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1.  The study of expanded tri-lobed flap in a rabbit model: possible flap model in ear reconstruction? 
BMC Surgery  2003;3:13.
Local flaps are widely used in reconstructive surgery. Tri-lobed skin flap is a relatively new flap and there has been no experimental model of this flap. This flap can be used for repair of full thickness defects in the face, ears and alar region. Based on the size of ears in a rabbit, we designed a model of ear reconstruction using expanded tri-lobed flap. Local flaps are more advantageous in that they provide excellent color and texture matching up with those of the face, adequately restore ear contour, place scars in a favorable location and ideally accomplish these goals in a single stage with minimal donor site morbidity.
Eight adult New Zealand rabbits were divided into two groups. 50 ml round tissue expander were implanted to four rabbits. After completion of the expansion, a superiorly based tri-lobed flap was elevated and a new ear was created from the superior dorsal skin of each rabbit. Scintigraphy with Technetium-99m pertecnetate was performed to evaluate flap viability.
Subtotal flap necrosis was seen in all animals in non-expanded group. New ear in dimensions of the original ear was created in expanded group without complication. Perfusion and viability of the flaps were proved by Technetium-99m pertecnetate scintigraphy.
According to our knowledge this study is the first to demonstrate animal model in tri-lobed flap. Also, our technique is the first application of the trilobed flap to the possible ear reconstruction. We speculated that this flap may be used mastoid based without hair, in human. Also, tri-lobed flap may be an alternative in reconstruction of cylindrical organs such as penis or finger.
PMCID: PMC317328  PMID: 14678559
2.  Clasp knife in the gut: a case report 
BMC Surgery  2003;3:12.
A wide range of foreign bodies has been retrieved from the gut and reported. The presentation may be in the form of complications like intestinal obstruction, perforation and formation of abscesses etc but there is no case report of a half open clasp knife being retrieved from the ileum, the patient having thrived, in spite of its presence for a period of eight months.
Case presentation
A 30-year-old administrative clerk had undergone emergency abdominal surgery eight months previously under mysterious circumstances at a remote district hospital and had recovered completely. Later the blade of a knife was accidentally detected when an X ray of the abdomen was done during a routine follow-up visit to his family physician. Surgery revealed a clasp knife in the ileum, which was retrieved. The presence of an entero-enteric fistula short circuiting the loop was the secret of his earlier survival.
To the best of our information this is the first case-report of a clasp knife in the gut and of the patient thriving in spite of its presence. We report here the dramatic sequence of events.
PMCID: PMC317327  PMID: 14667247
Clasp knife; Ileum
3.  The creation of new rotation arc to the rat latissimus dorsi musculo-cutaneous flap with delay procedures 
BMC Surgery  2003;3:11.
Latissimus dorsi musculocutaneous flap is one of the most frequently performed reconstructive techniques in surgery. Latissimus dorsi muscle has two arcs of rotation. It is classified as type V muscle. This muscle can be elevated on the thoracodorsal artery to cover large defects in the anterior chest and also, the muscle can be elevated on the segmental vessels to cover midline defects posteriorly. The aim of this study was to create a new arc of rotation on a vertical axis for the muscle and investigate effectiveness of vascular and chemical delays on the latissimus dorsi muscle flap with an inferior pedicle in an experimental rat model. We hypothesized that the latissimus dorsi muscle would be based on inferior pedicle by delay procedures.
We tested two different types of delay: vascular and combination of vascular and chemical. We also tried to determine how many days of "delay" can elicit beneficial effects of vascular and combination delays in an inferior pedicled latissimus dorsi musculocutaneous flap. To accomplish this, 48 male Sprague-Dawley rats were randomly subjected to vascular or combination delay (vascular and chemical). In addition, one ear of each rat was assigned into a delay procedure and the other ear was used as a control. Results were evaluated macroscopically, and micro-angiography and histological examinations were also performed. As a result, there was a significant difference in viable flap areas between vascular delay alone and control groups (p < 0.05).
The higher rate of flap viability was obtained in seven-day vascular delay alone. However, there was no significant difference in the viability between seven-day vascular delay and five-day vascular delay (p < 0.05), so the earliest time when the flap viability could be obtained was at five days. The rate of flap viability was significantly higher in the vascular delay combined with chemical delay than the control group (p < 0.05).
The combination of vascular and chemical delays increased the rate of viability. Nevertheless, there was no significant difference between vascular delay alone and combination of vascular and chemical delays. Chemical delay did not significantly decrease the delay period. Better histological and microangiographical results were achieved in delay groups compared to control groups. We concluded that the arch of the latissimus dorsi musculocutaneous flap can be changed and the flap can be used for various purposes with the delay procedures.
