Hypertonic Saline for Severe Traumatic Brain Injury With Herniation: A Military Prehospital Case Report

Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.

Randomized controlled trials published on patients with hernias have a high percentage of unreproducible statistics

INTRODUCTION

Surgeons rely on randomized controlled trials (RCT) to compare the effectiveness of treatments. RCTs require careful planning and substantial effort to complete. Because of the careful study design, statistics performed are often easy to reproduce such as Chi-squared or t-test. Issues such as statistical discordance, or reporting statistical results that cannot be reproduced, should be uncommon.

METHODS

RCTs pertaining to hernias were identified in PubMed using the search terms "hernia" and "randomized controlled trial." Studies were selected using a random number generator. Studies were included if the primary outcome could be reproduced using the data and statistical test reported in the manuscript. Discordance between the obtained p-value from our analysis and the published p-value was assessed. Primary outcome was the number of studies that reported p-values that crossed the level of statistical significance (p-value = 0.05) but on reproduction analysis did not.

RESULTS

Of the 100 included RCTs, five reported p-values that crossed the "p = 0.05" threshold that our team was unable to reproduce using the statistical test reported in the manuscript. An additional three studies reported p-values that crossed the "p = 0.05" threshold that our team was unable to reproduce using the appropriate statistical test (i.e., Fisher's exact test when all expected cell counts < 5). All eight studies published p-values < 0.05, whereas, our re-analysis demonstrated p ≥ 0.05.

CONCLUSION

Eight percent of the RCTs analyzed in this study reported p-values < 0.05 that on reproduction analysis was ≥ 0.05. The next steps should be to determine reasons for discordance and how to prevent this from happening.

[Resolution of the Open Plenum of the All-Russian Public Organization "Society of Herniologists" (Moscow, 20.11.20)]

Resolution of the Open Plenum of the All-Russian Public Organization "Society of Herniologists" (Moscow, 20.11.20).

High-Throughput Manufacture of 3D Fiber Scaffolds for Regenerative Medicine

Engineered scaffolds used to regenerate mammalian tissues should recapitulate the underlying fibrous architecture of native tissue to achieve comparable function. Current fibrous scaffold fabrication processes, such as electrospinning and three-dimensional (3D) printing, possess application-specific advantages, but they are limited either by achievable fiber sizes and pore resolution, processing efficiency, or architectural control in three dimensions. As such, a gap exists in efficiently producing clinically relevant, anatomically sized scaffolds comprising fibers in the 1-100 μm range that are highly organized. This study introduces a new high-throughput, additive fibrous scaffold fabrication process, designated in this study as 3D melt blowing (3DMB). The 3DMB system described in this study is modified from larger nonwovens manufacturing machinery to accommodate the lower volume, high-cost polymers used for tissue engineering and implantable biomedical devices and has a fiber collection component that uses adaptable robotics to create scaffolds with predetermined geometries. The fundamental process principles, system design, and key parameters are described, and two examples of the capabilities to create scaffolds for biomedical engineering applications are demonstrated. Impact statement Three-dimensional melt blowing (3DMB) is a new, high-throughput, additive manufacturing process to produce scaffolds composed of highly organized fibers in the anatomically relevant 1-100 μm range. Unlike conventional melt-blowing systems, the 3DMB process is configured for efficient use with the relatively expensive polymers necessary for biomedical applications, decreasing the required amounts of material for processing while achieving high throughputs compared with 3D printing or electrospinning. The 3DMB is demonstrated to make scaffolds composed of multiple fiber materials and organized into complex shapes, including those typical of human body parts.

Minimally invasive oesophagectomy and emerging complications: intercostal lung hernia

Lung herniation is a rare entity, defined as a protrusion of the lung above the normal confines of thorax; it is caused by increased intrathoracic pressure and defects or weakness of the chest wall. Intercostal lung hernia can occur spontaneously or following thoracic trauma or surgery. Postoperative hernias are more commonly associated with less extensive surgical procedures, such as thoracoscopic surgery or mini-thoracotomy incisions, rather than with major thoracic procedures. We describe the first reported case of postoperative intercostal lung hernia following two-stage totally minimally invasive oesophagectomy for cancer, together with its successful surgical repair.

[Effect of auricular point pressing combined with electroacupuncture on postoperative pain and inflammatory cytokines in children with hernia]

OBJECTIVE

To explore the clinical efficacy and action mechanism of auricular point pressing combined with electroacupuncture (EA) on postoperative pain in children with hernia.

