Correction of erosion after suburethral sling insertion for stress incontinence: results and related sexual function

BACKGROUND: Suburethral slings are commonly used for the surgical treatment of female stress incontinence; occasionally they can cause erosion and dyspareunia. OBJECTIVES: The primary aim of this study is to determine the outcome after reclosure of the vaginal epithelium for suburethral sling erosion. Sexual function was assessed before and after intervention using the Female Sexual Function Index (FSFI) questionnaire. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective case-controlled study in which, between December 2005 and December 2007, we included patients who were referred to the Department of Urogynaecology because of vaginal erosion after suburethral sling insertion for urinary stress incontinence. For evaluation of sexual function, all patients filled in an FSFI questionnaire before intervention and at follow-up. All patients underwent gynaecological examination including colposcopy, and the site and size of the defect were noted. INTERVENTION: The edge of the vaginal epithelium was trimmed, mobilized, and closed with interrupted vertical Vicryl mattress sutures in a single layer. MEASUREMENTS: FSFI questionnaire and clinical findings. RESULTS AND LIMITATIONS: Twenty-one patients were included in the study. Eighteen patients with larger defects were operated on, and three defects healed after topical application of estrogen cream. In 16 patients, the defect had healed at follow-up; two patients with persisting defects were brought back to surgery and the procedure was repeated, paying particular attention to tension-free adaptation of vaginal tissue. In one patient, partial sling removal was performed after the second failed intervention. The domains of desire (p<0.0001), arousal (p<0.0003), lubrication (p<0.0001), satisfaction (p<0.0130), and pain (p<0.0001) improved significantly. Orgasm remained unchanged (p=0.4130; all two-tailed t-test). CONCLUSION: Suburethral erosion can be treated effectively by resuturing. Sexual function is improved in regard to desire, arousal, lubrication, satisfaction, and pain, but not orgasm. In septic patients and patients with a history of radiation, grossly infected tissue, or severe pain, excision of the mesh needs to be considered.

Is the effect of inguinal field block with 0.5 % bupivacaine on postoperative pain after hernia repair enhanced by addition of ketorolac or S(+) ketamine ?

Résumé Malgré l'apparition de nouvelles techniques chirurgicales dites « sans tension », l'antalgie post-opératoire après cure de hernie inguinale reste un défi pour les anesthésiologistes. Récemment on a suggéré que l'addition de ketamine ou d'un anti-inflammatoire non-stéroïdien (AINS) à un anesthésique local pourrait améliorer et prolonger l'analgésie postopératoire. Le but de cette étude, à laquelle ont participé 36 patients ASA I-II, était d'évaluer si la coadministration de S(+) ketamine ou de ketorolac renforcerait les effets analgésiques de la bupivacaïne après cure ambulatoire de hernie inguinale sous anesthésie générale. L'analgésie a consisté en une infiltration de la plaie associé à un bloc inguinal avec soit 30 ml de bupivacaïne 0,5 % (n=12), soit 27 ml de bupivacaïne 0,5 % + 3 ml de S(+) ketamine (75 mg) (n=12), soit 28 ml de bupivacaïne 0,5 % + 2 ml de ketorolac (60 mg) (n=12). La prise orale d'antalgique en phase postopératoire était standardisée. L'intensité des douleurs a été évaluée au moyen d'une échelle visuelle analogique (EVA), d'un score verbal d'estimation et par algométrie de pression respectivement 2, 4, 6, 24 et 48 heures après l'intervention. Les trois groupes de patients ont présenté le score de douleur évalué par EVA le plus élevé à 24 heures, score significativement différent de ceux mesurés à 6 et 48 heures (P <0.05). A part une sensation de douleurs significativement moindre (score verbal d'estimation) dans le groupe ketorolac à 24 et 48 heures et seulement à 48 heures dans le groupe ketamine, il n'y avait aucune autre différence entre les groupes pour la durée de l'étude (48 heures) en ce qui concerne les scores de douleur, les seuils de douleur à la pression ou la prise postopératoire d'antalgiques « de secours ». En conclusion, l'addition de S(+) ketamine ou de ketorolac, n'améliore que marginalement l'effet analgésique de la bupivacaïne. Ceci peut-être mis en relation avec la technique de cure de hernie « sans tension » induisant un bas niveau de douleur postopératoire. Abstract Objective: The aim of the study was to assess whether coadministration of S(±) ketamine or ketorolac would enhance or prolong local analgesic effect of bupivacaine after inguinal hernia repair. Design: Prospective double-blind randomized study evaluating pain intensity after surgery under general anesthesia. Setting: Outpatient facilities of the University Hospital of Lausanne. Patient: Thirty-six ASA I-II outpatients scheduled for elective day-case inguinal herniorraphy. Intervention: Analgesia strategy consisted of a wound infiltration and an inguinal field block either with 30 mL bupivacairie (0.5%) or with the same volume of a mixture of 27 mL bupivacaine (0.5%) + 3 mL S(+) ketamine (75 mg) or a 28 mL bupivacaine (0.5%) + 2 ML ketorolac (60 mg). Postoperative analgesic regimen was standardized. Outcome Measures: Pain intensity was assessed with a Visual Analog Seale, a verbal rating score, and by pressure algometry 2, 4, 6, 24, and 48 hours after surgery. Results: The 3 groups of patients experienced the highest Visual Analog Scale pain score at 24 hours, which was different from those at 6 and 48 hours (P < 0.05). Apart from a significantly lower pain sensation (verbal rating score) in the ketorolac group at 24 and 48 hours and only at 48 hours with ketamine, there were no other differences in pain scores, pain pressure thresholds, or rescue analgesic consumption between groups throughout the 48-hour study period. Conclusion: The addition of S (+)-ketamine or ketorolac only minimally improves the analgesic effect of bupivacaine. This may be related to the tension-free hernia repair technique associated with low postoperative pain.

