[Plastic surgery of the penis after circumcision]

One of the possible complications of circumcision is excessive resection of penile skin. This technical note describes two penile plasty techniques using scrotal skin after excessive circumcision.

Dystrophic calcification of the radial artery

The radial artery continues to enjoy resurgence in popularity as a conduit for coronary artery bypass grafting but few studies have examined the prevalence of preexisting disease in this vessel. We highlight a potential, avoidable pitfall when use of the radial artery for coronary artery bypass grafting is proposed.

[Surgical techniques to deal with lens nucleus' fragment of posterior capsular rupture during the phacoemulsification]

OBJECTIVE

To investigate some surgical techniques in dealing with a impending dropped nucleus when posterior capsular rupture during the phacoemulsification.

METHODS

The postoperative results of 18 cases (18 eyes) whose posterior capsular of lens ruptured with a impending dropped nucleus during the phacoemulsification were studied retrospectively. Three surgical techniques to prevent lens nucleus' fragments dropping into the vitreous cavity were applied. They are consecutive phacoemulsification with lower flowing rate and lower irrigation, injection of viscoelastic substance with high elasticity and anterior segment vitrectomy with no irrigation. The follow-up was 12-24 months (average, 18.2 months).

RESULTS

Except for a special case, no lens nucleus' fragments dropped into the vitreous cavity. Posterior chamber intraocular lens(IOL) was implanted primarily in all cases (18 eyes). Best corrected visual acuity was above 0.5 in 15 eyes (83.3%). The main complications included corneal edema and cystoid macular edema.

CONCLUSION

With safety, effectiveness and less complications, these three surgical techniques are suitable to deal with different types of impending dropped lens nucleus' fragments during the phacoemulsification. It is advisable to apply these techniques in clinical practice.

[Intraoperative cholangiography in laparoscopic cholecystectomy for acute cholecystitis]

In our prospective study we wanted to prove whether the safety of laparoscopic treatment of acute cholecystitis could be improved by intraoperative cholangiography. From July 1993 to June 1998 210 patients with acute cholecystitis underwent a laparoscopic cholecystectomy. In 23 cases (10.9%) a conversion was necessary. 189 patients underwent a laparoscopic cholangiography. In 2 cases (1.1%) an incision of the common bile duct was detected which had been mistaken for the cystic duct. So the cutting of the common bile duct could be prevented. In 12 patients (6.3%) unknown common bile duct stones were found. The complication rate was 9.5% without any mortality or major injury of the common bile duct.

A simple way to treat chronic atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach

OBJECTIVE

We describe an original radiofrequency ablation technique to treat chronic atrial fibrillation in patients undergoing mitral valve surgery. Most of the procedure is carried out epicardially, in order to avoid an undue increase of surgical time and trauma.

METHODS

The ablations are performed using a temperature-controlled multipolar radiofrequency catheter. Two encircling lesions around the ostia of the right and of the left pulmonary veins are carried out epicardially, usually before cardiopulmonary bypass. Through a conventional left atriotomy the ablation procedure is completed with two endocardial lesions connecting the two encirclings between them and to the mitral valve annulus. After the mitral valve procedure is performed, the left appendage is sutured.

RESULTS

From February 1998 to May 1999, 40 patients with chronic atrial fibrillation (43. 1+/-51.9 months) underwent combined radiofrequency ablation and mitral valve surgery. Mean left atrial diameter was 56.8+/-10.7 mm. Mean cardiopulmonary bypass and aortic cross-clamp time were, respectively, 119.1+/-26.3 and 76.7+/-21.0 min. Mean postoperative blood loss was 287.2+/-186.6 ml. No reexploration for bleeding occurred. One patient died of pneumonia 12 days after operation. No patient needed permanent pacemaker implantation. Mean postoperative hospital stay was 7.3+/-5.6 days. At follow-up (mean 11.6+/-4.7 months), 30/39 (76.9%) of the patients were in stable sinus rhythm. All patients in sinus rhythm 3 months after operation recovered both left and right atrial contractility at echocardiographic control (mean 7.3+/-3.4 months). The left atrial diameter decreased significantly in patients recovering sinus rhythm.

CONCLUSIONS

Epicardial radiofrequency ablation is a safe means to achieve surgical ablation of atrial fibrillation with a high success rate. The simplicity of the technique and the low procedure-related risk should dictate combined treatment virtually in all patients with atrial fibrillation undergoing open heart operations.

