Easy and successful treatment of pilonidal sinus after explanation of its causative process

Hair insertion causes pilonidal sinus, it prevents spontaneous recovery, delays healing of any wound in the depth of the natal cleft, and is the cause of recurrence. An understanding of the hair insertion process made it possible to avoid hair insertion in 6545 cases of the condition with the use of the advancing flap operation. Results have proved this to be an easy and successful way of treating and preventing recurrence of pilonidal sinus. Furthermore, that understanding has introduced the possibility of preventing pilonidal sinus, through ways simpler than the simplest operation.

Meta-analysis of techniques for closure of midline abdominal incisions

BACKGROUND

Various randomized studies have evaluated techniques of abdominal fascia closure but controversy remains, leaving surgeons uncertain about the optimal method of preventing incisional hernia.

METHOD

Medline and Embase databases were searched. All trials with a follow-up of at least 1 year that randomized patients with midline laparotomies to closure of the fascia by different suture techniques and/or suture materials were subjected to meta-analysis. Primary outcome was incisional hernia; secondary outcomes were wound dehiscence, wound infection, wound pain and suture sinus formation.

RESULTS

Fifteen studies were identified with a total of 6566 patients. Closure by continuous rapidly absorbable suture was followed by significantly more incisional hernias than closure by continuous slowly absorbable suture (P < 0.009) or non-absorbable suture (P = 0.001). No difference in incisional hernia incidence was found between slowly absorbable and non-absorbable sutures (P = 0.75), but more wound pain (P < 0.005) and more suture sinuses (P = 0.02) occurred after the use of non-absorbable suture. Similar outcomes were observed with continuous and interrupted sutures, but continuous sutures took less time to insert.

CONCLUSION

To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure.

Comparison of robotic versus laparoscopic skills: is there a difference in the learning curve?

OBJECTIVES

To evaluate the learning curve between robot-assisted and manual laparoscopic suturing, as well as to assess other skills. Laparoscopic reconstructive procedures have been limited by instrumentation, small working spaces, and fixed angles at the trocar level to place sutures. Robot-assisted laparoscopic suture placement may provide one means of increasing dexterity and facilitating laparoscopic reconstructive procedures.

METHODS

Eight physicians participated in this study. A series of five trials were performed to assess dexterity (task 1) and free-hand suturing (task 2). Each task was performed using robot-assisted and manual laparoscopy. The participants were categorized as novice and experienced laparoscopists. Task 1 involved passing sutures through the eye of seven needles positioned 1 cm apart in a P configuration. Task 2 involved tying one surgeon's knot, followed by two subsequent knots.

RESULTS

The average time for trials 1 and 5 of task 1, robot-assisted laparoscopy, was 242.6 and 101.8 seconds, respectively (P <0.001). Both groups demonstrated a statistically significant difference (P <0.001) between the first and last trial. The average time for trials 1 and 5 of task 1, manual laparoscopy, was 205.3 and 169 seconds, respectively. The differences in the learning curves for robot-assisted and manual laparoscopy were statistically significant in favor of robotic assistance. Manual laparoscopic suturing did not demonstrate as much of a difference for the experienced surgeon. Overall, the difference in improvement between robot-assisted and manual laparoscopy was not statistically significant.

CONCLUSIONS

Robot-assisted laparoscopic allows suturing and dexterity skills to be performed quicker than does manual laparoscopy.