Surgery for incarcerated hernia: short-term outcome with or without mesh.

BACKGROUND: Incarcerated hernias represent about 5-15 % of all operated hernias. Tension-free mesh is the preferred technique for elective surgery due to low recurrence rates. There is however currently no consensus on the use of mesh for the treatment of incarcerated hernias, especially in case of bowel resection. AIM: The aims of this study were (i) to report our current practice for the treatment of incarcerated hernias, (ii) to identify risk factors for postoperative complications, and (iii) to assess the safety of mesh placement in potentially infected surgical fields. METHODS: This retrospective study included 166 consecutive patients who underwent emergency surgery for incarcerated hernia between January 2007 and January 2012 in two university hospitals. Demographics, surgical details, and short-term outcome were collected. Univariate analysis was employed to identify risk factors for overall, infectious, and major complications. RESULTS: Eighty-four patients (50.6 %) presented inguinal hernias, 43 femoral (25.9 %), 37 umbilical hernias (22.3 %), and 2 mixed hernias (1.2 %), respectively. Mesh was placed in 64 patients (38.5 %), including 5 patients with concomitant bowel resection. Overall morbidity occurred in 56 patients (32.7 %), and 8 patients (4.8 %) developed surgical site infections (SSI). Univariate risk factors for overall complications were ASA grade 3/4 (P = 0.03), diabetes (P = 0.05), cardiopathy (P = 0.001), aspirin use (P = 0.023), and bowel resection (P = 0.001) which was also the only identified risk factor for SSI (P = 0.03). In multivariate analysis, only bowel incarceration was associated with a higher rate of major morbidity (OR = 14.04; P = 0.01). CONCLUSION: Morbidity after surgery for incarcerated hernia remains high and depends on comorbidities and surgical presentation. The use of mesh could become current practice even in case of bowel resection.

A pedicled bone graft from the acromion: an anatomical investigation regarding surgical feasibility.

