Decision analysis model of incisional hernia after open abdominal surgery

Background The incidence rate of incisional hernias after open surgery has been reported to be higher than that of port site hernias after laparoscopic surgery. No studies have compared the costs for the health care system in treating those two types of hernia. Methods A systematic review was conducted to obtain the baseline data, and a decision analysis model was created to simulate the occurrence and recurrence of incisional and port site hernias. Results The overall risk of having incisional hernias was eight-times higher than that of having port site hernias (7.4% vs 0.9%). A cost savings of ￡93 per patient can be generated for the health care system in the UK. Similar results were obtained for Germany, Italy and France. Conclusions The additional treatment costs for incisional hernia should be taken into account when the costs of a surgery performed by open approach are compared with by laparoscopy.     

Shoulder instability: impact of glenohumeral arthrotomography on treatment

We used arthrotomography to study the glenoid labrum in 114 patients. Sixty-nine of the patients had anatomic instability of the shoulder (including recurrent dislocation and subluxation of the shoulder), and 45 patients had functional instability of the shoulder (denoted by chronic pain, clicking of the joint, and the sensation that an unstable condition exists without the objective signs of it). Labral tears were revealed arthrotomographically in 86% of the patients with anatomic instability, while only 40% of the patients with functional instability had labral abnormalities, and these were primarily of minor severity. Fifty-six patients (44 of whom had anatomic instability; 12, functional instability) required surgery. The surgical findings were correlated with the arthrotomographic findings, and no false-positive results were revealed. However, arthrotomography demonstrated only part of the pathologic condition of two patients. These results confirm that there is a strong correlation between labral pathologic conditions and anatomic instability of the shoulder. Arthrotomographic studies have a great impact on the selection of therapy in cases of both anatomic and functional instability of the shoulder.     

Rupture of the posterior tibial tendon: CT and surgical findings

Computed tomography (CT) was performed in 42 patients with 49 clinically suspected tears of the posterior tibial tendon. Twenty-eight of the 49 suspected tears were subsequently surgically explored and repaired. Three patterns of tendon abnormalities were recognized on CT scans: type I-intact, hypertrophied, heterogeneous tendon; type II-attenuated tendon; and type III-absence of a portion of a tendon. Types I and II correlated with partial rupture seen during surgery, and type III correlated with complete rupture of the tendon. CT findings were accurate in 96% of the patients who underwent surgery. In four cases (14%), tendon rupture was seen on CT scans, but the extent of the injury was underestimated and the rupture was misclassified. Reactive periostitis of the distal tibia was seen in 71% of diseased tendons and may represent an important factor in the diagnosis of tendon rupture.     

Arthroscopy of the shoulder joint.

Arthroscopy is without doubt the most comprehensive procedure for shoulder lesions, providing even better inspection of the interior of the joint than conventional open procedures. In 174 diagnostic arthroscopies, it proved more reliable than the computed tomography scan, ultrasound, or arthrography. The results of ultrasonography proved disappointing despite the enthusiastic reports on this technique, probably due to imperfections of equipment and lack of expertise rather than any inherent defect in the method. Arthrography seems to have a high incidence of false results. Though an invasive method requiring anesthesia, arthroscopy offers many diagnostic advantages such as an assessment of the role of the long biceps tendon and glenohumeral ligaments in recurrent or ordinary dislocation and the recognition of rotator cuff lesions not detectable at arthrography. It is also possible to assess the nature of shoulder instability and so to plan the appropriate operative procedure. A major advantage of arthroscopy is the possibility of carrying out treatment in the same session, though many of the suggested procedures are very demanding in terms of technical skill and time; the complication rate is often excessive. It is therefore best to restrict operative arthroscopy to simpler procedures such as irrigation in joint infections, the trimming of infolded flaps of labrum or stubs of biceps tendon, and the removal of loose bodies, where results are excellent. Arthroscopic repair of the rotator cuff or stapling of the labrum are more questionable regarding successes, complications, and recurrence. The equipment for arthroscopic operations needs improvement. Perhaps the major advantage of arthroscopic diagnosis is that it directs open procedures to the essential, thus minimizing operative trauma.