Progress of peripheral nerve repair

Study on repair of peripheral nerve injury has been proceeding over a long period of time.With the use of microsurgery technique since 1960s, the quality of nerve repair has been greatly improved.In the past 40 years,with the continuous increase of surgical repair methods,more progress has been made on the basic research of peripheral nerve repair.     

Transthoracic repair of Morgagni’s hernia

Background Foramen of Morgagni’s hernia is an uncommon congenital diaphragmatic hernia. Repair is mostly performed through laparotomy. We prefer the transthoracic approach, which allows better and safer control during thoracic dissection, although it is considered more painful and related to greater morbidity. In recent years we introduced the transxiphoid hand-assisted videothoracoscopic approach, which combines the advantages of the thoracic route with a mini-invasive procedure facilitated by one hand inside the chest. Methods A retrospective review was performed over a 20-year period (1985–2005). Twenty-two patients who had a foramen of Morgagni’s hernia repaired were identified and relevant data were collected. Average age was 57 ± 10 years and one half of the patients were asymptomatic. Chest roentgenograms, chest computerized tomography, and barium enema were used as diagnostic utilities. Posterolateral thoracotomy was performed in 17 (15 right-sided) patients, whereas in 5 (all right-sided) the defect was repaired by transxiphoid hand-assisted videothoracoscopy. Operative time, pain scored by visual analog scale, hospital stay, and cosmetic results by acceptance score were reviewed for every patient. Results Hernial sac was present in all cases and contained only omentum (n = 13), omentum plus transverse colon (n = 7), omentum plus transverse colon and small bowel (n = 2). In 6 patients (2 videothoracoscopy) we repaired the large defects with polypropylene mesh. Videothoracoscopy achieved significant good results compared to thoracotomy in operative time (85 ± 7.9 versus 110 ± 11.3 min, p < 0.01), 24-h visual analog scale (3.5 ± 1.1 versus 6.7 ± 3.9, p < 0.01), hospital stay (2.6 ± 0.5 versus 6.4 ± 1.2 days, p < 0.01), and acceptance score (4.3 ± 0.5 versus 3.1 ± 0.8, p < 0.05). Postoperative course was always uneventful. Patients were followed for an average period of 58.6 ± 14.7 and 109.7 ± 43.5 months, respectively: no recurrences were found in any group. Conclusions We believe that the transthoracic approach is a safe and effective method for repairing Morgagni’s hernia. The videothoracoscopic approach is a promising alternative and it may be facilitated by introducing a hand inside the chest. This study has been carried out within the Research Fellowship Program Dottorato di Ricerca in Tecnologie e Terapie Avanzate in Chirurgia, appointed by Tor Vergata University and was supported in part by the Ministry of Health (60%)     

Timing of traumatic lumbar hernia repair: is delayed repair safe? Report of two cases and review of the literature

Fewer than 100 cases of traumatic lumbar hernias are described in the English literature. The herniation has been described as a consequence of a combination of local tangential shearing forces combined with an acute increase in intra-abdominal pressure secondary to sudden deceleration sustained during blunt abdominal trauma. Delayed diagnosis is not uncommon, as nearly a quarter of these are missed at initial presentation. These hernias are best managed by operative intervention; however, there is no well-defined treatment strategy regarding either the timing or the type of repair. Several approaches, including laparoscopy, have been described to repair these defects. Various techniques, including primary repair, musculoaponeurotic reconstruction, and prosthetic mesh repair, have been described. These repairs are usually complicated because of the lack of musculoaponeurotic tissue inferiorly near the iliac crest. We describe here two cases of traumatic lumbar hernia managed by initial watchful waiting and subsequent elective repair using a combined laparoscopic and open technique and one with and one without bone anchor fixation.     

Is repeated repair of the meniscus worthwhile?

Meniscal injuries are one of the most commonly encountered problems by orthopaedic surgeons. It is well established that meniscectomy will result in increased joint surface contact forces and the predictable progression of arthritis. The management of meniscal tears has evolved and current evidence would suggest that every attempt should be made to repair meniscal tears when appropriate. The reported success rate of meniscal repair is encouraging, but relatively little is known about the outcome of repeated repair of a re-torn meniscus. This review presents an illustrative case of a recurrent lateral meniscal tear in a young female, that has required surgical repair on three occasions over a fourteen year period. Despite recurrent tears of her lateral meniscus, the patient was symptom-free in the intervening periods and at her latest operation, her articular cartilage showed minimal evidence of chondral damage. Longer-term follow-up is required to determine whether repair of a re-torn meniscus prevents the progression of degenerative changes within the knee joint that is associated with meniscectomy.     