METHODS

A total of 93 children with inguinal hernia were randomly divided into an auricular point group, an EA group and a combination group, 31 cases in each group. All the three groups were treated with routine postoperative treatment and nursing, and analgesic and sedative drugs were used when necessary. After awaking, the children in the auricular point group were treated with auricular point pressing at Shenmen (TF₄), Jiaogan (AH_6a) and Pizhixia (AT₄); the seeds of cowherb were placed at the auricular points and the same nurse used index finger and thumbs to press the points for 2 min, and repeated after 30 min. The pressing time was 8-11 AM and 14-17 PM for 3 days. The children in the EA group were treated with EA at Sanyinjiao (SP 6) and Zusanli (ST 36); the needles were perpendicularly inserted with mild reinforcing-reducing method; EA instrument was connected with needles and the current intensity was under the maximal tolerance of children; the needles were retained for 20 min, three times a day for continuous 3 days. The children in the combination group were treated with auricular point pressing and EA for 3 days. The Wong-Baker facial expression evaluation method was used to observe the pain scores 1-3 h, 4-24 h, 25-48 h and 49-72 h after operation; the contents of TNF-α, IL-6 and IL-8 were compared 1 day, 2 days and 3 days after operation; the number of cases using sedative drugs and average hospitalization days were compared among the three groups.

RESULTS

①Among the children aged 8-15 years old, the pain scores 4-24 h and 25-48 h after operation in the combination group were lower than those in the auricular point group and the EA group (all P<0.05); among the children aged 4-7 years old, differences of the pain scores in each time after operation were not significant statistically among the three groups (all P>0.05). ②The contents of TNF-α, IL-6 and IL-8 in serum 1 day, 2 days and 3 days after operation in the combination group were lower than those in the auricular point group and the EA group (all P<0.05). ③The number of cases using analgesic and sedative drugs after operation in the combination group was fewer than that in the auricular point group and the EA group (all P<0.05). ④The average hospitalization days in the combination group were shorter than those in the auricular point group and the EA group (all P<0.05).

CONCLUSION

Compared with auricular point pressing or EA alone, the combination of auricular point pressing and EA could not only effectively relieve the postoperative pain, but also reduce the expression of inflammatory cytokines in children with hernia, improving the clinical efficacy.

Critical Under-Reporting of Hernia Mesh Properties and Development of a Novel Package Label

BACKGROUND

With an array of hernia meshes with varying properties, intraoperative decision making for the optimal mesh is critical. Although meshes are subjected to regulatory review through the Food and Drug Administration, it is unknown whether mesh properties are visually accessible. To facilitate greater knowledge for the surgeon on mesh choice, we aimed to comprehensively analyze hernia mesh packaging and regulations.

STUDY DESIGN

Labeling guidelines and 510(k) requirements across Food and Drug Administration-regulated products were analyzed and compared with mesh packaging. Packages and Instructions for Use were analyzed for commonly available hernia meshes. Literature review was conducted to understand recommended guidelines for mesh products. A novel hernia mesh packaging label was designed to rectify under-reporting.

RESULTS

We found that food labels undergo critical scrutiny and detailed specifications, yet medical devices are not subjected to similar guidelines. The highest reported property on packages was the presence of a barrier (80%), and the lowest reported property was barrier composition (33%). For Instructions for Use, the lowest reported properties were mechanics (31%) and thickness (11%), both of which were not reported on packaging. Descriptive terms for pore size and mechanics were reported inconsistently. To overcome this under-reporting of properties, we propose a novel packaging label with properties chosen from regulatory guidelines, packaging analysis, and literature review.

CONCLUSIONS

Although standardized terminology has been proposed in literature, property knowledge has not adequately permeated surgery, industry, or regulatory guidelines. There is extreme under-reporting and lack of consistency of clinically important mesh properties. Standardized packaging labels will provide accessibility of these properties and aim to bring standardized terminology into practice. With an increase in access to important properties, this can facilitate intraoperative decision making on a case-by-case basis.

In vitro study of the mechanical performance of hernia mesh under cyclic loading

The use of prostheses for hernia surgery, made from synthetic polymers may lead to development of postoperative complications. The reason for this can be the mismatch of the mechanical properties of meshes and the loads acting on them. The aim of this work was to investigate the behavior of 3 different hernia meshes under in vitro simulated physiological conditions followed by cyclic loadings. Meshes, Ultrapro (poliglecaprone and polypropylene), Dynamesh (polyvinylidenefluoride) and Surgipro (polypropylene) were selected. For in vitro degradation test, samples were kept in alkaline and acid mediums at 37 °C during 42 and 90 days and analyzed in terms of their weight loss and thickness changes. This was followed by cyclic loading in three increasing load stages. The greatest weight loss and thickness reduction were suffered by Ultrapro mesh. The mesh showed pH independent characteristics. Surgipro mesh had pH independent behavior due to the degradation process, with slight weight loss and thickness reduction. The degradation mechanism of Dynamesh is highly dependent on the pH, with acid surrounding medium acting as a degradation catalyst. Mechanical hysteresis was observed in all three meshes. The larger deformations occurred in Surgipro (25%); necking phenomenon was also observed. The deformation of Dynamesh was 22%, the mesh unweaves under applied load and was unable to withstand the third period of cyclic loads. Ultrapro mesh exhibits the lowest level of deformation (10%). Despite the different compositions and architectures of the meshes, all three underwent permanent plastic deformation, which will induce decreased mesh flexibility over time.

