Utility of the Surgical Apgar Score in a District General Hospital

Background  

The Surgical Apgar Score (SAS) is a simple tool for intraoperative risk stratification. The aim of this prospective observational study was to assess its performance in predicting outcome after general/vascular and orthopedic surgery and its utility in a U.K. district general hospital.     

老年腹股沟疝的外科治疗

腹股沟疝是外科常见病及多发病 ,尤其多见于老年患者。据美国健康中心资料 ,美国每年因疝手术住院患者约 68万人 ,其中 1 / 3(34 % )是 65岁以上的老年人[1 ] 。我国老龄人口众多 ,不但老年疝的发病率高过西方国家 ,而且传统疝修补术后造成的高复发率也很突出 ,因此 ,探索老年腹股沟疝的治疗是当今外科所关注的一个热点问题。1　老年腹股沟疝的发病机理腹股沟疝的发生 ,主要是两方面的原因 :①腹壁强度的减弱 ;②腹内压的升高。老年人随着年龄的增长 ,腹壁肌肉日益薄弱 ,特别是腹横筋膜组织薄弱 ,这就使腹股沟区嵌闭机理失效 ,加之腹内压升…     

小儿腹股沟疝简便手术

介绍一种小儿腹股沟疝简便手术方法，其基本原则是分离并保留输精管及睾丸动静脉后，不找疝囊的情况下高位结扎三管以外的精索结构。此法的优点是简捷、快速、安全。手术一个切口同时作两侧，因而尤其适用于诊断不明确之双侧腹股沟斜疝患儿。     

Do We Follow Evidence-Based Medicine Recommendations During Inguinal Hernia Surgery? Results of a Survey Covering 2441 Hernia Repairs in 2007

Background  

We conducted a survey to determine whether hernia surgeons follow evidence-based medicine (EBM) criteria in their daily routine.     

Rives Technique for the Primary Larger Inguinal Hernia Repair: A Prospective Study of 1000 Repairs

Objective

We report a prospective study of repairs using the Rives technique of the more difficult primary inguinal hernias, focusing on the immediate post-operative period, clinical recurrence, testicular atrophy, and chronic pain. A mesh placed in the preperitoneal space can reduce recurrences and chronic pain.

Methods

For the larger primary inguinal hernias (Types 3, 4, 6, and some 7), we favour preperitoneal placement of a mesh, covering the myopectineal orifice by means of a transinguinal (Rives technique) approach. The Rives technique was performed on 943 patients (1000 repairs), preferably under local anaesthesia plus sedation in ambulatory surgery.

Results

The mean operative time was 31.8 min. Pain assessment after 24 h with an Andersen scale and a categorical scale gave two patients with intense pain on the Andersen scale, and four patients who thought their state was bad. Surgical wound complications were below 1%, and urinary retention was 1.2% mostly associated with spinal anaesthesia and, in one case, bladder perforation. There was spermatic cord and testicular oedema with some degree of orchitis in 17 patients. The clinical follow-up of 849 repairs (86.4%), mean (range) 30.0 (12–192) months, gave five recurrences (0.6%), three cases (0.4%) of testicular atrophy, and 37 (4.3%) of post-operative chronic pain (8 patients with visual analogue scale of 3–10).

Conclusions

The Rives technique requires a sound knowledge of inguinal preperitoneal space anatomy, but it is an excellent technique for the larger and difficult primary inguinal hernias, giving a low rate of recurrences and chronic pain.

     

疝囊旷置术治疗小儿腹股沟斜疝

作者自 1985年起采用疝囊旷置术治疗 1.2～ 8岁小儿腹股沟斜疝 2 3 2例 ,方法简便 ,效果良好 ,报告如下。1　手术方法及结果采用氯胺酮全麻 ,5ｍｇ/Ｋｇ ,一次性肌肉注射。切口采用经下腹部自然横纹切口 ,长约 3ｃｍ ,依次切开皮肤、皮下脂肪 ,横行切开腹外斜肌腱膜 ,分开腹横肌 ,显露腹膜 ,横行切开腹膜 ,提取腹膜切口下缘 ,并向下牵拉即可显露疝囊内口。如有疝囊内容物 ,可牵出复位 ,而后用数把蚊式钳轻轻提起疝囊内口后唇 ,使精索血管与被提起的疝囊内口的后唇边缘分离。将疝囊内口后唇与腹膜切口的上缘用 4号丝线间断缝合关闭腹腔 ,使疝…     

