Disruption and infection of median sternotomy: a comprehensive review

Disruption and infection of median sternotomy wounds are grave complications often associated with prolonged hospitalization, high cost, and significant mortality. Effective prevention techniques are still debated. Successful management requires early recognition based on a high index of suspicion, detailed physical examination, appreciation of the clinical signs and symptoms, timely imaging studies, and prompt surgical therapy. Improvements in perioperative management and critical care of patients with multisystem organ failure can reduce morbidity and mortality rates. Sternal salvage and direct sternal reclosure are possible when the infection is diagnosed early. Techniques utilizing lateral sternal support should be first-line options in the condition. Muscle flap techniques should be the next consideration when direct closure has failed or cannot be attempted.

Entero-colocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: case report and review of the literature

BACKGROUND

The underlying risk associated with visceral mesh erosion is the close opposition of adjacent intestines to the prosthetic graft. This highly morbid condition has been described with most types and techniques of abdominal wall mesh repair.

PATIENT

We report the case of a 52-year-old man who presented with an entero-colocutaneous fistula 10 years after prosthetic mesh repair of an incisional hernia. The fistula was excised and the abdominal wall defect repaired with a tissue-impervious composite.

CONCLUSIONS

The use of a tissue-impervious barrier avoids development of enteric fistula when a prosthesis is placed directly over the viscera.

Biomechanical comparison of median sternotomy closures

BACKGROUND

Poor healing of median sternotomy can significantly increase morbidity, mortality, and hospital costs. Effective union requires reliable sternal fixation. Although wire has proven the most reliable and widely used sternotomy closure material, no experimental studies have compared a large variety of wiring techniques in a human model. We developed an easily reproducible experimental model using cadaveric human sterna and compared several wiring methods to assess closure strength and stability.

METHODS

Fifty-three fresh adult human cadaveric sternal plates with adjacent ribs were fixed with specially designed spiked stainless steel clamps and attached to a texture analyzer. Single peristernal and transsternal, alternating single peristernal and transsternal, figure-eight peristernal, figure-eight pericostal, and Robicsek closures using no. 5 stainless steel wires were tested. We evaluated bone density, stiffness, and displacement using perpendicular, repetitive variable force loads of 800 Newtons cycling at a rate of 0.5 mm/s.

RESULTS

There were no significant differences in age, sex, or bone density in outcome measures of the sternal groups. No clamp failures or clamp damage to the specimens occurred. The single peristernal and alternating peristernal and transsternal closures proved superior in strength and stability (p < 0.001). The figure-eight peristernal, then the single transsternal, then the Robicsek were next stablest groups in decreasing order. The figure-eight pericostal closure had the highest failure rate (p < 0.001).

CONCLUSIONS

This novel model of sternotomy closure testing was reliable, inexpensive, and easily reproducible. The mechanical stability of peristernal and alternating peristernal and transsternal wires was significantly greater than that of the other tested methods. Pericostal figure-eight closures were not sufficiently stable to be considered a reliable method of primary sternotomy repair.

Handlebar hernia: ultrasonography-aided diagnosis

Traumatic hernia resulting from blunt impalement of the abdominal wall, known as "handlebar hernia," is seldom addressed in the surgical literature, with only 28 previously reported cases. We describe our experience with this rare traumatic hernia diagnosed by physical examination and confirmed by ultrasonography. Published reports suggest handlebar hernia's potential for serious underlying injury and the diagnostic importance of computed tomographic scanning. The case presented here demonstrates the value of bedside ultrasonography in diagnosis confirmation and surgical planning for this condition.

Congenital posterolateral diaphragmatic hernia in an adult

A Bochdalek hernia (BH) occurs when abdominal contents herniate through the posterolateral segment of the diaphragm. Most BHs present with life-threatening cardiorespiratory distress in the neonatal period. Rarely, hernias that remain clinically silent until adulthood present as life-threatening surgical emergencies. Our recent experience with a life-threatening emergency due to a BH in a 29-year-old male patient prompted us to reinforce that this entity does exist in adults and should be considered in the differential of acute abdominal pain.

Cyanoacrylate adhesive in management of severe presacral bleeding

Effective hemostasis is critical in severe presacral hemorrhage because the bleeding may be fatal. We report our successful use of combined hemostatic sponge and cyanoacrylate glue in three patients with life-threatening presacral hemorrhage after abdominoperineal resection of the rectum for carcinoma.

