A clinical trial of wound closure by constant tension approximation.

BACKGROUND: Wounds that heal slowly may pass through a subacute phase and proceed to reach a chronic situation. The latter may heal slowly, if at all. These wounds often heal by secondary intention with a single layer of epithelium that has a tendency to break down. Methods that expedite healing by full-thickness skin usually involve operative procedures. A nonoperative method of achieving coverage of tardy wounds with full-thickness skin, partial or complete depending on the wound, would be valuable. PATIENTS AND METHODS: A device has been designed that approximates the wound margins by applying constant low-grade tension over a period of days or weeks. One or more devices have been applied to the wounds of 25 patients to date. RESULTS: Healing has been obtained in those patients (20) where the devices were used optimally. In 5 patients, optimal use was not possible, mostly for socioeconomic reasons; the latter included noncompliance, insurance problems, economic difficulties, and personal considerations. In these 5 cases, healing was obtained in the 3 that were available for follow-up, full-thickness skin coverage being estimated by grid photography to be in the 80% to 90% range. One patient was lost to follow-up after the wound was 95% covered by full-thickness skin. One patient whose wound reduced in size declined further treatment after 12 days of treatment. CONCLUSIONS: It appears that when constant-tension, low-grade force is applied to subacute and chronic wounds, healing is accelerated and, depending on the wound, a considerable number of ulcers can be closed by full-thickness skin.

Management of groin hernias by laparoscopy.

The surgical treatment of groin hernias continues to undergo technical modifications. The introduction of minimally invasive surgery had added a possible new dimension, replacing an inguinal approach by laparoscopy. Conceived some 15 years ago, the thesis was subjected to a clinical trial where coincidental abdominal hernial openings were closed at laparotomy. This study was followed by an experimental study at which time the openings were closed laparoscopically. The satisfactory results led to the development of a stapling instrument that could be passed through a cannula at laparoscopy and used to close the abdominal hernial opening. The clinical trial of treating hernias by laparoscopy was originally directed to the management of indirect inguinal hernias, but its use has since been expanded to include treatment of direct, femoral, obturator, incarcerated, recurrent, and bilateral hernias. The laparoscopic anatomy of the inguinal hernia, different from that seen by an inguinal approach, is briefly reviewed. The details of the operative technique are presented, as are the bases of other laparoscopic techniques that have evolved. Thirty-one hernial orifices have been closed and followed over 18 months. The results appear to be satisfactory in 27 instances. There were early technical failures in 2: One patient developed a recurrence after 5 months, later shown to be due to a sliding hernia; and symptoms of meralgia paresthetica of indeterminate origin appeared in one case. The advantages over the traditional approach are described; the disadvantages of the laparoscopic approach are those of laparoscopy itself and the absence of a long-term follow-up.