新生儿腹股沟嵌顿疝的诊治分析

目的总结新生儿腹股沟嵌顿疝的诊治经验。方法2012年7月~2019年3月我院共收治32例新生儿腹股沟斜疝嵌顿,均完善腹壁疝彩超,彩超提示疝内容物存在血供可试行手法复位(复位成功后家属选择手术时间),复位失败安排急诊手术,彩超提示疝内容物无血流信号安排急诊手术。结果手法复位成功8例,择期完成手术。余24例手法复位失败急诊手术,其中10例采用开放手术,14例采用腹腔镜手术。24例术中见嵌顿内容物14例为小肠,2例为盲肠,2例为大网膜,6例为卵巢;睾丸坏死4例,卵巢坏死1例,肠坏死5例。术后切口感染3例,经换药处理后痊愈出院。32例随访2个月~6年10个月,中位随访时间2年11个月,无复发、鞘膜积液及睾丸萎缩发生,开放手术患儿发生医源性隐睾1例,2例对侧异时疝,均再次手术。结论新生儿腹股沟斜疝消化道症状常见,全面查体及彩超检查非常重要。一经诊断应及时手术治疗,以避免嵌顿所导致的严重并发症。术式首选腹腔镜下腹膜外疝囊高位结扎术。     

Laparoscopic versus open appendicectomy in children: A UK District General Hospital experience

Aims

The aim of this study was to evaluate the potential role of laparoscopic appendicectomy in reducing morbidity and length of stay in children compared to open procedures in a UK District General Hospital setting.

Methods

A three-year retrospective review of children ≤ 15 years with histologically confirmed appendicitis who underwent laparoscopic (LA) and/or open (OA) appendicectomy was performed. Choice of operation was based on individual surgeon’s preference and on patient’s body size. Data collected included rate of histologically complicated appendicitis, post-operative length of stay (LOS), and collective and differential morbidity rates, i.e., wound infection, intra-abdominal collection, and ileus. Chi-square and Mann–Whitney tests were used for statistical analysis. P < 0.05 was regarded as significant.

Results

Eighty children (70% male) were identified at median age 11 (3–15) years. They could be divided into complicated (n = 18, 22%) and simple appendicitis (n = 62, 78%). Appendicectomy was performed in all as an OPEN (n = 53, 66%) or LAPAROSCOPIC (n = 27, 34%) procedure. Both groups were comparable in gender distribution (P = 0.11) and rate of complicated appendicitis (30% vs. 19%, respectively; P = 0.27). Median age was significantly lower in the OPEN group [10 (3–15) vs. 12 (7–15) years; P < 0.004]. Laparoscopic appendicectomy had a significantly lower rate of collective morbidity (3.8% vs. 25.9%; P < 0.003), including lower rate of intra-abdominal collection (1.9% vs. 14.8%; P < 0.01). Median LOS was not significantly different (1 day vs. 2 days; P = 0.14).

Conclusion

Laparoscopic appendicectomy in children in a UK District General Hospital is safe and was associated with significantly less post-operative morbidity than the open technique.     

Surgical Outcomes of Lichtenstein Tension-Free Hernioplasty for Acutely Incarcerated Inguinal Hernia

Purpose The purpose of our study was to evaluate the short-term and long-term outcomes of emergency Lichtenstein tension-free hernioplasty for acutely incarcerated inguinal hernia. Methods We conducted a retrospective study of patients who underwent emergency Lichtenstein hernioplasty for acutely incarcerated inguinal hernia between September 2002 and January 2006 in a major city hospital in Thailand. We analyzed the early postoperative complications and surgical outcomes. Results All 24 patients were men, with a mean age of 53.8 ± 19.2 years (range 19–77). There was no perioperative mortality and only two postoperative complications (8.3%): a subcutaneous fluid collection, which resolved spontaneously within 2 weeks; and a superficial surgical site infection, which was treated successfully by intravenous antibiotics. The hospital stay was 3.8 ± 2.1 days (range 2–12). All patients attended regular follow-up visits (mean 20.2 ± 10.7 months, range 3–43). Clinical recurrence was found in one patient (4.2%), 7 months postoperatively. Conclusion Lichtenstein hernioplasty can be used effectively as an emergency operation for incarcerated inguinal hernia with a good outcome and an acceptably low rate of postoperative complications.     

Inguinal Hernia in the New Millennium

Since 1884, when Edoardo Bassini started the modern era of surgical correction of inguinal hernia (today the most common procedure performed by the general surgeon), many techniques have been introduced, some short-lived, others with proven long-term results. At the start of the new millennium, the surgeon has three clear alternatives: tension repairs, tension-free repairs, and laparoscopic procedures. This paper analyzes these three options and offers an update regarding the pros and cons of the most commonly performed operations in surgical centers around the world.     