Mesenteric cystic lymphangioma: unusual cause of intra-abdominal catastrophe in an adult

Mesenteric cystic lymphangiomas (MCLs) are rare benign cystic tumours of unknown aetiology, most often seen in paediatric patients. The clinical presentation is diverse, ranging from an incidentally discovered abdominal cyst to symptoms of acute abdomen. A 20-year-old male presented with generalised abdominal pain, nausea and vomiting of several hours duration following heavy lifting. Emergency laparotomy revealed a 15 x 10 x 8-cm pedicled cystic mass of the mid-ileal mesentery, causing a volvulus. The cyst and a 20-cm gangrenous intestinal segment were resected with anastomosis. The postoperative course was uncomplicated. MCLs should be included in the differential diagnosis of cystic intra-abdominal lesions. Even when asymptomatic and discovered incidentally, they must be treated surgically because of the potential to grow, invade vital structures and develop life-threatening complications.

Recurrent intercostal herniation of the liver

Abdominal intercostal hernia occurs rarely, with only 26 previous cases reported in the professional literature. A 51-year-old man presented with a painful right chest protrusion. One year earlier he had experienced a severe coughing spell and spontaneous rib fracture and chest protrusion. He was treated with endogenous tissue reinforcement and had no clinical improvement. Magnetic resonance imaging revealed the liver protruding through the chest wall. The hernia was reduced and the chest wall was repaired with prosthetic mesh and cables. Attention to the chest wall anatomy and reliable tissue closure including pericostal or transcostal nonabsorbable sutures and a prosthetic bridge over the defect are the best way to eliminate the patient's risk for recurrence.

Single wire versus double wire loops for median sternotomy closure: experimental biomechanical study using a human cadaveric model

BACKGROUND

Healing of median sternotomy requires reliable sternal fixation. Although both single and double wire kits are commercially available, no experimental study has compared the two closures in a human cadaveric model. We used a recently described human experimental cadaveric model to compare the stability of the closures.

METHODS

Sixteen fresh adult human cadaveric sternal plates with adjacent ribs were fixed with custom designed spiked stainless steel clamps and attached to a biomechanical testing device. Single No. 5 peristernal and double peristernal closures were tested. The stability of the unions was tested using perpendicular, repetitive force loads increasing from 0 to 800 Newtons at a rate of 0.5 mm/second.

RESULTS

The two study groups did not differ in age or sex. No clamp failures or damage to the specimens occurred. The double peristernal closure exhibited a significantly lower permanent displacement than the single wire group, suggesting a superior strength and stability of that closure.

CONCLUSIONS

To the extent to which this human cadaveric model resembles in vivo median sternotomy, these data suggest that the biomechanical stability of the peristernal double wire closure may exceed that of single wires.

Sciatic hernia: a comprehensive review of the world literature (1900-2008)

BACKGROUND

Sciatic hernias are considered the rarest pelvic floor hernias, with a very limited number of published reports worldwide. The condition has received limited attention in the surgical literature.

DATA SOURCES

The data reported herein are based on a literature review including MEDLINE and CURRENT CONTENTS computerized database searches. The existing bibliographies on sciatic hernia were explored for articles pertaining to the review. Finally, the Internet was searched for articles not listed in the available medical databases.

CONCLUSIONS

Sciatic hernia is unusual, and can present the physician with diagnostic and treatment dilemmas. The hernia may present with obscure pelvic pain, intestinal obstruction, life-threatening gluteal sepsis, or as an asymptomatic, reducible mass that distorts the gluteal fold. Small sciatic hernia can remain hidden behind the gluteus maximus muscle. The diagnosis requires imaging studies in such cases. Treatment of sciatic hernia is always surgical and requires prosthetic reinforcement for the best result.

Subxiphoid incisional hernias after median sternotomy

BACKGROUND

Subxiphoid incisional hernias are notoriously difficult to repair and are prone to recurrence. The few reports on subxiphoid hernia published over the last two decades have not fully addressed the etiology, pathology, treatment, and outcome of this problem. This review was performed to analyze the published experience and increase the understanding of these difficult hernias.

METHODS

We reviewed the extensive literature, including the Medline and Current Contents computerized database searches, and searched the available bibliographies.

RESULTS

Seven retrospective studies of a total of 113 patients who had clinical subxiphoid hernias after median sternotomy were found. An additional surgical technique describing a modified median sternotomy preventing the hernia, and a single review article on selected technical considerations of subxiphoid ventral repair were also found.

