Management of stab wounds to the anterior abdominal wall

The meeting of the Publication "Evidence Based Telemedicine - Trauma and Emergency Surgery" (TBE-CiTE), through literature review, selected three recent articles on the treatment of victims stab wounds to the abdominal wall. The first study looked at the role of computed tomography (CT) in the treatment of patients with stab wounds to the abdominal wall. The second examined the use of laparoscopy over serial physical examinations to evaluate patients in need of laparotomy. The third did a review of surgical exploration of the abdominal wound, use of diagnostic peritoneal lavage and CT for the early identification of significant lesions and the best time for intervention. There was consensus to laparotomy in the presence of hemodynamic instability or signs of peritonitis, or evisceration. The wound should be explored under local anesthesia and if there is no injury to the aponeurosis the patient can be discharged. In the presence of penetration into the abdominal cavity, serial abdominal examinations are safe without CT. Laparoscopy is well indicated when there is doubt about any intracavitary lesion, in centers experienced in this method.

Use of the amniotic membrane to cover the peritoneal cavity in the reconstruction of the abdominal wall with polypropylene mesh in rats

OBJECTIVE: to evaluate the efficacy of the amniotic membrane used with polypropylene mesh against the formation of adhesions and its influence on healing. METHODS: twenty five female Wistar rats were anesthetized for creating a parietal defect in the anterior abdominal wall. Its correction was made with polypropylene mesh alone and associated with amniotic membrane. In the control group (n=11), the screen was inserted alone. In group A (n=7) we interposed the amniotic membrane between the screen and the abdominal wall. In group B, the amniotic membrane was placed on the mesh, covering it. After seven days, the animals were euthanized for macroscopic and microscopic evaluation of healing. RESULTS: adhesions were observed in all animals except one in the control group. Severe inflammation was observed in all animals in groups A and B and in three of the control group, with significant difference between them (A and B with p=0.01). Pronounced angiogenic activity was noted in one animal in the control group, six in group A and four in group B, with a significant difference between the control group and group A (p=0.002) and group B (p=0.05). The scar collagen was predominantly mature, except in five animals of the control group, with significant difference between the control group and group A (p=0.05) and group B (p=0.05). CONCLUSION: The amniotic membrane did not alter the formation of adhesions in the first postoperative week. There were also pronounced inflammation, high angiogenic activity and predominance of mature collagen fibers, regardless of the anatomical plane that it was inserted in.

Use of surgical mesh of different compositions in the correction of the abdominal wall defect in rats

Objective: To analyze the performance of two surgical meshes of different compositions during the defect healing process of the abdominal wall of rats. Methods: thirty-three adult Wistar rats were anesthetized and subjected to removal of an area of 1.5 cm x 2 cm of the anterior abdominal wall, except for the skin; 17 animals had the defect corrected by edge-to-edge surgical suture of a mesh made of polypropylene + poliglecaprone (Group U - UltraproTM); 16 animals had the defect corrected with a surgical mesh made of polypropylene + polidioxanone + cellulose (Group P - ProceedTM). Each group was divided into two subgroups, according to the euthanasia moment (seven days or 28 days after the operation). Parameters analyzed were macroscopic (adherence), microscopic (quantification of mature and immature collagen) and tensiometric (maximum tension and maximum rupture strength). Results : there was an increase in collagen type I in the ProceedTM group from seven to 28 days, p = 0.047. Also, there was an increase in the rupture tension on both groups when comparing the two periods. There was a lower rupture tension and tissue deformity with ProceedTM mesh in seven days, becoming equal at day 28. Conclusion : the meshes retain similarities in the final result and more studies with larger numbers of animals must be carried for better assessment.

Abdominal wall protrusion following herpes zoster

We present the case of a 62-year-old woman with abdominal segmental paresis consequent to radiculopathy caused by zoster, which was confirmed by electroneuromyography. The paresis resolved completely within three months. Recognition of this complication caused by zoster, which is easily misdiagnosed as abdominal herniation, is important for diagnosing this self-limited condition and avoiding unnecessary procedures.

