Ileal pouch and trauma.
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Accidents, Traffic↗
Biomedical subjects
G T Deans
Publications and source records attributed to G T Deans.
Pyomyositis mimicking right iliac fossa mass: review of the literature.
Pyomyositis is a pyogenic infection of skeletal muscle. Its incidence in temperate countries though low is rising. Most cases from the temperate region involve immuno-compromised patients. The onset is usually insidious with progression to large purulent collections. Because of its low incidence in temperate countries, it is often initially misdiagnosed. A high index of suspicion with appropriate imaging techniques, aggressive surgical intervention and adjunctive antibiotic therapy are the keys to prompt resolution. A case of pyomyositis mimicking right iliac fossa (RIF) mass is described with a review of the literature.
Abdominal Abscess↗
Small bowel volvulus: a review.
Small bowel volvulus is a rare but life-threatening surgical emergency. The aetiology may be primary, as is often seen in Africa and Asia, while in Western countries other predisposing conditions usually initiate the volvulus. Early preoperative investigation and expedient surgical treatment is required if bowel infarction is to be prevented. Central abdominal pain resistant to narcotic analgesia should heighten the suspicion of the diagnosis. The diagnostic value of computerised tomography (CT) scanning in such situations has been emphasised. If the bowel is infarcted resection is required, but the optimum treatment for cases with viable small bowel is uncertain, the alternatives either being resection, fixation, or simple derotation.
Diagnosis, Differential↗
Controlled trial of preperitoneal local anaesthetic for reducing pain following laparoscopic hernia repair.
BACKGROUND: A prospective randomized trial was performed to determine whether local anaesthetic solutions injected into the preperitoneal space may provide additional pain relief following transabdominal preperitoneal laparoscopic hernia repair. METHODS: One hundred patients undergoing transabdominal preperitoneal laparoscopic hernia repair were allocated randomly to receive (1) bupivacaine 1.5 mg/kg, (2) bupivacaine 1.5 mg/kg with 1 in 200000 adrenaline, (3) bupivacaine 3 mg/kg or (4) saline instilled into the preperitoneal space at the end of the operation. An independent clinical assessor determined the level of pain using a visual analogue pain score and noted the parenteral and oral analgesia requirements at 4, 8, 12 and 24 h after operation. RESULTS: At each of the time intervals, there was no significant difference between the groups for pain scores (at 24 h, P = 0.71) or the number of doses of either morphine (at 24 h, P = 0.73) or oral analgesia (at 24 h, P = 0.89). There was also no significant difference in the time to return to normal activity or work between the groups. CONCLUSION: This study suggests that instilling local anaesthetic into the preperitoneal space has no significant effect on postoperative pain relief requirement following laparoscopic hernia repair. Other methods of reducing postoperative pain should be sought that may facilitate day-case laparoscopic hernia surgery.
Adult↗
A measurement of the ability to drive after different types of inguinal hernia repair.
Recovery following different types of inguinal hernia repair has been objectively assessed by measuring reaction times when the subject performs an emergency stop in a driving simulator. A control group of patients who underwent varicose vein surgery to the groin under general anaesthetic without any muscle dissection demonstrated no alteration in response times. Eighty-two percent of those who underwent laparoscopic repair and 64% of those who underwent Lichtenstein repair returned to their preoperative times by 7 days after surgery. There was no difference in recovery of response times after Lichtenstein repair performed under local or general anaesthetic, in comparison with 33% of patients after Bassini repair. These results may influence the advice given by surgeons to patients after inguinal hernia surgery.
Automobile Driving↗
Are complications of endoscopic sphincterotomy age related?