OBJECTIVE: To investigate the technical feasibility of harvesting a vascularized bone graft from the acromion pedicled on the acromial branch. BACKGROUND: Complex fractures of the proximal humerus may result in partial or total avascular necrosis of the head fragment. Treatment of avascular necrosis of the humeral head is dependent upon the stage of disease as well as the dimension and location of necrosis. In general, the outcome is poor and complete restoration of the shoulder function is rarely attained. Contrary to osteonecrosis of carpal bones (where vascularized bone grafts have been routinely carried out for decades), reports of analogous procedures at the humeral head are anecdotal. METHODS: Based on selective post-mortem computer-tomographic angiography of 5 and the dissection of 30 embalmed human cadaver shoulders, we describe the anatomy of the acromial branch of the thoracoacromial trunk. The main focus was the constancy of its anatomical course, its dimensions and potential use as a nutrient vessel for a pedicled bone graft from the acromion. RESULTS: The course of the acromial branch revealed a constant topographic relationship to anatomical landmarks. Its terminal branches reliably supplied the anterior part of the acromion. The vascularized bone graft could be sufficiently mobilized to allow tension-free transfer to the humeral head as well as to the lateral two-thirds of the clavicle. CONCLUSION: We demonstrated the feasibility of vascularized bone graft harvesting from the acromion. This technique could be a joint-preserving procedure for osteonecrosis of the humeral head or may assist in the revision of a clavicular pseudoarthrosis.

A tailored approach for the treatment of indirect inguinal hernia in adults--an old problem revisited.

A patent processus vaginalis peritonei (PPV) presents typically as an indirect hernia with an intact inguinal canal floor during childhood. Little is known however about PPV in adults and its best treatment. A cohort study included all consecutive patients admitted for ambulatory open hernia repair. In patients with a PPV, demographics, hernia characteristics, and outcome were prospectively assessed. Annulorrhaphy was the treatment of choice in patients with an internal inguinal ring diameter of < 30 mm. Between 1998 and 2006, 92 PPVs (two bilateral) were diagnosed in 676 open hernia repairs (incidence of 14%). Eighty nine of the 90 patients were males, the median age was 34 years (range: 17-85). A PPV was right-sided in 67% and partially obliterated in 66%. Forty-one patients had an annulorrhaphy and 51 patients had a tension-free mesh repair. The median operation time was significantly shorter in the annulorrhaphy group (38 vs. 48 min, P <.0001). In a median follow-up period of 56 months (27-128), both groups did not differ concerning recurrence (1/41 vs. 2/51), chronic pain (3/41 vs. 4/51), and hypoesthesia (5/41 vs. 9/51). There was however a clear trend to less neuropathic symptoms in favor of annulorrhaphy (0/41 vs. 5/51, P < 0.066). PPV occurs in 14% of adults undergoing hernia repair. In selected patients, annulorrhaphy takes less time and is associated with equally low recurrence but less potential for neuropathic symptoms.

Algies après cure de hernie inguinale: que faire [Pain after inguinal hernia repair: what to do?]

Hernia repair one of the most frequently performed operations in general surgery. With the introduction of tension-free mesh repair, recurrence rates dropped well below 5% for open and laparoscopic procedures. However, chronic postoperative pain remains a widely neglected complication with a high socio-economic impact. It occurs in about 10-20% of patients after hernia repair. We review the different types of post-herniorrhaphy pain with the typical diagnostic features and we conclude with a pragmatic algorithm based on our clinical experience.

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.

Inguinal hernias in patients of 50 years and above. Pattern and outcome

OBJECTIVE: to evaluate a one year experience with inguinal hernia repair, in patients of > 50years, with respect to the type of inguinal hernia, type of surgery, postoperative complications and recurrence. METHODS: a prospective descriptive study of patients (n=57) > 50 years operated for inguinal hernia during a one year period. Tension-free meshplasty and herniorrhaphy, using 3"x6" polypropylene mesh and 2-0 polypropylene suture, were performed in elective and emergency surgery respectively. Follow-up visits were scheduled at six weeks, three and six months postoperatively. RESULTS: the most representative age group was 61-70 years, and all patients were male. 52 (91.22%) patients had unilateral inguinal hernias, while five (8.77%) had bilateral hernias. In 50 (87.71%) patients, the hernia was uncomplicated, while seven (12.28%) patients presented with some complication such as obstruction or strangulation. Elective surgery was performed in 50 (87.71%) patients while seven (12.28%) patients were operated in emergency. Postoperatively, 50 (87.7%) patients had uneventful recovery, while seven (12.28%) patients developed some complications which were treated conservatively. Mean hospital stay was six days. One recurrence was observed and there was no peri/postoperative death. CONCLUSION: tension-free meshplasty and herniorrhaphy are safe, simple and applicable even in elderly patients after adequate pre-operative assessment and optimization. Although associated with longer hospital stay, the mortality rate is nil and complication as well as recurrence rate is low. Hence, timely repair is necessary in elderly patients even in those with comorbid conditions.

