Potential problems with the transverse rectus abdominis myocutaneous flap in breast reconstruction and how to avoid them.

The transverse rectus abdominis myocutaneous flap offers a versatile and reliable technique of repair provided certain anatomical, physiological and surgical principles are closely followed. The operative technique and technical details are described and discussed.

Microsurgical composite tissue transplantation: indications and technical considerations in breast reconstruction following mastectomy.

Twenty-six patients are presented who underwent reconstruction of the breast and thorax following mastectomy. A successful result ensued in 96 percent of the patients. Indications for the use of microsurgical composite tissue transplantation in breast reconstruction following mastectomy include. 1. Inability to employ an island latissimus dorsi musculocutaneous flap 2. Previous failure of an island latissimus dorsi musculocutaneous flap 3. The restoration of form and contour with minimal secondary donor deformity The present series includes 12 patients who underwent reconstruction utilizing the vascularized groin flap and 14 utilizing the contralateral latissimus dorsi musculocutaneous flap. The advantages and disadvantages of the different donor tissues are presented and contrasted with other vascularized donor tissue also employed in breast reconstruction following mastectomy. Technical modifications correlating the limitations of the donor tissue to the complexities of the recipient site and contributing to successful transplantation are detailed. The authors wish to emphasize that microsurgical composite tissue transplantation for reconstruction of the breast following mastectomy has applicability in only a small carefully selected subgroup of patients--approximately 9 percent.

Operative cholangiography. The case for selective instead of routine operative cholangiography.

The role of routine operative cholangiography was studied prospectively in 124 surgical patients undergoing cholecystectomy over a 23-month period. The reliability of preoperative and operative clinical risk factors for common bile duct (CBD) pathology were correlated with the operative and cholangiographic findings. Though several of these clinical risk factors (jaundice, dilated CBD, elevated alkaline phosphotase) were present in over 80 per cent of the patients with CBD pathology, none had an overall predictive accuracy greater than 40 per cent. The operative cholangiogram was superior to the clinical criteria in distinguishing patients with common bile duct pathology from those patients with disease limited to the gallbladder provided that a dilated CBD was not considered an absolute indication for CBD exploration. Operative cholangiography was the best overall screening test for identifying patients with CBD pathology. A subgroup of patients was identified in whom this screening test was not needed. Of our study group, 44 per cent had no clinical risk factors for CBD pathology present, and no unsuspected CBD calculi were found by the use of routine cholangiography in any of these patients. Based on this clinical study and a critical review of the current literature, adequate evidence to support the policy of routine operative cholangiography was not found. In fact, a policy of selective cholangiography performed only on patients clinically at risk of having CBD pathology appears indicated. This approach would not only decrease the incidence of negative CBD exploration, but also would reduce the overall cost of cholecystectomy by 52 million dollars annually without any increase in patient risk.

Acute bilateral renal artery occlusion. Revascularization with the splenic artery.

Although acute renal artery occlusion usually leads to kidney necrosis, preexisting collateral vessels may occasionally preserve the organ long enough to permit revascularization. This principle was demonstrated in a patient in whom bilateral acute renal artery occlusion developed following repair of an aortoduodenal fistula. Approach to the aorta for primary revascularization was interdicted by extensive scarring. Accordingly, bilateral renal artery revascularization was successfully effected with the use of the splenic artery and reversed saphenous vein grafts through extra-anatomic planes. This experience demonstrates the importance of an aggressive diagnostic and therapeutic approach to acute renal artery occlusion, as well as the usefulness of the large-caliber, lengthy, disease-free, dispensable splenic artery as a revascularization source.