Measurement of intra-abdominal pressure in large incisional hernia repair to prevent abdominal compartmental syndrome.

INTRODUCTION: The repair of large incisional hernias may occasionally lead to a substantial increase in intra-abdominal pressure (IAP), and rarely to abdominal compartmental syndrome (ACS) with subsequent respiratory, vascular, and visceral complications. Measurement of the IAP has recently become a common practice in monitoring critical patients, even though such measurements were obtained in the early 1900s. PATIENTS AND METHODS: A prospective study involving 54 patients undergoing elective abdominal wall gap repair (mean length, 17.4 cm) with a tension-free technique after incisional hernia was conducted. The purpose of the study was to determine whether or not urinary pressure for indirect IAP measurement is a reliable method for the early identification of patients with a higher risk of developing ACS. IAP measurements were performed using a Foley catheter connected to a HOLTECH® medical manometer. IAP values were determined preoperatively, after anesthetic induction, upon patient awakening, upon patient arrival in the ward after surgery, and 24 h after surgery before removing the catheter. All patients were treated by the same surgical team using a prosthetic composite mesh (PARIETEX®). RESULTS: Incisional hernia repair caused an increase in the mean IAP score of 2.68 mmHg in 47 of 54 patients (87.04%); the IAP was decreased in two patients (3.7%) and remained equal in five patients before and 24 h after surgery (9.26%). FEV-1, measured 24 h after surgery, increased in 50 patients (92.6%), remained stable in two patients (3.7%), and decreased in two patients (3.7%). The mean increase in FEV-1 was 0.0676 L (maximum increase = 0.42 L and minimum increase = 0.01 L) in any patient who developed ACS. CONCLUSIONS: Measurement of urinary bladder pressure has been shown to be easy to perform and free of complications. Measurement of urinary bladder pressure can also be a useful tool to identify patients with a higher risk of developing ACS.

Treatment for persistent chronic neuralgia after inguinal hernioplasty.

Following an inguinal hernia repair with open or laparoscopic technique, 1-15% of patients show persistent neuralgia, a severe, potentially debilitating, complication. Several therapeutic procedures have been proposed, but consensus regarding choice of treatment has not yet been achieved. We performed a prospective study on 32 such cases. Patients underwent anaesthetic infiltration to identify, when possible, the involved nerve, and we then carried out a step-by-step therapeutic protocol. In the initial phase, patients were treated with oral analgesic and afterwards with repeated infiltrations of anaesthetic and cortisone. Surgery was reserved for patients not responding to the infiltrations, though with no good success. The authors believe that noninvasive methods are to be preferred, whereas neurectomy interventions should be reserved for selected cases.

Spigelian hernia: a case report and review of the literature.

Spigelian hernia is a rare abdominal hernia that occurs through Spigelian aponeurosis. The Authors present a case of Spigelian hernia associated with narrowing of sigmoid colon and diverticular pathology. They also described historical background, surgical anatomy and etiopathogenesis of this hernia. By a remarkable revision of literature, they sum up epidemiology and clinical features of Spigelian hernia. Furthermore, they discuss diagnostic and therapeutic principles.

Large incisional hernia in the elderly: which kind of treatment?

Incisional hernia is one of the commonest long-term complications of open abdominal surgery. Especially in old patients (over 70 years), the incisional hernias represent an invalidating pathology whose treatment, for the high incidence of associated respiratory and cardiovascular disease, offers difficulties related to the preoperative and postoperative management as well as to the surgical treatment. This paper reports the Author's experience about the surgical treatment of large incisional hernia (> 10 cm) with open prosthetic mesh repair in geriatric patients.

[Necrotizing fasciitis: our experience]. / Le fasciti necrotizzanti: esperienza personale.