Perforation of the posterior tracheal wall during percutaneous dilatational tracheotomy

Dilatative percutaneous tracheotomy is more and more indicated in intensive-care medicine. We report on the perforation of the posterior tracheal wall observed in 3 patients after this procedure. In 2 patients the tracheo-oesophageal fistula was closed by the use of a pediculated flap from the infrahyoideal muscle. The third patient died due to the underlying disease. As demonstrated by the 3 cases reported here, this complication cannot be avoided in every case neither by the use of an endoscope nor by extensive personal experience of the physician. The possibility of this complication should be known, because it seems to be typical of this procedure. In the case of perforation of the posterior tracheal wall, active surgical treatment seems to be a successful method to deal with this complication.

Intraoperative carotid evaluation

HYPOTHESIS

Intraoperative duplex scanning can identify technical defects and increase the quality of carotid artery repair.

DESIGN

We evaluated 100 consecutive carotid operations in 96 patients (60 men and 36 women) from 1995 to 1998. Spectral-derived peak systolic flow velocities (PSV) were graded (PSV < 100 cm/s, normal laminar flow; PSV 100-150 cm/s, mild or moderate flow disturbance; PSV > 150 cm/s, severe flow disturbance). Prospective criteria for intraoperative revision included PSV greater than 150 cm/s, spectral broadening, and B-mode imaging of intimal flaps or intraluminal debris. Preoperative, intraoperative, and 6-week follow-up duplex scan results were analyzed.

SETTING

All patients were evaluated and treated at a single academic institution.

INTERVENTIONS

All procedures were performed with the patient under general endotracheal anesthesia; 86% underwent shunting and 70% underwent patching.

MAIN OUTCOME MEASURE

Number and type of revisions, patency of repair, residual and recurrent stenosis, and ipsilateral neurologic events.

RESULTS

There were 33 intraoperative duplex studies with abnormal findings. Seven involved the common carotid artery and resulted in intraoperative revision of 5 intimal flaps at the site of the proximal clamp. In 11 patients, incomplete eversion endarterectomy resulted in elevated distal intimal flaps in the external carotid artery that were repaired through a separate arteriotomy. There were 15 abnormalities in the internal carotid artery prompting 5 revisions. Five studies with PSV of 100 to 150 cm/s had no defects on B-mode imaging and were observed without treatment. Five false-positive studies were attributed to increased flow velocity due to contralateral occlusive discase. At 6 weeks' follow-up, 4 of 5 repaired common carotid arteries were normal on duplex scan and 1 had a mild residual stenosis. Ten of the 11 external carotid repairs were patent and 1 was occluded. Four of the 5 internal carotid artery repairs were normal on postoperative evaluation and 1 had a mild residual stenosis. Of the 10 abnormal internal carotid arteries that were observed, 9 were normal on postoperative duplex and 1 had a mild residual stenosis. One perioperative stroke occurred in a patient with a normal, patent carotid repair.

CONCLUSIONS

Intraoperative duplex evaluation of carotid reconstruction is an efficient, sensitive tool that can detect technical lesions that will jeopardize surgical reconstruction. Interpretive judgment is required because all flow disturbances do not dictate surgical intervention. This technique enables the surgeon to maximize the quality of the arterial reconstruction during carotid artery surgery.

Microkeratome complications of laser in situ keratomileusis

PURPOSE

To evaluate the incidence, types, and outcome of microkeratome complications that occur during laser in situ keratomileusis (LASIK).

DESIGN

Retrospective, noncomparative, case series.

PARTICIPANTS

Three thousand nine hundred ninety-eight eyes that underwent primary LASIK by four surgeons between November 1996 and August 1998 at a university-based refractive center.

METHODS

All cases with significant microkeratome complications leading to abandonment of the LASIK procedure were identified and reviewed.

MAIN OUTCOME MEASURES

Incidence of complications, change in best corrected visual acuity (BCVA), change in refractive error, and types of complication.

RESULTS

There were 27 complications leading to abandonment of the LASIK procedure of 3998 eyes. The overall rate of microkeratome complication was 1 in 150 (0.68%), but it was 1 in 77 (1.3%) in the surgeons' first 1000 eyes, decreasing to 1 in 250 (0.4%) in the last 1000 eyes. Of the 24 planned bilateral cases, 15 complications (63%) happened on the first operated eye. Twenty-six of 27 eyes (96%) recovered to within one line of preoperative BCVA, and one eye lost two lines. At last examination before any repeat refractive procedures, spherical equivalent manifest refraction returned to within 1 diopter (D) of its preoperative value in 18 of 19 eyes (95%), and astigmatism in 16 of 19 eyes (84%) returned to within 1 D of its preoperative value. Sixteen of 27 eyes (59%) had repeat LASIK. Two eyes had complications at repeat LASIK, one of which led to abandonment of the LASIK procedure for a second time.

