Post-mastectomy breast reconstruction using the inflatable tissue expander.

Breast reconstruction following mastectomy has previously relied on the insertion of a silicone gel implant or the use of a myocutaneous flap. We report the use of an innovation, the inflatable tissue expander, for both immediate and delayed breast reconstruction in 26 patients where soft tissue cover was inadequate to permit the use of the silicone implant. By serial inflation of the tissue expander with saline, sufficient tissue cover was achieved for a second operative placement of a silicone prosthesis of appropriate volume to match the normal breast. To date, 10 patients undergoing delayed reconstruction and 5 of 16 patients with immediate reconstruction have had their final prosthesis inserted, while 3 women are satisfied with the result of the expandable implant and desire no further surgery. Only two technical complications have arisen with loss of the expander in one patient who had had recent radiotherapy and in another the tissue expander was placed much too high on the chest wall. Mechanical failure occurred in three cases where disruption of the seam led to sudden deflation in two and a slow leak from the injection port developed in one. One patient also attempted self-inflation leading to deflation of the tissue expander. The cosmetic results were subjectively and objectively very good with capsular distortion present in only one case. We feel that the inflatable tissue expander is simple and safe to use, may be used for immediate reconstruction without compromising the ablative surgery and should be a choice available to general surgeons for providing safe and cosmetically acceptable reconstructive surgery.

Vertical abdominal incisions--a choice?

A prospective randomized trial was carried out on 207 patients undergoing laparotomy using three different vertical abdominal incisions--midline, 'medial' paramedian incision and 'lateral' paramedian incision. The lateral paramedian incision is slightly more time-consuming to perform than the other two incisions but there is a statistically greater incidence of incisional hernia in midline and medial paramedian wounds than with the lateral paramedian incision. It is suggested that when a vertical abdominal incision is being considered the lateral paramedian should be the incision of choice.

A morphologic study on the effect of suturing the submucosa of the large intestine.

Five suture materials, chromic catgut, braided silk, Prolene, Teflon coated braided Dacron and Dexon have been examined morphologically for their effect on the submucosal collagen structure of the large intestine. The rougher surfaced materials, such as catgut, braided silk and Dexon, cause considerable damage to the submucosa on either side of an intestinal anastomosis. Because of this damage, it would appear that these sutures are more likely to jeopardize the integrity of an intestinal anastomosis.

A morphologic study of the submucosa of the large intestine.

The morphologic structure of human, rat and mouse submucosa is similar. The strength, natural tension and extensibility of the submucosa can be readily interpreted form the physical properties of collagen and its structural arrangement as a pliable honeycomb. The perforations allow blood and lymph vessels to reach the mucosa.

Effects of adrenergic stimulation on the choledochoduodenal sphincter mechanism.

The object of this study was to access the effects of systemic bolus injections of epinephrine and of norepinephrine upon the sphincter at the choledochoduodenal junction in the cat and the dog. The bile duct was transected and the downstream segment was cannulated. Two methods were used to assess sphincteric activity. In method I the bile duct was perfused with Ringer's solution at a constant pressure and the flow rate of the solution was recorded. In method II the bile duct was perfused at a constant rate of flow and the terminal intraductal pressure was recorded. Intraduodenal pressure and respiratory movements were also recorded. There was a significant decrease in sphincteric activity following both epinephrine and norepinephrine administration in both cats and dogs, using both constant pressure and constant flow methods.

Tension pneumoperitoneum: a report of 4 cases.

Four cases of tension pneumoperitoneum are described. In 3 patients this condition followed a perforation of a grossly distended caecum. In 2 of these patients there was an associated malignant neoplasm of the pelvic colon with obstruction. The third patient had a pseudo-obstruction of the transverse colon. The fourth patient had a tension penumoperitoneum with associated surgical emphysema in the neck and subcutaneous tissues of the abdomen and chest walls, following perforation of a duodenal ulcer. The aetiology, presentation and management, together with the mechanism of tension pneumoperitoneum, are discussed.