Mechanisms and clinical applications of the vacuum-assisted closure (VAC) Device: a review

The use of sub-atmospheric pressure dressings, available commercially as the vacuum-assisted closure (VAC) device, has been shown to be an effective way to accelerate healing of various wounds. The optimal sub-atmospheric pressure for wound healing appears to be approximately 125 mm Hg utilizing an alternating pressure cycle of 5 minutes of suction followed by 2 minutes off suction. Animal studies have demonstrated that this technique optimizes blood flow, decreases local tissue edema, and removes excessive fluid from the wound bed. These physiologic changes facilitate the removal of bacteria from the wound. Additionally, the cyclical application of sub-atmospheric pressure alters the cytoskeleton of the cells in the wound bed, triggering a cascade of intracellular signals that increases the rate of cell division and subsequent formation of granulation tissue. The combination of these mechanisms makes the VAC device an extremely versatile tool in the armamentarium of wound healing. This is evident in the VAC device's wide range of clinical applications, including treatment of infected surgical wounds, traumatic wounds, pressure ulcers, wounds with exposed bone and hardware, diabetic foot ulcers, and venous stasis ulcers. VAC has also proven useful in reconstruction of wounds by allowing elective planning of the definitive reconstructive surgery without jeopardizing the wound or outcome. Furthermore, VAC has significantly increased the skin graft success rate when used as a bolster over the freshly skin-grafted wound. VAC is generally well tolerated and, with few contraindications or complications, is fast becoming a mainstay of current wound care.

Can a double-row anchorage technique improve tendon healing in arthroscopic rotator cuff repair?: A prospective, nonrandomized, comparative study of double-row and single-row anchorage techniques with computed tomographic arthrography tendon healing assessment

BACKGROUND

Increasing the rate of watertight tendon healing has been suggested as an important criterion for optimizing clinical results in rotator cuff arthroscopic repair.

HYPOTHESIS

A double-row anchorage technique for rotator cuff repair will produce better clinical results and a better rate of tendon healing than a single-row technique.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

We compared 31 patients undergoing surgery with a double-row anchorage technique using Panalok anchors and Cuff Tack anchors and 35 patients with rotator cuff tear undergoing surgery with a single-row anchorage arthroscopic technique using Panalok anchors. We compared pre- and postoperative Constant score and tendon healing, as evaluated by computed tomographic arthrography 6 months after surgery, in these 2 groups.

RESULTS

The Constant score increased significantly in both groups, with no difference between the 2 groups (P = .4). Rotator cuff healing was judged anatomic in 19 patients with double-row anchorage and in 14 patients with single-row anchorage; this difference between the groups was significant (P = .03).

CONCLUSION

In this first study comparing double- and single-row anchorage techniques, we found no significant difference in clinical results, but tendon healing rates were better with the double-row anchorage. Improvements in the double-row technique might lead to better clinical and tendon healing results.

Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications

PURPOSE

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for full-thickness excision of benign and malignant rectal neoplasms located 4 to 24 cm above the anal verge. Entrance into the peritoneal cavity during TEM has been regarded as a complication that mandates conversion to open laparotomy for adequate repair of the defect. This study compares the rate of complications arising from TEM with and without intraperitoneal entry.

METHODS

Patients undergoing peritoneal entry were compared to those who did not.

RESULTS

No perioperative deaths occurred. There was no significant difference in the incidence of postoperative complications. No major complications occurred with peritoneal entry, and all peritoneal entries were closed transanally via endoscope.

CONCLUSIONS

Entry into the peritoneum during TEM is not associated with an increased incidence of complication. Entry into the peritoneum during TEM excision does not mandate conversion to open laparotomy but may be safely repaired endoscopically. Lesions likely to be above the peritoneal reflection and within reach of the endoscope (4 to 24 cm) should be considered for TEM excision.

Tissue adhesive versus suture wound repair at 1 year: randomized clinical trial correlating early, 3-month, and 1-year cosmetic outcome

STUDY OBJECTIVE

To compare the 1-year cosmetic outcome of wounds treated with octylcyanoacrylate tissue adhesive and monofilament sutures and to correlate the early, 3-month, and 1-year cosmetic outcomes.

METHODS

We prospectively randomized 136 cases of traumatic laceration to repair with octylcyanoacrylate tissue adhesive or 5-0 or smaller monofilament suture. A wound score was assigned by a research nurse, and validated by a second nurse blinded to the treatment, at 5 to 10 days after injury (early), 3 months, and 1 year. Standardized photographs were taken at 3 months and 1 year and shown to a cosmetic surgeon blinded to the method of closure, who rated the wounds on a validated cosmesis scale.

