341/393. Use of tissue expanders for wound closure of spinal infections or dehiscence. Posterior spinal incisions that are made through skin and have been compromised by radiation or prior incisions can be difficult to obtain stable closure. In addition, if a wound has developed a postoperative infection or wound dehiscence caused by poor wound healing, severe complications can develop. The technique of expanding adjacent normal skin with implantable tissue expanders has been used in select cases with success. The techniques and indications for tissue expansion in posterior lumbar wounds is reviewed and several case reports presented. ( info) |
342/393. povidone-iodine: an adjunct in the treatmen of wound infections, dehiscences, and fistulas in head and neck surgery. Extensive research has been done to elucidate the cellular and biochemical events of a healing wound. Similarly, new techniques are continually being investigated which would stimulate and augment the reparative process. This paper describes the uses and biochemistry of povidone-iodine which has gained widespread acceptance as a surgical preparation. However, its use as a topical agent for treating head and neck wound infections, dehiscences, and salivary fistulas has gained little recognition. povidone-iodine is a unique compound formed by binding free iodine to polyvinylpyrrolidone. Previously, the toxic effects of iodine limited its use to preparation of the skin for surgery. When bound to the pyrrolidine molecule, iodine becomes water soluble and markedly less toxic. As a result, the broad antimicrobial spectrum of iodine may be used topically to control wound sepsis. It can be applied to mucosal surfaces without producing burns. The brown color acts as an indicator of its clinical effectiveness. When the dressings become light yellow or pale, free iodine is no longer being released and the dressing should be changed. povidone-iodine is not a panacea for correcting interruption in the healing process during the postoperative period. The basic management of wound infections, dehiscences, and fistulas remains unchanged. Incision and drainage, debridement and flap contracture, lateralization, and diversion are necessary to initiate the healing process. Familarity with each phase of healing provides the basis for managing each of these surgical problems. Topical povidone-iodine not only controls wound sepsis but augments wound healing. The physiologic correlation with each phase of wound healing for these various surgical problems is elaborated and clinical cases presented. ( info) |
343/393. Sonographic appearance of uterine scar dehiscence. We describe the sonographic appearance of two cases of uterine scar separation in patients with prior cesarean deliveries. In the first case, the anteriorly located placenta appeared to be a placenta previa with accreta and in the second case the placenta was also located directly beneath the uterine scar thus masking a separation until the third stage of labor was complete. These two cases demonstrate an unusual sonographic and clinical presentation of uterine scar separation involving anteriorly located placentas. ( info) |
344/393. Secondary post partum haemorrhage due to uterine wound dehiscence. BACKGROUND: Secondary post partum haemorrhage due to uterine scar dehiscence is a potentially life threatening complication of caesarean section. It is of special importance in any population with a high caesarean section rate. CASES: Two illustrative cases are described. Both presented with life threatening haemorrhage about four weeks after delivery by lower segment caesarean section. One was successfully managed with uterine wound debridement and resuture. The other required total abdominal hysterectomy. CONCLUSIONS: This cause of post partum haemorrhage must be considered in any patient who presents with heavy bleeding in the puerperium following caesarean section. These patients should always be admitted to hospital, and the uterine wound should be palpated after dilation of the cervix at examination under anaesthesia. laparotomy and repair or hysterectomy is essential if a defect can be felt in the wound. The choice of procedure is discussed in the text. ( info) |
345/393. Implantable cardioverter-defibrillator: another device to cover. The implantable cardioverter-defibrillator is a mechanical device developed to manage patients with life-threatening arrhythmias when pharmacologic control has failed or produced unacceptable side effects. It is a significant amount of foreign material with a generator pack (volume 113 to 145 cc, weight 197 to 235 gm) and two or three leads and patches that are inserted into or placed on the heart. Although it has worked very well in preventing premature death, there have been complications associated with the device itself. The most significant of these has been exposure and/or infection. We present three patients who have experienced this problem. Improved coverage has been accomplished by burying the implant beneath the rectus abdominis muscle in situations where skin and subcutaneous tissue alone have proved inadequate. By dividing one or two tendinous inscriptions and the anterior limb of the internal oblique fascia, a musculofascial pocket is created to contain the generator and lead wires. This provided satisfactory coverage in two of our three patients. The single failure resulted from external trauma to the abdominal wall. ( info) |