BACKGROUND: Endoscopic retrograde cholangiopancreatography sphincterotomy is increasingly performed in younger patients undergoing laparoscopic cholecystectomy. However, the safety of endoscopic sphincterotomy in this age group, relative to that in older patients, is unknown. AIM: To determine whether the development of short term complications following endoscopic sphincterotomy is age related. PATIENTS AND METHODS: A prospective multicentre audit of 958 patients (mean age 73, range 14-97, years) undergoing a total of 1000 endoscopic sphincterotomies. RESULTS: Two deaths occurred, both from postsphincterotomy acute pancreatitis. Postprocedural complications developed in 24 patients: pancreatitis in 10, ascending cholangitis in seven, bleeding in four, and retroperitoneal perforation in three. There were six complications (five cases of pancreatitis and one bleed; 2.2%) and no deaths in the 281 (29.3%) patients aged under 65 years. In comparison, 18 (2.6%) of the 677 patients aged over 65 years developed a complication (cholangitis in seven, pancreatitis in five, bleeding in three, and perforation in three). Patients under 35, 45, 55, and 65 years were not at significantly increased risk of complication than those over these ages (relative risk for those under compared with those over 65 years 0.83, 95% confidence intervals 0.41-1.67, p = 0.74). CONCLUSION: Short term complications following endoscopic sphincterotomy are not related to age. Younger patients undergoing laparoscopic cholecystectomy need not be denied endoscopic sphincterotomy for fear that the risks are greater than if they undergo surgical exploration of the common bile duct.
Adolescent↗
Laparoscopic hernia repair (TAPP): a new method to reduce port-site-herniation.
This article describes a method of transperitoneal laparoscopic hernia repair to reduce port-site herniation by using one umbilical 12-mm port site and a 5-mm laparoscope.
Hernia↗
An audit of thyroid surgery in a general surgical unit.
A total of 143 patients undergoing thyroid surgery in a general surgical unit over an 8-year period were reviewed. In only two patients did thoracic inlet views or thyroid function tests alter clinical management. Fine-needle aspiration failed to detect one well-differentiated follicular carcinoma (false-negative rate 1.1%). The sensitivity for malignancy of fine-needle aspiration, ultrasound and radioisotope scan were 94%, 53% and 24%, respectively. The corresponding specificity was 59%, 72% and 58% and accuracy 65%, 70% and 49%, respectively. The specificity of fine-needle cytology for detecting neoplastic disease (adenoma or carcinoma) was 86% and accuracy 91%. Combinations of fine-needle cytology, ultrasound and radioisotope scanning increased the sensitivity for malignancy, so that fewer tumours were missed, but at the cost of reduced specificity, positive predictive value and accuracy. Hence, ultrasound was only recommended when fine-needle aspiration was inconclusive. Overall perioperative morbidity was 6.3% (one case of postoperative bleeding, two wound infections, four cases of prolonged hypocalcaemia). There were two proven cases of transient, but no permanent, recurrent laryngeal nerve injuries as a result of surgery. Thyroid surgery may be performed satisfactorily by general surgeons with an interest in thyroid disease. Fine-needle cytology is the most informative preoperative investigation. Although aspiration cytology, ultrasound, and scintigraphy all have appropriate indications and limitations, there is no single test or group of tests that can substitute for careful clinical assessment and follow-up.
Adolescent↗
A prospective study of adult inguinal hernia repairs using absorbable sutures.
A prospective study was conducted over a 5-year period to determine whether inguinal hernia repair could be safely performed with absorbable suture material (polydioxanone) with reference to recurrence rates, wound pain, haematoma formation and wound infection. Analysis is available for 111 operations involving 111 patients. Mean follow-up was 36 (range 21-66) months, with 81 procedures monitored for more than 2 years. Two-layered hernia repair was used in all cases with polydioxanone as the chosen suture material. Mean post-operative stay was 2.1 days, with no hospital wound infections and three haematomas. Review identified 1 wound infection. There have been two recurrences. Preliminary results suggest that hernia repair with absorbable suture materials is comparable to traditional non-absorbable repair in terms of recurrence and associated wound complications. The additional benefit is the absence of foreign material in the wound region following degradation of the absorbable material. This does not appear to compromise the integrity of the hernia repair. Mesh repairs are increasingly preferred to Shouldice-style repairs in elective inguinal hernias. However, we believe that polydioxanone should be the suture material of choice in obstructed or strangulated hernia. A larger study is required to verify this, as well as a longer follow-up period. The use of absorbable material warrants further investigation.
