Incisional hernia: new approaches and aspects

This thesis is about the anatomy, diagnosis, treatment and outcome of incisional hernia. New approaches and aspects are discussed in the following chapters. The following definitions were derived from Butterworth’s medical dictionary 1. A hernia is the protrusion of an internal organ through a defect in the wall of the anatomical cavity in which it lies. An abdominal hernia is the protrusion of abdominal content through the abdominal wall. A ventral hernia is any hernia protruding through the abdominal wall. An incisional hernia is a hernia protruding through an operation scar. Incisional hernias can be classified according to their localization 2. Abdominal hernias include groin (i.e. inguinal and femoral) hernias and ventral hernias. Ventral hernias include umbilical, incisional, epigastric and spigelian hernias. This thesis is restricted to incisional hernias through midline incisions

Behandeling van proximale humerusfracturen bij volwassenen

Samenvatting. Achtergrond: Fracturen van de proximale humerus zijn veel voorkomende letsels. De behandeling van deze fracturen, inclusief chirurgische interventies, varieert sterk. Doel: In kaart brengen van bewijs voor verschillende therapeutische interventies en revalidatie voor fracturen van de proximale humerus. Zoekstrategie: Onderzocht werden the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register, the Cochrane Central Register of Controlled Trails, MEDLINE, EMBASE en andere registers en bibliografische weergave van rapporten van trials. Deze zoekactie werd in maart 2010 beëindigd. Selectie: Alle Randomised Controlled Trials (RCT’s) die betrekking hebben op de behandeling van de fracturen van de proximale humerus bij volwassenen werden geselecteerd. Dataverzameling en analyse: Twee personen verrichtten onafhankelijk van elkaar de studieselectie, risicoinventarisatie op bias en dataverzameling. Door de heterogeniteit van de trials bleken de gegevens niet geschikt te zijn voor een meta-analyse. Resultaten: Zestien kleine gerandomiseerde trials met 801 patiënten werden geïncludeerd. Het was niet mogelijk om de bias in deze studies uit te sluiten. Acht onderzoeken evalueerden conservatieve therapie. In één studie blijkt een armsling in het algemeen meer comfortabel dan de minder gebruikte lichaamsfixatie/bandage van de arm. Er was enig bewijs dat vroege fysiotherapeutische behandeling, in vergelijking met fysiotherapie starten na drie weken van immobilisatie, resulteert in minder pijn en mogelijk een beter herstel bij patiënten met een niet gedisloceerde of een stabiele fractuur. Vergelijkbaar was er bewijs voor vermindering van pijn op korte termijn zonder negatieve gevolgen voor een resultaat op langere termijn in geval van een vroege mobilisatie in de eerste week in vergelijking met de mobilisatie na drie weken. Twee onderzoeken leverden enig bewijs voor een in het algemeen redelijk resultaat bij patiënten die, zonder medische supervisie maar wel met een adequate instructie voor een fysiotherapeutisch programma behandeld werden. Operatieve interventie verbeterde het herstel van de anatomie van de fractuurfragmenten in twee onderzoeken maar dit leidde tot meer complicaties in een van deze onderzoeken en resulteerde niet in een verbetering van de schouderfunctie. De voorlopige gegevens uit een ander onderzoek leverden geen significant verschil in complicaties, kwaliteit van het leven en kosten tussen plaatosteosynthesen conservatieve therapie. In één onderzoek leidde een hemiarthroplastiek tot een betere functie op korte termijn met minder pijn en invaliditeit in vergelijking met conservatieve behandeling van ernstige letsels. Een tension band fixatie bij ernstige letsels ging gepaard met een hoog reoperatie aantal in vergelijking met een hemiarthroplastiek in één studie. In één ander onderzoek werden betere functionele resultaten voor één type hemiarthroplastiek gevonden. Slechts zeer beperkt bewijs suggereerde vergelijkbare resultaten van vroege versus uitgestelde schoudermobilisatie na hetzij een operatieve fractuurfixatie (één onderzoek) of een hemiarthroplastiek (één onderzoek). Conclusie van de auteurs: Er is onvoldoende bewijs voor adequate informatie over de behandeling van proximale humerusfracturen bij volwassenen. Vroege fysiotherapie, zonder immobilisatie, lijkt adequaat voor de behandeling van sommige niet gedisloceerde fracturen. Het is onduidelijk of de operatieve therapie, zelfs voor specifieke fractuurtypen, zal leiden tot een consistent beter lange termijn resultaat

