1 - N° 1 - Año 2006
Autores: Gonzalo Mañanes, Marcos Hurvitz.
The pilonidal sinus or sacrococcygeal cyst has usually been treated as a congenital pathology. The surgical treatment generated a lot of morbidity as regards torpid postoperative states with big areas of suppuration and months of inactivity. We consider this as acquired pathology and have treated it in accordance, searching for better functional and esthetic results.
Establish, with this simple and cheap technique, good outcomes measured by aesthetic, functional and a few relapsed results.
42 patients over 18 years old, with pilonidal sinus not previously operated have been studied. Relapse, esthetic effects of the technique and the return to normal activity have been analyzed. All the patients have been operated with local anesthesia, as outpatients and have been checked 30, 60 and 90 days after the surgery.
All the patients returned to their normal lives within ten days.Two patients had relapse but the same technique was repeated. Incisions were completely healed 15 days after the surgery.
The stated technique is good because the patient spends a short time as inpatient, the esthetic results are excellent and relapses are scarce.
Autor: Marcos Hurvitz.
The pain after anorectal surgery was controlled through pudendal nerve block added to analgesia. This study was designed to evaluate the treatment of postoperative pain comparing the results after the pudendal nerve block.
PATIENTS AND METHODS: One hundred and eleven patients were included in the trial, twenty (60) men who underwent anal pathology surgery. From March 2001 to June 2004. Two groups were formed. Group I : 60 patients with pudendal block. Group II : 51 patients without nerve block. In both groups, intravenous meperidine was used. Pain was evaluated with the following classification: 0 to 4: mild (useful option); 4 to 7 moderate (useless option); 7 to 10 severe (useless option). The required analgesic doses in 24 hours were registered and classified into: acceptable (3 or fewer), and excessive (4 or more).
RESULTS: Analgesic doses: Group I: acceptable, 48 patients; and excessive, 12 patients. Group II : acceptable, 18 patients; and excessive, 33 patients (p=0.016). Pain level: Group I: mild: 51 patients, moderate/severe: 9 patients. Group II: mild: 33 patients; moderate/severe: 18 patients. (p=0.15) There were no complications related to the method.
CONCLUSION: The pudendal nerve block diminishes the required analgesic doses in the anal pathology postoperative.
Key words: postoperative pain- anal surgery- analgesic-pudendal nerve block
Colonic Primary Anastomosis without Mechanical Preparation
(39 - 48)
Prospective and descriptive
Patints and Method
30 patients operated from January 2002 to March 2003. 13 were scheduled and 17 urgent surgeries. The most frequent pathology was colon obstructive tumor (67%) followed by benign pathology of the left colon such as the volvulus and the diverticular disease. We performed primary anastomosis without protection ostomy and without mechanical preparation both in urgent and scheduled surgery. We did not perform ontable lavage either. The antibiotic prophylaxis is with ornidazole or metronidazole and gentamicin. Anastomosis are performed, whenever possible, end to end with polypropilene surget 3/0. Patients follow-up lasted 30 days, trying to analize the postoperative morbility and mortality rates.
One patient had a suture leakage, was operated 72 hours later with Hartmann procedure and died due to sepsis. Another three patients had a contained evisceration but only one required reoperation. Three patients had wound infection and one had intrabdominal abscess, which it drained by puncture, Global morbidity rate was 20% and global mortality rate was 6.6%.
Primary anastomosis with mechanical preparation and protection ostomy is not indispensable for a safe evolution and without complications of colon surgery. Anyway, greater and comparative studies are necessary to round up this concept.
PENETRATING ABDOMINAL WOUNDS WITH COLONIC LESION
(49 - 58)
Penetrating abdominal wounds are a frequent cause for laparotomy in an emergency room. A good revision of the colonic lesions in our area is necessary as the behavior study since ancient wars, can not always be applied. This is the reason why we evaluated the results of patients with laparotomy in penetrating wounds with colonic compromise.
Patients and methods
47 patients with penetrating abdominal wounds, firearms and blades were operated between January 1999 and March 2003. The colon was relevant in 22 of them. Exploratory laparotomy with median suprainfraumbilical incision was performed taking less than two hours altogether. Primary suture of the colon, derivative ostomes or exteriorized lesion as colostomy were performed.
31 years old. 14 male. 3 were operated in 1999, 4 in 2000, 6 in 2001 and 9 in 2002/2003. 9 were wounded with blades and 13 with firearms. 8 primary suture in blades and 10 in firearms. 3 colostomies in firearms. First intention Hartmann operation was included. 1 right colon resection due to blind gut inviability. 5 associated lesions in patients with blade wounds and 8 with firearms, all of them in the small intestine. There were 2 unnoticed lesions of the colon which were reoperated with Hartmann. One of the patients was reoperated twice more due to abdominal abscesses, as fecal peritonitis was observed in the first reoperation. Conclusions
We observed increase in the penetrating abdominal wounds. Primary suture of the colon is safe and effective though there are intestine associated lesions.
Patients and Methods
Patients who had been operated and re-operated with second-intention scars, very often with a replacement mesh. 19 patients with Hartmann surgery reconstructed via laparoscopy, 9 diverticular, 8 tumoral and 2 firearm wounds. 7 patients with more than one surgery and with scars second intention closed with replacement mesh in 6 cases. (our series to analyze) All men, between 19 and 83 years old. The laparoscopic technique was diverse: The abdominal entrance was through a trocar for the camera, far from the primary wound or detaching the colostomy first.
The causes of the complex abdomen were the re-operations: intra-abdominal abscess, leakage in an entero enteroanastomosis, unseen colon injury, colostomy necrosis. We converted a patient’s surgery because it was not possible to go ahead to the anastomosis site with the mechanical suture (with previous radiotherapy). One patient had an unseen small intestine injury and required laparotomy 48 hours later. Hospital stay was 3 to 5 days. Mortality of the series: 1 patient.
Hartmann reconstruction via laparoscopy is useful and possible even in patients with peritoneal multiple surgeries and faulty scars.
LAPAROSCOPY IN PENETRATING ABDOMINAL WOUNDS
(70 - 81)
A negative laparotomy has its morbidity because it is frequently accompanied by complications and a longer hospital stay. The use of laparoscopy for the diagnosis of peritoneal penetration wounds would be a valid alternative to reduce the quantity of laparotomies. Our aim was the determination of feasibility and security to use this technique in peritoneal penetration wounds. Retrospective, descriptive.
Patients and method
Patients (n=11) were strictly selected regarding their hemodynamic state, localization and possible way of the external wound and associated diseases. Laparoscopy was used without trying to solve the pathology. Penetrating diagnosis and possible organ injury diagnosis was performed.
11 patients underwent surgery from January 2002 to December 2004. 4 patients were wounded with a firearm. From the wounds caused by a weapon with a blade, 3 were without penetration, 1 without apparent lesion so laparotomy was not performed, the patient’s follow up was with echography and clinical care. The rest of patients who were wounded with a blade underwent laparotomy and in all of them organ lesions were found. From the firearm wounds, one of them did not bear penetration and no lesion was found in another.
It is possible to apply this method in the emergencies area. So it would be very useful to go ahead determining the indications and contraindications. Also, to study morbidity reduction and hospital cost.