RESULTS

We were able to examine 77 lacerations at 1 year for follow-up. No differences were found in the demographic or clinical characteristics between groups. Likewise, at 1 year no difference was found in the optimal wound scores (73% versus 68%, P =.60) or in visual analog scale cosmesis scores (69 versus 69 mm, P =.95) for octylcyanoacrylate and sutures, respectively. Agreement was poor between early and 3-month wound scores (kappa=.34; 95% confidence interval [CI],.10 to.58) but a strong association existed between 3-month and 1-year wound scores (kappa=.71; 95% CI,.52 to.90). We noted a moderate correlation between 3-month and 1-year results on the visual analog cosmesis scale (intraclass correlation,.48; 95% CI, .30 to.63).

CONCLUSION

One year after wound repair, no difference is noted in the cosmetic outcomes of traumatic lacerations treated with octylcyanoacrylate tissue adhesive and sutures. The assessment of wounds 3 months after injury and wound repair provides a good measure of long-term cosmetic outcome.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial

BACKGROUND

Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias.

METHODS

We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230.

FINDINGS

Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths.

INTERPRETATION

This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size.

FUNDING

Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Construct validation of the ProMIS simulator using a novel laparoscopic suturing task

BACKGROUND

The use of simulation for minimally invasive surgery (MIS) skills training has many advantages over current traditional methods. One advantage of simulation is that it enables an objective assessment of technical performance. The purpose of this study was to determine whether the ProMIS augmented reality simulator could objectively distinguish between levels of performance skills on a complex laparoscopic suturing task.

METHODS

Ten subjects--five laparoscopic experts and five laparoscopic novices--were assessed for baseline perceptual, visio-spatial, and psychomotor abilities using validated tests. After three trials of a novel laparoscopic suturing task were performed on the simulator, measures for time, smoothness of movement, and path distance were analyzed for each trial. Accuracy and errors were evaluated separately by two blinded reviewers to an interrater reliability of >0.8. Comparisons of mean performance measures were made between the two groups using a Mann-Whitney U test. Internal consistency of ProMIS measures was assessed with coefficient alpha.

RESULTS

The psychomotor performance of the experts was superior at baseline assessment (p < 0.001). On the laparoscopic suturing task, the experts performed significantly better than the novices across all three trials (p < 0.001). They performed the tasks between three and four times faster (p < 0.0001), had three times shorter instrument path length (p < 0.0001), and had four times greater smoothness of instrument movement (p < 0.009). Experts also showed greater consistency in their performance, as demonstrated by SDs across all measures, which were four times smaller than the novice group. Observed internal consistency of ProMIS measures was high (alpha = 0.95, p < 0.00001).

CONCLUSIONS

Preliminary results of construct validation efforts of the ProMIS simulator show that it can distinguish between experts and novices and has promising psychometric properties. The attractive feature of ProMIS is that a wide variety of MIS tasks can be used to train and assess technical skills.

Laryngoplasty with or without ventriculectomy for treatment of left laryngeal hemiplegia in 230 racehorses

OBJECTIVE

The purpose of this study was to examine the influence of laryngoplasty on racing performance and to determine if any of the following variables had a significant effect on outcome: breed (Thoroughbred v Standardbred), endoscopic grade of laryngeal function, ventriculectomy versus no ventriculectomy, type of prosthetic suture used, and number of prostheses placed.

STUDY DESIGN

Retrospective study of laryngoplasty with or without ventriculectomy for treatment of left laryngeal hemiplegia in racehorses between 1986 and 1993.

ANIMALS OR SAMPLE POPULATION

230 horses (174 Thoroughbreds, 56 Standardbreds).

