Assessment and management of stomal complications: a framework for clinical decision making.
Assessment and management of stoma complications are often the responsibility of nurses across the continuum of care. These complications can occur at different times based on their etiology - immediately postoperatively or even several years after surgery - and often require modifications in a person's daily stoma management. This article presents a conceptual framework to help categorize types of stoma complications based on either etiology or location and offers management options to facilitate quality care. The five major categories of complications include Poor Siting, Stoma Proper, Peri-Intestinal Area, Mucocutaneous Junction, and Iatrogenic. Most of these suggested approaches to care are the recommendations of certified ostomy nurses based on their educational training, expert opinion, and successful experiences. Although these recommendations have often solved the specific problems and greatly improved the quality of life for the person with stomal complications, much research is still needed to confirm and/or improve these nursing approaches. (+info)
Effect of straining on diaphragmatic crura with identification of the straining-crural reflex. The "reflex theory" in gastroesophageal competence.
BACKGROUND: The role of the crural diaphragm during increased intra-abdominal pressure is not exactly known. We investigated the hypothesis that the crural diaphragm undergoes reflex phasic contraction on elevation of the intra-abdominal pressure with a resulting increase of the lower esophageal pressure and prevention of gastro-esophageal reflux. METHODS: The esophageal pressure and crural diaphragm electromyographic responses to straining were recorded in 16 subjects (10 men, 6 women, age 36.6 +/- 11.2 SD years) during abdominal hernia repair. The electromyogram of crural diaphragm was recorded by needle electrode inserted into the crural diaphragm, and the lower esophageal pressure by a saline-perfused catheter. The study was repeated after crural anesthetization and after crural infiltration with saline. RESULTS: The crural diaphragm exhibited resting electromyographic activity which showed a significant increase on sudden (coughing, p < 0.001) or slow sustained (p < 0.01) straining with a mean latency of 29.6 +/- 4.7 and 31.4 +/- 4.5 ms, respectively. Straining led to elevation of the lower esophageal pressure which was coupled with the increased electromyographic activity of the crural diaphragm. The crural response to straining did not occur during crural diaphragm anesthetization, while was not affected by saline infiltration. The lower esophageal pressure declined on crural diaphragm anesthetization. CONCLUSIONS: Straining effected an increase of the electromyographic activity of the crural diaphragm and of the lower esophageal pressure. This effect is suggested to be reflex in nature and to be mediated through the "straining-crural reflex". The crural diaphragm seems to play a role in the lower esophageal competence mechanism. Further studies are required to assess the clinical significance of the current results in gastro-esophageal reflux disease and hiatus hernia. (+info)
Laparoscopic incisional hernia repair in obese patients.
BACKGROUND AND OBJECTIVES: Laparoscopic incisional hernia repair is coming to the forefront as a preferred method of repair due to the advantages offered by minimally invasive techniques. To evaluate safety and feasibility of this approach in obese patients when performed by a general surgeon trained in basic laparoscopy with no prior experience in this technique, we reviewed our early experience in the first 18 patients. METHODS: All patients with incisional hernias presenting to a single surgeon from 2000 to 2002 were offered laparoscopic repair. Patients were informed about the limited experience of the surgeon in this particular field. Those who consented were repaired laparoscopically using a standard 4-port technique, one 12-mm port and three 5-mm ports. All patients with body mass index > or =30 were included in this review. A retrospective review of the data included demographics, operative time, blood loss, hospital stay, postoperative complications, and patient satisfaction. RESULTS: Nineteen laparoscopic repairs were completed in 18 patients. No conversions to open repair were necessary. All patients were females except for 2. All hernia sacs were left in place, some of which were empty while others required extensive lysis of adhesions to release sac contents. Mean fascial defect was 102.5 cm2. One defect was closed primarily without mesh, while the rest were closed using Composix mesh in 1 and Dual Plus Gore-Tex mesh in the rest. Three patients were discharged from the recovery room. Mean follow-up was 24 months. No wound or mesh infections occurred. Eight patients had no complications. Eight patients had asymptomatic seromas. Two patients had hematomas; none of them required drainage. One patient had nonspecific dizziness. One patient presented with bowel obstruction secondary to early recurrence (within a week). The repair was salvaged laparoscopically. Upon evaluation by telephone calls, all patients indicated extreme satisfaction with the results. CONCLUSIONS: A general surgeon with training in basic laparoscopy can safely perform laparoscopic incisional hernia repair on obese patients with minimal complications. The procedure requires a short leaning curve of no more than 3 cases and few extra materials to be feasible at any hospital in the US. Patient satisfaction with this technique is certainly gratifying. (+info)
Ventral abdominal wall dysmorphogenesis of Msx1/Msx2 double-mutant mice.
Msx1 and Msx2 genes encode the homeodomain transcription factors. Several gene knockout mice and expression studies suggest that they possess functionally redundant roles in embryogenesis. In this study, we revealed that Msx1 and Msx2 were expressed during ventral body wall formation in an overlapping manner. Msx1/Msx2 double-mutant mice displayed embryonic abdominal wall defects with disorganized muscle layers and connective tissues. These findings indicate that Msx1 and Msx2 play roles in concert during embryonic ventral abdominal wall formation. (+info)
Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele.