Female↗
The ability of laparoscopic clips to withstand high intraluminal pressure.
OBJECTIVE: To determine if commercially available clips for laparoscopic surgery become displaced with high intraluminal pressures. DESIGN: In vivo model in which the splenic, renal, and mesenteric vessels together with the gallbladder of anesthetized living pigs were individually occluded using titanium and absorbable clips and then subjected to pressures of 300 mm Hg; and in vitro model in which the procedure was repeated on freshly removed human gallbladders with the attached segment of cystic duct. INTERVENTION: The intraluminal pressure of the occluded segment was increased until (1) the clip was released, (2) the vessel burst, or (3) the predetermined pressure (300 mm Hg) was obtained. RESULTS: A total of 90 clips were examined. No clip could be displaced from any porcine vessel at intraluminal pressures of up to 300 mm Hg. One vessel burst before the predetermined pressure was obtained, the clips remaining intact. Clips placed on the porcine and human models also could not be displaced by a pressure of 300 mg Hg. CONCLUSION: Commercially available titanium and absorbable clips do not disrupt when subjected to high intraluminal pressures. Postoperative bile leaks are more likely to result from necrosis of the cystic duct than displacement of the clip by the pressure within the biliary system.
Animals↗
Prospective trial comparing Lichtenstein with laparoscopic tension-free mesh repair of inguinal hernia.
A prospective study of 242 patients with inguinal hernia who underwent tension-free mesh repair by the laparoscopic transperitoneal (n = 121) or the open Lichtenstein (n = 121) technique was performed. There was no significant difference in operation time between the laparoscopic (median (range) 35 (20-90) min) and Lichtenstein (40 (20-90) min) procedures. Discharge within 24 h of operation was more common after laparoscopic surgery (89.3 per cent versus 48.7 per cent). Consequently, hospital stay was reduced with this approach (median (range) 1 (1-7) days versus 2 (1-10) days for patients who had a Lichtenstein repair). There was no significant difference in parenteral analgesia requirements or visual analogue pain scores between the two groups. Although use of oral analgesia in hospital was greater in patients who underwent Lichtenstein hernioplasty, this may reflect their longer stay. Rehabilitation to normal activity and return to work was shorter in patients receiving laparoscopic repair (median 7 and 10 days, respectively) than Lichtenstein repair (14 and 21 days) (P < 0.001). Initial results suggest that laparoscopic procedures may be associated with more rapid rehabilitation compared with that of open tension-free mesh surgery. Most patients with inguinal hernia undergoing tension-free mesh repair by either technique would be suitable for day-case surgery.
Adolescent↗
Neoplastic lesions of the appendix.
Neoplasms occur in 0.5 per cent of appendices. Ultrasonography or computed tomography is beneficial, but preoperative detection is rare. At operation, the diagnosis is considered in under half of cases. Mucocele, localized pseudomyxoma peritonei, benign tumours and most appendiceal carcinoids are cured by appendicectomy alone. Right hemicolectomy is indicated for: (1) invasive adenocarcinoma; (2) tumours close to the caecum; (3) lesions larger than 2 cm; (4) mucin production; (5) invasion of the lymphatics, serosa or mesoappendix; and (6) cellular pleomorphism with a high mitotic rate. Tumours of 1-2 cm, small mucinous carcinoids, adenocarcinoma confined to the mucosa, and tumours in children may be treated by appendicectomy alone at the surgeon's discretion. The 5-year survival rate associated with classical carcinoid is more than 90 per cent. The prognosis of mucinous carcinoid is intermediate between that of classical carcinoid and well differentiated adenocarcinoma. The prognosis of adenocarcinoma is determined by Dukes' stage and is similar, stage for stage, to that of colorectal carcinoma.
Adenocarcinoma↗
Recurrent inguinal hernia after laparoscopic repair: possible cause and prevention.