METHODS

The medical records of racehorses or horses intended for racing were reviewed. Signalment, admitting complaints, physical examination findings, resting endoscopic grade of laryngeal function, type of prosthetic suture material used, number of prosthetic sutures placed, presence or absence of ventriculectomy, and postoperative complications were recorded.

RESULTS

Upper respiratory tract noise and exercise intolerance were the most common presenting complaints. Two horses had a laryngeal grade of 2, 109 horses a laryngeal grade of 3, and 119 horses a laryngeal grade of 4. Two double-strand braided polyester sutures were used in 147 horses, a single double-strand polyester suture was used in 49 horses, and a single double-strand nylon suture was used in 34 horses. Ventriculectomy was performed on 186 horses. The most common complication recognized during hospitalization was coughing in 50 horses. Telephone follow-up was obtained for 176 horses. For 168 horses, respiratory noise after surgery was decreased in 126 horses, the same in 28, and increased in 14. After hospital discharge, coughing occurred in 43 of 166 horses, and a nasal discharge occurred in 26 horses. Postoperative racing performance for 167 horses was subjectively evaluated by respondents as being improved in 69% of the horses. Overall owner satisfaction with the outcome after surgery was 81%. Of 230 horses, 178 raced at least one time after surgery. Overall, 117 horses raced three or more times before and after surgery, and 65 of these horses had improved performance index scores. None of the variables of surgical interest affected performance index scores.

CONCLUSIONS AND CLINICAL RELEVANCE

Laryngoplasty with or without ventriculectomy allowed 77% of the horses to race at least one time after surgery, improved racing performance in 56% of the horses that completed three races before and after surgery, and improved subjectively evaluated racing performance in 69% of the horses.

Augmented versus virtual reality laparoscopic simulation: what is the difference? A comparison of the ProMIS augmented reality laparoscopic simulator versus LapSim virtual reality laparoscopic simulator

Background

Virtual reality (VR) is an emerging new modality for laparoscopic skills training; however, most simulators lack realistic haptic feedback. Augmented reality (AR) is a new laparoscopic simulation system offering a combination of physical objects and VR simulation. Laparoscopic instruments are used within an hybrid mannequin on tissue or objects while using video tracking. This study was designed to assess the difference in realism, haptic feedback, and didactic value between AR and VR laparoscopic simulation.

Methods

The ProMIS AR and LapSim VR simulators were used in this study. The participants performed a basic skills task and a suturing task on both simulators, after which they filled out a questionnaire about their demographics and their opinion of both simulators scored on a 5-point Likert scale. The participants were allotted to 3 groups depending on their experience: experts, intermediates and novices. Significant differences were calculated with the paired t-test.

Results

There was general consensus in all groups that the ProMIS AR laparoscopic simulator is more realistic than the LapSim VR laparoscopic simulator in both the basic skills task (mean 4.22 resp. 2.18, P < 0.000) as well as the suturing task (mean 4.15 resp. 1.85, P < 0.000). The ProMIS is regarded as having better haptic feedback (mean 3.92 resp. 1.92, P < 0.000) and as being more useful for training surgical residents (mean 4.51 resp. 2.94, P < 0.000).

Conclusions

In comparison with the VR simulator, the AR laparoscopic simulator was regarded by all participants as a better simulator for laparoscopic skills training on all tested features.

Type 2 fractures of the distal clavicle: a new surgical technique

Neer type 2 fractures of the distal clavicle have a high rate of nonunion and delayed union. In this series nine cases of coracoclavicular ligament reconstruction with Dacron graft material led to union at the fracture site. All patients had no symptoms and returned to full activity. This technique allows for stable fixation with early mobilization and return to work and sports.

