Chirurgie; memoires de l'Academie de chirurgie最新文献

With the experience obtained in a surgical air borne unit and the long term results in a rear zone hospital, we analyse treatments of bone and joint acute traumas in a field hospital. This injuries appear in a particular context: delayed treatments with little staff and equipment. The surgeon has to be fast with protective measures, debridement of soft tissues, bone stabilisation and vascular repair. We discuss the respective place of each treatment: amputations are dictated by the gravity of the wounds; orthopedic methods are used for the upper limb, for the lower limb they are waiting technics; external fixation stabilizes fastly bone injuries, facilitates transportation and permits delayed reconstruction technics. Indications have to be adapted to circumstances: in a surgical unit with rear evacuation possibility the dramatic choice of amputation is often avoided by external fixator; in a short time mission for civilian populations, amputations are more often used but if conservative treatment is preferred, external fixator must be widely used.

Many regional anesthetic techniques can be used in the setting of abdominal surgery. Spinal anesthesia has limited indications for lower abdominal surgery (below T10), especially abdominal wall surgery and anal surgery. Indications of epidural anesthesia are quite similar, while epidural analgesia can be extensively used for postoperative analgesia, provided great attention is paid to strict monitoring and safety rules. Finally, peripheral regional anesthetic techniques are discussed, highlighting their advantages in this particular setting.

The lifelong risk of overwhelming infection after splenectomy is well recognized. Although children are at greater risk, adults are clearly vulnerable. This is an incentive to safely preserve the spleen in splenic injuries. Nonoperative management and use of different surgical techniques and synthetic materials to stop bleeding have been experienced and reported. They have the major advantage of spleen mass preservation and prevention of splenectomy complications: but also some disadvantages, for instance: prolonged hospital stay and subdiaphragmatic collection or delayed spleen rupture. This has prompted us for splenic salvation without any attempt to stop bleeding by transposition of spleen into an extraperitoneal cavity created surgically. During a 4 year period (from the end of 1989 to the fall of 1993) ten trauma patients were treated with this original technique. All of these patients had a definitive indication for emergency laparotomy. The procedure was successful in all patients without any unexpected complication.

Abdominal wall and contents can be used out of the coeliac cavity, as tissues donors site, for filling up or covering defects. Microsurgical technology mastery can extend their use in all the human body parts, especially in the craniofacial area. More than 110 digestive free transplants have been used during a 8 year period in head and neck surgical repairs. The report shows how to exploit at their best the anatomical and physiological properties of diverse abdominal tissues. Beyond this, the possible association of these transplants with other repair techniques opens new therapeutical perspectives, such as chimerical flaps whose pedicle distributes to heterogenous (or heteroclite) components, double flaps with a single or a double pedicle, replacing, at one single operative time, each missing tissue by the most adequate transplant. In consideration of this, abdominal tissues are an inexhaustible source of transplants, even through some imperfections must be managed.

We inserted a calibrated coral callus to lock addive medial osteotomy of the tibia in 38 patients. We followed these patients for 1 to 6 years evaluating clinical, radiological and histological outcome. Rehabilitation was very insufficient. In our later cases, the porosity of the coral insert was improved, apparently facilitating bone penetration.

Morbidity, absention and duration of cares are important factors for the treatment of groin hernias. Deep and tension free cure is a key element to decrease the rate of recurrence. Utilization of prosthesis cannot provide a rate of 100%. This must be taken into consideration for indications. Beside we must take into account specific risks of each technique. Hernia treatment cannot be unique. This parietal surgery must remain a technique with low morbidity. As for treatment of unilateral hernia, we have qualified a technique of hernioplastia depending upon theses criteria, by inguinal incision, without prosthesis. Our technique includes: A complete dissection of the inguinal canal. The resection of the sac of the hernia at the internal ring. A deep cure of the fascia transversalis. A systematic incision of discharge on the anterior face of the rectus sheath. This incision is extremely internal and constitutes a large musculo-aponeurotic flap of 8 to 12 cm that makes this cure tension free possible. In the term of 10 years, our recurrence rate is below 1% for type I or II hernias in Nyhus classification. Consequently we discuss the indications for prosthesis. They must be reserved for hernias with high recurrence risk, bilateral hernias of for recurrent hernias.

The authors have reviewed 37 patients aged 64 to 91 years or their charts in the purpose to evaluate the results of surgical treatment of severe acquired contractures of arms hands and legs. They describe the deformations, surgical technique, morbidity, and the results. 4 patients deceased within the first week after surgery; morbidity was very low. The results were satisfactory: nursing was greatly facilitated and pain during nursing care and toilet disappeared, the patients could again seat in a wheel chair. They conclude that this surgery can be very helpful for these disabled patients.

Seven cases of pneumatosis cystoides intestinalis affecting the colon (PKC) revealed 5 times by a nonspecific symtomatology and 2 times by an occlusion were reported. In three of the patients the disease was found as a primary idiopathic form free of clinical antecedents. In 4 of the patients the pneumatosis was found to be secondary to a pulmonary disease, a gastric ulcer, a connectivite of a corticotherapy. The PKC was generally diagnosed either by barium enema or by computed tomography and less frequently by colonoscopy with deep biopsy allowing differential diagnosis with colonic polyposis. The mechanism and etiology of the PKC were not fully understood. The illness is a benign condition that often responds to a conservative management--i.e. abstention, oxygenotherapy, diet or antibiotherapy- or exceptionally to surgical colonic resection in case of acute complication.

Thirty one cases of failed antireflux surgery were analyzed. The first operation had been performed on 24 patients with uncomplicated reflux and 7 patients with complicated reflux. There was an abnormality of the cardia in all cases. Twenty eight patients had been operated through an abdominal approach and 3 through a thoracic approach. The failure was diagnosed during the first year in 12 patients. The reflux became complicated in 17 cases. Oesophageal stenosis was the most common complication. Twenty four patients were reoperated through an abdominal approach and 7 through a thoracic approach. In 29 cases out of 31, an anatomical cause of the failure was found and rectified. Mortality was nil. The results of iterative surgery were good in 80 p. cent of cases after a mean follow up of 6 years.