Laparoscopic ventral hernia repair: are there comparative advantages over traditional methods of repair?

Recent studies have noted advantages of laparoscopic over open repair of ventral hernias. Because few reports have involved comparison with traditional repair we report a comparison between laparoscopic and open approaches. We retrospectively reviewed the records of patients undergoing ventral hernia repair over a 28-month period. Patients were grouped into three categories: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. There were 295 ventral hernia repairs and there was no difference in age, gender, operative complications, or hospital stay between the groups. Mesh and defect size was greater in the laparoscopic group. The overall postoperative complication rate was greater in the open group with mesh. Yet when specific wound complications were analyzed there was no difference between the groups. Furthermore a death occurred in the laparoscopic group from an unrecognized bowel injury. The recurrence rate was greatest in the open repair without mesh group. Finally hospital cost was greatest in the laparoscopic group and third-party reimbursement was better for the open techniques. We were unable to demonstrate a significant advantage to laparoscopic ventral hernia repair. Although many patients with large fascial defects were well served with this approach it may not be a better option for these patients.     

Hernia repair: why do we continue to perform mesh repair in the face of the human toll of inguinodynia?

Fifteen to 20 years ago, transversalis and Shouldice Hospital repairs were standard, with a 4% to 6% rate of recurrence. With a focus on recurrence, various mesh repairs were proposed to reduce the incidence of recurrence. With these repairs, an increased incidence of inguinodynia due to the entrapment of the nerves proximate (adjacent) to the mesh has been observed. Many surgeons doubted its existence; however, there is sufficient evidence that with mesh repair in which the affected nerves are resected, the incidence of severe pain is lessened considerably. Triple neurectomy has been proposed as a therapy, but only 80% of patients are relieved of pain. Recurrence is insufficient to make patients' lives miserable, with mesh repair reporting up to a 21% incidence of inguinodynia. Although few surgeons today perform this procedure and most residents have never seen it, the author proposes that mesh repairs be abandoned and the transversalis or Shouldice Hospital repair be adopted.     

Clinical application of axonal repair technique for treatment of peripheral nerve injury

Althoughtheapplicationoffinemicrosurgicaltechniquewithepineurialorperinurialstitcheshasimprovedtheoperativeefficacyofperipheralnerveinjuriestoa greatextent ,thetotaloutcomeofnerverepair ,however ,isnotallthatcouldbedesired .1Thecruxliesmostlyinthemisdirectionoftheregeneratingaxonscausedbythedisorganizationoftheinternalfascicularstructure .2DeMedinaceli3describedanewtechniqueofnerverepair,termed ”cellsurgery”,withwhichtheperipheralnerveisrepairedattheaxonallevelbyminimizingphysicalandchemical…     

Does surgical repair of pelvic prolapse improve patients' quality of life?

OBJECTIVES: The aims of this study were to evaluate the efficacy of surgical repair in patients with pelvic prolapse, and to assess the postoperative quality of life (QOL). METHODS: A total of 70 patients (mean age: 66.7 years) underwent transvaginal two-corner bladder neck suspension in combination with transvaginal hysterectomy (63 cases), and anterior with (49) or without (21) posterior colporrhaphy. The status of recurrence and complications were followed in all patients at a mean follow-up period of 32.0 months. Postoperative patients' quality of life (QOL) consisting of four items (sensation of vaginal bulging, urinary incontinence, difficulty to urinate, and health-related QOL) was assessed in 52 cases whose were followed at least two years (mean: 41.6 months, range: 24.3-69.1). RESULTS: Sixty-eight patients (97%) were recurrence-free. Nine of the 39 (23%) patients with difficulty to urinate before surgery had persistent symptoms postoperatively. Multivariate analysis revealed that cystometric abnormalities, voiding symptoms at seventh days after surgery, and weak detrusor contraction were independent prognostic factors for persistent voiding symptoms. As for the QOL, all items had significant improvement at 13 months after surgery as compared to baseline condition. A longitudinal study showed improvement of these symptoms sustained at least up to four years. CONCLUSIONS: This study suggests that surgical repair can achieve results with long-term durability as well as improving the QOL. In addition, assessment of the detrusor function may be needed for patients who complain difficulty to urinate in avoiding persistent such symptoms.     