Fixation of patella fractures with braided polyester suture: a biomechanical study

We tested the quality of fixation of displaced transverse patella fractures using braided polyester suture to investigate the suitability of this material as an alternative to stainless steel wire for fixation of these fractures. Osteotomies were created to simulate fractures of the patella in ten cadaveric knee specimens and were sequentially fixed using two techniques: the modified tension-band technique and the longitudinal anterior band (Lotke) technique. Each technique was implemented using either 1.25-mm stainless steel wire or 7-metric braided polyester suture (No. 5 Ethibond). The quality of fixation for each technique was tested by measuring the fracture gap during three simulated extensions of the knee against gravity on a materials testing machine. All techniques behaved comparably under the loading conditions used. In the four groups, there was no fixation failure (fracture gap > 3 mm) nor any significant difference between the mean maximum fracture gaps. The quality of fixation for braided polyester suture was comparable to that of stainless steel wire for such fractures, providing sufficient stability to withstand loads likely to be encountered during postoperative rehabilitation. Our results support the use of braided polyester suture as an alternative to stainless steel wire for fixation of displaced patella fractures.

Meniscus suture techniques: a comparative biomechanical cadaver study

The primary stability of four common meniscus suture techniques was tested on human cadaver menisci. The test series was carried out under standard conditions (25 degrees C, 100% air humidity) using the Instron 1122 Tensometer. The tearing stress of different sutures was reproducible in different specimens dependent only on the suture technique. Knot-end techniques gave inferior results (tearing stress, 24 +/- 9 N) compared with arthroscopic techniques using a loop placed on the meniscus surface (tearing stress, 89 +/- 4 N). When an open meniscus repair is performed, a vertical stitching technique (tearing stress, 105 +/- 4 N) should be the preferred method. Horizontal sutures are weaker (tearing stress, 44 +/- 18 N).

Autologous, cadaveric, and synthetic materials used in sling surgery: comparative biomechanical analysis

OBJECTIVES

To compare the biomechanical properties of allografts, autografts, and synthetic materials used in sling surgery using the Instron tensinometer.

METHODS

The sling grafts we studied consisted of autologous tissues (dermis, rectus fascia, and vaginal mucosa), cadaver tissues (decellularized dermis and freeze-dried, gamma-irradiated fascia lata), and synthetics (Gore-Tex and polypropylene mesh). The sling grafts were constructed into two types of slings: full strip sling (FSS) versus patch suture sling (PSS). The slings were loaded onto the Instron tensinometer and uniaxially loaded in tension until failure. From the load deformation curve, the mechanical properties of the sling grafts were compared.

RESULTS

A total of 140 sling grafts were analyzed. In rank order for the FSSs, cadaver allografts had the strongest tensile strength followed by the synthetics and autologous tissues (P <0.05). The tensile strength of the FSSs was greater than for the PSSs for all groups (P </=0.001). In rank order for the PSSs, the synthetics and dermal tissues (autograft and allograft) had the highest tensile strength followed by cadaver fascia lata, rectus fascia, and vaginal mucosa (P <0.05).

CONCLUSIONS

The tensile strength of the FSS was greater than that of the PSS for the autograft, allograft, and synthetic tissues. The autograft and allograft tissues were significantly weaker as a PSS. The synthetics were more durable as a PSS compared with the organic tissues. When a PSS is constructed from autograft and allograft tissues, the risk of suture pull-through and recurrent stress incontinence must be considered.

Controlled reduction of postkeratoplasty astigmatism

Corneal transplants were performed in 50 eyes using eight deeply placed interrupted 24 micron (10--0) monofilament nylon sutures followed by a more superficial continuous 16 micron (11--0) monofilament nylon suture placed around the wound in 16 equal bites. After surgery the 24 micron sutures in the steepest corneal meridian based on central and peripheral keratometry were cut. This suture technique permitted the donor cornea to assume its normal shape more rapidly while reducing the induced postkeratoplasty astigmatism. With this technique corneal astigmatism was reduced an average of 3.4 diopters (range 0--10 diopters), which allowed patient to achieve a mean visual acuity at three months of 20/50 and at 11 to 13 months of 20/35. Although this suture technique does not eliminate postkeratoplasty astigmatism, it permits the surgeon to reduce actively high degrees of astigmatism present after corneal transplantation.

Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy

BACKGROUND

The leading cause for morbidity and mortality after pancreaticoduodenectomy is a pancreatic anastomotic leak and fistula. The two most commonly performed anastomoses after pancreaticoduodenectomy are pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ). The role of standardization on outcomes after pancreaticoduodenectomy has not been sufficiently addressed.

AIM

The goal is to study the impact of a standardized technique of pancreatic anastomosis (PJ) after pancreaticoduodenectomy in a tertiary referral cancer teaching hospital.

MATERIALS AND METHODS

A single-institution database was analyzed over 15 years. The entire data were subdivided into two periods, viz., period A (1992 to 2001), when PG (dunking) was predominantly used, and period B (2003-2007), when a standardized technique of PJ (duct to mucosa) was employed.

RESULTS

There were 144 pancreaticoduodenectomies performed during period A with a pancreatic fistula rate of 16%. During period B, 123 pancreaticoduodenectomies were performed with a pancreatic fistula rate of 3.2% (p < 0.0005).

CONCLUSIONS

It appears that a standardized approach to the pancreatic anastomosis and a consistent practice of a single technique can help to reduce the incidence of complications after pancreaticoduodenectomy.

Tensile strength of mesh fixation methods in laparoscopic incisional hernia repair

BACKGROUND

Fixation of the mesh is crucial for the successful laparoscopic repair of incisional hernias. In the present experimental study, we used a pig model to compare the tensile strengths of mesh fixation with helical titanium coils (tackers) and transabdominal wall sutures.

METHODS

Thirty-six full-thickness specimens (5 x 7 cm) of the anterior abdominal wall of nine pig cadavers were randomized for fixation of a polypropylene mesh (7 x 7 cm) by either tackers or transabdominal wall sutures. The number of fixation points varied from one to five per 7-cm tissue length, with distances between fixation points of 2.3, 1.8, 1.4, and 1.2 cm, respectively. The force required to disrupt the mesh fixation (tensile strength) was measured by a dynamometer. Statistical analysis was performed using the Wilcoxon test and the Spearman rank correlation test.

RESULTS

The mean tensile strength of mesh fixation by transabdominal sutures was significantly greater than that by tackers for each number of fixation points: 67 N vs 28 N for a single fixation point (p <0.001), 115 N vs 42 N for two fixation points (p <0.001), 150 N vs 63 N for three fixation points (p <0.05), 151 N vs 73 N for four fixation points (p <0.05), and 150 N vs 82 N for five fixation points (p <0.05). Increasing the number of fixation points over three per 7 cm (distance between fixation points of 1.8 cm) did not improve tensile strength.

CONCLUSION

The tensile strength of transabdominal sutures is up to 2.5 times greater than the tensile strength of tackers. Therefore, the use of transabdominal sutures for mesh fixation appears to be preferable for laparoscopic incisional hernia repair.

Median sternotomy dehiscence

Sternal dehiscence requiring reoperation occurred in 36 out of 4,531 patients who had a sternotomy incison within an eight-year period. Twisted sternal wire sutures were used for the first four years and a crimped steel plate fixation was used during the second four years with a marked and significant decrease in the incidence of dehiscence from 17 out of 1,000 patients to 3 out of 1,000 patients. Thirty-five of the 36 patients were men, and 4 required reoperation for bleeding. Other factors such as mammary artery dissection, tracheostomy, and body weight of more than 82 kg were not significant. Although infection was noted in 20 patients, it was thought to be secondary. Early reoperation with antibiotic irrigation achieved wound stability in the 34 survivors with only 3 patients requiring additional procedures for chronic osteomyelitis of the sternum.

