The majority of epigastric hernias, up to 75% are asymptomatic. The most common presenting feature is a lump that the patient has noticed but that is not causing any symptoms. Alternatively, a lump may be felt during examination of the abdomen for another reason. Smaller hernias, even when they are not incarcerated, tend to cause more symptoms than do larger ones. Symptomatic hernia present with a wide variety of complaints, many of which are seemingly unrelated to the hernia. Common symptoms include epigastric pain that is dull, burning, or colicky and sometimes radiates to the lower abdomen, back, or chest; this may occasionally be accompanied by abdominal distention, dyspepsia, nausea, and vomiting. The typical pain of an epigatsric hernia is the epigastric pain on exertion. The pain is often exacerbated by bending or standing and relived by reclining in the supine or prone position.
Abdominal wall hernias in adults do not spontaneously heal or close, and nearly all enlarge with time. In most patients, if they are an appropriate surgical candidate, the presence of a hernia is an indication for repair that allows the potentially dangerous sequelae of incarceration, obstruction, or strangulation to be avoided. When questioned, surgeons thought that pain and limitations of daily activities were the most important indications for repair.Regardless, nearly 23% of repairs were performed in asymptomatic patients in an effort to avoid serious consequences. As stated, hernias tend to enlarge over time; therefore, delaying repair can often make it more difficult. However, the true natural history of untreated ventralhernias remains unknown at this time and is the subject of several ongoing trials.
Majority of the patients in my study presented with symptoms within one year of noting the hernia swelling. In general, hernias of short duration appear to strangulate more commonly than longstanding ones. The explanation lies in the relative rigidity of the hernial ring when a hernia appears first and its gradual stretching and laxity as time passes. Gallegos et al. found the rate of increase of cumulative probability of strangulation in a hernia to be the greatest in the first 3 months of its presence.”
Between the period of January 2011 to September 2012, 185 cases of ventralhernias treated at TVMCH were studied and followed for a period of 6 to 18 months. Ventralhernias were common surgical problems second only to groin hernias. More than 45% of ventralhernias were Incisional followed by, umbilical, paraumbilical hernias and epigastric hernias.. Most of the Incisional hernias developed >5yrs of previous surgery. Swelling, pain and complications along with aesthetic concerns are the causes for seeking surgical solution .Most of ventralhernias were uncomplicated at the time of presentation, remaining presented with either obstruction or strangulation necessitating emergency repair. Incidence of Incisional hernias was more in females with male to female ratio of 6.7:1, while epigastric and umbilical hernias were more common in males with male to female ratio of 4:1 and 1.2:1 respectively. Previous surgery was the single most important cause for ventral (Incisional) hernias. Other etiological factors were multiparity, obesity, anemia, COPD, BPH, diabetes mellitus, alcoholism and smoking. Post operative wound infection was important cause for development of Incisional hernias.
27. Nathwani, D., M. Morgan, R. G. Masterton, M. Dryden, B. D. Cookson, G. French, and D. Lewis. 2008. Guidelines for UK practice for the diagnosis and management of methicillin-resistant Staphylococcus aureus (MRSA) infec- tions presenting in the community. J. Antimicrob. Chemother. 61:976–994. 28. Nguyen Van, J.-C., M.-D. Kitzis, A. Ly, A. Chalfine, J. Carlet, A. Ben Ali, and F. Goldstein. 2006. De ´tection de la colonisation nasale de Staphylococcus aureus re ´sistant a ` la me ´thicilline: e ´tude prospective comparant l’amplification ge ´nique temps re ´el vs les milieux chromoge `nes se ´lectifs. Pathol. Biol. (Paris) 54:285–292. 29. Oberdorfer, K., S. Pohl, M. Frey, K. Heeg, and C. Wendt. 2006. Evaluation of a single-locus real-time polymerase chain reaction as a screening test for specific detection of methicillin-resistant Staphylococcus aureus in ICU pa- tients. Eur. J. Clin. Microbiol. Infect. Dis. 25:657–663.