[The key points of prevention for special surgical complications after radical operation of gastric cancer]

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.

Acquires Anterior Thoracic Lung Herniation and Repair: A Rare Case and Discussion

We report a case of acquired anterior thoracic lung herniation in a 63-yeal-old female. This painful herniation developed four years after uncomplicated video-assisted thoracic surgery for lung cancer resection and adjuvant radiation for concomitant breast cancer. The herniation site was remote from all prior incisions, and demonstrated intercostal muscle denervation and radiation fibrosis. The 8 cm x 10 cm chest wall defect was reconstructed with inlay PROCEED mesh and reinforced with a pedicled latissimus dorsi flap. Five months postoperatively the patient had complete resolution of symptoms, no evidence of herniation, and a stable wound.

Paradoxical Herniation after Unilateral Decompressive Craniectomy: A Retrospective Analysis of Clinical Characteristics and Effectiveness of Therapeutic Measures

AIM

We aimed to investigate the importance of early diagnosis and proper management of paradoxical herniation based on the data of 13 patients who had 14 occurrences of paradoxical herniation.

MATERIAL AND METHODS

The characteristics and the effectiveness of treatments of 13 patients with paradoxical herniation were reviewed and analyzed retrospectively.

RESULTS

Paradoxical herniation occurred in eight patients (61.54%) during the postoperative 2 weeks and they presented with typical symptoms of brain herniation and a tense skin flap without sinking at the region of decompressive craniectomy. On the other hand, six patients developed paradoxical herniation in the postoperative period of 2 weeks to 2 months and presented with sinking skin flaps and delayed neurological deficits. Furthermore, all patients received emergency treatments, including sufficient hydration, clamping cerebrospinal fluid (CSF) drainage, and being placed in the Trendelenburg position. Six patients achieved full neurologic recovery after successful cranioplasty.

CONCLUSION

Intracranial hypotension causing paradoxical herniation can rapidly progress, especially along with CSF depletion. It is important for neurosurgeons to suspect paradoxical herniation in a subset of patients with large cranium defects and tense skin flap without sinking during the postoperative 2 weeks. Paradoxical herniation is rapidly reverted by improving CSF hydration, and performing early cranioplasty referred as the definitive treatment.

Bioprosthetic mesh of bacterial cellulose for treatment of abdominal muscle aponeurotic defect in rat model

The use of meshes for treatment of hernias continues to draw attention of surgeons and the industry in the search of an ideal prosthesis. The purpose of this work is to use meshes manufactured from bacterial cellulose, evaluate their organic tissue interaction and compare with an expanded polytetrafluorethylene (ePTFE's) prosthesis used to repair acute defect of muscle aponeurotic induced in rats. Forty-five male Wistar rats were classified using the following criteria: (1) surgical repair of acute muscle aponeurotic defect with perforated bacterial cellulose film (PBC; n = 18); (2) compact bacterial cellulose film (CBC; n = 12) and (3) ePTFE; (n = 15). After postoperative period, rectangles (2 × 3 cm) including prosthesis, muscles and peritoneum were collected for biomechanical, histological and stereological analysis. In all cases, the maximum acceptable error probability for rejecting the null hypothesis was 5 %. Between PBC and CBC samples, the variables of strain (P = 0.011) and elasticity (P = 0.035) were statistically different. The same was found between CBC and ePTFE (elasticity, P = 0.000; strain, P = 0.009). PBC differed from CBC for giant cells (P = 0.001) and new blood vessels (P = 0.000). In conclusion, there was biological integration and biomechanical elasticity of PBC; therefore, we think this option should be considered as a new alternative biomaterial for use as a bio prosthesis.

Expertise, accidents and hernias in the context of the right to health, Colombia 1915-1946

For most physicians, the assessment of disability in cases of work accident or occupational disease is very relative matter, and clinical judgments are subjective and unsatisfactory in legal settings. Work accident legislation gives them the task of deciding on any causal links between accident and disease and indicating any economic compensation that should be awarded. They must therefore reach beyond their scientific knowledge to understand the multitude of social factors that underlie these problems in the world of work. In this article, we analyze Colombian sources from the first half of the 20th century on the physiology of labor, fatigue, professional risk, work accidents, occupational diseases, among other issues. The aim is to advance understanding of how the field of medical knowledge established an ethical approach for experts in cases of occupational accidents, focusing on hernias, typical misfortunes of the world of work.