Microlaryngoscopic repair of iatrogenic pharyngeal pouch perforations: Treatment of choice?

BACKGROUND: Endoscopic stapled diverticulostomy (ESD) has become the preferred technique for managing pharyngeal pouches. Iatrogenic perforation, created during stapling, is a rare but serious complication with significant morbidity and mortality. The conventional management in these instances is to convert it to an external procedure and excise the pouch. METHODS: Iatrogenic perforations were noticed after stapling in 3 cases in our series of 73 patients who underwent ESD. They were repaired using microlaryngoscopic techniques. RESULTS: All patients had an unremarkable postoperative course. CONCLUSIONS: Selected cases with iatrogenic perforations can be repaired primarily and observed with excellent outcome, obviating the need for an external pouch excision.     

Does method of sternal repair influence long-term outcome of postoperative mediastinitis?

Background

Post-sternotomy mediastinitis reduces survival after cardiac surgery, potentially further affected by details of mediastinal vascularized flap reconstruction. The aim of this study was to evaluate survival after different methods for sternal reconstruction in mediastinitis.

Methods

Two hundred twenty-two adult cardiac surgery patients with post-sternotomy mediastinitis were reviewed. After controlling infection, often augmented by negative pressure therapy, muscle flap, omental flap, or secondary closure was performed. Outcomes were reviewed and survival analysis was performed.

Results

Baseline characteristics were similar. In-hospital mortality (15.7%) did not differ between groups. Secondary closure was correlated with negative pressure therapy and reduced length hospital of stay. Recurrent wound complications were more common with muscle flap repair. Survival was unaffected by sternal repair technique. By multivariate analysis, heart failure, sepsis, age, and vascular disease independently predicted mortality, while negative pressure therapy was associated with survival.

Conclusions

Choice of sternal repair was unrelated to survival, but mediastinal treatment with negative pressure therapy promotes favorable early and late outcomes.     

Laparoscopic ventral hernia repair: Does primary repair in addition to placement of mesh decrease recurrence?

Background  

The advent of laparoscopic ventral hernia repair (LVHR) not only reduced the morbidity associated with open repair but also led to a decrease in the hernia recurrence rate. However, the rate continues to remain significant.     

Is laparoscopic repair of incarcerated abdominal hernias safe? Analysis of short-term outcomes

Background

There is a paucity of literature surrounding the safety and feasibility of laparoscopic repair for acutely incarcerated abdominal hernias. The objective of this study was to compare the 30-day morbidity and mortality between laparoscopic and open repairs of incarcerated abdominal hernias.

Methods

A retrospective cohort study was conducted using data from the National Surgery Quality Improvement Program from 2005 to 2012. The study population was selected using ICD-9 diagnostic codes describing abdominal hernias with obstruction, but without gangrene. Cases with documented bowel resection were excluded. Group classification was based on CPT coding. Study outcomes included the 30-day major complication, reoperation and mortality rates. Multivariable logistic regression models were used to adjust for confounding for all study outcomes.

Results

A total of 2688 and 15,562 patients were in the laparoscopic and open group, respectively. After adjustment for clinically relevant confounders, laparoscopic surgery was associated with a significantly lower 30-day infectious (OR 0.36, p < 0.001, 95 % CI 0.23–0.56) and serious complication rates (OR 0.66, p < 0.001, 95 % CI 0.55–0.80). However, there was no statistical difference with respect to the 30-day reoperation (OR 0.81, p = 0.28, 95 % CI 0.56–1.18) or mortality rates (OR 0.94, p = 0.80, 95 % CI 0.58–1.53).

Conclusions

Patients with incarcerated abdominal hernias who underwent laparoscopic repair had a significantly lower 30-day morbidity compared to patients with open repair. Although the 30-day reoperation and mortality rates were also lower, there was no statistically significant difference. Laparoscopic surgery appears to be safe in the management of select incarcerated abdominal hernias.

     

How to diminish reoperation rates after initial repair of tetralogy of Fallot?