Hernias are very common surgical condition. Millions of new patients are added to the pool in each year. Most common type of hernia is inguinal hernia. Ventralhernias are , hernias arising from anterior abdominal wall which includes umbilical, paraumbilical, incisional, epigastric hernias. Ventralhernias arises due to weakness of the abdominal wall. The laxity of abdominal wall can be due to various reasons . It can be due to congenital weakness, after pregnancy, previous surgeries, weight lifting, chronic cough. Incisional hernias are common among ventralhernias. Vertical scars, scar of emergency surgeries, faulty technique in closure of abdomen, layered closure of abdomen, systemic diseases contribute to incisional hernias.
A sequence of conservative measures to control uterine hemorrhage should be attempted before resorting to more radical surgical procedures. If an intervention does not succeed, the next treatment in the sequence should be swiftly instituted. Indecisiveness delays therapy and results in excessive hemorrhage. Moreover, there is a relationship between the duration of time that passes prior to deciding to perform the hysterectomy, the amount of blood loss, and the likelihood that the hysterectomy will be seriously complicated by coagulopathy, severe hypovolemia, tissue hypoxia, hypothermia, and acidosis, which further compromise the patient's status. Timing is critical to an optimal outcome: hysterectomy should not be performed too early or too late.
Antimicrobials may be used to prevent or treat established surgical infection. Antibiotics do not replace surgical drainage of infection. The use of antibiotics for the treatment of established surgical infection ideally requires recognition and determination of sensitivities of the causative organisms. Antibiotic therapy should not be held back if they are indicated, the choice being empirical and may later be modified depending on microbiological findings. However, once antibiotics have been administered, the clinical picture may become confused and, if a patient ’s condition does not rapidly improve, the opportunity to make a precise diagnosis may have been lost. It is unusual to have to treat SSIs with antibiotics, unless there is evidence of spreading infection, bacteraemia or systemic complications (SIRS and MODS). The appropriate treatment of localized SSI is interven-tional radiological drainage of pus or open drainage and debridement (Williams et al. 2008).
Currently there are more than 80 different types of meshes available on the market for IPOM repair of abdo- minal wall hernias. Synthetic meshes can be broadly classi- fied into macroporous, microporous and composite meshes. Macroporous meshes such as polyp-propylene (PP) allows for ingrowth of scar tissue. However if these are put in con- tact with the bowel surface they cause formation of adhe- sions and enterocutaneous fistulas (7). Microporous mesh- es such as expanded Polytetraflouroethylene (ePTFE) does not allow for tissue ingrowth but may lead to encapsulation and subsequent infection. ePTFE has been shown to cause infection requiring explanation of meshes in several cases (8) . To deal with these problems synthetic meshes with anti adhesive coatings have also been developed. Most of the coating material comprises of an absorbable layer such as collagen hydrogel, omega 3 fatty acids and oxygenated cellulose. There are some experimental trials claiming reduced risk of adhesions to composite and coated synthet- ic meshes when compared to traditional synthetics (9-10). Biological meshes are expensive and are normally reserved for repair of hernias in potentially infected fields. In the absence of randomised controlled trials there is no data to suggest the superiority of the various meshes available, one over the other.