OBJECTIVES: Posterior compartment descent may encompass perineal hypermobility, isolated enterocele or a 'true' rectocele due to a rectovaginal septal defect. Our objective was to determine the prevalence of these conditions in a urogynecological population. METHODS: One hundred and ninety-eight women were clinically evaluated for prolapse and examined by translabial ultrasound, supine and after voiding, using three-dimensional capable equipment with a 7-4-MHz volume transducer. Downwards displacement of rectocele or rectal ampulla was used to quantify posterior compartment prolapse. A rectovaginal septal defect was seen as a sharp discontinuity in the ventral anorectal muscularis. RESULTS: Clinically, a rectocele was diagnosed in 112 (56%) cases. Rectovaginal septal defects were observed sonographically in 78 (39%) women. There was a highly significant relationship between ultrasound and clinical grading (P < 0.001). Of 112 clinical rectoceles, 63 (56%) cases showed a fascial defect, eight (7%) showed perineal hypermobility without fascial defect, and in three (3%) cases there was an isolated enterocele. In 38 (34%) cases, no sonographic abnormality was detected. Neither position of the ampulla nor presence, width or depth of defects correlated with vaginal parity. In contrast, age showed a weak association with rectal descent (r = -0.212, P = 0.003), the presence of fascial defects (P = 0.002) and their depth (P = 0.02). CONCLUSIONS: Rectovaginal septal defects are readily identified on translabial ultrasound as a herniation of rectal wall and contents into the vagina. Approximately one-third of clinical rectoceles do not show a sonographic defect, and the presence of a defect is associated with age, not parity. (+info)
Results of laparoscopic versus open abdominal and incisional hernia repair.
BACKGROUND: Incisional hernia is a frequent complication of abdominal surgery. The object of this study was to confirm the safety, efficacy, and feasibility of laparoscopic treatment of abdominal wall defects. METHODS: Fifty consecutive laparoscopic abdominal and incisional hernia repairs from September 2001 to May 2003 were compared with 50 open anterior repairs. RESULTS: The 2 groups were not different for age, body mass index, or American Society of Anaesthesiologists scores. Mean operative time was 59 minutes for the laparoscopic group, 164.5 minutes for the open group. Mean hernia diameter was 10.6 cm for the laparoscopic group, 10.5 cm for the open group. Mean length of stay was 2.1 days for the laparoscopic group, 8.1 days for the open group. Complications occurred in 16% of the laparoscopic and 50% of open group. Median follow-up was 9.0 months for the laparoscopic group, 24.5 months for the open group. Recurrence rates were 2% for laparoscopic group and 0% for the open group. CONCLUSION: Results for laparoscopic abdominal and incisional hernia repair seem to be superior to results for open repair in terms of operative time, length of stay, wound infection, major complications, and overall hospital reimbursement. (+info)
Patient characteristics associated with defects of the peritoneal cavity boundary.
BACKGROUND: Conflicting literature exist regarding the patient characteristics that may confer an increased risk for anatomic complications of the peritoneal cavity boundaries. METHODS: We collected data from 75 randomly selected units in the United States and Canada, representing a total of 1864 peritoneal dialysis (PD) patients. RESULTS: 200 of these patients experienced a total of 217 anatomic complications between July 2000 and June 2001; 16 patients had more than 1 complication. Hernias comprised 60.4% of all complications: 24.9% inguinal, 18.9% umbilical, 13.8% ventral, 2.3% femoral, and 0.5% intrathoracic. Other complications included pericatheter or subcutaneous leak (25.3%), hydrothorax (6.0%), and miscellaneous (8.3%). Peritoneal dialysis modalities in use at the time of complication were automated PD (52.3%), continuous ambulatory PD (38.6%), and nocturnal intermittent PD (9.1%). The overall incidence of hernias was 7%. CONCLUSIONS: Logistic regression analysis found no association between hernias and age, body surface area, PD modality, volume of dialysate, time of largest dwell (day/upright vs night/recumbent), or type of catheter used. Cystic disease conferred a 2.5-fold increase in risk for anatomic complications (p < 0.001); female gender conferred an 80% reduction in risk (p < 0.0001), and Kt/V > or = 2.0 conferred a 52% reduction in risk (p < 0.05) for hernia. (+info)
Abdominal incisional hernia repair using the Composix Kugel Patch: two case reports.
We describe two patients with abdominal incisional hernias, which occurred after appendectomy and replacement of an artificial blood vessel. Both were treated by operative hernial repair with the Composix Kugel Patch (C.R. Bard Inc.), a composite mesh that combines polypropylene mesh and expanded polytetrafluoroethylene (Gore-Tex). The mesh has various beneficial characteristics. It is a reinforcing material for the abdominal wall; even when in direct contact with the intestinal tract it is minimally adherent to the intestinal tract. The mesh expands readily and is easily fixed to the abdominal wall because it has a shape-memory ring. The long-term results of operative repair with this mesh have not yet been reported, but it is hoped that the aforementioned characteristics will yield favorable outcomes. (+info)