CONCLUSIONS

There is a significant learning curve in the use of the microkeratome. If ablation is not performed, flap complications rarely lead to significant visual loss and generally do not result in a change in refractive error.

Delayed toe transplantation: experimental study and clinical application

Delay of the operation in toe transplantation was performed with circulatory crisis, and 100 percent survival of the transplants was achieved. In 10 cases of toe transplantation in which circulatory crisis occurred, the operation was delayed. The vascular pedicle was divided, and the toe was transferred 17 to 21 hours after the donor toe was dissected. To investigate the mechanism of delayed toe transplantation, experiments in rabbits were carried out. In 36 rabbits, the hind limbs were severed except for the vascular pedicle. The endothelin content and nitric oxide content of the tissues in the hind limb and the arterial wall were tested in postoperative intervals of 4, 8, 16, 24, and 48 hours, respectively. The results showed that in 10 cases of delayed toe transplantation, all toes survived. As for the results of the experiment, there was significant increase of endothelin content and decrease of nitric oxide content in the local tissues and the arterial wall 4 to 8 hours after the operation. In postoperative 16 to 24 hours, endothelin content returned to normal level, and nitric oxide content increased remarkably. It is concluded that delayed pedicle division and toe transfer is an effective method in toe transplantation with vascular variations and circulatory crisis. The mechanism is related to the endothelin and nitric oxide content in the local tissue and the arterial wall. The indications for delayed toe transfer are also discussed.

[Conventional aortic surgery after endovascular aortic reconstruction]

INTRODUCTION

Endovascular therapy of aortic aneurysms is an attractive alternative to conventional aortic surgery. A number of patients, however, will fail endovascular therapy and require open surgical repair.

METHODS

We report our experience with conversion to open aortic repair. Of 306 patients given endovascular therapy for an infrarenal aortic aneurysm, 30 (9.8%) required conversion to conventional repair.

RESULTS

Thirteen patients (43.3%) suffered complications, 3 (10%) of which were fatal. Conversion to open aortic repair after endovascular therapy is technically more demanding than primary open repair, particularly because of clamp techniques and stent-extraction.

CONCLUSIONS

Emergent conversion operations, especially when preceded by significant retroperitoneal bleeding from vascular tears due to endovascular manipulations are complicated by significant morbidity and mortality.

Surgical injury of the biliary tract in children

A retrospective clinical study was performed to evaluate the etiology, incidence, diagnosis, management and outcome of patients presenting with surgical injury to the biliary tract. 4 boys were treated for operative biliary tract injuries between 1970 and 1997. This number represents less than 0.03% of all patients who underwent laparotomy in our unit during the same period. The mean age of the patients at presentation was 7.5 +/- 3 (range, 4 to 10 years). Accidental ligation of choledochus (n = 2), vascular insult of the biliary tract (n = 1) and formalin toxicity (n = 1) were the causes of injuries. The latter presented with caustic sclerosing cholangitis and biliocutaneous fistula while obstructive cholangitis (n = 2) and jaundice (n = 1) were noted in the remaining patients. The duration between surgical injury and presentation ranged from 6 to 125 days. All patients presented with elevated levels of transaminases, alkaline phosphatase and bilirubin. Ultrasonography, percutaneous transhepatic cholangiography and biliary drainage catheter placement were performed in all patients to visualize the extent of injury and to provide better patient status for operation. Biliary stent application provided temporary relief of obstruction in one patient, but all patients required surgical treatment subsequently. Roux-en-Y hepaticojejunostomy (n = 3), and choledochoduodenostomy (n = 1) were the operative procedures. No complications were encountered in the short and long-term follow-up. Our experience revealed that surgical biliary tract injuries have special features that warrant consideration with respect to prevention and management in children. They may be caused by partial or complete transection, suture ligation, clip application or vascular insult and can be avoided by adequate exposure, accurate gentle dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. The presenting clinical picture depends on the cause, extent and duration of the injuries. Preoperative detailed evaluation of the hepatobiliary system by radiological and endoscopic means is mandatory for successful treatment. Percutaneous and/or endoscopic techniques can be employed in selected cases, but if these fail or can not be done, open surgical techniques should be performed without hesitation as delayed treatment results in biliary cirrhosis and hepatic failure. Excision of excessive scar tissue at the biliary tract and portal hilus, constructing the widest possible stoma, obtaining mucosa to mucosa approximation around 360 degrees, enduring a good blood supply to the anastomotic line and avoiding tension on the anastomosis are mainstays of successful surgery. Thus, reconstructive biliary tract surgery should be considered as a specialized procedure and should be performed by skillful and experienced hands.

