Surgery for large hydrocele

Nine hundred fifty cases of moderate to large hydrocele were surgically treated by excising the skin, dartos, spermatic fascia, sac, and the median septum, leaving sufficient scrotal skin to construct a new scrotum—just enough to accommodate both the testes. The cure was complete, and the postoperative complications were minimal. The redundant skin and subcutaneous tissues were removed because they would otherwise hang and flop against the inner aspect of the patient's thighs, resulting in great difficulty and dissatisfaction in walking. This method of skin excision can also be applied to a huge inguinoscrotal hernia after its repair.     

Primary malignant melanoma of the oral cavity. A review of 20 cases

Twenty patients with primary malignant melanoma of the oral cavity have been described. They formed 3.9 percent of the total number of patients with malignant neoplasms of the oral cavity. The upper gingiva was most commonly affected. In this series, there were 14 male patients and 6 female patients who ranged in age from 26 to 80 years (average 58 years). The first symptom of melanoma was hyperpigmentation of the mucosa in 10 patients, tumor in 7, and pain in 3 edentulous patients with prostheses. Radical surgery was performed in 13 patients, followed by chemotherapy and radiotherapy in 9 cases. Only 1 patient survived 9 years. The remaining 12 died 11 to 18 months after radical treatment. Palliative therapy was applied in three patients, two patients were treated symptomatically, and two patients refused treatment. Early detection of melanoma is an indication for radical treatment and may increase the survival rate of patients with this disease, which is still very low.     

Colon perforation in Ehlers-Danlos syndrome: Report of two cases and review of the literature

Two cases of spontaneous perforation of the colon in Ehlers-Danlos syndrome type IV are reported, and eight cases previously reported in the English literature are reviewed. Emergency surgery for acute free colon perforation in patients with Ehlers-Danlos syndrome should be carried out in the following standard manner: exteriorization of the perforation or resection of the involved colon with end colostomy, and either closure of the rectal stump (Hartmann procedure) or distal mucous colostomy. The reported experience although small, indicates that a high incidence of recurrent perforation can be expected if bowel continuity is reestablished. Permanent colostomy status, therefore, appears advisable, despite the young ages of most of the patients.     

A radiological study of the movements of the two components of the Monk prosthesis (hard-top ‘duo-pleet’) in patients

Following replacement of the femoral head with the Monk hard-top ‘duo-pleet’ prosthesis, radiological studies show that movement of the replaced hip takes place between the acetabulum and the metal shell and between the high density polyethylene cup and metal ball. Movements improve with the passage of time. The two sites of movement may contribute to a greater range of hip movement, a better safeguard against loosening and possibly less medial migration of the prosthesis than solid metal prostheses like the Thompson and Austin Moore types.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation: XII. Anorectal mobilization: A new surgical access to rectal lesions. Preliminary report

A new technique for the removal of inaccessible benign intrarectal lesions and malignant lower third rectal tumors with sphincter preservation is presented. The procedure was performed in eight patients, four with huge bilharzial papillomas and four with malignant lower third rectal tumors. The essential feature of the operation is preservation of the levator tunnel, which is responsible for maintaining normal, voluntary continence and defecation. The results were satisfactory. The technique provides easy access to the interior of the rectum, and it extends the indications for sphincter-saving operations to include malignant lower third rectal tumors. It is hoped that this procedure will eliminate the use of abdominoperineal excision in the treatment of rectal cancer.     

Study of triangular fibrocartilage of the wrist joint in Colles'' fracture

Poor results in Colles' fracture may be due to tears of the triangular fibrocartilage at the wrist joint. A series of patients have been studied by arthrography of the wrist; some were operated on and the findings confirmed. A series of 60 patients was studied.     