[Design and Fabrication of a Device for Intraperitoneal Treatment of Pediatric Hernia]

For treatment of pediatric inguinal hernia, we fabricated a device, i.e. so called "filling type pediatric hernia sac", which treats the problem from the abdominal cavity, through the abdominal and is a self-adaptive closer, using synthetic material. The device includes filling rack, self-adaptive umbrella support bar, bottom piece, outside pulling line and device fixing lines. The filling rack is composed of 2 concentric circles of 3.0 cm diameter with peripherally fixed together and can be pulled into the shapes of a ball or an olive. The supporting bar is structured of 3 pieces with 0.5 cm wide, 4.0 cm long, cross-fixed on top of the filling rack. The bottom piece is in a circular structure with a diameter of 3.0 cm, and it is connected to the filling rack bottom. Adjust positioning stay outside the fixed on the top of the device are connected at one end, and the other end free through filling the top frame connected with the bottom slice of central fixation. By using this device, we treated 37 pediatric inguinal hernia cases with 38 side-inguinal hernia successfully. The mean duration of post-operation follow-ups was 14.6 ± 5.89 months, without hernia recurrence, obvious scar and hard sections of inguinal region. This device could provide a convenient, safe and effective plugging technology for children's pediatric hernia.

Leakage and internal herniation are the most common complications after gastric bypass

INTRODUCTION

The aim is to report the diagnostic strategy, clinical findings and treatment in patients admitted on suspicion of early or late complications associated with a previous laparoscopic Roux-en-Y gastric bypass (LRYGB).

MATERIAL AND METHODS

Patients admitted in 2011-2012 to our department with the International Classification of Diseases 10 code DZ980C (condition with a gastric bypass) were identified using the Hospital register system. Patient data included co-morbidity, time between LRYGB and the actual admission, body mass index development, diagnostic strategy, clinical findings and treatment of complications. Early and late complications were defined as </> 30 days post-operatively.

RESULTS

Among 186 patients, the primary early complication was leakage or unexplained abdominal pain. Internal hernia or unexplained abdominal pain was observed most frequently as a late complication. The majority of patients had a computed tomography performed as their first diagnostic procedure. 19% of patients who were operated for internal hernia underwent a re-operation. Among patients undergoing laparoscopy, 72% had internal hernia and 20% had a leak. The length of stay was 18 days for patients with leakage compared to three days for patients with internal hernia.

CONCLUSION

In conclusion, the primary early complication of LRYGB patients was leakage, and internal hernia was the most frequent late complication. A substantial number of the patients who are readmitted after LRYGB suffer from unexplained abdominal pain that should be managed by specialised centres.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Lung hernia - a review

Lung hernia is a protrusion of lung tissue through one of its bounding structures. This uncommon condition develops most commonly as a result of trauma or after thoracic operations. Other lung hernias, particularly supraclavicular, are congenital. Diagnosis is usually clinical, but must be confirmed by roentgenography or computed tomography. Presence of incarceration or other symptoms makes operation obligatory. Incarcerated tissue should be released promptly, but may have to be resected. For closure of a hernia defect the use of autologous tissues is recommended. When these are not available, synthetic materials are acceptable. Some hernias are asymptomatic and no treatment is necessary.

[Recent progress of small intestinal submucosa in application research of tissue repair and reconstruction]

OBJECTIVE

To review the recent progress of the small intestinal submucosa (SIS) in application research of tissue repair and reconstruction.

METHODS

The domestic and international articles on the SIS were reviewed and summarized.

RESULTS

As a natural extracellular matrix, SIS has outstanding biological advantages, such as good mechanical property, tissue compatibility, and lower immunogenicity. SIS has been used to repair and reconstruct various types of tissue defects in animal models and clinical application, especially in the treatment of hernia, urinary system disease, and refractory skin trauma. The development of the tissue engineering technology expands the field of SIS repair and reconstruction and promotes the intensive study of SIS. However, the long-term effect of SIS in tissue repair and reconstruction still remains to be further observation, while the cell/SIS material construction by tissue engineering technology also needs more studies.

CONCLUSION

SIS has a widely promising application future in the tissue repair and reconstruction.

Handlebar injuries in children

INTRODUCTION

Handlebar injuries in children may lead to severe organ lesions despite minimal initial signs and without visible skin bruise. We present our experiences applying a diagnostic and therapeutic algorithm for blunt abdominal trauma, and present the history of two selected cases.