The plug and patch: a new technique for repair of corporal perforation during placement of penile prostheses

PURPOSE

Proximal corporal perforation is an uncommon intraoperative complication during placement of a penile prosthetic device. Unrecognized corporal perforation can result in migration or malfunction of the prosthesis. A windsock repair using a nonabsorbable mesh plug has been described. We describe a new technique called the plug and patch to treat this complication.

MATERIALS AND METHODS

From July 1994 to May 1999, 175 patients underwent placement of a penile prosthesis at our institution. Of the patients 8 (4.5%) had proximal corporal perforation. Each perforation was repaired using our plug and patch technique. A 5x7 cm. polyglycolic acid patch was folded on itself and passed into the area of the corporal perforation to act as a plug. A solitary absorbable suture was placed affixing the tail of the patch to the corpora. The corpus was subsequently re-dilated and remeasured, and the prosthesis was placed as usual.

RESULTS

All 8 patients were satisfied with the penile prosthesis. There were no infectious complications or proximal migration of the prosthetic cylinders. The plug repair added an average of 6 minutes to the operating time. Only 1 patient had discomfort in the area of the repair, which resolved spontaneously approximately 6 weeks postoperatingly.

CONCLUSIONS

The plug and patch is a rapid and effective technique to repair intraoperating proximal corporal perforations. Potential advantages include shorter operating time, technical simplicity and the use of only absorbable materials. This technique may result in lower infection rates compared to the standard windsock repair.

Intra-operative premature rupture of the cerebral aneurysms. Analysis of the causes and management

The causes and management of intra-operative premature rupture are analysed and discussed. During the past 6 years, the authors, performed 398 consecutive direct surgical interventions for ruptured cerebral aneurysms. Intra-operative premature rupture is defined as a rupture which occurs before the securing of the parent arteries or the neck of the aneurysm and is out of control, at least temporarily. The causes and management were retrospectively analyzed by reviewing video tape recordings. Intra-operative premature ruptures which met the above definition occurred in 24 cases (6.0%). The causes were as follows: 1.) dural opening and arachnoid opening (8.3%), 2.) haematoma removal (12.5%), 3.) brain retraction (16.7%), 4.) aneurysm dissection (62.5%). A double suction technique was used to control bleeding and haemostasis with a small piece of cotton or a temporary clip, performed in 20 cases (83.3%). However, in cases with premature rupture immediately after the dural or arachnoid opening, the extension of the haematoma into the subarachnoid space resulted in severe brain swelling and partial resection of the brain had to be done to secure temporary clipping. The double suction technique and primary haemostasis using a small piece of cotton or temporary clip resulted in good outcome even in cases with premature rupture. However, very early premature rupture also occurred although its incidence was extremely rare. The removal of part of the brain can secure the working space but the outcome was poor.

Alternative tricortical methods of screw implantation for anterior cervical plate fixation: a preliminary report

An experience with 26 cases of anterior cervical interbody plate fixation with an alternative method of screw implantation is described. The follow up ranges from 15 to 51 months. The screws are placed obliquely such that they engage the anterior cortex of the body and traverse through the cortices adjoining the disc space. By this method the screws not only hold the plate firmly with a tricortical purchase, but also, by virtue of their course, stabilise the two adjoining vertebral bodies by themselves. In five of these cases only tricortical screws without the metal plate were used for fixation. Cortico-cancellous iliac crest bone graft shredded into small pieces is placed between the vertebral bodies after adequately preparing the bed. A 100% bony union rate was achieved, with no morbidity or instrument fatigue or failure. The described technique of plate fixation appears to be biomechanically stronger. It provided a rigid segmental internal fixation permitting early mobilisation of the patient with minimal external support.

