An alternative classification of incisional hernias enlisting morphology, body type and risk factors in the assessment of prognosis and tailoring of surgical technique.

Incisional hernias occur in 5-10% of patients who have undergone laparotomy and are associated with a high morbidity and significant socioeconomic costs. Better understanding of the anatomy and improved methods for reinforcement of the abdominal wall with alloplastic meshes have reduced the recurrence rate to 1-10% depending on the type of hernia and the technique employed. A number of surgical repair techniques and mesh types are available. However, precise criteria for incorporating patient body type, risk factors for recurrence, hernia morphology, and the available biomaterials into planning of the surgical approach (open versus laparoscopic) have yet to be established. The elaboration of such criteria would require comparative evaluation of long-term results in a sufficiently large number of patients, e.g. in multicentre trials or meta-analyses of standardised data from different centres. Current classifications have the drawback that they fail to take account of prognostically relevant risk factors for recurrence and are not self-explanatory. The authors present a classification of incisional hernias that is self-explanatory and practicable in routine clinical practice. Based on the cornerstones of morphology (M), hernia size in cm (S), and risk factors for recurrence (RF), the scheme enables easy description and documentation of the hernia, and provides evidence for the indications and limitations of the main surgical repair techniques. Since randomised studies can scarcely be conducted on incisional hernias due to the numerous morphological variables, the classification presented here may offer an alternative means for comparative data analysis.

[Terminolateral esophagojejunostomy after gastrectomy with the biofragmentable anastomosis ring in the dog model]. / End-zu-Seit Osophagojejunostomie mit dem biofragmentierbaren Anastomosenring nach Gastrektomie am Hundemodell.

INTRODUCTION: Esophagojejunostomy after total gastrectomy still remains a high risk anastomosis with a considerable morbidity and mortality. The majority of these anastomoses are performed by the intraluminal stapler technique, yet stenoses are a known late complication even after an uneventful postoperative course. In the present study, the osophagojejunostomy with the biofragmentable anastomosis ring (BAR) was examined in dogs. METHODS: 28 dogs were randomized into a group of manual suture (n = 14) and a BAR-group (n = 14). After gastrectomy, the esophagojejunostomy was performed by hand-suture with polypropylene 4-0 in the manual suture group, and with the 25/1.5 mm BAR in the BAR-group. In both groups the Roux-en-Y jejunojejunostomy was performed by hand-suture. The dogs were evaluated on postoperative days 4, 7 and 14 with regard to macroscopy, bursting strength, tissue hydroxyproline and histology. RESULTS: There was one leakage without clinical effect in the hand-sewn group on postoperative day 4; there was no leak in the BAR-group. In observing fibre-free enteral feeding, neither functional disorders nor obstruction of the BAR were observed. The general anastomosis parameters were matchable between the groups. CONCLUSION: The infracarinal BAR-esophagojejunostomy is comparable to the hand-sewn anastomosis in the dog-model.

[Billroth I anastomosis with biodegradable anastomosis ring in the animal model]. / Billroth-I-Anastomose mit dem Biofragmentierbaren Anastomosen-Ring (BAR) im Tiermodell.

In the present study, the Billroth-I anastomosis with the biofragmentable anastomosis ring was examined in dogs. 24 dogs were randomized into a group of manual suturing (n = 12) and a BAR-group (n = 12). In the group of manual suturing, a distal gastric resection and gastroduodenostomy with sero-submucous suture was performed. In the BAR-group, the distal gastric resection was done with the linear stapler PLC-75, whereby the BAR gastroduodenostomy crossed the stapling line. The dogs were evaluated on p.o. days 4, 14, and 30 and tested for bursting strength and bursting location, appearance of mucosa, hydroxyprolin concentration, and histologic features. There was no functional disorder in the gastrointestinal transit in any animal; in summary with regard to the various parameters, the crossing of BAR and stapling line does not represent any additional risk factor in the Billroth-I anastomosis in dogs.

[From Murphy's button to the Valtrac Ring. 100 years in search of a paradigm]. / Der Weg von Murphys Knopf zum Valtrac-Ring. 100 Jahre auf der Suche nach einem Paradigma.

In the context of continuous development in the area of anastomotic sutures leading to exceptional results in surgical practice, the biofragmentable anastomosis ring (BAR) described in 1985 by Hardy et al. represents a breakthrough in a 100 years' search of a paradigm. The first anastomotic button created in 1892 by J.B. Murphy was at once accepted as a quick and safe method of intestinal anastomosis. In 1896 Czerny demanded the following: "The task of technology is ... to create buttons with material that is entirely or partly dissolved in the intestinal lumen." Polyglycolic acid--developed in the sixties and now in widespread use for resorbable surgical sutures--was the material to fulfill the requirements already stated in the relevant literature 100 years ago, namely in the form of Hardy's BAR, which represents a redesigned Murphy button exploiting the recent biotechnological developments of this century.

Estenose de reto após trauma de pelve: relato de um caso / Rectal stenosis after pelvic trauma: a case report

Os autores apresentam um relato de caso de estenose tardia de reto, conseqüente a trauma de bacia. A paciente H. F. S., 52 anos, foi atendida no pronto-socorro, após acidente de trânsito, colisäo entre veículos. Apresentava disjunçäo sacro-ilíaca esquesda, fratura bilateral de fêmur e perna esqueda, TCE leve, contusöes e escoriaçöes generalizadas. O tratamento imediato foi traçäo de membros inferiores e com fixador externo na perna. Ficou internada por 65 dias, recebendo alta hospitalar com consolidaçäo óssea quase completa das fraturas. Durante o internamento teve um quadro de diarréia e obstipaçäo. Após sete dias da alta evoluiu com quadro de suboclusäo intestinal, tratada clinicamente, apresentando diarréia e constipaçäo. A história pregressa ao trauma revelava hábito intestinal normal. Foi encaminhada ao serviço de cirurgia apresentando distensäo abdominal, dor pélvica, ao toque evidenciava uma estenose de 90 por cento da luz retal a 6 cm da linha anorretal. A retoscopia demonstrou sinais de retite, hiperemia de mucosa e microulceraçöes ao nível da estenose. A biópsia diagnosticou proctite crônica inespecífica. Foram descartadas patologias como proctite estenosante por clamídia e sífilis. A T.A.C. foi normal e o enema opaco demonstrou estenose circular curta no reto. O diagnóstico final foi de estenose de reto causada por trauma de bacia e disjunçäo sacro-ilíaca. O tratamento inicial foi de dilataçäo por retossigmoidoscópio e digital, o qual näo foi satisfatório. O tratamento definitivo foi a retossigmoidectomia com anastomose colorretal com grampeador intraluminar. A paciente evoluiu satisfatoriamente estando atualmente normal. Concluímos que o trauma pélvico de modo geral pode levar a lesäo do reto por este ser fixo a estruturas vizinhas e a evoluçäo para estenose se näo tratada precocemente. O tratamento por dilataçäo digital é um modo alternativo porém näo eficaz e o tratamento definitivo é a retossigmoidectomia