MATERIALS AND METHODS

We retrospectively assessed the charts of children below 16 years of age, only who were observed for 24 h or more in our institution due to a handlebar injury between 2004 and 2011. All children were treated according to an institutional algorithm.

RESULTS

40 patients with a median age of 9.5 years were included. Diagnosed lesions were: ruptures of the liver (n = 6), spleen (n = 5), kidney (n = 1), and pancreas (n = 2), small bowel perforation (n = 3), and hernias of the abdominal (n = 2) or thoracic wall (n = 1). Surgical interventions were performed in 8 patients. The outcome was favorable in all the cases. Overall median hospitalization duration was 4.5 days (range 1-19 days). The overall duration between the accident and arrival at our emergency unit was 2.75 h (median, range 1-19 h). 20 children presented directly at our emergency unit after a median of 1.7 h (range 1-19.5 h). 20 children were referred by a family physician or a primary hospital after a median of 4.0 h (range 1-46 h).

CONCLUSION

Handlebar injuries in children resulted in serious trunk lesions in half of the present patient series. The spectrum of injuries in handlebar accidents varies widely, especially injuries to the abdomen can unmask often only in the course. We advocate close observation of patients with thoracic and abdominal handlebar injuries which may be regarded as blunt stab wounds. An institutional algorithm for blunt abdominal trauma management is supportive for emergency care in patients with handlebar injuries.

Stab wound of the heart with unusual sequelae

A 31-year-old woman was admitted to the emergency department with a stab wound to the heart. She was initially stable but rapidly developed hypotension. While the operating room and staff were in preparation, she underwent pericardiocentesis. She was then rushed to the operating room by the general surgical trauma team, who performed a bilateral anterior thoracotomy to control the bleeding. In the recovery room, the patient was still hypotensive, so cardiothoracic surgery was consulted. An echocardiogram revealed severe hypokinesis of both ventricles. The cardiothoracic surgeons returned her to the operating room and discovered that the anterior pericardium had been completely removed by the trauma team. This had caused the posterior pericardium to form a "bowstring" that almost totally obstructed pulmonary venous return and restricted right ventricular outflow of blood, inducing right-sided heart failure. This pericardial string also strangulated the left atrium posteriorly, forming 2 compartments. We repositioned the patient's heart and implanted ventricular assist devices bilaterally to provide temporary circulatory support. The patient made a good recovery. We suggest that bilateral assist device placement can be beneficial in the recovery of a stunned but otherwise normal heart.

Durability of biologic implants for use in hernia repair: a review

In the past 10 years, hernia repair has evolved from primarily using suture closure to using mesh repair. Synthetic mesh implants were the initial gold standard, but the rate of complications such as infection, adhesions, and erosion was higher with synthetics than has been observed with newer biologic implants. As efforts to develop the ideal implant continue, the advantages of biologics for hernia and other soft-tissue repair become increasingly apparent. Animal-sourced biologics have the potential advantage over human dermis of being more amenable to standardization, and porcine dermal collagen architecture closely resembles that of human dermis. Cross-linking the collagen adds strength and durability to the implant that facilitates healing of surgical wounds, just as endogenous collagen, which is cross-linked, has innate durability that enhances natural wound healing. This review defines and assesses durability of the acellular collagen (biologic) implant options available for hernia repair. The factors that affect wound healing-and hernia repair--are summarized. Additionally, the particular features that enhance durability are described, and durability-related clinical outcomes discussed in the literature are cited to aid clinicians in making informed surgical choices.

Conjugation of gold nanoparticles to polypropylene mesh for enhanced biocompatibility

Polypropylene mesh materials have been utilized in hernia surgery for over 40 years. However, they are prone to degradation due to the body's aggressive foreign body reaction, which may cause pain or complications, forcing mesh removal from the patient. To mitigate these complications, gold nanomaterials were attached to polypropylene mesh in order to improve cellular response. Pristine samples of polypropylene mesh were exposed to hydrogen peroxide/cobalt chloride solutions to induce formation of surface carboxyl functional groups. Gold nanoparticles were covalently linked to the mesh. Scanning electron microscopy confirmed the presence of gold nanoparticles. Differential scanning calorimetry and mechanical testing confirmed that the polypropylene did not undergo any significantly detrimental changes in physicochemical properties. A WST-1 cell culture study showed an increase in cellularity on the gold nanoparticle-polypropylene mesh as compared to pristine mesh. This study showed that biocompatibility of polypropylene mesh may be improved via the conjugation of gold nanoparticles.

