Resectional surgery for malignant disease of abdominal digestive organs is not surgery of the organ itself, but also that of the mesenteric organ.

Despite large strides in molecular oncology, surgery remains the bedrock in the management of visceral cancer. The primacy of surgery cannot be understated and a mesenteric (i.e. ontogenetic) approach is particularly beneficial to patients. Heald greatly advanced the management of rectal cancer with his description of the anatomical foundation of total mesorectal excision (TME), dramatically improving outcomes worldwide with this mesenteric-based approach. Moreover, complete mesocolic excision (CME) based on similar principles is becoming popular. Introduced by Hohenberger, CME resembles TME insofar as it emphasises strictly anatomical dissection along embryological planes to detach an intact (i.e. "complete") mesentery with peritoneal envelope. CME also incorporates "central" vascular ligation (CVL) which broadly correlates with the "D3 lymphadenectomy" of Eastern literature. As many surgeons already practise anatomical and mesenteric-based surgery, it is unclear how the putative benefits of CME (including CVL) arise. Herein, we argue that these may relate to a more extensive resection of the mesentery, and thus mesenteric tumour deposits within the connective tissue lattice of the mesentery, and not necessarily the lymphadenectomy alone. We believe the connective tissue interface between the bowel wall and mesentery provides an alternative mode of spread of pathogenic elements. Whilst this remains a suggestion only, it would explain the histological independence of tumour deposits and why a greater mesenterectomy could be associated with benefits in survival. If this argument holds, it follows that resectional surgery for digestive organ malignancy is not surgery of the organ itself (or lymphatics only), but also that of the contiguous mesentery.

Complications - A surgeon's perspective and humanities' methods for personally dealing with them: The "4 R's".

Herein the author includes his philosophical take on how surgeons' deal with complications. He explains how often Mortality and Morbidity meetings miss a fundamental point of how the surgeon him/herself deals with complications. The author proposes a classification of the 4 commonest coping strategies used by mankind to deal with the doubt and uncertainty that a career in surgery, a real marathon, entails. This is explored in an honest, easy to read and amusing way with some real truths within.

Surgery in the older person: Training needs for the provision of multidisciplinary care.

Introduction Many older surgical patients are exposed to high risks of morbidity and mortality when undergoing both elective and emergency surgery. Methods We provide an overview of perioperative care teams and the educational opportunities available to surgeons who undertake surgery in the older person. Findings The number of older people undergoing surgery is increasing at a rate faster than the proportion of older people in the overall population. Management of the older surgical patient throughout the surgical pathway forms part of the Specialty Training Curriculum for Geriatric Medicine. While 'surgery in childhood' continues to form part of the general surgical higher training syllabus, surgery in the later years of life does not. There are limited postgraduate courses and training opportunities currently available to surgeons in this field. There is clear societal need to address perioperative care for older surgical patients, which has proved successful in some centers. Moreover, surgical trainees support the inclusion of geriatric medicine issues into their training. Conclusions The ageing population requires a multidisciplinary perioperative approach, with dedicated and appropriately trained clinicians and allied health care professionals to improve outcomes.

Female gender and diabetes mellitus increase the risk of recurrence after laparoscopic incisional hernia repair.

BACKGROUND: Laparoscopic hernia repair is used widely for the repair of incisional hernias. Few case studies have focussed on purely 'incisional' hernias. This multicentre series represents a collaborative effort and employed statistical analyses to provide insight into the factors predisposing to recurrence of incisional hernia after laparoscopic repair. A specific hypothesis (ie, laterality of hernias as well as proximity to the xyphoid process and pubic symphysis predisposes to recurrence) was also tested. METHODS: This was a retrospective study of all laparoscopic incisional hernias undertaken in six centres from 1 January 2004 to 31 December 2010. It comprised a comprehensive review of case notes and a follow-up using a structured telephone questionnaire. Patient demographics, previous medical/surgical history, surgical procedure, postoperative recovery, and perceived effect on quality of life were recorded. Repairs undertaken for primary ventral hernias were excluded. A logistic regression analysis was then fitted with recurrence as the primary outcome. RESULTS: A total of 186 cases (91 females) were identified. Median follow-up was 42 months. Telephone interviews were answered by 115/186 (62%) of subjects. Logistic regression analyses suggested that only female sex (odds ratio (OR) 3.53; 95% confidence interval (CI) 1.39-8.97) and diabetes mellitus (3.54; 1-12.56) significantly increased the risk of recurrence. Position of the defect had no statistical effect. CONCLUSIONS: These data suggest an increased risk of recurrence after laparoscopic incisional hernia repair in females and subjects with diabetes mellitus. These data will help inform surgeons and patients when considering laparoscopic management of incisional hernias. We recommend a centrally hosted, prospectively maintained national/international database to carry out additional research.

Abdominal compartment syndrome caused by tension pneumoperitoneum in a scuba diver.