346/393. pneumothorax and wound dehiscence related to collagenase deregulation: treatment with diphenylhydantoin. BACKGROUND. Wound dehiscence is an uncommon complication of operation, usually related to a recognized risk factor. A clinical dilemma arises when dehiscence has no identifiable cause or treatment. methods. We describe the case of a previously healthy 45-year-old man in whom recurrent spontaneous pneumothoraces developed followed by multiple dehiscences of thoracotomy, diaphragmatic, and abdominal wounds. Analysis over several years of laboratory investigation of cultured tissue from test incisions was initially unsuccessful. The patient was supported symptomatically until a remarkable laboratory finding enabled us to develop an effective treatment plan. RESULTS. Cultured patient fibroblasts were ultimately found to express abnormally elevated levels of collagenase, which could be inhibited by diphenylhydantoin (phenytoin) in vitro. Treatment of the patient with a course of diphenylhydantoin allowed adequate healing of test incisions and subsequent definitive surgical treatment with successful wound healing. CONCLUSIONS. This report of the rigorous application of the scientific method to the investigation and treatment of an enigmatic case of wound dehiscence might serve as a guide to surgeons faced with similar healing problems. ( info) |
347/393. Spontaneous right ventricular rupture after sternal dehiscence: a preventable complication? mediastinitis and/or sternal dehiscence developed in 143 out of 10,263 patients (1.4%) who underwent cardiac surgery between January 1979-December 1993. Mediastinal drainage, sternal debridement and early wound closure with pectoralis major and/or rectus abdominalis muscle flaps was the treatment employed. Between these two stages of treatment, massive hemorrhage developed in seven patients (0.07%) from a tear of the anterior wall of the right ventricle (RV). Six patients survived. Temporary control of the bleeding was achieved with digital or full palm pressure control of the ventricular tear. This was followed by immediate repair in the operating room (OR). The only death was due to exsanguination in the intensive care unit. The other six patients were taken to the OR. The anterior RV was freed from the underside of the sternum and the RV tear repaired with or without the aid of femoral-femoral bypass. These six then had muscle flap wound closures at that time or shortly after. All six were hospital survivors and are currently alive. We believe that RV rupture results from the sternal edges pulling the anterior surface of the RV apart, since the RV is stuck to the underside of the sternum. This experience indicates that the RV must be freed in all cases during initial sternal debridement. Hopefully this simple maneuver will prevent this horrendous complication. ( info) |
348/393. pressure necrosis of a caesarean section scar with exteriorization of the gravid uterus. A case report. A case of pressure necrosis of a caesarean section scar with protrusion of the gravid uterus through the wound is described. We can find no mention of a similar case in the literature. The management during the pregnancy presented some alarming problems, all of which were overcome, and the pregnancy was terminated by caesarean hysterectomy at 38 weeks. A healthy baby was delivered and the mother recovered. ( info) |
349/393. Valvulitis involving a bioprosthetic valve in a patient with systemic lupus erythematosus. A 37-year-old man with systemic lupus erythematosus, who underwent an aortic valve replacement with a Carpentier-Edwards porcine valve for severe aortic insufficiency, was admitted to the hospital with pulmonary edema. Transesophageal echocardiography revealed severe aortic insufficiency arising from partial dehiscence of the valve sewing ring, as well as centrally from the valve cusp. In addition, marked thickening of the mitral valve was observed with severe eccentric regurgitation. At surgery, valvulitis of the native mitral and bioprosthetic aortic valves was demonstrated, with a perforation of the porcine valve cusp. After replacement of both valves, the patient had a stormy postoperative course with recurrent communications between the left ventricle and atrium requiring multiple surgeries and eventually died. This case illustrates the severity of valvulopathy and ensuing complications that can affect patients with systemic lupus erythematosus and demonstrates that the valvulopathy can affect bioprosthetic valves, a finding that has significant implications as to the type of valve replacement in these patients. ( info) |
350/393. epikeratophakia to correct traumatic aphakia after penetrating keratoplasty. A 19-year-old man with keratoconus sustained ocular trauma and became aphakic in his operated left eye 2 months after penetrating keratoplasty. Original corneal wound repair was performed without intraocular lens implantation. Attempts to correct his aphakia with a contact lens failed when the patient became intolerant to its use. As an alternative, the patient had elective epikeratophakia. A standard 8.5 mm lenticule was placed over existing corneal graft. This operation resulted in 12.25 diopters of correction and a best corrected visual acuity of 20/25 at 30 months postoperatively. There was no sign of abnormalities at the host cornea or the transplanted lenticule. This case indicates that epikeratophakia may be successfully performed over existing corneal grafts. ( info) |