Cerebrovascular bypass and aneurysm trapping for the treatment of an A2-segment anterior cerebral artery pseudoaneurysm and herniation through a skull base defect following trauma

Fractures of the anterior skull base can lead to pseudoaneurysm formation as a result of direct injury to a vessel wall. Pseudoaneurysms in this location are challenging to treat, as both perforator and distal blood supply must be maintained. Additionally, traumatic skull base fractures can lead to a rare condition of cerebral blood vessel herniation through the bony defect, further complicating treatment planning. Treatment of these lesions is essential to (1) prevent the occurrence of potentially fatal subarachnoid hemorrhage and (2) prevent dissection from propagating and compromising blood flow to distal vessels, perforators, and even parent vessels. We present a unique case of a traumatic proximal anterior cerebral artery pseudoaneurysm, herniating through a skull base defect. Treatment consisted of aneurysm trapping and bypass with skull base reconstruction.

Bladder hernia

OBJECTIVE

To report a new case of bladder hernia. We reviewed the clinical features, diagnosis and treatment of this disease.

METHODS

Case report of a patient diagnosed with bladder hernia.

RESULTS

We expose the clinical picture and the most common form of diagnosis and the more effective treatment.

CONCLUSIONS

Bladder hernia is rare disorder that is diagnosed clinically and whose treatment is surgical, with very good results.

Current developments in hernia repair; meshes, adhesives, and tacking

Open and laparoscopic hernia surgery continues to evolve with new products allowing surgeons multiple choices in treating their patients. The evolution towards tension-free techniques in dealing with hernias requires that today's surgeons know the options available in meshes as well as fixation methods in order to have the best outcomes. In recent years, there has been a rapid expansion in the number of meshes available. Currently, there are numerous uncoated, coated, and biologic meshes in production that can be used in hernia repair. This paper will focus on the latest developments in coated meshes that allow for intra-abdominal placement as well as the different types of biologic meshes and their typical uses. Tacking devices for laparoscopic hernia repair now come in titanium as well as absorbable devices. AbsorbaTack™ (Covidien, Norwalk, CT) and Sorbafix™ (Davol, Warwick, RI) are two of the newest absorbable tacking devices thought to possibly benefit patients with decreased pain and long-term complications as compared with their titanium counterparts. Adhesives continue to be used more and more for hernia repair, especially in inguinal and paraesophageal hernia repairs. Tissucol™/Tisseel™ (Baxter, Deerfield, IL) and Evicel™ (Ethicon, Somerville, NJ) are two types of fibrin glues that are available for use in hernia repair. Practitioners using these biologic adhesives think there is less pain compared with tacking.

[Endoscopic diagnosis and complex treatment of Barrett's esophagus complicated by hernia of esophageal foramen of the diaphragm]

A protocol is suggested of complex diagnosis and treatment of Barrett's esophagus using sparing endoscopic removal of Barrett's epithelium in combination with surgery and medicinal antireflux therapy. Eighty-three patients were diagnosed and treated for hernia of esophageal foramen of the diaphragm and gastro-esophageal reflux complicated by Barrett's esophagus. Ninety-two percent of patients receiving our four-component treatment were cured; no recurrent esophageal adenocarcinoma was reported during the 56.7 +/- 2.4 month follow-up. Conversely, in patients receiving three-component treatment, efficacy was 56%; esophageal adenocarcinoma was reported in 3 (12%).

Parastomal hernia repair with acellular dermal matrix

PURPOSE

Treatment of parastomal hernia is often complicated by a high recurrence rate and likelihood of wound contamination. We reported an initial series of parastomal hernia repairs performed with acellular dermal matrix.

METHODS

We reviewed a series of 11 patients who had parastomal hernia repairs with acellular dermal matrix and recorded the type of ostomy, previous repair, associated intestinal pathology, type of repair performed, perioperative complications, and rate of recurrence.

RESULTS

Between 2004 and 2006, 11 patients underwent parastomal hernia repair with acellular dermal matrix by the senior author. Nine of 11 patients had associated Crohn's disease or ulcerative colitis and 3 had recurrent parastomal hernias that had failed initial repair. Mean follow-up was 8.7 months (range: 1-21 months). Two patients developed wound infections that did not require implant removal and healed with local wound care. Three patients developed recurrent hernias.

CONCLUSIONS

Parastomal hernia with acellular dermal matrix results in recurrence rates comparable to those reported in the literature for synthetic mesh repair. It offers the advantages of avoiding stoma relocation and of not requiring implant removal in cases of wound infection.

Evaluation of the Success of Medical Management for Presumptive Cervical Intervertebral Disk Herniation in Dogs

OBJECTIVE

To determine the success of medical management of presumptive cervical disk herniation in dogs and variables associated with treatment outcome.

DESIGN

Retrospective case series.

ANIMALS

Dogs (n=88) with presumptive cervical disk herniation.