CONCLUSIONS

The incidence of subxiphoid hernia after median sternotomy can be possibly reduced by paraxiphoid extension of the sternotomy, reinforcement near the xiphoid end of the incision, or by optimizing closure of the distal sternotomy and the linea alba. Abdominal wall reinforcement by open-mesh closure or laparoscopic transperitoneal prosthetic repair can effectively deal with the defect. Long-term outcome analyses are not yet available.

Spigelian hernia in a child: case report and review of the literature

Spigelian hernias (SHs) are rarely observed among children. The diagnosis is not difficult to make once it has been considered. The condition requires a high index of suspicion because of its high potential for life-threatening complications. A 12-year-old boy underwent open appendectomy for presumed acute appendicitis. A normal appendix found at laparotomy suggested another etiology for the acute abdomen. Incarceration of the greater omentum in a spigelian hernia was found, and the hernia repaired. The repair of pediatric SH is straightforward and utilizes endogenous tissues. Patients should be followed up for as long as possible to develop data on the durability of the repair technique selected.

Trocar-site hernia complicated by necrotizing fasciitis--case report and review of the literature

Only a few reports have been published describing necrotizing soft tissue infection (NSTI) following laparoscopic surgery; none identify trocar-site hernia as an etiologic factor. We present a case report and review of the literature. A 43-year-old previously healthy man underwent uneventful laparoscopic cholecystectomy. An unrecognized strangulated lateral trocar-site hernia resulted in fatal NSTI. A Medline database search (1966-2002) identifies ten detailed reports of NSTIs following laparoscopic surgery. Multiple risk factors were identified in almost all patients. The mortality rate was 20%. Patient survival from NSTI requires early recognition, aggressive surgical intervention, and intensive medical care. NSTI can occur following minimally invasive surgery, and physicians should maintain a high index of suspicion when patients begin to develop postoperative symptoms. Trocar-site hernia arises as another etiologic factor for NSTI in the domain of minimally invasive surgery.

Recurrent Spigelian hernia: a rare cause of colonic obstruction

Spigelian hernia is considered a surgical rarity. Recent articles describe only six recurrent hernias and a scant number of patients with colonic obstruction resulting from incarceration. A patient with intestinal obstruction resulting from recurrent Spigelian hernia with strangulated colon is described. The patient underwent tension-free repair using a prosthetic mesh. Recent literature suggests that the deficiency of connective tissue in patients with hernias justifies the widespread use of permanent mesh for tissue reinforcement and avoidance of recurrences. The rare case presented should be regarded as an illustrative example for application of the tension-free repair principle in the definitive management of recurrent Spigelian hernia.

Palisade dorsoventral lavage for neglected peritonitis

A modification of the procedure of laparostomy with palisade dorsoventral lavage for treating neglected peritonitis is described. It consists of adding a polyethylene foil to cover the intestines and thus avoiding the direct contact between them from one side, and the suction drains and the palisade laparostomy screen from the other. Between 1988 and 1995, 19 patients with neglected peritonitis (APACHE II scores from 12 to 42; mean 22.3) were managed using this modified technique. A total of 81 reexplorations were done (average, 4.3 reexplorations per patient). The technique proved effective (21% mortality, n = 4). No intestinal perforations, fistulas, or residual pus collections occurred among survivors or among those who died. Primary fascial closure was achieved in all survivors and during an 18-months followup, no incisional hernia occurred. Based on these results, we believe this technique is extremely useful when both laparostomy and continuous peritoneal irrigations are considered in patients with neglected peritonitis.

Gastrointestinal "crosses": an indication for surgery

BACKGROUND

We present our experience with a unique type of foreign body that was specifically designed to arrest in its passage and cause perforation of the gastrointestinal tract.

STUDY

Between 1994 and 1999, nine male prisoners from the same jail presented after ingestion of "crosses." A cross is constructed from the two halves of a standard paperclip that are tied together with a rubber band. The resulting construction is elastic: the two branches can be pulled to lie parallel, but they assume their original position once released. The cross is wrapped into paper with its branches parallel and ingested. After release from the wrapper, it "opens" and causes bowel perforations.

RESULTS

All patients underwent emergency surgery for foreign body removal and treatment of peritonitis. A total of 19 crosses were removed from the patients. Six (32%) were found in the stomach; five, in the duodenum (28%); three, in the jejunum and ileum (16%); and one, in the pylorus and colon. There was no morbidity or mortality.

CONCLUSIONS

Foreign bodies of this type never pass distally. The ultimate key to success in the management of patients who have ingested crosses is emergency surgical intervention.