Helvetica chirurgica acta最新文献

The pinless external fixator, introduced into clinical practice for open tibial fractures, suggested itself for use as a traction substitute because of its pinless frame. The aim of this feasibility study was to replace the conventional calcaneal pin traction by a joint-bridging pinless fixator, inserted under local anesthesia. 10 patients with 6 malleolar dislocation fractures, 3 pilon tibial and 1 open distal tibial fracture were immobilised by a joint-bridging pinless fixator during 10.4 days (5-16 days) till swelling had subsided and definitive fracture treatment, consisting of plate fixation, took place. The implantation of the joint-bridging pinless fixator in local anaesthesia was well tolerated by all patients. This traction substitute offered good patient comfort and easy care. Although the provided stability was less than a conventional fixator, all patients were able to lift up their fractured extremity without pain.

Dislocation of the proximal tibiofibular joint is a rare injury. Diagnosis is initially often missed. Physical examination and radiographic findings of a 22-year-old football player are reported. Classification and therapeutic options are discussed.

Since introduction of laparoscopic appendectomy we have the possibility to examine the whole abdominal cavity and not only the ileocaecal region and right adnex. The aim of the study is to find out if there is an advantage in laparoscopic diagnostics compared to conventional laparotomy for suspected acute appendicities. We compared prospectively all patients who underwent laparoscopy for acute right lower abdominal pain between August 1991 and March 1993 with a comparable group retrospectively analyzed who underwent conventional appendectomy in 1989. In both groups 20% of patients had a normal appendix. In 1% of the laparoscopically operated patients we couldn't find any pathological findings, in 12% of the conventionally operated group we couldn't find an accurate diagnosis. The average operation time of laparoscopically operated patients without acute appendicities was 20 minutes shorter compared to conventionally operated patients. We found identically results for the duration of hospital stay. The median hospital stay for conventionally operated patients was 6.6 days, for laparoscopically operated patients 4.7 days. The complications were in both groups 1-2%. We conclude that in laparoscopy the diagnostics are more reliable, and with a diagnostic accuracy of almost 100% the unnecessary appendectomy with a higher morbidity would not be necessary in 12% of patients.

The role of defecography with respect to rectoceles and to any grade of rectal prolapses has not been defined so far. Therefore, we studied 42 out of 45 patients that were submitted to a defecography between 1988 and 1992 for defecation disorders of unknown origin. In particular, we compared the diagnosis obtained by anamnestic data and the physical examination with the defecographic results and the definitive diagnosis with regard to the chosen therapies and the results. Rectocele and rectal prolapse were very frequent pathologies with 69% and 33% respectively. Of 23 patients with a clinically palpable rectocele, defecography was false negative in 4 and moreover, it did not provide any information about the functional relevance of the rectocele. Yet, it disproved the clinically diagnosed prolapses in 6 of 15 subjects, but revealed one in 5 of 27 patients that were presumed normal. On the other hand, a previously not diagnosed rectocele was detected in 6 out of 19 patients by means of defecography, but none of them proved to be of any clinical relevance. Of all rectoceles, only 48% were regarded responsible for the patients' symptoms and were therefore operated. Hereby, the indication for a surgical approach based more on anamnestic data and the proctological examination than on radiographic findings. Contrarily, the indication for a rectopexy--even if given only in 4 of those 14 patients with any grade of invagination--mainly based on the dynamics during defecation as documented by defecography.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastrointestinal injuries after blunt abdominal trauma in childhood are seldom. In 30% of the patients, the site of injury is the duodenum. In 60% associated injuries including other abdominal or extraabdominal lesions are found. Most frequently duodenal damage consists in parietal haematoma, seldom in duodenal laceration. Duodenal haematoma can be resolved non-operatively in 50%. Operation is recommended for children in whom there is no evidence of partial resolution of the obstruction after 10-14 days or in cases with development of a parietal laceration with peritonitis and/or retroperitonitis. For diagnostic computed tomography is the examination of choice.

Laparoscopy is a new fascinating technique. However, after the first wave of enthusiasm, laparoscopy currently raises different problems related with surgical training. A national survey concerning laparoscopy and its teaching was sent to every surgeon-in-chief, chief resident and resident of all Swiss teaching hospitals. Surgical training is nowadays an important problem in Switzerland. Our survey revealed that laparoscopy intensifies this problem: a specific training in laparoscopy is desired by all surgeons and has to take place in the Swiss Board of Surgery (FMH). A preliminary experience of conventional surgery is desirable. Then a laparoscopic training should start on experimental certified models and be applied progressively on patients in attendance with a trained surgeon.

Increasing costs in health system, reduction of bed capacities and lack of nurses force to search for solution. To prove that day surgery may be a kind of solution, a pilot project was analysed during 8 months. This project was fully integrated in normal clinical management. Operated patients (n = 100; hernias, varicosis, proctological and other indications), preoperatively selected by specific criterias, and the family doctors were questioned retrospectively of their experiences. The results were very encouraging. Moreover we stated that day surgery is cost-covering. So day surgery is to consider as an important factor to cost-reduction.

Atherosclerosis predominantly affects the ilio-superficial femoral axis, and tends to spare the deep femoral artery which can offer excellent outflow for proximal reconstructions for occlusive vascular disease of the lower limbs. Often symptoms are relieved and ischemic lesions can heal. The deep femoral artery can also provide good, pulsatile inflow for distal reconstructions when it is desirable to avoid the groin (either because of multiple previous dissections or because of infection). Occasionally two-level sequential bypasses to and from the deep femoral artery are required for multilevel disease where the groin is to be avoided. Over the past 4 years we have performed 190 arterial reconstructions (41 central, 125 distal and 24 sequential two-level procedures). 19 times the proximal, distal or intermediate anastomosis was on the deep femoral artery. Short- and long-term results were good in these difficult patients, with relief of symptoms or significant improvement in most patients. Two major (and no minor) amputations were ultimately required. Arterial reconstructions using the deep femoral artery cannot only salvage many limbs, but offer good symptomatic relief in patients who are not suitable for usual reconstructive procedures.