Carcinoid tumors of the colon. A study of 72 patients

Since carcinoid tumors rarely originate in the colon (excluding those that arise in the appendix and rectum), there are few large clinical series describing these neoplasms. Seventy-two patients with colonic carcinoids treated over a 40 year period have been reviewed. The peak incidence was in the seventh decade and females outnumbered males 2:1. Virtually all patients were symptomatic, usually complaining of abdominal pain. The symptom duration averaged 3.6 months. Thirty-eight percent of patients had masses in the right lower quadrant and 16 percent, hemoccult-positive stools. Three patients had a documented elevation of the urinary 5-HIAA level. Nearly 70 percent of the lesions were situated in the right segment of the colon. Barium enemas usually detected the neoplasms. Most patients had colon resections and five had resection of adjacent organs. Forty-four percent of the lesions had spread to regional sites and 38 percent to distant points. Most lesions were bulky. The operative mortality was 19 percent overall. Chemotherapy and radiotherapy did not appear to provide good palliation. Synchronous or metachronous neoplasms developed in 30 patients, especially in the colon, during the period of follow-up. The crude survival rates were 58, 51, 25 and 10 percent at 1, 2, 5, and 10 years, respectively.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation: XV. Chronic anal fissure: A new theory of pathogenesis

Pathologic changes in chronic anal fissures were studied in 52 patients. In 40 patients, epithelial cells could be identified in the fissure floor superficial to the internal anal sphincter. The cells were rounded, oval, or columnar and were arranged in clumps or pseudoacinar formations. In 10 patients the anorectal sinus was detected in the fissure floor, whereas in 2 patients no epithelial cells could be found.It seems that chronic anal fissure results from disruption of the anal lining, which exposes epithelial cells or the anorectal sinus in the wound floor to repeated infection. It is believed that these epithelial cells are just anorectal sinus remnants that exist in the submucosa of the anal canal proper as epithelial debris or anorectal band. Epithelial cells act as multiple sequestra that harbor the infection and are responsible for fissure chronicity. These patients are predisposed to anal traumatization by feces, owing to the anorectal band's constricting effect on the anal canal proper.The exclusive fissure location in the anal canal proper and not in the rectal neck is due to the anorectal sinus remnants contained therein. The posterior and, rarely, anterior median fissure position is ascribed to the existence of two weak anal areas. The break commonly occurs posteriorly because the posterior anal wall lacks sufficient support. It is concluded that fissure excision, including anorectal bandotomy, at present, is the best treatment to achieve a radical cure.     

Obturator foramen approach. II. A new surgical approach for management of the short-pedicled undescended testicle

A new approach for the management of the short-pedicled undescended testicle is presented. It was used in four patients with the testicle lying deep to the internal inguinal ring after all methods of cord elongation failed to bring the testicle down to the scrotum. The technique consists of passing the testicle through the obturator foramen to the scrotum. No complications were encountered, and the results have been satisfactory. Normally the vas deferens and testicular vessels describe a loop along their inguinal and pelvic course. The obturator foramen approach shunts this loop, which may be lacking in the undescended testicle lying deep to the internal inguinal ring.     

Primary hyperparathyroidism: A personal experience with 242 cases

Two hundred forty-two patients with primary hyperparathyroidism operated on at Akron City Hospital are reviewed. The importance of the association of peptic ulcer and pancreatitis with primary hyperparathyroidism is stressed. Nineteen percent of the patients had associated peptic ulcer or pancreatitis. The mechanisms involved in the production of these diseases in patients with primary hyperparathyroidism are emphasized. The two deaths occurred in the small but challenging group of patients with acute parathyroid crisis and carcinoma.The decision concerning the extent of parathyroidectomy should be made by the surgeon for each patient, based on the number, location and gross appearance of the identified glands. Removal of a single enlarged gland, if the other three glands are normal, is all that needs to be done in most cases. A recurrence rate of 1 percent and an appreciable decrease in postoperative tetany support this conservative approach. Subtotal parathyroidectomy should be reserved for patients with diffuse hyperplasia.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. Treatment of hemorrhoids: report of a technique