Necrotizing fasciitis is a rare and dramatic soft-tissue; infection starting from the subcutaneous tissue, involving the fascia and the underlying muscle and causes necrosis and, suddenly, gangrene. Most frequently the necrotizing fasciitis is localized in anorectal or genitourinary region and in traumatized muscles. Its mortality rate is 20%. Predisposing factors for these infections have included advanced age, obesity, hypertension, atherosclerosis, malnutrition, renal failure, immunosuppression and, primarily, diabetes mellitus. The infection is caused by a lot of gram +, gram -, and anaerobic bacteria that act synergistically. The early diagnosis, a correct chemotherapy, an aggressive surgical treatment of the necrotic area and hyperbaric oxygen treatment allow the patient's recovery, dramatically reducing the functional consequences. The Authors analyze retrospectively five cases of necrotizing fasciitis observed in the last two years (August 2001-August 2003) and stress clinical findings and surgical treatment.

[Intraoperative injuries of the superior laryngeal nerve in thyroid surgery]. / Lesioni intraoperatorie del nervo laringeo superiore in chirurgia tiroidea.

The intraoperative injury of the external branch of the Superior Laryngeal Nerve (SLN) is a disregarded complication of thyroid surgery that becomes a serious one for particular professional groups. The Authors retrospectively evaluate 124 cases of total thyroidectomies performed by the same surgeon from 1999 to 2002. Clinically evaluated SLN lesions (hypomobility of the vocal cord) was registered in six patients (4.8%). Routine identification of SLN and meticulous dissection of the superior thyroid vessels must be the technical benchmark to avoid nerve injury, even if bulky disease, anatomic variations and previous surgery may increase the chance of nerve damaging.

Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia.

BACKGROUND: In the last few decades there has been a clear tendency in civilian practice towards primary repair of gunshot wounds to the colon, resulting in a substantial decrease in the number of colostomies performed for this type of injury. METHODS: The series described here comprises 24 patients with gunshot wounds to the colon treated at the hospital of Jowar in the Middle Shebelle region of Somalia between 1999 and 2001. All injuries were caused by war arms firing high-velocity projectiles. RESULTS: In 18 patients surgery consisted of resection and immediate anastomosis, while in the remaining six patients colostomies were performed including five loop colostomies and one terminal colostomy. The sepsis-related mortality was 25% (6/24). CONCLUSION: Our experience had a peculiar setting, namely that of a civil war in a developing country. In this kind of "difficult" situation there probably exists no ideal procedure and the decisions taken at the operating table are influenced by various factors that are often related to subjective assessment.

[Reoperations in lung surgery]. / I reinterventi in chirurgia polmonare.

A second thoracotomy in patients who have undergone previous chest surgery can be performed soon or immediately after the first operation and is usually aimed at resolving severe or even life-threatening postoperative complications. Late reoperations, on the other hand, are either performed to resolve complications of previous surgery or to remove second primary lung tumors (SPLCs) or metastases. The most exacting reoperation in this context is completion pneumonectomy, which is particularly indicated in the case of failure of the residual lobe to re-expand after primary surgery; it is also used for--rarely occurring--fistulas of the lobar bronchi and for new ipsilateral primary lung tumors. This type of surgery is technically complicated and has been associated, in our experience and that of others, with a certain mortality. Technically less difficult is a second ipsilateral thoracotomy for exploratory purposes or minor parenchymal resection, and the same is true of contralateral lobar or sublobar resections. Lastly, Abruzzini's operation, for fistulas of the primary bronchus, is relatively complicated but often leads to good results; we have performed 15 such operations with only one death occurring due to acute myocardial infarction.

[Inguinal hernia repair in a teaching course for surgeons. A training program]. / L'intervento di riparazione dell'ernia inguinale nell'iter formativo del chirurgo. Proposta di un percorso didattico.

The Authors suggest a training programme for surgeons in post graduates courses. With this object in view, the inguinal hernia repair by Lichtenstein has been chosen as the most suitable one. The training course has been divided into theoretic lessons and surgical practice in the operating theatre, carried out in stages as assistant and then as operating surgeon. The good standard achieved, together with the clinical results obtained, demonstrates the effectiveness of the teaching method.

[Pulmonary carcinoids. Analysis of 53 cases]. / Carcinoidi polmonari. Analisi di 53 casi.