METHODS

Dogs with presumptive cervical and thoracolumbar disk herniation were identified from medical records at 2 clinics and clients were mailed a questionnaire related to the success of therapy, clinical recurrence of signs, and quality of life (QOL) as interpreted by the owner. Signalment, duration and degree of neurologic dysfunction, and medication administration were determined from medical records.

RESULTS

Ninety-seven percent of dogs (84/87) with complete information were described as ambulatory at initial evaluation. Successful treatment was reported for 48.9% of dogs with 33% having recurrence of clinical signs and 18.1% having therapeutic failure. Bivariable logistic regression showed that non-steroidal anti-inflammatory drug (NSAID) administration was associated with success (P=.035; odds ratio [OR]=2.52). Duration of cage rest and glucocorticoid administration were not significantly associated with success or QOL. Dogs with less-severe neurologic dysfunction were more likely to have a successful outcome (OR=2.56), but this association was not significant (P=.051).

CONCLUSIONS

Medical management can lead to an acceptable outcome in many dogs with presumptive cervical disk herniation. Based on these data, NSAIDs should be considered as part of the therapeutic regimen. Cage rest duration and glucocorticoid administration do not appear to benefit these dogs, but this should be interpreted cautiously because of the retrospective data collection and use of client self-administered questionnaire follow-up.

CLINICAL RELEVANCE

These results provide insight into the success of medical management for presumptive cervical disk herniation in dogs and may allow for refinement of treatment protocols.

Cardiovascular Complications After Lung Surgery

Cardiovascular complications following thoracic surgery remain a challenge to the physician, the hospital, and the health care system. These events add significantly to morbidity, mortality, and the cost of care of the general thoracic surgery patient. A proactive approach to identify patients at high risk for such complications is needed. In this manner, one may enhance prevention and treatment if problems occur. A thoughtful and complete preoperative risk assessment can identify patients who have potential contributing comorbidities, leading to a reduced incidence of postoperative events. Standardization of preoperative, intraoperative, and postoperative care can reduce postoperative events. Implementation of guidelines and pathways that are evidence based can lead to enhanced patient care, better patient and staff satisfaction, and improved outcomes from the operation. Although postoperative cardiac events cannot be completely eliminated from the thoracic surgery population, the prevention, treatment, and follow-up strategies outlined herein can attenuate these significant morbid and mortal events.

Treatment of "hernia" in the writings of Celsus (first century AD)

Descriptions concerning "hernia" can be found from the early historical years, and its treatment was a subject mentioned by numerous physicians of Antiquity, such as Hippocrates and Praxagoras of Kos. Yet, Aulus Cornelius Celsus, a famous doctor and encyclopedist of the first century AD, was among the first to propose surgical treatment and carry it out successfully, according to his accounts. Many physicians attempted to treat several types of "hernia" before him, but more "scientific" information with details and complete descriptions could be found only in Celsus' work. In his book De Medicina, Celsus described eight types of "hernia": bronchocele, umbilical hernia, intestinal and omental hernias, hydrocele, varicocele, sarcocele (hernia carnosa), and inguinal hernia. Among them, some retain their ancient nomenclature up to now, although others have acquired gradually different terminology or are not recognized by physicians today as "hernias" (e.g. , bronchocele). For each type of "hernia", Celsus provided his readers with an extremely detailed, well reasoned description of the execution of surgical procedures accompanied usually with pre- and postoperative instructions. His innovations particularly concerned ligature of the vessels. He recommended that an injured vessel be tied in two places with lint threads and then cut between the ties. Other pre- and postoperative practices, such as sterilization and bandaging of the incised area, were elements that helped in the advances of medicine, and some of them still exist in modern medicine.

Presentation and management of common post-weight loss surgery problems in the emergency department

Morbid obesity is an epidemic in this country. An increasing number of patients are undergoing weight loss surgery in an effort to combat the negative physical and psychological impact of morbid obesity. Fueling the increasing interest in surgical treatment of morbid obesity has been the development of new laparoscopic techniques. There are several surgical approaches to morbid obesity, and each has its own unique set of risks and potential complications. As more patients have weight loss surgery, clinicians working in the emergency department will frequently encounter complications of these procedures. To ensure timely diagnosis and optimal care, clinicians should be familiar with the standard weight loss approaches and the potential complications of these interventions.