A case of living-related partial liver transplantation using the right gastroepiploic artery for hepatic artery reconstruction

A 13-year-old boy with liver cirrhosis underwent living-related partial liver transplantation with a left lobe from his mother. A standard hepatic artery reconstruction using the recipient right hepatic artery was anticipated. Unfortunately, the recipient hepatic artery was found to be severely arteriosclerotic and was unsuitable for reconstruction. Instead, the right gastroepiploic artery, measuring 2.0 mm in diameter, was mobilized and was anastomosed to the left hepatic artery of the graft in an end-to-end fashion. Arterial blood flow was satisfactory. The patient's postoperative course was uneventful, and he was transferred to a floor bed on the 5th postoperative day.

Tilting disc versus bileaflet aortic valve substitutes: intraoperative and postoperative hemodynamic performance in humans

BACKGROUND AND AIM OF THE STUDY

Due to an asymmetrical/eccentric flow profile at the level of the aortic valve, there is an optimal orientation for each aortic valve design. This study evaluates intraoperative flow dynamics (turbulence and pressure gradient) and follow up results (pressure gradient and left ventricular mass regression) for Medtronic Hall tilting disc (MH) and St. Jude Medical bileaflet (SJM) valves, with both valves in their optimum orientation as defined in previous animal experiments.

METHODS

In a randomized prospective study, MH and SJM valves (size > or = 23 mm) were implanted in their optimum orientation in 24 patients with aortic stenosis. Turbulence measurements were performed intraoperatively via a perivascular ultrasound transducer; Reynold's normal stress (RNS) values were calculated as key markers for turbulent stresses. Transvalvular pressure gradients, interventricular septum and posterior wall thickness were measured by transesophageal echocardiography intraoperatively and six months postoperatively.

RESULTS

Mean valve size was 23.8 mm in both groups. Intraoperative RNS values (MH 7.5 +/- 2.2 N/m2 versus SJM 9.8 +/- 2.3 N/m2) and pressure gradients (MH 10.0 +/- 2.6 mmHg versus SJM 20.0 +/- 3.4 mmHg) were significantly lower for the tilting disc valve. At six months follow up, pressure gradients were reduced by half for both valves (MH 5.3 +/- 1.7 mmHg; SJM 10.4 +/- 2.3 mmHg), with the difference between the valves being maintained. Left ventricular mass regression was accelerated for MH patients with regard to interventricular septum thickness.

CONCLUSION

Our results indicate that the tilting disc mechanism shows superior hemodynamic performance with respect to turbulence and transvalvular pressure gradients compared with the bileaflet mechanism when both valves are implanted in their optimum orientation. This led to significant acceleration of interventricular septum mass regression. The superiority of the tilting disc mechanism is more pronounced in the smaller-sized valves.

[Iatrogenic injury of the pelvic artery during hip joint replacement and errors in the treatment of this complication]

The authors present the case-history of a serious injury of the pelvic artery in a 70-year-old female patient during replacement of the hip joint, incl. some errors made in the treatment of this complication. The authors discuss medical and organizational aspects of the solution of this case.

Risk of intraoperative aneurysm clip slippage: a new experience with titanium clips

Slippage of an aneurysm clip as a result of insufficient clip-closing force cannot be predicted, even when using force-testing devices. Descriptions of intraoperative clip slippages are rarely found in the literature. The authors summarize four unusual cases in which titanium aneurysm clips slipped by a scissorslike mechanism during surgery. They analyze the possible factors implicated in such a dangerous situation and discuss corrective choices.

[Results of routine intraoperative cholangiography]

Most bile duct injuries result from an incorrect interpretation of bile duct anatomy. In 500 laparoscopic cholecystectomies we used a modified technique of cholecystcholangiography. This method is very easy and needs only 5 minutes. We found variants of bile duct anatomy in 74 cases and occult bile duct stones in 20 patients. We recommend this method which decreases the risk of bile duct injuries and gives the opportunity to approximate the golden standard of conventional cholecystectomy.

[Prevention and management of complications with laparoscopy cholecystectomy]

OBJECTIVE

To prevent the complication of laparoscopy cholecystectomy (LC).

METHODS

This text analysed 1,200 cases retrospectively with LC from Feb. 1993 to May. 1998.

RESULTS

Three cases with biliferous duct injury, two cases with bile leakage from the stamp of cystic duct, two cases with gallbladder artery injury.

CONCLUSIONS

Strict preoperative examination and standard operative procedure can reduce markedly complication of LC.