Abdominal compartment syndrome is a surgical emergency caused by a raised intra-abdominal pressure, which may lead to respiratory, cardiovascular and renal compromise. It is most commonly seen in post-operative and trauma patients and it has a variety of causes. Tension pneumoperitoneum (TP) is a rare cause of abdominal compartment syndrome most often seen after gastrointestinal endoscopy with perforation. We present the case of a fit 52-year-old experienced female diver who developed TP and shock following a routine training dive to 27m. Following accidental inhalation of water, she had an unstaged ascent and, on reaching the surface, developed severe acute abdominal pain and distension. She was brought to our emergency department by air ambulance for assessment. Clinical and radiological examination revealed a shocked patient with dramatic free intra-abdominal gas and signs of abdominal compartment syndrome, which was treated with needle decompression. Symptoms and signs resolved quickly with no need for further surgical intervention. TP is a surgical emergency where surgery can be avoided with prompt diagnosis and treatment.

A retrospective wound review of standard four-port laparoscopic cholecystectomy: is there need for single-port laparoscopic surgery?

BACKGROUND: This study was designed to assess the satisfaction or otherwise of a proportion of the U.K. population who have undergone standard four-port laparoscopic cholecystectomy within the past 18 months. The results should indicate whether there is potential demand for a new, improved approach to surgery. METHODS: Patients who underwent laparoscopic cholecystectomy between October 2008 and October 2009 in two geographically separated general hospitals were identified from hospital databases. Notes were reviewed to confirm the technique and lack of conversion to an open procedure. Those who had immediate complications were excluded. A telephone questionnaire was conducted to answer questions related to long-term cosmetic and general satisfaction of the current procedure. RESULTS: Of the patients surveyed, 93% were happy or extremely happy with the current procedure, 48% experienced some wound-related issues (pain, infection), and 65% of those were at the umbilicus (a possible reflection of location and retrieval site for gallbladder). Cosmesis was rated less important than hospital cleanliness and experience of the surgeon. CONCLUSIONS: Overall satisfaction was high with the existing technique. The high rate of umbilical wound problems is an issue that will not be eradicated by introduction of single-port laparoscopic surgery.

Pouch of Douglas pelvic hernia: a rare entity managed laparoscopically.

Pouch of Douglas hernias are uncommon forms of pelvic hernia. They are most commonly seen in multiparous, elderly women and those having undergone previous pelvic surgery (Stamatiou et al. in Am Surg 76(5):474-479, 2010). Herein, we present a case of a 77-year-old female presenting with groin pain due to a Pouch of Douglas hernia. She had no previous abdominal or pelvic surgery. This was repaired via a trans-abdominal pre-peritoneal approach and the patient's symptoms resolved. To our knowledge, this is the first case report in the literature of an idiopathic Pouch of Douglas hernia managed laparoscopically.

Epiploic appendagitis: a case report highlighting correlation between clinical features, computed tomography images and laparoscopic findings.

We present a case of a 72 year old male patient, who presented to the emergency department with a 2 day history of right iliac fossa pain. On examination he was apyrexial and haemodynamically stable, yet displayed signs of right iliac fossa peritonism. Inflammatory markers were mildly raised. Computed tomography and diagnostic laparoscopy both demonstrated typical features of epiploic appendagitis. Epiploic appendagitis is an uncommon cause of the acute abdomen, yet is probably underdiagnosed. The term was first used by Lynn et al. in the mid 1950s. With the increase in CT scanning and diagnostic laparoscopy, we feel that both surgeons and radiologists need to be increasingly aware of the clinical and radiological appearances of epiploic appendagitis.

[Preprosthetic orthodontic preparation and Brånemark implants]. / Préparation orthodontique préprothétique et fixtures de Brånemark.

The patient presented an important bone loss in the edentulous area 21 to 23. The 11 had a temporary crown and a removable prosthesis has replaced the anterior missing teeth. The orthodontic treatment of this class II division 1 was to be undertaken in order to reduce the maxillary proalveolie and to line up the mandibular incisors. The difficulty of the orthodontic treatment was due to the importance of the anterior edentulous area which did not allow a continuous multiring treatment but a bilateral one and a succession of anterior removable prosthesis as anchoring points. The temporary crowns on osseointegrated fixtures replacing 22 and 23 were used to obtain the final orthodontic movements needed in the orthodontic preprosthetic treatment. However, if the fixtures had been placed at the beginning of the treatment in order to use them among other anchoring points, the complete orthodontic treatment would have been faster and much easier. At that time, our major handicap was to determine the ideal position of the fixtures which would allow the orthodontic application as well as a successful cosmetic fixed prosthesis. The use of scanner, three dimensional reconstruction Scanlam, surgical stents and fixed prosthesis with inlay cores would have brought the solution to this problem. Today, the use of osseointegrated fixtures can be applied in much more complex orthodontic movements.

[Complete bridge on osseointegrated fixtures avoiding a temporary complete denture]. / Bridge complet sur fixtures ostéo-intégrées évitant la prothèse complète d'attente.

The possibility of placing fixtures between periodontically compromised teeth enables the immediate conversion from a fixed prosthesis supported by natural abutments to a temporary one supported by osseo-integrated fixtures. During the second surgical stage, the bridge on natural teeth is removed, the abutments are placed on the osseo-integrated fixtures and a new temporary bridge is prepared out of acrylic resin and gold cylinders screwed on the titanium abutments after the extraction of the residual teeth. The temporary bridge is realised for one side of the arc and then the other in order to control at all time the occlusion as well as the cosmetic aspect of the bridge. This approach avoids the passage by a mobile denture, shortens the healing period from 18 to 6 months and enables the prosthodentist to foresee the potential problems with the permanent fixed prosthesis.