PMCID: PMC317326  PMID: 14667248
4.  Fistulotomy and drainage of deep postanal space abscess in the treatment of posterior horseshoe fistula 
BMC Surgery  2003;3:10.
Posterior horseshoe fistula with deep postanal space abscess is a complex disease. Most patients have a history of anorectal abscess drainage or surgery for fistula-in-ano.
Twenty-five patients who underwent surgery for posterior horseshoe fistula with deep postanal space abscess were analyzed retrospectively with respect to age, gender, previous surgery for fistula-in-ano, number of external openings, diagnostic studies, concordance between preoperative studies and operative findings for the extent of disease, operating time, healing time, complications, and recurrence.
There were 22 (88%) men and 3 (12%) women with a median age of 37 (range, 25–58) years. The median duration of disease was 13 (range, 3–96) months. There was one external opening in 12 (48%) patients, 2 in 8 (32%), 3 in 4 (16%), and 4 in 1 (4%). Preoperative diagnosis of horseshoe fistula was made by contrast fistulography in 4 (16%) patients, by ultrasound in 3 (12%), by magnetic resonance imaging in 6 (24%), and by physical examination only in the remainder (48%). The mean ± SD operating time was 47 ± 10 min. The mean ± SD healing time was 12 ± 3 weeks. Three of the 25 patients (12%) had diabetes mellitus type II. Nineteen (76%) patients had undergone previous surgery for fistula-in-ano, while five (20%) had only perianal abscess drainage. Neither morbidity nor mortality developed. All patients were followed up for a median of 35 (range, 6–78) months and no recurrence was observed.
Fistulotomy of the tracts along the arms of horseshoe fistula and drainage of the deep postanal space abscess with posterior midline incision that severs both the lower edge of the internal sphincter and the subcutaneous external sphincter and divides the superficial external sphincter into halves gives excellent results with no recurrence. When it is necessary, severing the halves of the superficial external sphincter unilaterally or even bilaterally in the same session does not result in anal incontinence. Close follow-up of patients until the wounds completely healed is essential in the prevention of premature wound closure and recurrence.
PMCID: PMC317325  PMID: 14641926
5.  Postsurgical pain outcome of vertical and transverse abdominal incision: Design of a randomized controlled equivalence trial [ISRCTN60734227] 
BMC Surgery  2003;3:9.
There are two ways to open the abdominal cavity in elective general surgery: vertically or transversely. Various clinical studies and a meta-analysis have postulated that the transverse approach is superior to other approaches as regards complications. However, in a recent survey it was shown that 90 % of all abdominal incisions in visceral surgery are still vertical incisions. This discrepancy between existing recommendations of clinical trials and clinical practice could be explained by the lack of acceptance of these results due to a number of deficits in the study design and analysis, subsequent low internal validity, and therefore limited external generalisability. The objective of this study is to address the issue from the patient's perspective.
This is an intraoperatively randomized controlled observer and patient-blinded two-group parallel equivalence trial. The study setting is the Department of General-, Visceral-, Trauma Surgery and Outpatient Clinic of the University of Heidelberg, Medical School. A total of 172 patients of both genders, aged over 18 years who are scheduled for an elective abdominal operation and are eligible for either a transverse or vertical incision. To show equivalence of the two approaches or the superiority of one of them from the perspective of the patient, a primary endpoint is defined: the pain experienced by the patient (VAS 0–100) on day two after surgery and the amount of analgesic required (piritramide [mg/h]). A confidence interval approach will be used for analysis. A global α-Level of 0.05 and a power of 0.8 is guaranteed, resulting in a size of 86 patients for each group. Secondary endpoints are: time interval to open and close the abdomen, early-onset complications (frequency of burst abdomen, postoperative pulmonary complications, and wound infection) and late complications (frequency of incisional hernias). Different outcome variables will be ranked by patients and surgeons to assess the relevance of possible endpoints from the patients' and surgeons' perspective.
This is a randomized controlled observer and patient-blinded two-group parallel trial to answer the question if the transverse abdominal incision is equivalent to the vertical one due to the described endpoints.
PMCID: PMC293467  PMID: 14614782
6.  Liver abscess secondary to a broken needle migration- A case report 
BMC Surgery  2003;3:8.
Perforation of gut by sharp metallic objects is rare and rarer still is their migration to sites like liver. The symptoms may be non-specific and the discovery of foreign body may come as a radiological surprise to the unsuspecting clinician since the history of ingestion is difficult to obtain.