Achilles tendon rupture repair: biomechanical comparison of the triple bundle technique versus the Krakow locking loop technique

This study was designed to compare the tensile strength of ruptured Achilles tendons repaired using either the triple bundle technique or the Krakow locking loop technique. Eight pairs of fresh frozen cadaveric Achilles tendons were harvested. A simulated "Achilles tendon rupture" was created 4 cm from the calcaneal insertion in all sixteen tendons by transversely cutting the tendon with a scalpel. One Achilles tendon "rupture" of a pair was repaired using the triple bundle technique, while the other tendon of the pair was repaired using the Krakow locking loop technique. Then, using a servohydraulic testing machine, each tendon was tested to failure in tension at a displacement rate of 2.54 cm/sec. The average rupture load for the triple bundle technique was 453 N (range 397 n 549 N), while the average rupture load for the Krakow locking loop technique was 161 N (range 121 n 216 N). This difference in averages represents a statistically significant superiority of 2.8 to 1 (p < 0.001) in favor of the triple bundle technique.

Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration

In a prospective clinical investigation of 2,144 deliveries, we elucidate the indications for episiotomy and how different methods of anesthesia affect the frequency of episiotomy and the perineal problems after episiotomy compared with those after spontaneous perineal laceration. We found a significantly higher infection rate (p less than 0.001) and a longer healing period in the episiotomy group. These differences remain even if only primigravida or the indication, imminent perineal laceration, is studied. The results indicate that many women will unnecessarily suffer after an episiotomy. The patient's subjective problems are significantly increased, both immediately and at the 3-month postoperative follow-up.

Ergonomic principles of task alignment, visual display, and direction of execution of laparoscopic bowel suturing

BACKGROUND

Laparoscopic suturing is technically a demanding skill in laparoscopic surgery. Ergonomic experimental studies provide objective information on the important factors and variables that govern optimal endoscopic suturing. Our objective was to determine the optimum physical alignment, visual display, and direction of intracorporeal laparoscopic bowel suturing using infrared motion analysis and telemetric electromyography (EMG) systems.

METHODS

Ten surgeons participated in the study; each sutured 50-mm porcine small bowel enterotomies toward and away from the surgeon in the vertical and horizontal bowel plane with either isoplanar (image display corresponds with actual lie of the bowel) or nonisoplanar (bowel displayed horizontally but mounted vertically in the trainer and vice versa) display. The end points were the placement error score, execution time, leakage pressure, motion analysis, and telemetric EMG parameters of the surgeon's dominant upper limb.

RESULTS

Suturing was demonstrably easier in the vertical than in the horizontal plane, resulting in a better task quality (placement error score, p < 0.0001; leakage pressure, p < 0.005) and shorter execution time (p < 0.05). Nonisoplanar display of the surgical anatomy degrades performance in terms of both task efficiency and task quality. On motion analysis, a wider angle of excursion and lower angular velocity were observed during the vertical suturing with isoplaner display. Compared to horizontal suturing, supination at the wrist was significantly greater during vertical than horizontal suturing (p < 0.05). Within each category (vertical vs horizontal suturing), the direction of suturing (toward/away from the surgeon) did not influence the extent of pronation/ supination at the wrist. In line with the degraded performance, significantly more muscle work was expended during horizontal suturing. This affected the forearm flexors (p < 0.05), arm flexors and extensors (p < 0.005 and p < 0.05, respectively), and deltoid muscles (p < 0.005) and was accompanied by significantly more fatigue in the related muscles. Small bowel enterotomies sutured toward the surgeon in both the vertical and the horizontal planes exhibited less placement error score than when sutured away from the surgeon, with no significant difference in the motion analysis and EMG parameters.

CONCLUSIONS

Optimal laparoscopic suturing (better task quality and reduced execution time) is achieved with vertical suturing toward the surgeon with isoplanar monitor display of the operative field. The poorer task performance observed during horizontal suturing is accompanied by more muscle work and fatigue, and it is not improved by monitor display of the enterotomy in the vertical plane.

