Minimally invasive surgery in trauma: technology looking for an application.

BACKGROUND: Minimally invasive surgery has achieved pre-eminence for certain operations in general surgery over the last two decades, as the reduction in surgical insult has produced faster recovery with enhanced patient satisfaction and favourable health economics. Minimally invasive techniques have been less enthusiastically adopted by the trauma surgical community, despite some evidence of efficacy for nearly 40 years. METHODS: The literature on minimally invasive techniques in trauma was reviewed. RESULTS AND CONCLUSIONS: To date, minimally invasive surgery has played only a small role in trauma surgery. As clearer indications emerge and technology improves, surgeons should be encouraged to incorporate laparoscopy and video-assisted thoracoscopy (VATS) into their protocols and gain familiarity and expertise with their use.

Appendico-cutaneous fistula in cystic fibrosis.

Appendico-cutaneous fistulae are rare. We describe a 12-year-old girl with cystic fibrosis (CF) and a chronically draining sinus in the right iliac fossa, found to be a primary appendico-cutaneous fistula. Misdiagnosis of right iliac fossa pain in patients with CF and the preponderance of complicated disease frequently lead to manifestations of appendicitis rarely seen in usual clinical practice.

Intubated, ventilating patients with complete tracheal transection: a diagnostic challenge.

Tracheal transection is a rare injury after blunt trauma. The presence of complete tracheal transection in the intubated, ventilating patient is even more rare and constitutes a major diagnostic challenge. The liberal use of computed tomography (CT) scans as an adjunct to endoscopy is paramount.

Dispositional pessimism predicts delayed return to normal activities after inguinal hernia operation.

BACKGROUND: The traditional outcome measure to assess effectiveness of inguinal hernia operation was recurrence. Open mesh repair has reduced recurrence rates and attention is now turning to outcomes other than recurrence. The factors influencing the large variation in reported times of resumption of normal activities after inguinal hernia repair are many and diverse. The human factors influencing resumption of normal activity are rarely reported. METHODS: We undertook a prospective study of 206 patients undergoing primary inguinal hernia repair in an ambulatory setting in a public hospital to ascertain whether dispositional outlook on life affected resumption of normal activity after hernia repair. Outlook on life was assessed using the life orientation test. An independent observer assessed the patients preoperatively and determined timing of resumption of normal activities. RESULTS: Regression analysis showed a highly significant relationship between delayed return to normal activity and dispositional pessimism (P =.0004). DISCUSSION: Dispositional pessimism correlates strongly with delayed return to normal activities. Further studies of this kind will help to elucidate the human factors that affect recovery after operation. Studies which use return to normal activities as a measure of the outcome of a surgical technique should include an assessment of the patient's preoperative outlook on life. Surgeons should consider the personality of the patient presenting for groin hernia repair and may wish to tailor their counseling accordingly.

The malignant epidemic--changing patterns of trauma.

OBJECTIVES AND SETTING: The worldwide burden of trauma is increasing, but is unequally distributed between nations. Trauma in South Africa targets the young and productive in society and imposes a major burden on the health infrastructure. We undertook a review of injury trends among patients attending the Johannesburg Hospital Trauma Unit (JHTU) and the Johannesburg Medicolegal Laboratory (JMLL) in order to document the evolution in patterns of trauma over a 17-year period of great social and political change. DESIGN, SUBJECTS AND OUTCOME MEASURES: This was a retrospective review of all priority-one patients attending the JHTU from January 1985 to December 2001. The JHTU trauma database was used to retrieve information on patient demographics, wound mechanism and injury severity. The database at the JMLL, maintained since 1996, was examined and the manner and place of death were analysed. RESULTS: The JHTU has seen an unprecedented increase in the number of trauma patients over the last 17 years. The patients' demographic profiles have altered and injury is now predominantly due to interpersonal violence. Unnatural deaths examined at the JMLL have declined by 19% since 1996; however, the proportion of those deaths due to gunshot wounds has risen. CONCLUSIONS: The social and political changes in South Africa in recent years have led to changes in the injury profiles seen at the JHTU. Part of the increase can be explained by desegregation and a reduction in the provision of local hospital services; however, the impact of urbanisation within South Africa, cross-border migration and the high incidence of substance abuse are recognised. Evidence supports the implementation of legislative, environmental, social and behavioural interventions to contain and reduce the incidence and impact of violence and injury. Concerted efforts must be made at all levels to curb South Africa's trauma epidemic.

Penetrating vascular trauma in Johannesburg, South Africa.

An awareness that time crucially affects outcome underpins the principles of management of vascular injury. Patients with hard signs of vascular injury should undergo urgent exploration. Soft signs mandate investigation, and arteriography is still the standard of care. Noninvasive vascular imaging may prove its worth in the future. All patients with penetrating arterial injury should receive broad-spectrum antibiotic prophylaxis. Early repair of carotid artery injury provides the best likelihood of a neurologically intact survivor. There is a definite and emerging role of endovascular therapy both for difficult access injuries and for the later complications of vascular injury, such as false aneurysm and arteriovenous fistulas. The experimental and clinical evidence for the use of intraluminal shunts in peripheral vascular injury is compelling, and experience in their use is accumulating. Vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment; resuscitation and prompt revascularization are likely to lead to satisfactory outcomes. The major trauma load in South Africa represents an unparalleled experience in management of vascular injury, which seems likely to continue for the foreseeable future.

Off-pump cardiac revascularization after a complex stab wound.

Penetrating cardiac injuries are among the most dramatic and lethal of all injuries. High survival rates in selected reports have given the erroneous impression that the lethality of cardiac injuries has diminished in recent years. In a review of 1,198 cases of penetrating cardiac trauma from South Africa, only 6% of patients arrived at hospital alive. Many patients with proximal coronary artery injuries present without signs of life. Cardiopulmonary bypass is advocated as a means of salvage, but mortality rates are high. We present a case of arterial revascularization using off-pump technology.