Case series and literature review: popliteal artery injury following total knee replacement.

We present a case series and literature review of injury to the popliteal vessels during total knee replacement (TKR). This is rare but may be limb-threatening with devastating consequences for the patient. An individual surgeon will see few cases. Over a 28-month period 3913 elective TKRs were performed at three hospitals in East Anglia, United Kingdom. We present nine cases (0.23%) of popliteal artery injury following TKR. All required further investigation and intervention. The range of pathology included intra-operative haemorrhage (3 cases), thrombosis (2 cases), pseudo-aneurysm (3 cases) and arteriovenous fistula (1 case). Definitive treatment of the arterial injury was by primary repair (4 cases), interposition graft (2 cases), bypass graft (2 cases), endovascular stenting (1 case) and primary above-knee amputation (AKA; 1 case). There was morbidity in four patients: two AKAs, one case of foot-drop, and one unsightly fasciotomy scar. There was no mortality. Compared to other published studies (totalling 141 cases) complications resulting from direct arterial injury were significantly more common in our series. Incidence remains steady. More careful surgical technique may be the most effective preventative measure. Ongoing awareness is therefore essential for early diagnosis and management of this rare but serious complication.

Superior mesenteric artery syndrome in association with an abdominal aortic aneurysm.

Superior mesenteric artery (SMA) syndrome, also known as Wilkie syndrome, is a rare condition characterised by compression of the third part of the duodenum against the aorta by the SMA. This can cause symptomatic duodenal obstruction. It is rarely associated with an abdominal aortic aneurysm (AAA). We report the case of a male patient presenting with an AAA and recurrent upper gastrointestinal symptoms. SMA syndrome was diagnosed with imaging and was then successfully treated by aneurysm repair. This is the smallest AAA associated with SMA syndrome in the literature. We propose an anatomical mechanism for SMA syndrome in this case.

Audit of patient experience of day-case inguinal hernia repair.

BACKGROUND: This study was prompted by a complaint from a patient citing he had suffered postoperative pain and scrotal bruising. We audit postoperative pain following inguinal herniorrhaphy and patient understanding of postoperative complications. METHODS: A telephone survey was carried out to assess patient experience of day-case inguinal herniorrhaphy (DIH). Having identified that there was some dissatisfaction with the outcome of DIH, a prospective audit was carried out to assess causative factors. Changes in practice were made; chiefly, the provision of patient-information leaflets and the standardisation of intraoperative and postoperative analgesia. Repeat audit then assessed the effects of these changes. RESULTS: Ten percent of patients had a poor understanding of postoperative complications following inguinal herniorrhaphy. Thirty-eight percent had early postoperative pain; wound infiltration of local anaesthetic at the end of inguinal herniorrhaphy reduced the incidence of early postoperative pain to 23%. CONCLUSIONS: Audit is an important tool in surgical quality assurance for DIH. Small changes in practice with adherence to good protocols can have a marked effect on patients' experience.

Factors affecting outcome following endoscopic thoracic sympathectomy.

BACKGROUND: Endoscopic thoracic sympathectomy (ETS) is an effective treatment for palmar hyperhidrosis and has been extended to craniofacial symptoms such as blushing and facial sweating. Adverse effects, including compensatory sweating, may cause patients to regret surgery. Such adverse events are currently unpredictable. This study investigated whether age, sex or bodyweight influenced the outcome. METHODS: A total of 110 patients who had bilateral ETS for palmar hyperhidrosis or facial symptoms (blushing or sweating) were asked to complete a questionnaire before and after surgery regarding physical and emotional symptoms, and overall satisfaction. RESULTS: Seventy-nine usable questionnaires were obtained. A decrease (an improvement) in physical symptom score was found in all patients; the median (interquartile range) change was - 15 (-9 to - 18) for facial symptoms and - 8 (-6.75 to - 9) for palmar symptoms. Similarly, there was an improvement in emotional symptom score of - 16 (-8 to - 28) for facial symptoms and - 13 (-7.25 to - 18.5) for palmar symptoms. More compensatory sweating was noted in those treated for facial symptoms (P = 0.007). There was no influence of age, sex or body mass index on outcome. CONCLUSION: ETS is an effective treatment for palmar and facial symptoms. Side-effects may be worse in patients treated for facial symptoms.

Drawbacks of endoscopic thoracic sympathectomy.

BACKGROUND: Endoscopic thoracic sympathectomy (ETS) has come into widespread use for palmar hyperhidrosis and other complaints of the upper limb and of the head and neck, but there are concerns about its safety. This review highlights the operative complications and long-term side-effects that may occur. METHODS: A Medline search was carried out using the terms 'thoracoscopic sympathectomy', 'endoscopic thoracic sympathectomy' and 'complications'. References from identified articles were handsearched for further relevant articles. The senior author's experience and personal communications were also taken into account. RESULTS AND CONCLUSION: No death following ETS has ever been reported in the literature, but nine anecdotal fatalities are known, five resulting from major intrathoracic bleeding and three from anaesthetic mishap. Significant intrathoracic bleeding may occur in up to 5 per cent of patients but only a minority require thoracotomy; pneumothorax occurs in 2 per cent of patients and two instances of brain damage are known. In the longer term compensatory hyperhidrosis is extremely common and 1-2 per cent of patients regret having had surgery because of its severity. Horner's syndrome, on the other hand, is rare. Improvements in instrumentation, adequate training and careful patient selection may help reduce the drawbacks of ETS.

The technique of endoscopic thoracic sympathectomy: resection, clipping and cautery.

Three authors describe their individual technique for performing ETS. These are 1) a two-port approach under singlelung ventilation using a double-lumen tube and cutting the chain, 2) a two-port approach under endotracheal or mask anesthesia and clipping of the chain, and 3) a single-port approach under endotracheal or mask anesthesia and cautery of the chain. The sections are purely didactic and no attempt is made to compare or contrast the methods.