Mesothelial cell sheets cultured on fibrin gel prevent adhesion formation in an intestinal hernia model

In the present study, we examined a novel technique to prevent adhesion formation in a rat intestinal hernia model with mesothelial cell sheets cultured on fibrin gel. Mesothelial cells were obtained from isologous rats by enzymatic disaggregation of mesentery and cultured on fibrin gel. Electron microscopy revealed that these cultured cells form contiguous monolayer cell sheets with well-developed microvilli. These tissue-engineered constructs were grafted in vivo to an intestinal hernia model that results in regular surgical adhesions without treatment. Five days postgrafting, rats were sacrificed. Adhesion formation was not observed in rats grafted with the constructs, whereas severe adhesions were observed in all control rats. Constructs seeded with mesothelial cells isolated from EGFP-transgenic rats clearly revealed that grafted mesothelial cells remained at the host tissue site even after fibrin scaffold degradation. These cells developed more abundant microvilli in vivo than those in vitro. These results show that cultured mesothelial cell sheets are effective in preventing adhesion formation and should reduce postoperative complications caused by adhesion formation.

Management of disorders of the posterior pelvic floor

INTRODUCTION

Constipation is a relatively common problem affecting 15 percent of adults in the Western world, and over half of these cases are related to pelvic floor disorders. This article reviews the clinical presentation and diagnostic approach to posterior pelvic floor disorders, including how to image and treat them.

METHODS

A Pubmed search using keywords "rectal prolapse," "rectocele," "perineal hernia," and "anismus" was performed, and bibliographies of the revealed articles were cross-referenced to obtain a representative cross-section of the literature, both investigational studies and reviews, that are currently available on posterior pelvic floor disorders.

DISCUSSION

Pelvic floor disorders can occur with or without concomitant physical anatomical defects, and there are a number of imaging modalities available to detect such abnormalities in order to decide on the appropriate course of treatment. Depending on the nature of the disorder, operative or non-operative therapy may be indicated.

CONCLUSION

Correctly diagnosing pelvic floor disorders can be complex and challenging, and the various imaging modalities as well as clinical history and exam must be considered together in order to arrive at a diagnosis.

Trocar site hernia

OBJECTIVE

To review the relationship between the pathogenesis and clinical manifestations of trocar site hernias seeking to confirm the definition of trocar site hernias by classification.

DATA SOURCES

We searched this subject in English on MEDLINE by combining the words "trocar," "port," "hernia, and "laparoscopy."Data Extraction and

STUDY SELECTION

We limited the main operations to cholecystectomy, colon and rectal surgery, fundoplication, and gastric surgery; finding 44 reports on these procedures. Of these, 19 were case reports, 18 were original articles (setting criteria; the incidence of the trocar site hernia was clarified, and involved >100 patients), and 7 technical notes on "how to do it" were collected. We obtained 19 additional reports using the references of those previously obtained. We, thus, reviewed 63 reports (24 case reports, 27 original articles, 7 technical notes, and 5 review articles).

DATA SYNTHESIS

Trocar site hernia was classified into 3 types. The early-onset type that occurred immediately after the operation, with a small-bowel obstruction, especially the Richter hernia, frequently developing. The late-onset type that occurred several months after the operation, mostly with local abdominal bulging with no small-bowel obstruction developing. The special type that occurred indicated the protrusion of the intestine and/or omentum. Trocar site hernias with fascial defects of 10 mm or larger should be closed, including the peritoneum. Opinion varied if a 5-mm trocar site defect should be closed.

CONCLUSION

It is useful to clearly classify trocar site hernias to improve management of laparoscopic procedures.

Functional and morphological evaluation of a low-weight, monofilament polypropylene mesh for hernia repair

With more than 1 million implantations per year worldwide, mesh repair has become a standard procedure for the treatment of hernias. Apart from various technical problems, the type of material has been proven to be of considerable importance for the functional and histological outcome, particularly for long-term implantation. Whereas the advantageous application of low-weight, large-pore meshes based on multifilaments can be stated without doubt, it is still open whether similar results can be achieved on the basis of pure monofilaments. In the present study, a low-weight polypropylene mesh (LW) made purely of monofilaments was compared to a common heavy-weight polypropylene mesh (HW) in regard to the functional consequences and the tissue response. After implantation in rats as an inlay for 3--90 days, the abdominal-wall mobility of the implant region was recorded by 3D stereography, and the tensile strength of both the suture zone and the mesh was measured. The morphometry of the histological reaction in regard to the inflammatory infiltrate, the connective tissue, the number of granulocytes, macrophages, and fibroblasts served to reflect the tissue response. As parameters for the remodeling process at the interface the cellular activation was evaluated by TUNEL (DNA-strand breaks or apoptosis, respectively), Ki 67 (cell proliferation), and HSP 70 (cell stress). The measured tensile strength of the LW mesh confirmed a sufficient strength of the material-reduced mesh modification. After implantation the consecutive impairment of the abdominal-wall mobility was reduced compared to the HW mesh, concomitant to the reduced fibrotic level at the interface. At the end of the observation period the foreign-body reaction was significantly lowered for the LW mesh, almost reaching physiological values. In conclusion, these data confirm the improved biocompatibility of material-reduced mesh implants.