We have performed a retrospective analysis of 53 cases of bronchial carcinoids using our own patient data from more than 4700 lung tumors and 1632 resections. The male/female ratio was 1:12 (28/25) and the age range 13 to 75 years (mean 52.2). Fifty-three tumors resections of varying extent were performed, including one radical pneumonectomy in a patient who had previously undergone a lobectomy, and one limited resection of the main left bronchus; there was no intraoperative mortality. After histological examination, 44 tumors (83%) were found to be typical carcinoids and nine (17%) atypical carcinoids. The median follow-up period was 4.56 years, with a range from 1 to 10 years. Only one patient with an atypical carcinoid tumor had a relapse and died three years after, while another patient underwent surgery of the contralateral lung for a second primary lung cancer (SPLC). On the basis of these observations we would like to underline the importance of an accurate histopathological classification for both therapeutic and prognostic purposes; given the higher aggressiveness of atypical carcinoids, these tumors would be eligible for a therapeutic approach analogous to that adopted for bronchogenic carcinoma.

[Use of the eutectic ointment EMLA (Eutectic Mixture of Local Anesthetics) in the surgical treatment of inguinal hernia under local anesthesia]. / L'uso della crema eutettica EMLA nel trattamento chirurgico dell'ernia inguinale in anestesia locale.

The use of EMLA eutectic cream is very effective and well tolerated in superficial anaesthesia. It is particularly indicated in surgical treatment of inguinal hernia by local anaesthesia, to achieve the analgesia of superficial layers. This allows to reduce the total dose of anaesthetics administrated by infiltration, reducing the risk of overdose, eliminating the pain due to injection, and is very agreeable for the patients.

[Local anesthesia in the surgery of inguinal hernia. Technical notes]. / L'anestesia locale nella chirurgia dell'ernia inguinale. Note di tecnica.

Routine use of local anaesthesia associated with tension-free hernioplasty in surgical treatment of inguinal hernia allows an immediate patient walking and prompt discharge from the hospital unit: with this technique 89 cases in two years were operated. The anaesthesia-related discomforts and complications are minimal. The addition of an intravenous sedative (propofol) premis to extend this approach to anxious patients too.

[Clinical-therapeutic considerations in a case of miliary tuberculosis in an indonesian girl]. / Considerazioni clinico-terapeutiche su un caso di tubercolosi diffusa ad evoluzione grave in una bambina indonesiana.

The authors describe the case of widespread miliary tuberculosis, that arose in a ten year-old Indonesian girl of middle-class, who has been living in Italy from about three years. The girl was probably contaminated by a subject belonging to the same ethnic-social community, who was affected with tubercular disease. The diagnosis was effected on the ground of: clinical picture including continued-remitting fever, a loose cough, asthenia, anorexia, weight reduction, aching tumefaction on the left side of the neck; isolation of Mycobacterium tuberculosis from the expectoration, blood, urine, and a lymph node located on the left side of the neck; radiological picture that revealed a widespread miliary tuberculosis. In spite of polychemotherapy with isoniazid , rifampicin, pirazinamide, and streptomycin that was subsequently replaced by ethambutol, the course of the illness worsened and it was characterized with fever, cachexia, respiratory insufficiency and repeated episodes of pneumothorax. For such reasons on the ground of susceptibility to the antibiogram amikacin and ciprofloxacin, as well as glucocorticoids to limit the fibrousness, were added to the specific therapy that was already being out. For persisting of relapsing pneumothoraxes, the patient underwent a thoracoscopy and plerodesis with talcum powder. After four months of antitubercular therapy, the research of M. tuberculosis resulted negative in the expectoration, urine, bronchus-alveolar washing liquid and blood, in addition to improvement in general state of health with remission of fever was noticed.

[Epidermoid cyst of the spleen. Description of a clinical case]. / Cisti epidermoide della milza. Descrizione di un caso clinico.

A case of epidermoid cyst of the spleen in a young man is reported. The importance of the echotomography and CT for diagnosis of this unusual pathology is pointed out. The role of splenectomy as first choice in the treatment of splenic cysts is emphasized.

Use of the fiberoptic bronchoscopy in the elderly.

The authors emphasize the primary role fiberoptic bronchoscopy has for diagnostic and therapeutic purposes in the elderly affected by pulmonary disease. Safety, efficacy and tolerability of the method in the elderly are obtained through a preliminary and careful evaluation of the patients, either clinical or instrumental.