Prehospitale triage bij traumapatiënten

The prehospital trauma triage system consisting of regional ambulance services and overarching availability of mobile medical teams, the level criteria for trauma centres and in-hospital care for trauma patients are well-organised in the Netherlands.- However, the quality of prehospital triage in the Netherlands is inadequate at the moment, with an average under-triage rate of more than 30%. There is, thus, much room for improvement in the quality of prehospital triage.- Research in this area is now taking off, partly because of the arrival of a new quality indicator from the Netherlands National Health Care Institute, which states that at least 90% of multiple-trauma patients should be primarily taken to a level 1 trauma centre

Elleboogluxaties: snel oefenen voor het beste resultaat!

Abstract: A dislocation with only ligament damage is called a simple elbow dislocation. A complex elbow dislocation is associated with fractures. Early mobilization exercises may prevent elbow stiffness. Case one is 27-year old woman with a simple elbow dislocation. Patient was started early mobilization exercises immediately. Case two is a 58-year old man with a complex elbow dislocation. Following open reduction and internal fixation, a hinged elbow fixator was applied, and patient immediately started with active mobilization exercises. Case three is a 49-year old women with elbow stiffness and joint ingruency following persistent joint instability after a simple elbow dislocation. After arthrolysis, a hinged elbow fixator was mounted. In conclusion, early mobilization exercises after an elbow dislocation is mandatory to full functional recovery. Plaster immobilization should not be used. In case of persistent instability, a hinged external fixator is indicated

Open surgical procedures for incisional hernias

BACKGROUND: Incisional hernias occur frequently after abdominal surgery and can cause serious complications. The choice of a type of open operative repair is controversial. Determining the type of open operative repair is controversial, as the recurrence rate may be as high as 54%. OBJECTIVES: To identify the best available open operative techniques for incisional hernias. SEARCH STRATEGY: Electronic databases MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1990 to 2007 and trials were identified from the known trial reference lists. SELECTION CRITERIA: Studies were eligible for inclusion if they were randomized trials comparing different techniques for open operative techniques for incisional hernias. DATA COLLECTION AND ANALYSIS: Statistical analyses were performed using the fixed effects model. Results were expressed as relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes with 95% confidence intervals. MAIN RESULTS: Eight trials comparing different open repairs for incisional hernias were identified; one trial was excluded. The included studies enrolled 1,141 patients. The results of three trials comparing suture repair versus mesh repair were pooled. Hernia recurrence was more frequent, wound infection less frequent in the direct suture group compared to the onlay or sublay mesh groups. The recurrence rates of two trials comparing onlay and sublay positions were pooled. This comparison yielded no difference in recurrences (two studies pooled), although operation time was shorter in the onlay group (one study). No difference was found in recurrence, satisfaction with cosmetics, or infection between the onlay standard mesh and skin autograft groups, following analysis pooling the two treatment arms. However, the analysis demonstrated less pain in the skin autograft group. Other trials comparing different mesh materials or different positions of the mesh, or comparing mesh with the components separation technique are described individually. The comparison between lightweight and standard mesh showed a trend for more recurrences in the lightweight group. The comparison between onlay and intraperitoneal mesh positions resulted in non significant fewer hernia recurrences, less seroma formation and more postoperative pain in the intraperitoneal group. No differences in the recurrence rates between the components separation and the intraperitoneal mesh technique. AUTHORS' CONCLUSIONS: There is good evidence from three trials that open mesh repair is superior to suture repair in terms of recurrences, but inferior when considering wound infection. Six trials yielded insufficient evidence as to which type of mesh or which mesh position (on- or sublay) should be used. There was also insufficient evidence to advocate the use of the components separation technique