Case report
A unique case of a broken sewing needle in the liver causing a hepatic abscess and detected as a radiological surprise is presented. The patient had received off and on treatment for pyrexia for the past one year at a remote primary health center. Exploratory laparotomy along with drainage of abscess and retrieval of foreign body relieved the patient of his symptoms and nearly one-year follow up reveals a satisfactory recovery.
It is very rare for an ingested foreign body to lodge in the liver and present as a liver abscess. An ultrasound and a high clinical suspicion index is the only way to diagnose these unusual presentations of migrating foreign bodies. The management is retrieval of the foreign body either by open surgery or by percutaneous transhepatic approach but since adequate drainage of the abscess and ruling out of a fistulous communication between the gut and the liver is mandatory, open surgery is preferred.
PMCID: PMC239862  PMID: 14531934
Hepatic abscess; Foreign body migration
7.  Low grade fibromyxoid sarcoma of the falciform ligament: a case report 
BMC Surgery  2003;3:7.
Low grade fibromyxoid sarcomas (LGFMS) are very rarely seen. They commonly arise from deep soft tissues of the lower extremities. Very few cases of intra-abdominal location have been reported.
Case presentation
We report a 37 year old man who presented with an abdominal mass and dragging pain. Pre-operative imaging suggested the possibility of a subcapsular hemangioma of liver.
Laparoscopy was useful to locate the tumor as arising from falciform ligament and made the subsequent surgery simpler. This is one of the large fibromyxoid sarcomas to be reported.
PMCID: PMC222986  PMID: 14507419
8.  An unusual cause of small bowel obstruction: Gossypiboma – case report 
BMC Surgery  2003;3:6.
The term "gossypiboma" denotes a mass of cotton that is retained in the body following surgery. Gossypiboma is a medico-legal problem especially for surgeons. To the best of our knowledge, the patient presented herein is the second reported patient in whom the exact site of migration of a retained surgical textile material into the intestinal lumen could be demonstrated by preoperative imaging studies.
Case presentation
A 74-year-old woman presented with symptoms of small bowel obstruction due to incomplete intraluminal migration of a laparotomy towel 3 years after open cholecystectomy and umbilical hernia repair. Plain abdominal radiography did not show any sign of a radio-opaque marker in the abdomen. However, contrast enhanced abdominal computerized tomography revealed a round, well-defined soft-tissue mass with a dense, enhanced wall, containing an internal high-density area with air-bubbles in the mid-abdomen. A fistula between the abscess cavity containing the suspicious mass and gastrointestinal tract was identified by upper gastrointestinal series. The presence of a foreign body was considered. It was surgically removed with a partial small bowel resection followed by anastomosis.
Although gossypiboma is rarely seen in daily clinical practice, it should be considered in the differential diagnosis of acute mechanical intestinal obstruction in patients who underwent laparotomy previously. The best approach in the prevention of this condition can be achieved by meticulous count of surgical materials in addition to thorough exploration of surgical site at the conclusion of operations and also by routine use of surgical textile materials impregnated with a radio-opaque marker.
PMCID: PMC201033  PMID: 12962549
gossypiboma; foreign bodies; retained surgical towel; intestinal obstruction; radiography; CT
9.  Cotton Bezoar- a rare cause of intestinal obstruction: case report 
BMC Surgery  2003;3:5.
Bezoars usually present as a mass in the stomach. The patient often has a preceding history of some psychiatric predisposition. Presentation could be in the form of trichophagy followed by trichobezoar (swallowing of hair leading to formation of bezoar), orphytobezoar (swallowing of vegetable fibres). Rapunzel syndrome is a condition where the parent bezoar is in the stomach and a tail of the fibres or hair extends in to the jejunum. Presentation as intestinal obstruction due to a bezoar in the intestine without a parent bezoar in the stomach is rare, therefore we report it here.
Case report
A 35 year old lady tailor with a previous history of receiving treatment for depression on account of being infertile- years after her marriage, presented to the surgical emergency department with features of acute intestinal obstruction. Exploratory laparotomy and enterotomy revealed a cotton bezoar in the terminal ileum without a parent bezoar in the stomach. She was managed by resection of the affected segment of the ileum and end-to-end anastomosis of the bowel. In the postoperative period the patient gave a history of ingesting cotton threads whenever she was depressed.
Presence of cotton bezoar is rare and an intestinal bezoar in the absence of parent bezoar in the stomach is still rarer.
PMCID: PMC194753  PMID: 12956890
cotton bezoar; ileum
10.  Creatinine clearance versus serum creatinine as a risk factor in cardiac surgery 
BMC Surgery  2003;3:4.