BACKGROUND: Complete correction of tetralogy of Fallot has good long-term results. Right ventricular outflow tract obstruction and pulmonary insufficiency occur which require reintervention. The present study evaluated the efficacy of reoperation following complete correction of tetralogy of Fallot, the sites of recurrences and impact of techniques used at first operation. METHODS: Between 1980 and 1999, 501 patients underwent complete correction of tetralogy of Fallot. Reoperation rate was 7.4%. Residual or recurrent right ventricular outflow tract stenosis was seen in 25 patients (68%), and 7 patients (19%) had severe pulmonary insufficiency. Age at redo was 9.1+/-6.4 years. Restenosis was most frequently observed (75%) at the bifurcation of the pulmonary artery. Extended 1-patch enlargement was used until 1989 and thereafter changed to a 2-patch technique. RESULTS: Valvar-supravalvar 1-patch technique had a redo rate of 33.3%, compared with 4.3% for the 2-patch technique, p = 0.0264, with excellent freedom from reoperation rate. At reoperation right ventricular-pulmonary artery (RV-PA) conduits managed 29 patients and 3 had supravalvar patch enlargement. Hospital mortality was 5.4% (2 of 37). Twenty-five patients (68%) were in New York Heart Association functional class I to II at end of the follow-up, and none required further interventions. CONCLUSIONS: Redo rate following complete correction of tetralogy of Fallot was 7.4%. Right ventricular outflow tract pathology was the dominant reason for reoperations (86%). At reoperation, RV-PA conduits was the most frequently used technique. Reoperation was efficient in reducing the RV-PA gradient, had low hospital and late mortality. A 2-patch valvar-supravalvar enlargement at first operation reduced the risk for redo in long-term follow-up.     

Results of biventricular repair of congenital cardiac malformations: definitive corrective surgery?

Objectives: Congenital cardiac malformations are usually corrected in the neonatal period or in early infancy. Corrective surgery may not always be definitive, especially in complex malformations. Long-term morbidity is influenced by reoperations and their risk. Methods: This study analyzes our single-center experience over more than 20 years in a selected group of patients. Data were gathered, with special focus on causes and incidence for reoperations, respectively. Results: Freedom from reoperation after 5, 10, and 15 years for each cardiac malformation was determined. The numbers describe in the following order patient years (y), number of patients (n), and freedom from reoperation at follow-up interval (%), respectively: atrial septal defect (15 864y, n=1198, 99±0/99±0/99±0), partial atrioventricular septal defect (2506y, n=234, 95±2/93±2/93±2), total anomalous pulmonary venous connection (742y, n=141, 93±1/91±0/91±0), complete atrioventricular septal defect (1715y, n=377, 81±3/76±3/72±4), tetralogy of Fallot <1 year (1503y, n=197, 94±4/85±1/74±3), transposition of great arteries (1459y, n=375, 88±2/83±4/73±7), interrupted aortic arch (IAA) (481y, n=98, 63±6/52±7/45±8), common arterial trunk (CAT) (599y, n=109, 64±6/24±6/11±5). Conclusions: In most congenital malformations surgical correction is definitive and the rate of reoperations is low. In complex anomalies, such as CAT and IAA, reoperations at long-term are more common. Analysis of such results and recognition of a sometimes inevitable operative morbidity helps to predict long-term outcome and influences the follow-up.     

Results of open repair of the rotator cuff – a long-term review of 79 shoulders

In 72 patients with 79 tears of the rotator cuff that had been completely repaired by open surgery, the outcome was evaluated on the basis of history, Constant functional score and radiography. At a mean follow-up period of 6.75 years, the Constant score was 71.5 points on average, showing a high correlation with the patients’ subjective satisfaction, but the score was not a reliable indicator of recurrence. The larger the cuff tear, the poorer the result was. However, deterioration was not related to the duration of follow-up or the patient’s age. The presence of acromioclavicular arthrosis also had no influence on the overall result. A comparison of follow-up radiographs with those obtained immediately after surgery revealed (despite postoperative flat subacromial resection) evidence of heterotopic bone formations or ossifications in nearly half of the patients. However, except for individual cases, this had no significant influence on the clinical result or the Constant score. Received: 16 December 1999     

Decalcificated human dentin matrix in autogenous repair of skull defects

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