Frontalis suspension in congenital ptosis using a polyfilament, cable-type suture

Fifty-five frontalis sling procedures were performed with use of 4--0 polyfilament, cable-type ophthalmic suture (Supramid Extra) as the material for suspension. Recurrences numbered 16, recorded through a follow-up period of one to ten years. Trauma accounted for five recurrences. A pattern of gradual droop of the lid operated on became most obvious between six and ten years postoperatively and accounted for six of seven recurrences during this period. These findings suggest that this suture material is a poor alternative to fascia lata for permanent frontalis suspension in patients with congenital ptosis and should be used only in unusual circumstances, or when a temporary procedure is indicated.

Cat bite wounds: risk factors for infection

STUDY OBJECTIVE

In the last ten years, many emergency medicine specialists have studied animal bite wounds. The majority of these studies have addressed the controversies of prescribing prophylactic antibiotics or suturing wounds. This study was undertaken to determine risk factors for cat bite wound infections.

DESIGN

Prospective survey.

SETTING

Community hospital emergency medicine residency program.

TYPE OF PARTICIPANTS

One hundred eighty-six consecutive patients with 216 cat bite/scratch wounds over a two-year period.

INTERVENTIONS

A standardized wound cleaning protocol with debridement and suturing, if indicated, was used. Variables analyzed included patient age and gender; wound age, type, number, location, and depth; prehospital therapy; emergency department therapy; and antibiotics used.

RESULTS

The mean patient age was 19.5 +/- 15.9 years. The mean time interval from wounding to ED treatment was 10.2 +/- 39.2 hours. By anatomical sites, there were 33 (15%) head/neck, 48 (22%) arm, 97 (45%) hand, ten (5%) truncal, and 28 (13%) lower extremity wounds. By wound type, there were 122 (56%) punctures, 54 (25%) abrasions, 37 (17%) lacerations, and two (1%) avulsions. One hundred fifty (71%) of the wounds were partial thickness, and 62 (29%) were full thickness. Twenty-four (12.9%) of the patients had clinical evidence of wound infection on arrival to the ED. Five (2.7%) developed clinical evidence of infection despite ED treatment. None of the 14 (7.5%) patients with only "claw" injuries developed infection. The overall patient infection rate for those with cat "bites" was 15.6%. Factors associated with wound infections included older age (P less than .001), longer time intervals until ED treatment (P less than .0001), wounds inflicted by "pet" cats (P = .001), attempting wound care at home (P = .0004), having a more severe wound (P = .01), and having a deeper wound (P = .0001). Data from 148 patients who had only "bite" wounds and did not have clinical evidence of infection on initial presentation to the ED also were analyzed for wound infection risk factors. Wound infections were more likely to develop in patients with lower extremity wounds who did not receive prophylactic oral antibiotics (P = .071) and those with puncture wounds who did not receive prophylactic oral antibiotics (P = .085).

CONCLUSION

In this study, wound type and wound depth were the most important factors in determining the likelihood of developing wound infection regardless of whether the patient was prescribed prophylactic oral antibiotics.

Mechanical performance of square knots and sliding knots in surgery: comparative study

Various square knots, sliding knots, and surgeon's knots in mono- and multifilament suture material of different diameters were tested with respect to knot strength and knot security. Loop holding capacity of knots varied from 37.2 to 149.8 N, depending on the kind of knot, knot configuration, kind of suture, suture structure, and suture dimension. On the whole, square knots proved to be more reliable than sliding knots. Knot performance of surgeon's knots was not better than that of square knots. Knot security of three-throw sliding knots and two-throw square knots and surgeon's knots was rather poor. These knots cannot be recommended for clinical use. In smaller diameter mono- and multifilament suture material, knot performance of sliding knots that contained one extra throw was identical to that of square knots. It is concluded that the outcome of the comparison of square knots and sliding knots depends on knot configuration, suture material, and suture size. The implications of these laboratory findings for clinical use are discussed.