Análise retrospectiva de casuística de hernioplastia inguinal videolaparoscópica TAPP

Pós-graduação em Bases Gerais da Cirurgia - FMB

Análise retrospectiva de casuística de hernioplastia inguinal videolaparoscópica TAPP

Pós-graduação em Bases Gerais da Cirurgia - FMB

Biogeochemistry of an Amazonian podzol-ferralsol soil system with white kaolin

The podzol-ferralsol soil systems, which cover great areas of Amazonia and other equatorial regions, are frequently associated with kaolin deposits and store and export large amounts of carbon. Although natural organic matter (NOM) plays a key role in their dynamics, little is known about their biogeochemistry. In order to assess the specific role of dissolved organic matter (DOM) on NOM storage in deep horizons and to determine possible relationships between kaolin formation and DOM properties, we studied the groundwater composition of a typical podzol-ferralsol soil catena from the Alto Rio Negro region, Brazil. Groundwater was sampled using tension-free lysimeters placed according to soil morphology. DOC, E-H, p(H), and dissolved Si, Al3+, Fe2+, and Fe3+ were analyzed for all samples and values are given in a database. Quantification of other dissolved ions, small carboxylic acids and SUVA(254) index and acid-base microtitration was achieved on selected samples. Part of the DOM produced by the hydromorphic podzols is directly exported to the blackwater streams; another part percolates at greater depth, and more than 90% of it adsorbs in the Bh-Bhs horizons, allowing carbon storage at depth. Humic substances are preferentially adsorbed with regard to small carboxylic compounds. With regard to kaolin genesis, kaolinite precipitation is favored by Al release from NOM mineralization within the Bh-Bhs and kaolin bleaching is ensured by iron reduction due to acidity and relatively low E-H. Fe2+ mobility can be related to small E-H variations and enhanced by the significant concentration of small carboxylic acids. The long-term result of these processes is the thickening of the kaolin, and it can be inferred that kaolin is likely to occur where active, giant podzols are close to a slope gradient sufficient enough to lower the deep water table.

Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study

CONTEXT: Failure of a colorectal anastomosis represents a life-threatening complication of colorectal surgery. Splenic flexure mobilization may contribute to reduce the occurrence of anastomotic complications due to technical flaws. There are no published reports measuring the impact of splenic flexure mobilization on the length of mobilized colon viable to construct a safe colorectal anastomosis. OBJECTIVE: The aim of the present study was to determine the effect of two techniques for splenic flexure mobilization on colon lengthening during open left-sided colon surgery using a cadaver model. DESIGN: Anatomical dissections for left colectomy and colorectal anastomosis at the sacral promontory level were conducted in 20 fresh cadavers by the same team of four surgeons. The effect of partial and full splenic flexure mobilization on the extent of mobilized left colon segment was determined. SETTING: University of Sao Paulo Medical School, Sao Paulo, SP, Brazil. Tertiary medical institution and university hospital. PARTICIPANTS: A team of four surgeons operated on 20 fresh cadavers. RESULTS: The length of resected left colon enabling a tension-free colorectal anastomosis at the level of sacral promontory achieved without mobilizing the splenic flexure was 46.3 (35-81) cm. After partial mobilization of the splenic flexure, an additionally mobilized colon segment measuring 10.7 (2-30) cm was obtained. After full mobilization of the distal transverse colon, a mean 28.3 (10-65) cm segment was achieved. CONCLUSION: Splenic flexure mobilization techniques are associated to effective left colon lengthening for colorectal anastomosis. This result may contribute to decision-making during rectal surgery and low colorectal and coloanal anastomosis.

Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients

OBJECTIVE: To analyze the clinical outcome of horizontal ridge augmentation using autogenous block grafts covered with an organic bovine bone mineral (ABBM) and a bioabsorbable collagen membrane. MATERIAL AND METHODS: In 42 patients with severe horizontal bone atrophy, a staged approach was chosen for implant placement following horizontal ridge augmentation. A block graft was harvested from the symphysis or retromolar area, and secured to the recipient site with fixation screws. The width of the ridge was measured before and after horizontal ridge augmentation. The block graft was subsequently covered with ABBM and a collagen membrane. Following a tension-free primary wound closure and a mean healing period of 5.8 months, the sites were re-entered, and the crest width was re-assessed prior to implant placement. RESULTS: Fifty-eight sites were augmented, including 41 sites located in the anterior maxilla. The mean initial crest width measured 3.06 mm. At re-entry, the mean width of the ridge was 7.66 mm, with a calculated mean gain of horizontal bone thickness of 4.6 mm (range 2-7 mm). Only minor surface resorption of 0.36 mm was observed from augmentation to re-entry. CONCLUSIONS: The presented technique of ridge augmentation using autogenous block grafts with ABBM filler and collagen membrane coverage demonstrated successful horizontal ridge augmentation with high predictability. The surgical method has been further simplified by using a resorbable membrane. The hydrophilic membrane was easy to apply, and did not cause wound infection in the rare instance of membrane exposure.

Early implant placement following single-tooth extraction in the esthetic zone: biologic rationale and surgical procedures

Early implant placement is one treatment option for implant therapy following single-tooth extraction in the anterior maxilla. The surgical technique presented here is characterized by tooth extraction without flap elevation, a 4- to 8-week soft tissue healing period, implant placement in a correct three-dimensional position, simultaneous contour augmentation on the facial aspect with guided bone regeneration using a bioabsorbable collagen membrane combined with autogenous bone chips and a low-substitution bone filler, and tension-free primary wound closure. The surgical step-by-step procedure is presented with a case report. In addition, the biologic rationale is discussed.

Ankle dorsiflexion arthrodesis to salvage Chopart's amputation with anterior skin insufficiency

BACKGROUND In Chopart-level amputations the heel often deviates into equinus and varus when, due to the lack of healthy anterior soft tissue, rebalancing tendon transfers to the talar head are not possible. Consequently, anterior and lateral wound dehiscence and ulceration may occur requiring higher-level amputation to achieve wound closure, with considerable loss of function for the patients. METHODS Twenty-four consecutive patients (15 diabetes, 6 trauma, and 3 tumor) had Chopart's amputation and simultaneous or delayed additional ankle dorsiflexion arthrodesis to allow for tension-free wound closure or soft tissue reconstruction, or to treat secondary recurrent ulcerations. Percutaneous Achilles tendon lengthening and subtalar arthrodesis were added as needed. Wound healing problems, time to fusion and full weight-bearing in the prosthesis, complications in the prosthesis, and the ambulatory status were assessed. Satisfaction and function were evaluated by the AmpuPro score and the validated Prosthesis Evaluation Questionnaire scale. RESULTS Five patients had successful soft tissue healing and fusions but died of their underlying disease 2 to 46 months after the operation. Two diabetic patients required a transtibial amputation. The other 17 patients were followed for 27 months (range, 13-63). The average age of the 4 women and 13 men was 53.9 years (range, 16-87). Postoperative complications included minor wound healing problems in 8 patients, wound breakdown requiring revision in 4, phantom pain in 3, residual equinus in 1, and adjacent scar carcinoma in 1 patient. The time to full weight-bearing in the prosthesis ranged from 6 to 24 weeks (mean 10). The mean AmpuPro score was 107 points (of 120), and the mean Prosthesis Evaluation Questionnaire scale was 147 points (of 200). No complications occurred with the prosthesis. Twelve patients lost 1 to 2 mobility classes (mean 0.9). The arthrodeses all healed within 2.5 months (range, 1.5 to 5 months). CONCLUSION Adding an ankle arthrodesis to a Chopart's amputation either immediately or in a delayed fashion to treat anterior soft tissue complications was a successful salvage in most patients at this amputation level. It enabled the patients to preserve the advantages of a full-length limb with terminal weight-bearing. LEVEL OF EVIDENCE Level IV, retrospective case series.