Videolaparoscopia no trauma abdominal

Despite the use of laparoscopy in abdominal trauma for several decades, it was only after the advent of video chip camera that an explosion of interest ocurred, giving rise to possibilities and perspectives not only in diagnosis but also in therapeutics. In trauma, its use has been gradually defined and experience has shown the benefits of the method in early diagnosis of visceral injuries as well as avoiding unnecessary laparotomies. Trauma laparoscopy is a safe method, can reduce negative and nontherapeutic laparotomies. The worrisome failure of laparoscopy to detect gastrintestinal injuries, specially small bowel lesions can be avoided with a mandatory and apropriated "run bowel" exploration. We believe that in hemodinamically stable patients, video laparoscopy is safely indicated in some situations in trauma, such as evaluation of diaphragmatic injuries in thoraco abdominal stab wounds and tangential gunshot wounds of anterior abdominal wall.

Immunohistochemical evaluation of fibrillar components of the extracellular matrix of transversalis fascia and anterior abdominal rectus sheath in men with inguinal hernia

OBJECTIVE: to evaluate the role of fibrillar extracellular matrix components in the pathogenesis of inguinal hernias. METHODS: samples of the transverse fascia and of the anterior sheath of the rectus abdominis muscle were collected from 40 men aged between 20 and 60 years with type II and IIIA Nyhus inguinal hernia and from 10 fresh male cadavers (controls) without hernia in the same age range. The staining technique was immunohistochemistry for collagen I, collagen III and elastic fibers; quantification of fibrillar components was performed with an image analysis processing software. RESULTS: no statistically significant differences were found in the amount of elastic fibers, collagen I and collagen III, and the ratio of collagen I / III among patients with inguinal hernia when compared with subjects without hernia. CONCLUSION: the amount of fibrillar extracellular matrix components did not change in patients with and without inguinal hernia.

Ureteral reconstruction with abdominal wall muscle flap: experimental study in rabbits

The authors detail the experimental development of a technique for the reconstruction of the ureter using a tubular shape, muscle flap of the abdominal wall. the preliminary results indicate the feasibility of this surgical technique.

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

Hérnia traumática da parede abdominal

A rare case of blunt traumatic abdominal hernia is presented in which jejunal loops herniated through the abdominal wall. The patient had a serious motor vehicle accident seven years ago, while wearing the seat belt. He developed a traumatic hernia in the anterior lateral abdominal wall, which was operated, and relapsed after some months. The patient was reoperated and we observed the unattachment of the anterior lateral abdominal musculature from the ilium crest. After the hernial sac treatment, the defect was solved with the use of a polypropylene mesh. The postoperative evolution was good and four months later there were no signs of recurrence. Traumatic abdominal hernia remains a rare clinical entity, despite the increase in blunt abdominal trauma. Traumatic abdominal wall hernia falls into two general categories: small lower quadrant abdominal defects, typically the result of blunt trauma with bicycle handlebars, and larger abdominal wall defects related to motor vehicle accidents. The diagnosis may be often established by the physical examination alone. Conventional radiology and computerized tomography usefulness have been proved. In the vast majority of cases, early repair is recommended. The appropriate treatment is the reduction of the herniated bowel into the abdomen, the debridment of nonviable tissues, and a primary tension free closure of the detect.

Tricobezoares no estômago, duodeno e íleo

A 21-year-old girl presents with a 15-day history of epigastric pain and vomiting. Ten days later, constipation and abdominal distension followed. The patient reported similar epigastric pain and vomiting for 6 days last year. A painless epigastric 12-by-8-centimeter tumor was observed on abdominal palpation, and rectal examination revealed an extrinsic tumor compressing anterior rectal wall. Upper digestive endoscopy showed a trichobezoar. Upon laparotomy, one gastric and one duodenal trichobezoar were removed through an anterior gastrotomy. Another one was found 40 centimeters proximal to the ileo-cecal valve and removed through a proximal ileotomy. Trichobezoar is an unspecific disease, which diagnosis is made upon suspicion. Early recognition of bezoars is important because morbidity and mortality rise considerably once complications occur. We illustrate this case to emphasize the need for early recognition and surgical management in order to reduce morbimortality.

Trauma abdominal penetrante consecutivo à corrente elétrica industrial

The authors present a case report of a victim of high power electric shock. The main electric lesion was a penetrating abdominal wound with loss of substance of the abdominal wall and an electric lesion of the hepatic segment and of the gallbladder. The surgical treatment included hepatic segmentectomy, cholecystectomy, repair of the abdominal wall with Marlex prosthesis and skin graft, besides the debridment of the lesions of extremities. The postoperative evolution was satisfactory and the follow-up for 6 months didn't show any sequelae.

