groin pain when the pain is associated with an inguinal hernia and allows for a short recovery time back to full athletic activity.

The efficacy of epidural anesthesia for endoscopic preperitoneal herniorrhaphy: a prospective study.

Laparoscopic herniorrhaphy has been criticized because of the need for general anesthesia. The endoscopic preperitoneal approach allows the use of epidural anesthesia, obviating the potential complications and side effects seen with general anesthesia. The purpose of this study was to determine the efficacy of epidural anesthesia for preperitoneal herniorrhaphy. Fifty-two patients underwent repair of a total of 80 hernias over a 6-month period. Thirty-six patients underwent their repairs with the use of epidural anesthesia with the goal of a T-4 sensory level. A tension-free prosthetic repair was performed in all patients. Seventeen patients had unilateral repairs and nineteen had bilateral repairs under epidural, while seven patients had unilateral repairs and nine patients had bilateral repairs under general anesthesia. There were no significant differences in patient demographics. All herniorrhaphies were electively performed on an outpatient basis by a single surgeon (A.L.S.) in a teaching setting. There were no significant differences for unilateral and bilateral repairs when type of anesthesia was compared. There was only one conversion from epidural to general anesthesia, secondary to poor sensory blockade first noticed during creation of the preperitoneal space (97% success rate). Seven patients receiving epidural anesthesia experienced pneumoperitoneum during the procedure. This did not effect the ability to perform the hernia repair successfully. There were no complications related to the epidural anesthetic. Endoscopic preperitoneal herniorrhaphy can be performed effectively under epidural anesthesia, obviating the need for general anesthesia.

Gasless laparoscopic esophagomyotomy.

A case of gasless laparoscopic esophagogastric myotomy for achalasia is presented. The technical aspects of the technique as well as the benefits of this approach are reviewed.

Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia.

With the expansion of both laparoendoscopic surgery and the number of those performing it, the surgeon must remain cognizant of the uncommon complication of herniation through a previous trocar site. Herniation through laparoscopic trocar defects most often occurs as a Richter's hernia, hence its presentation can be insidious and can lead to significant morbidity. A retrospective chart review of 1300 consecutive laparoscopic cholecystectomies over 5 years was performed. An incidence of 0.77 per cent for trocar site herniations was found. All of the trocar site hernias occurred through large (> or = 10 mm) defects at the umbilical site. Ninety per cent of those patients with trocar site herniations had an umbilical hernia or midline incisional hernia found incidentally upon entrance into the peritoneal cavity. All of the herniations occurred despite primary fascial closure of the trocar sites. One trocar site hernia resulted in a small bowel obstruction secondary to an incarcerated Richter's hernia. This required a small bowel resection. Consequently, we now close trocar fascial defects in patients with preexisting hernias in a formal fashion. We recommend that trocar ports be removed under direct vision and that large fascial defects (> or = 10mm) be primarily closed. Furthermore, we recommend in those patients with incidentally found umbilical hernias that both the fascial edge and complete extent of the hernia defect be defined and then closed as a formal herniorrhaphy with interrupted nonabsorbable suture and a synthetic patch if necessary.

Bile leak following laparoscopic cholecystectomy.

The incidence and significance of bile leak after open cholecystectomy have been studied. The purpose of this study was to determine the incidence and significance of postoperative bile leak associated with both emergent and elective laparoscopic cholecystectomies. One thousand four hundred patients undergoing laparoscopic cholecystectomy from July 1990 to January 1995 were retrospectively reviewed. Twenty-seven percent of laparoscopic cholecystectomies were performed urgently for acute cholecystitis. Diisopropyl-iminodiacetic acid (DISIDA) scan was used to determine the presence of a bile leak or obstruction. Also, a subgroup of 63 patients from March to May of 1992 was studied in a nonblinded prospective fashion to determine the rate of asymptomatic bile leak. The incidence of bile leak in the subgroup of 63 patients was 4.7% (n = 3). All of these bile leaks were asymptomatic and of no clinical significance. The incidence of bile leak in the remaining 1337 was 0.14% (n = 2). These bile leaks were discovered by DISIDA scan following a workup of atypical abdominal pain following laparoscopic cholecystectomy. Both of these patients underwent ERCP with papillotomy. There were no ductal injuries in the entire series. Symptomatic bile leaks following laparoscopic cholecystectomy are rare. Asymptomatic bile leaks occur infrequently and are of no clinical significance.

Small bowel obstruction following endoscopic extraperitoneal-preperitoneal herniorrhaphy.

Laparoscopic hernia repair has a number of unique potential complications. These include complications of pneumoperitoneum, general anesthesia, trocar injuries and complications of small bowel obstruction related to trocar site fascial defects, intraabdominal adhesions, and reaction with the synthetic mesh. A totally extraperitoneal approach should, in theory, eliminate postoperative small bowel obstruction in that the peritoneal space is never entered. A case of small bowel obstruction following totally extraperitoneal-preperitoneal herniorrhaphy is presented.

Safety, accuracy, and diagnostic yield of needle localization biopsy of the breast performed using local anesthesia.