Extended Lateral Approach for Intra-articular Calcaneal Fractures: An Inverse Relationship between Surgeon Experience and Wound Complications

The current reference standard for the treatment of displaced intra-articular calcaneal fractures is open reduction and internal fixation using an extended lateral approach. In the present retrospective study, we evaluated the results of a consecutive series of patients treated in the same fashion from June 2005 to September 2011 using a subcuticular single-layer closure technique. We also determined the risk factors for the development of wound complications and the rate of wound complications. Also, we assessed which patient, fracture, and surgical characteristics affected these complications. During the 75-month study period, we operated on 53 displaced intra-articular calcaneal fractures in 50 patients using the extended lateral approach. The incision was closed using the subcuticular technique in 49 cases (92.45%). In the subcuticular closure group 2 (4.1%) deep infections and 2 (4.1%) superficial wound complications (1 dehiscence and 1 infection) occurred. Wound edge or flap necrosis was not encountered. The use of bone-void filler and the experience of the surgical team were significantly (p < .001 and p = .026, respectively) associated with the occurrence of wound complications. The subcuticular single-layer suture technique is a suitable closure technique in the treatment of displaced intra-articular calcaneal fractures. It was associated with a low complication rate combined with the extended lateral approach. The effect of bone void fillers on the incidence of complications should receive more attention in future research. The association between wound complications and the experience level of the surgical team supports the need for centralization of this complex injury

Reliability of predictors for screw cutout in intertrochanteric hip fractures

Background: Following internal fixation of intertrochanteric hip fractures, tip apex distance, fracture classification, position of the screw in the femoral head, and fracture reduction are known predictors for screw cutout, but the reliability of these measurements is unknown. We investigated the reliability of the tip apex distance measurement, the Cleveland femoral head dividing system, the three-grade classification system of Baumgaertner for fracture reduction, and the AO classification system as predictors for screw cutout. Methods: All patients with an intertrochanteric hip fracture who were managed with either a dynamic hip screw or a gamma nail between January 2007 and June 2010 were evaluated from our hip trauma database. Results: The tip apex distance measurement was reliable and patients with device cutout had a significantly higher tip apex distance. The agreement between observers with regard to screw position and fracture reduction was moderately reliable. After adjustment for tip apex distance and screw position, A3 fractures were at more risk of cutout compared with A1 fractures. Poor fracture reduction was significantly related with a higher incidence of cutout in univariate analysis, but not in multivariate analysis. Central-inferior and anterior-inferior positions, after adjustment for tip apex distance and screw position, were significantly protective against cutout. Conclusion: To decrease probable risks of cutout, the tip apex distance needs to stay small or the screw needs to be placed central-inferiorly or anterior-inferiorly. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyrigh

The Acute Compartment Syndrome of the Lower Leg: A Difficult Diagnosis?

Three patients, two adults and one child, developed an acute compartment syndrome of the lower leg. Due to delay in diagnosis, severe complications developed, resulting in two transfemoral amputations. In the youngest patient, the lower leg was able to be saved after extensive reconstructive surgery. In most cases, acute compartment syndrome of the lower leg is seen in combination with a fracture (40%), although other causes (minor trauma or vascular surgery) are also known. Moreover, patient history (pain out of proportion to the associated injury) and physical examination are central to the diagnosis. In some cases, however, a reliable diagnosis cannot be made clinically, as in the case of unconscious, intoxicated or intubated patients, as well as small children. Under these circumstances, intra-compartmental pressure measurement can be of great assistance. After confirmation of the diagnosis, immediate fasciotomy of all lower leg compartments should be performed. The eventual outcome of this syndrome is directly related to the time elapsed between diagnosis and definitive treatment. Although the diagnosis can be difficult, delays in treatment should be avoided at all costs. The acute compartment syndrome of the lower leg is a surgical emergency and should be dealt with immediately