Incisional hernias in patients with aortic aneurysmal disease: the importance of suture technique.
OBJECTIVE: To study the rate of incisional hernia at 12 months in patients undergoing abdominal aortic aneurysm repair compared with others undergoing other surgery through midline incisions. METHODS: A prospective study of 1023 patients, 85 of these with aneurysmal disease. Wounds were continuously closed and the suture technique was monitored by the suture length to wound length ratio. RESULTS: Wound incisions were longer and operations lasted longer in aneurysm patients than in others. Incisional hernia was less common if closure was with a suture length to wound length ratio of at least four. Wounds were closed with a ratio of four or more in 39% (33 of 85) of aneurysm patients and in 59% (546 of 923) of others (p < 0.01). In aneurysm patients no wound dehiscence was recorded, the rate of wound infection was low and incisional hernia occurred in the same amount as in others. CONCLUSIONS: It is concluded that the rate of incisional hernia is similar in patients with abdominal aortic aneurysmal disease and others. Wounds are closed with a less meticulous suture technique in aneurysm patients. (+info)
Congenital hernia of the abdominal wall: a differential diagnosis of fetal abdominal wall defects.
A 28-year-old woman was referred at 33 weeks of gestation with suspected fetal intestinal atresia. Sonography showed a large extra-abdominal mass on the right of the normal umbilical cord insertion. Following Cesarean section at 36 weeks and immediate surgical treatment, the malformation was not definable either as an omphalocele or as gastroschisis. This reported case involves a previously undocumented malformation of the fetal abdominal wall described as a 'hernia' of the fetal abdominal wall. (+info)
Familial phenotype differences in PKD11.
Familial phenotype differences in PKD1. BACKGROUND: Mutations within the PKD1 gene are responsible for the most common and most severe form of autosomal dominant polycystic kidney disease (ADPKD). Although it is known that there is a wide range of disease severity within PKD1 families, it is uncertain whether differences in clinical severity also occur among PKD1 families. METHODS: Ten large South Wales ADPKD families with at least 12 affected members were included in the study. From affected members, clinical information was obtained, including survival data and the presence of ADPKD-associated complications. Family members who were at risk of having inherited ADPKD but were proven to be non-affected were included as controls. Linkage and haplotype analysis were performed with highly polymorphic microsatellite markers closely linked to the PKD1 gene. Survival data were analyzed by the Kaplan-Meier method and the log rank test. Logistic regression analysis was used to test for differences in complication rates between families. RESULTS: Haplotype analysis revealed that each family had PKD1-linked disease with a unique disease-associated haplotype. Interfamily differences were observed in overall survival (P = 0.0004), renal survival (P = 0.0001), hypertension prevalence (P = 0.013), and hernia (P = 0.048). Individuals with hypertension had significantly worse overall (P = 0.0085) and renal (P = 0.03) survival compared with those without hypertension. No statistically significant differences in the prevalence of hypertension and hernia were observed among controls. CONCLUSION: We conclude that phenotype differences exist between PKD1 families, which, on the basis of having unique disease-associated haplotypes, are likely to be associated with a heterogeneous range of underlying PKD1 mutations. (+info)
The use of TWH catheters in CAPD patients: fourteen-year experience in technique, survival, and complication rates.
OBJECTIVE: To evaluate the technique of insertion, complication rates, and survival rates of Toronto-Western Hospital (TWH) peritoneal catheters in continuous ambulatory peritoneal dialysis (CAPD) patients. PATIENTS AND METHODS: A total of 222 TWH catheters were inserted into 203 CAPD patients (113 males and 90 females) with end-stage chronic renal failure during a period of 14 years (1 January 1982 to 31 August 1995). The mean age of the patients was 58.5 years (range 18-86 years). For the first 6 years, the peritoneal cavity approach was performed via a lower midline incision (45 insertions), various other approaches (17 insertions), and, finally, for the last 160 insertions (for approximately 8 years) the transverse paraumbilical incision was exclusively employed. The duration of CAPD ranged between 1 to 151 months (mean time 33.2 months). RESULTS: Regarding early and late complications (namely leakages, obstructions, eviscerations, tunnel infections, herniation, and others), as well as catheter survival, the transverse paraumbilical insertion, compared to other approaches, had the smallest number of complications. Thus, early leakage occurred in 5/222 (2.25%) versus 10/222 (4.5%), obstruction nil versus 2/222 (0.9%), and evisceration nil versus 1/222 (0.45%). In addition, as far as the late complications are concerned: tunnel infections 5/222 (2.22%) versus 13/222 (5.85%), herniations 1/222 (0.45%) versus 16/222 (7.3%), and cuff protrusion nil versus 7/222 (3.1%). Finally, overall peritonitis occurred with a rate of one episode every 21.2 months. Actuarial survival for 1 and 3 years was 75% and 37%, respectively. CONCLUSIONS: The transverse paraumbilical incision seems to be the most advantageous approach in inserting (by "surgical method") theTWH catheters. We found it to be a safe, simple, versatile procedure, giving good results in all parameters concerned. (+info)
CAPD in patients with autosomal dominant polycystic kidney disease.