Necrotizing fasciitis (NF) is still remained a dreaded disease with high morbidity and mortality due to rapidly progres- sive necrotizing infection. Objective: Review recent available literature on necrotizing fasciitis (NF) and compare it with our publications. Data and Source: Local and international published literature on NF from early nineties to 2012; Midline and pub Med literature search using the term “necrotizing fasciitis”. Data Synthesis: NF is more common in male patient, it is frequently polymicrobial. Common site of NF is the extremities. NF is classified according to the mi- crobes. Common co-morbid condition associated with NF is diabetes mellitus. Minor trauma and surgery are the major etiological risk factors for NF. There seems to be significant correlation between the use of non steroidal anti-inflam- matory medication (NSAID) and NF. Severe pain disproportionate to injury is the presenting symptom. Laboratory risk indicators for necrotizing fasciitis (LRINEC) score will diagnose NF early in emergency clinics. Tissue biopsy is the gold standard for the diagnosis of NF. Pathophysiology of NF is rapid horizontal spread of infection with fascial necro- sis and secondary vertical involvement of skin. More than 90% of NF patients need intensive care therapy. Early and bold debridement in combination with brave organ supportive intensive care will have better outcome of NF patients. Conclusion: High index of suspicion and knowledge is essential for early diagnosis of NF. Finger test and LRINEC score may help in early diagnosis. Early debridement, proper antibiotics and organ supportive intensive care will im- prove morbidity and mortality of NF patients.
Feline and canine neonatal and paediatric patients are tachycardic in comparison to their adult counterparts, with a normal paediatric heart rate being around 200 bpm for puppies and 250 bpm for kittens. They also have lower blood pressure than adult patients (Magrini 1978); however, their blood pressure increases as their sympathetic nervous system matures over the first few months of life. In the canine patient, mean arterial blood pressure does not reach a ‘normal’ adult value until around nine months of age. At one month of age, a systolic pressure of 48mmHg is thought to be normal (Magrini 1978); this is not only lower than that of adults but below even the mean arterial pressure at which impaired tissue perfusion is often considered to be occurring in most adult patients (Cooper 2015). Auscultation of the lungs of paediatric patients can be complicated by their increased respiratory rate and inherently higher interstitial fluid content (Tonneson et al. 2012), leading to normal breath sounds being interpreted as adventitious. Such differences in the respiratory and cardiovascular systems can complicate assessment of perfusion in these patients. A prospective study in 68 puppies and 30 adult dogs revealed that lactate has the potential to be a suitable marker of hypoperfusion (McMichael 2005). However, as with other haematological and biochemical values, adult reference ranges cannot be applied to neonatal dogs and cats. A definitive reference range for lactate has not yet been established.
The use of biological materials in clinical practice has led to innovative methods of treating abdominal wall de- fects in contaminated surgical fields, although there is still an insufficient level of high-quality evidence on their value, and there is still a very huge price difference be- tween the synthetic and biological meshes . All litera- ture reviews found in the MEDLINE database supported biologic mesh use in the setting of contaminated fields, but the literature included in these reviews consisted of case series and case reports with low levels of evidence . Despite the lack of a cohesive body of evidence, pub- lished studies on biological mesh suggest that cross-linked mesh prosthetics have the lowest failure rate in contami- nated and outright infected fields. To better guide sur- geons, prospective randomized trials should be undertaken to evaluate the short- and long-term out- comes associated with biological meshes [90, 95].
Costs of death: Generally, dead patients are not transferred to the hospital and declare dead by prehospital emergency medical technicians in the field. The costs of deceased patients in the hospital were estimated for cardiopulmonary resuscitation and other resuscitative measures as well as the costs of financial loss regarding life expectancy for the rest of life. Life expectancy was derived from the World Health Organization report of health statistics in 2015 to be 75.5 years (5). Finally, the deceased patients revealed in the follow-up phone calls, whom the leading cause of death was related to the trauma disability, were considered and the costs were assessed according to their life- expectancy, time off from work and Bank Annual Inflation rate.
We conducted a retrospective review of all patients treated in the emergency room who were diagnosed with defined unstable conditions unrelated to trauma present- ing at the major medical center (Soroka University Med- ical Center) of southern Israel. The studied shock room constitutes the single destination for all unstable subjects in a peripheral region with a population of over one mil- lion people. This hospital is also the only level 1 trauma center in the region and serves as the training center of medical students from the medical faculty of the Ben Gurion University of the Negev. The entire population receiving care at the medical center holds equal, satisfac- tory health insurance as mandated by the law of the country.