开放与腹腔镜无张力疝修补术治疗老年腹股沟疝的对比研究

目的比较开放和腹腔镜完全腹膜外无张力疝修补治疗老年腹股沟疝的疗效。方法 2006年1月～2010年1月136例老年腹股沟疝行开腹无张力填充式腹股沟疝修补术（开放组,n=72）或腹腔镜完全腹膜外腹股沟疝修补术（totally extraperitoneal hernioplasty,TEP）（TEP组,n=64）,比较2种术式疗效。结果开放组手术时间（65.3±18.1）min,明显短于TEP组（78.1±12.6）min（t=4.742,P=0.000）。开放组住院费用（4960.2±1033.3）元,明显低于TEP组（6998.0±1632.2）元（t=8.796,P=0.000）。开放组术后24 h和1周疼痛评分明显高于TEP组（Z=-7.144,P=0.000;Z=-6.408,P=0.000）;术后住院时间（4.9±2.4）d明显长于TEP组（3.6±1.5）d（t=-3.733,P=0.000）。136例无严重并发症。开放组72例随访8～46个月,平均15个月,其中〉24个月11例;TEP组64例随访4～35个月,平均14个月,其中〉24个月9例,2组均无术后复发。结论 2种术式治疗老年腹股沟疝是安全有效的。TEP疼痛轻,恢复快,应首选,尤其适用于双侧腹股沟疝修补;开放无张力疝修补术费用低,易开展,非常适用于合并有心肺疾病无法耐受全麻或CO2气腹的老年患者。     

The State of Surgical Task Sharing for Inguinal Hernia Repair in Limited-Resource Countries

Background

In limited-resource countries, the morbidity and mortality related to inguinal hernias is unacceptably high. This review addresses the issue by identifying capacity-building education of non-surgeons performing inguinal hernia repairs in developing countries and analyzing the outcomes.

Methods

PubMed was searched and included are studies that reported on task sharing and surgical outcomes for inguinal hernia surgery. Educational methods with quantitative and qualitative effects of the capacity-building methods have been recorded. Excluded were papers without records of outcome data.

Results

Seven studies from African countries reported 14,108 elective inguinal hernia repairs performed by 230 non-surgeons with a mortality rate of 0.36%. Complications were reported in 4 of the 7 studies with a morbidity rate of 14.2%. Two studies reported on follow-up: one with no recurrences in 408 patients at 7.4 months and the other one with 0.9% recurrences in 119 patients at 12 months. Direct comparison of outcomes from trained non-surgeons to surgeons or surgically trained medical doctors is limited but suggests no difference in outcomes. Quantitative capacity-building effects include increase in surgical workforce, case volume, elective procedures, mesh utilization, and decreased referrals to higher level of care institutions. Qualitative capacity-building effects include feasibility of prospective research in limited-resource settings, improved access to surgical care, and change in practice pattern of local physicians after training for mesh repair.

Conclusion

Systematic training of non-surgeons in inguinal hernia repair is potentially a high-impact capacity-building strategy. High-risk patients should be referred to a fully trained surgeon whenever possible. Randomized study designs and long-term outcomes beyond 1 year are needed.

     

腹腔镜治疗腹股沟疝的手术技巧和临床疗效分析

目的 探讨经腹腹膜前补片植入术(TAPP)和全腹膜外补片植入术(TEP)治疗腹股沟疝的手术技巧和临床效果.方法 回顾分析2007年7月至2008年10月期间我院实施腹腔镜腹股沟疝修补术23例(26侧)患者的临床资料,其中TAPP 9例(10侧),TEP 14例(16侧).结果 无一例中转为开放手术.1例TEP转行TAPP.平均手术时间(82.1±40.6) min,术中出血量(5.7±3.0) ml; TEP术中腹膜撕裂2例.术后并发症发生率为21.7%(5/23),其中术后血清肿1例,阴囊气肿2例,修补区暂时性神经感觉异常1例,尿潴留1例; 术后未出现慢性、持续性神经性疼痛、异物感,补片感染和切口感染.术后平均住院时间(4.3±0.9) d.术后随访1～15个月,平均(7.2±2.3)个月,无其他不适及复发病例.结论 腹腔镜腹股沟疝修补术安全、复发率低、并发症少、痛苦轻、住院时间短、恢复快.     

腹股沟疝补片修补术后补片感染外科处理方法的研究

目的探讨腹股沟疝补片修补术后补片感染的外科处理方法和经验。方法回顾性分析北京朝阳医院疝和腹壁外科2011年1月至2012年6月期间收治的67例腹股沟疝补片修补术后发生补片感染患者的临床资料,对患者的伤口愈合情况加以分析。结果67例患者均行清除感染补片及周围感染组织,未再重新放置补片,均行一期全层缝合伤口,同时放置伤口引流管。均成功清除了感染的补片;术后住院时间10～25d,平均16d;术后伤口一期愈合51例,拆线后伤口存在浅部感染、经局部换药后延期愈合16例。术后66例患者获访,随访时间为6～24个月（平均20个月）。随访期间,均无切口下积液、伤口感染、肠瘘、术后疼痛等并发症发生,无腹股沟疝复发。结论腹股沟疝补片修补术后补片感染的外科处理十分复杂,采用去除补片、彻底清创、一期缝合及放置伤口引流管的综合手术治疗方法可以获得比较满意的疗效。