O uso da prótese na correção das hérnias da parede abdominal é um avanço, mas o seu uso indiscriminado, um abuso

The objective is to alert the surgeon about the indiscriminate use of synthetic prosthesis in the correction of inguinal and incisional hernias. The authors provide a brief history of surgery on hernias and a review of the literature, showing the importance of classifying inguinal hernias to fit the type of surgical correction with the defect found, abstaining from treating all hernias, with the same type of surgical procedure. In our opinion, small indirect inguinal hernias (type 1 and 2 of Gilbert) and hernias in women must not, in general, be treated with prostheses. The synthetic material should be reserved for direct and large indirect hernias. Even so, this attitude, besides determining a higher cost for the procedure, can lead to important complications such as infection, rejection, fistula formation, chronic pain, alterations in spermatogenesis and the possibility of carcinogenesis, according to more recent reports. The physiology and anatomy of the abdominal wall should be considered when dealing with incisional hernia corrections, where the surgeon can choose among many techniques to correct those defects, and in selected cases, utilize synthetic material. We conclude that although the use of biomaterials has constituted a great advance in surgery for abdominal wall hernia corrections because they decrease recurrences, and permit treatment of large abdominal hernias, the indiscriminate prosthesis usage is an abuse, and it can determine many serious complications, certainly avoidable with a well indicated non mesh technique .

Temporary abdominal closure with zipper-mesh device for management of intra-abdominal sepsis

OBJECTIVE: to present our experience with scheduled reoperations in 15 patients with intra-abdominal sepsis. METHODS: we have applied a more effective technique consisting of temporary abdominal closure with a nylon mesh sheet containing a zipper. We performed reoperations in the operating room under general anesthesia at an average interval of 84 hours. The revision consisted of debridement of necrotic material and vigorous lavage of the involved peritoneal area. The mean age of patients was 38.7 years (range, 15 to 72 years); 11 patients were male, and four were female. RESULTS: forty percent of infections were due to necrotizing pancreatitis. Sixty percent were due to perforation of the intestinal viscus secondary to inflammation, vascular occlusion or trauma. We performed a total of 48 reoperations, an average of 3.2 surgeries per patient. The mesh-zipper device was left in place for an average of 13 days. An intestinal ostomy was present adjacent to the zipper in four patients and did not present a problem for patient management. Mortality was 26.6%. No fistulas resulted from this technique. When intra-abdominal disease was under control, the mesh-zipper device was removed, and the fascia was closed in all patients. In three patients, the wound was closed primarily, and in 12 it was allowed to close by secondary intent. Two patients developed hernia; one was incisional and one was in the drain incision. CONCLUSION: the planned reoperation for manual lavage and debridement of the abdomen through a nylon mesh-zipper combination was rapid, simple, and well-tolerated. It permitted effective management of severe septic peritonitis, easy wound care and primary closure of the abdominal wall.

Rectal stenosis in pigs associated with Salmonella Typhimurium and porcine circovirus type 2 (PCV2) infection

Rectal stricture is an acquired annular fibrous constriction of the rectum that results from a variety of chronic necrotizing enteric diseases. In pigs, it is in most cases a sequel of Salmonella infection. Porcine circovirus type 2 (PCV2) is a known pathogen causing immunosuppression in pigs worldwide. PCV2 infected pigs may be predisposed to salmonellosis. In this report, rectal stenosis was observed in 160 pigs from a herd that experienced an outbreak of enteric salmonellosis over a 4-month period. Distension of the abdominal wall and diarrhea were the main clinical signs observed. Five animals were analyzed showing annular cicatrization of the rectal wall 5.0-7.0 cm anterior to the anorectal junction and Salmonella-positive immunostaining in the large intestine. Salmonella Typhimurium was isolated from fragments of the large intestine. Porcine circovirus type 2 antigen was observed in the mesenteric lymph-node in 4 pigs and in the large intestine in 3 pigs.

Mediastinitis and pericardial effusion in a patient with AIDS and disseminated Mycobacterium avium infection: a case report

We report the case of a 36-year-old man who had acquired immune deficiency syndrome and developed suppurative mediastinitis extending over the left lung and anterior thoracic wall around the sternum, pericardial effusions, splenomegaly, and mesenteric and periaortic lymphadenomegaly due to Mycobacterium avium (genotype I). The organism was isolated from an axillary lymph node and the bone marrow. Mediastinitis associated with disseminated M. avium complex infection is uncommon and, to the best of our knowledge, this manifestation has not reported before.