Over the 1-year period in 2010, 3,319 patients accounted for 19,791 ED visits and were highlighted as recurrent attenders. Within this group, we identified 290 attendances for non-traumatic chest pain to the ED, accounted for by 158 patients over the age of 75 (Figure 1). These pa- tients are 57.6% female and 80.4% of Chinese background. The majority (91.4%) of these patients self-presented to the ED with a small minority of patients (8.6%) being brought by ambulance. Seasonal, daily and diurnal vari- ations in attendance followed the regular pattern of at- tendance for our emergency department.
In our study, we have described and compared the results of trabeculectomy surgery performed on 20 patients and trabeculectomy surgery with Ologen implant performed on 19 patients. At the end of a two year follow-up, though the drop in IOP in both groups was significant, sustained low levels were achieved more often in patients who had the collagen implant. Moreover, other ocular parameters suggestive of glaucoma progression like increase in the loss variance on automated perimetry or thinning of the retinal nerve fiber layer were not encountered.
Ventralhernias are often noted by the patient as an abdominal bulge. They can be exacerbated by any action that rises intraabdominal pressure such as coughing, lifting weights, valsalva manoeuvre or by head or leg rising. Rest or reduction of the incarcerated hernia may offer temporary relief. Smaller hernias are often assymptamatic or produce intermittent dragging pain. Discomfort of the ventral bulge is the most common initial symptom. But bowel obstruction can also be the first symptom that forces the patient to seek medical attention. Incarceration and strangulation are more common if the hernia neck defect is small. Skin may undergo pressure ischaemic necrosis.
Long-term results of surgical treatment were studied in all patients of the research groups in 1 year after surgery by repeated examinations. Recurrences of postoperative ventralhernias were found in 3 (16.7%) patients of the comparison group who were undergone the traditional method of allohernioplasty. There were no primary patients with postoperative recurrence of ventral hernia who were undergone surgical treatment according to the developed method of alloheneic plastic (p = 0.04). Patients with postoperative recurrence of ventral hernia were re-operated according to the developed method of open allohernioplasty with supramuscular arrangement of the mesh implant. 1 (5.6%) patient of the comparison group on the 47 th day after traditional allogeneic plasticity had an intestinal obstruction, which was caused by the formation of multiple adhesions between the conglomerate of the small intestine and the area of the anterior abdominal wall, where alloheronioplasty was performed. Thus, significantly better results of surgical treatment of postoperative ventralhernias after multi-stage surgical treatment of open gunshot wounds of the abdomen are observed in patients of the main group.
The majority of patients who were admitted as emergencies with complicated groin hernias have not sought previous medical attention or been diagnosed with the condition in the out patient department. This observation implies that most hernias that develop complications do so within a relatively short time in the natural history of the disease. In adults, Gallegos estimated the cumulative probability of strangulation for inguinal hernia is 2.8% after three months, rising to 4.5% at the end of 2 years.
congress of the ESCRS reviewed the patho-physiological alterations associated with pseudoexfoliation, the complications of cataract surgery, and the considerations for surgical modifications and IOL selection. They stressed on poor dilatation, and its management by injection of high viscosity visco elastic agent. They also advocated use of iris hooks, either plastic or metallic as necessary. Dr.Hachet cautioned against performing sphincterotomy, because it resulted in persistent dilatation and poor postoperative cosmosis. He advocated the use of capsular tension rings. Foldable IOL‟s is desirable to minimize the induction of blood-aqueous barrier breakdown. Also hydrophobic acrylic and silicone are associated with a low rate of PCO, but hydrophobic acrylic has an additional advantage as it causes the least amount of capsular contraction. For haptics, open loop haptics are probably preferred. Dr Kuchleal so discouraged the use of plate haptic design or accommodative IOL‟s in patients with pseudoexfoliation.