OBJECTIVE: To investigate whether there are specific complications to continuous ambulatory peritoneal dialysis (CAPD) in patients with autosomal dominant polycystic kidney disease (ADPKD) due to defects in various wall structures--causing hernia and diverticulitis--and to enlarged kidneys. DESIGN: The clinical experience of CAPD in 26 patients with ADPKD, treated for 11+/-6 months, was studied in retrospect and compared with that of 26 contemporary controls. Medical records were reviewed with respect to survival in this treatment form and any complication. Peritoneal dialysis capacity (PDC), as measured in 21 ADPKD patients and 20 controls, was also evaluated. SETTING: University Hospital. RESULTS: Before initiation of CAPD, enlarged kidneys necessitated nephrectomy in 2 of 26 ADPKD patients; both cases were registered as preparation for transplantation, not for CAPD. Survival in CAPD was similar in ADPKD patients and controls. Hernia was present in 4 ADPKD patients and 2 controls, and required transfer to hemodialysis in 1 patient from each group, temporarily. The incidence of peritonitis was 1 per 20 months in ADPKD patients versus 1 in 27 months in the controls, not significantly different. Peritonitis was caused by colonic bacteria in similar numbers. Residual renal function was 1.9 2.1 mL/min per 1.73 m2 in ADPKD patients versus 1.9+/-1.4 mL/min per 1.73 m2 in the controls. No difference was detected in any of the variables measured by PDC. CONCLUSION: There were no specific problems related to ADPKD. (+info)
Exploring the degree of concordance of coded and textual data in answering clinical queries from a clinical data repository.
OBJECTIVE: To query a clinical data repository (CDR) for answers to clinical questions to determine whether different types of fields (coded and free text) would yield confirmatory, complementary, or conflicting information and to discuss the issues involved in producing the discrepancies between the fields. METHODS: The appropriate data fields in a subset of a CDR (5,135 patient records) were searched for the answers to three questions related to surgical procedures. Each search included at least one coded data field and at least one free-text field. The identified free-text records were then searched manually to ensure correct interpretation. The fields were then compared to determine whether they agreed with each other, were supportive of each other, contained no entry (absence of data), or were contradictory. RESULTS: The degree of concordance varied greatly according to the field and the question asked. Some fields were not granular enough to answer the question. The free-text fields often gave an answer that was not definitive. Absence of data was most logically interpreted in some cases as lack of completion of data and in others as a negative answer. Even with a question as specific as which side a hernia was on, contradictory data were found in 5 to 8 percent of the records. CONCLUSIONS: Using the data in the CDR to answer clinical questions can yield significantly disparate results depending on the question and which data fields are searched. A database cannot just be queried in automated fashion and the results reported. Both coded and textual fields must be searched to obtain the fullest assessment. This can be expected to result in information that may be confirmatory, complementary, or conflicting. To yield the most accurate information possible, final answers to questions require human judgment and may require the gathering of additional information. (+info)
Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature.
OBJECTIVES: Laparoscopic repair of incisional ventral hernias with ePTFE mesh continues to evolve, with variable reporting of surgical techniques and outcomes. This report of 34 cases discusses, with a literature review of laparoscopic incisional hernia repair, specific factors associated with three recurrences. METHOD: Retrospective analysis and review of the literature. RESULTS: Thirty-two patients (16 female, 16 male), underwent 34 laparoscopic repairs: average age-54 years (27-80), average weight-207 lbs (100-300). Nineteen patients (62%) were undergoing first time repairs, 38% were redo cases and 5 cases (14%) involved previous mesh. Operating times averaged 101 minutes (45-220), and average length of stay was 1.9 days (0.6 days excluding 5 patients who required readmission), with 13 patients (38%) being discharged same-day. Two patients developed cellulitis (6%) treated without patch removal. Two enterotomies occurred (6%) both requiring patch removal. Five patients required readmission (14%), and one patient died postoperative day 29 secondary to end-stage liver disease. Three recurrences developed (9%): one secondary to missed enterotomy with reoperation, patch removal and hernia recurrence; one due to omission of suspension suture fixation; and one recurrence developed in a section of the intact old previous incision that extended beyond the original patch. Follow up has averaged 20 months (4-36). CONCLUSIONS: The laparoscopic repair of ventral and incisional hernias utilizing transabdominal placement of ePTFE patch can achieve excellent results with low morbidity in comparison with open surgical approaches. In reviewing the experience of other investigators, adequate fixation of the mesh, extension to cover the entire previous incision and standardizing the placement interval of the sutures are critical to the success of the repair. (+info)
The search for an ideal method of abdominal fascial closure: a meta-analysis.
BACKGROUND AND OBJECTIVE: The ideal suture for abdominal fascial closure has yet to be determined. Surgical practice continues to rely largely on tradition rather than high-quality level I evidence. The authors conducted a systematic review and meta-analysis of randomized controlled trials to determine which suture material and technique reduces the odds of incisional hernia. METHODS: MEDLINE and Cochrane Library databases were searched for articles in English published from 1966 to 1998 using the keywords "suture", "abdomen/surgery", and "randomized controlled trials". Randomized controlled trials, trials of adult patients, and trials with a Jadad Quality Score of more than 3, comparing suture materials, technique, or both, were included. Two independent reviewers critically appraised study quality and extracted data. The reviewers were masked to the study site, authors, journal, and date to minimize bias. The primary outcome was postoperative incisional hernia. Secondary outcomes included wound dehiscence, infection, wound pain, and suture sinus formation. RESULTS: The occurrence of incisional hernia was significantly lower when nonabsorbable sutures were used. Suture technique favored nonabsorbable continuous closure. Suture sinuses and wound pain were significantly lower when absorbable sutures were used. There were no differences in the incidence of wound dehiscence or wound infection with respect to suture material or method of closure. Subgroup analyses of individual sutures showed no significant difference in incisional hernia rates between polydioxanone and polypropylene. Polyglactin showed an increased wound failure rate. CONCLUSIONS: Abdominal fascial closure with a continuous nonabsorbable suture had a significantly lower rate of incisional hernia. The ideal suture is nonabsorbable, and the ideal technique is continuous. (+info)