A technique for the treatment of hemorrhoids has been presented. It is based on a recent study in which the persistence of the anorectal band, a remnant of the anorectal sinus, and failure of rectal neck remodeling are considered responsible for the initiation of the hemorrhoid disease. The constricting effect of the anorectal band on the rectal neck results in elevation of its pressure, straining at defecation, and prolapse of the rectal mucosa. There were 502 patients with third and fourth degree hemorrhoids. The preoperative rectal neck pressure was high in all of them. The technique comprises division of the anorectal band and hemorrhoid ligation. The results were satisfactory, and the complications were negligible. The rectal neck pressure was normalized and straining disappeared. The procedure is simple and easy. Compared with the other techniques for hemorrhoid treatment, it offers the advantage of dealing with the primary etiologic factor.     

Surgically treated traumatic subacute and chronic subdural haematomas: a review of 132 cases

One hundred and thirty-two cases of surgically treated traumatic subacute and chronic subdural haematomas are reviewed. A high male to female ratio of 5 : 1 is noted. The age distribution and the clinical picture are comparable with the pattern in other reported studies. All patients were treated with simple burr holes and evacuation of blood without membranectomy, postoperative drainage or posturing. The results were excellent as 62 per cent made a good recovery, 33 per cent had mild disability, 4 per cent had severe disability and only 1 patient died. There were no recurrences.The simplicity of making burr holes recommends the method to more doctors, thereby extending the frontiers of treatment beyond the confines of neurosurgical centres.     

Obturator foramen approach: I. A new technique for reconstruction of the vas deferens after extensive resections

A new approach for restoring continuity of the vas deferens after long segment resection is presented. The technique was used in six patients. It consists of passing the pelvic segment of the vas through the obturator foramen for anastomosis with the scrotal vasal segment. No complications were encountered, and the results were excellent. The vasal length was studied in 37 cadavers of different ages. The portion of the vas that could be spared by the obturator approach was calculated and found to represent as much as one third of the total vasal length. The indications for the technique are outlined.     

Prophylactic povidone iodine in minor wounds

A total of 628 patients requiring sutures for minor wounds in an accident and emergency unit was included in a controlled trial using povidone iodine dry powder spray (Disadine DP) as prophylaxis against wound infection. In patients with injuries of the forearm and hand there was a statistically significant reduction in infection rate (P < 0.02). Povidone iodine spray was found to be an effective, simple to use, not toxic, antiseptic prophylactic agent.     

Cannulation injuries of the ascending aorta. Repair using the aortic corset

Laceration of the aorta by a side-biting vascular clamp is an unusual but often lethal complication of proximal aortic cannulation. It can be effectively managed with an aortic corset.     

Biliary carcinoma. A review of 109 cases

One hundred nine patients operated on for bile duct carcinoma were reviewed. Herein, we reported 83 proximal duct tumors, 12 mid-duct tumors, and 14 distal third tumors. Resectability was 10 percent, 33 percent, and 100 percent, respectively, with an operative mortality of 0 percent, 25 percent, and 23 percent. The median survival time and 5 year survival rate for these resected groups were 21 months and 25 percent for proximal duct tumors, 8 months and 0 percent for mid-duct tumors, and 16 months and 20 percent for distal third tumors. Eighty-three patients were treated with strictly palliative procedures with an operative mortality of 19 percent, an adjusted median survival rate of 10.9 months, and a 5 year survival rate of 0. The 2 and 5 year survival rates of patients with well-differentiated tumors were 73 percent and 15 percent, respectively, whereas for patients with poorly differentiated lesions, it was 6 percent and 0. Although most patients require palliative decompressive procedures, resection should be attempted whenever possible. It is expected that nonoperative techniques will have an increased role in the treatment of poor-risk patients or those who have unresectable disease.     

Heterotopic bone formation in abdominal operation scars: Report of six cases with review of the literature

Six cases of heterotopic bone formation in abdominal operation scars are presented, and the literature on the subject is reviewed.