BACKGROUND: In changing our technique to performing needle localization breast biopsies (NLBB) using local anesthesia in an outpatient setting, we investigated whether or not our complication rates with local anesthesia were acceptable when compared with complications from a cohort of biopsies of the breast performed for palpable masses. We were also interested in determining whether or not our rate of missed biopsies was within acceptable ranges. STUDY DESIGN: Complications occurring in 283 patients who underwent 301 NLBB using local anesthesia between 1983 and 1991 were compared with complications occurring after excision of 249 palpable masses of the breast excised using local anesthesia during this period. RESULTS: Complications associated with NLBB were missed lesions, six (1.99 percent) of 301; hematoma, 12 (3.99 percent) of 301; abscess, three (0.99 percent) of 301; seroma, one (0.33 percent) of 301, and wound separation, two (0.66 percent) of 301, for a total of 24 complications (7.96 percent). These rates were not statistically different from the rates of complication after biopsies of palpable lesions using local anesthesia (p < 0.49). The 301 NLBB revealed 87 carcinomas (28.9 percent); 50 invasive and 37 in situ. Of the nonpalpable carcinomas, 43 percent were in situ. Only 11 percent carcinomas, 43 percent were in situ. Only 11 percent of the palpable lesions were in situ (p < 0.001). Forty-four patients with nonpalpable invasive carcinoma had a 25 percent rate of positive axillary lymph nodes. CONCLUSIONS: Needle localization breast biopsies can be performed using local anesthesia exclusively with less than a 2 percent chance of missed lesions and complication rates similar to those associated with biopsies of palpable lesions. The biology of these lesions varies. Although there is a high rate of in situ carcinoma, there is a significant rate of node positivity in the patients with nonpalpable invasive carcinoma.

Pulmonary risk factors of elective abdominal aortic surgery.

PURPOSE: The purpose of this study was to retrospectively identify risk factors for postoperative pulmonary complications in patients undergoing elective abdominal aortic surgery via a midline incision. METHODS: We reviewed 181 consecutive patients who underwent operation between July 1986 to December 1992. Preoperative factors analyzed included age, sex, diabetes mellitus, history of smoking, chronic obstructive pulmonary disease, obesity, indication for surgery (aneurysm [126] or aortoiliac occlusive disease [AIOD] [55]), history of coronary artery disease, length of preoperative hospital stay, American Society of Anaesthesiologists class, and pulmonary function tests. Intraoperative factors analyzed included endotracheal tube diameter, percent of inspired oxygen, blood loss, blood and crystalloid replacement, total operative time, epidural analgesia, and stress ulcer prophylaxis. RESULTS: Although the operative mortality rate was only 1.7% (3 of 181), major pulmonary complications occurred in 29 (16%) patients, including two lung-related deaths. Pneumonia occurred in 17 (9%) patients, prolonged intubation greater than 24 hours occurred in nine (5%), and reintubation caused by pulmonary insufficiency occurred in three (2%). On univariate analysis, the following were associated with major pulmonary complications (p < 00.05): American Society of Anaesthesiologists class IV, age greater than 70 years, ideal body weight greater than 150%, forced vital capacity of 80% or less predicted, forced expiratory flow rate (25 to 75) of 60% or less predicted, crystalloid replacement greater than 6 L, and total operative time greater than 5 hours. CONCLUSIONS: The presence of these pulmonary risk factors, notably increased age and weight, decreased forced vital capacity and forced expiratory flow rate (25 to 75), and expected prolonged operative time, influences our decision not to proceed with surgery for small aortic aneurysms or for AIOD causing claudication. Patients at high pulmonary risk with AIOD who require revascularization for limb salvage would be more likely to undergo extraanatomic bypass. Pulmonary risk factors may play as important a role as cardiac factors in elective aortic surgery.

Primary aortoduodenal fistula due to septic aortitis.

We report the second case of a primary aortoenteric fistula resulting from septic aortitis with a contained aortic leak into the retroperitoneum and finally erosion into the duodenum. An emergency laparotomy revealed a fistula between the third part of the duodenum and a decompressed sac (false aneurysm) arising from a nonaneurysmal, grossly infected pararenal aorta. The purpose of this report is to present this rare case in detail and to review primary aortoenteric fistulas reported in the English language literature. Most fistulas form in association with an abdominal aortic aneurysm and rarely are due to infection. Only 6% of patients presented with the classic triad of abdominal pain, a palpable mass, and gastrointestinal bleeding. Although 29% of patients presented with massive hemorrhage, adequate time usually existed for surgical treatment of these complications. A patient with ill-defined abdominal pain and fever who suddenly develops a palpable abdominal mass should have an emergency ultrasound or CT scan to exclude the possibility of an infected aortic aneurysm or a contained rupture of an infected nonaneurysmal aorta. If the symptoms are associated with bleeding and the patient is hemodynamically stable, emergent endoscopy should also be performed. If a primary aortoenteric fistula or an aortic pseudoaneurysm is confirmed, emergent surgery should be undertaken to avoid rupture into the bowel or retroperitoneum.