Eleven patients with recurrent inguinal hernia after laparoscopic hernia repair were referred for treatment. A medial recurrence associated with a mature peritoneal sac was identified in each case. The prosthetic mesh medial to the inferior epigastric artery had rolled away from the pubic ramus to expose Hesselbach's triangle. All cases were successfully treated by insertion of a second mesh to cover the defect and overlap the original mesh. To date there have been no further recurrences. Lessons learnt from experience of such laparoscopic transperitoneal hernia repair include that: the prosthetic mesh must be placed so that it reaches or crosses the midline; at least three staples should fix the mesh to the pubic ramus; a large mesh (13 x 9 cm) with a greater surface area should reduce the pressure tending to disrupt the mesh; and bilateral hernia is best managed by inserting a single piece of mesh (28 x 9 cm) fully unfolded as it crosses the midline to ensure coverage of both medial direct defects ('bikini repair'). Application of these principles may reduce the incidence of recurrence after laparoscopic inguinal hernia repair.
Adult↗
Laparoscopic adrenalectomy.
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Adrenal Gland Neoplasms↗
Laparoscopic 'bikini mesh' repair of bilateral inguinal hernia.
Laparoscopic hernia repair using a single piece of mesh was performed in 150 patients with bilateral inguinal hernia. The median operating time was 43 (range 30-90) min with a median hospital stay of 1 (range 1-10) days. In all, 138 patients were discharged within 24 h of operation. The median time for return to normal activity was 7 (range 2-60) days and that for return to work 14 (range 2-60) days. One patient required surgery for a port-site hernia and another for a Veress needle injury to the small bowel. Additional complications included bruising in nine patients, cord seromas in seven and urinary retention in two. There have been no recurrences after a median follow-up of 18 (range 1-38) months. The cost benefits of a short hospital stay and rapid return to work afforded by laparoscopic bilateral hernia repair warrant further evaluation.
Adult↗
Laparoscopy for undescended testes: embryological considerations.
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Adult↗
Laparoscopic nephrectomy: initial experience and cost implications.
OBJECTIVE: To assess the results and cost implications of laparoscopic nephrectomy. PATIENTS AND METHODS: Ten patients underwent attempted laparoscopic nephrectomy and nephro-ureterectomy. The cost of the laparoscopic procedures was estimated to allow comparison with that of open surgery. RESULTS: Two patients required conversion to an open procedure, one for a colonic tear, the other for irretrievable loss of pneumoperitoneum. The median operating time for successful cases was 3 h (range 2.5-4). The mean morphine equivalent of analgesia delivered per patient was 18 mg (range 10-28). There was no mortality. Post-operative complications consisted of one case of prolonged ileus and another of chest infection. The median hospital stay of successful cases was 5 days (range 4-17), and the mean time to return to normal activity was 4 weeks (range 3-6). The cost of the procedure using re-usable instruments was approximately 2000 pounds, comprising 100 pounds for equipment. 900 pounds theatre costs and 1000 pounds for hospital stay. Using disposable equipment adds up to 900 pounds to the cost. In comparison an open nephrectomy typically costs around 2300 pounds. CONCLUSION: Laparoscopic nephrectomy is associated with lower analgesia requirements, shorter hospital stay and quicker return to work than equivalent open procedures. The cost, particularly when performed with re-usable instruments, is not prohibitive being comparable with that of open nephrectomy. With further experience it should become part of the armamentarium of urological surgeons.
Adolescent↗
Amyloid tumour of the colon.
A case of amyloid tumour of the colon and the first in association with a carcinoma is reported. A previously healthy 65 year old man presented with non-specific symptoms of lower abdominal pain and flatulence without rectal bleeding. A clinical diagnosis of diverticular disease was made and colonoscopy performed. Two lesions (one at 15 cm and the other at 30 cm from the anal margin) were found on endoscopy and removed. On histology, the lesion at 15 cm was a moderately differentiated adenocarcinoma and that at 30 cm contained amyloid. Further tests (standard tinctorial methods and immunohistochemistry) revealed the 30 cm lesion to be an amyloid tumour of the colon of AL (lambda) type. When biopsy of an atypical, large, solitary colorectal lesion reveals amyloid deposition, the possibility of an amyloid tumour should be considered and the lesion resected.
Adenoma, Villous↗