Renal impairment is one of the predictors of mortality in cardiac surgery. Usually a binarized value of serum creatinine is used to assess the renal function in risk models. Creatinine clearance can be easily estimated by the Cockcroft and Gault equation from serum creatinine, gender, age and body weight. In this work we examine whether this estimation of the glomerular filtration rate can advantageously replace the serum creatinine in the EuroSCORE preoperative risk assessment.
In a group of 8138 patients out of a total of 11878 patients, who underwent cardiac surgery in our hospital between January 1996 and July 2002, the 18 standard EuroSCORE parameters could retrospectively be determined and logistic regression analysis performed. In all patients scored, creatinine clearance was calculated according to Cockcroft and Gault. The relationship between the predicted and observed 30-days mortality was evaluated in systematically selected intervals of creatinine clearance and significance values computed by employing Monte Carlo methods. Afterwards, risk scoring was performed using a continuous or a categorical value of creatinine clearance instead of serum creatinine. The predictive ability of several risk score models and the individual contribution of their predictor variables were studied using ROC curve analysis.
The comparison between the expected and observed 30-days mortalities, which were determined in different intervals of creatinine clearance, revealed the best threshold value of 55 ml/min. A significantly higher 30-days mortality was observed below this threshold and vice versa (both with p < 0.001). The local adaptation of the EuroSCORE is better than the standard EuroSCORE and was further improved by replacing serum creatinine (SC) by creatinine clearance (CC). Differential ROC analysis revealed that CC is superior to SC in providing predictive power within the logistic regression. Variable rank comparison identified CC as the best single variable predictor, even better than the variable age, former number 1, and SC, previously number 9 in the standard set of EuroSCORE variables.
The renal function is an important determinant of mortality in heart surgery. This risk factor is not well captured in the standard EuroSCORE risk evaluation system. Our study shows that creatinine clearance, calculated according to the Cockcroft and Gault equation, should be applied to estimate the preoperative renal function instead of serum creatinine. This predictor variable replacement gains a significant improvement in the predictive accuracy of the scoring model.
PMCID: PMC165583  PMID: 12812527
Renal function; Cockcroft-Gault formula; risk scoring; improving EuroSCORE; cardiac surgery; 30-days mortality
11.  The use of a new miniature cryoprobe for ablation of bone tissue: In vivo assessment of the probe and application of the method to bone in a sheep model 
BMC Surgery  2003;3:3.
So far, modern miniature cryoprobes were used for local destruction of soft tissue tumours without damaging the adjacent healthy tissue. In this study, cryoablation methodology was applied to bone and the cooling capacity of the probe was examined in vitro and in vivo.
Freezing was performed by cooling one or two probes (diameter 3.2 mm) to -180°C with liquid nitrogen. The cooling capacity of the probes was determined optically and thermally against a homogeneous reference gel, followed by in vivo measurements on femoral and tibial sheep bone followed by histological examination.
Thanks to the synergistic effect, the simultaneous use of 2 probes produced an almost spherical expansion of cold in the homogenous gelatin. During the in vivo freezes, the temperature curves showed a more moderate trend. Nevertheless, due to the synergistic effect, temperatures below -50°C could be reached at a distance of 1 cm from the probe. No local or systemic intraoperative complications were observed. Histological examination revealed cell necrosis up into the -10°C isotherm.
Adequate tissue cooling of the bone matrix can be achieved with in vivo freezes by means of one or more miniature cryoprobes. Therefore, this probe could provide an alternative to or supplement surgical resection of pathological bone processes.
PMCID: PMC156629  PMID: 12709264
cryosurgery; miniature cryoprobe; bone; bone tumour
12.  Surgical physiology of inguinal hernia repair - a study of 200 cases 
BMC Surgery  2003;3:2.
Current inguinal hernia operations are generally based on anatomical considerations. Failures of such operations are due to lack of consideration of physiological aspects. Many patients with inguinal hernia are cured as a result of current techniques of operation, though factors that are said to prevent hernia formation are not restored. Therefore, the surgical physiology of inguinal canal needs to be reconsidered.
A retrospective study is describer of 200 patients operated on for inguinal hernia under local anaesthesia by the author's technique of inguinal hernia repair.
The posterior wall of the inguinal canal was weak and without dynamic movement in all patients. Strong aponeurotic extensions were absent in the posterior wall. The muscle arch movement was lost or diminished in all patients. The movement of the muscle arch improved after it was sutured to the upper border of a strip of the external oblique aponeurosis (EOA). The newly formed posterior wall was kept physiologically dynamic by the additional muscle strength provided by external oblique muscle to the weakened muscles of the muscle arch.
A physiologically dynamic and strong posterior inguinal wall, and the shielding and compression action of the muscles and aponeuroses around the inguinal canal are important factors that prevent hernia formation or hernia recurrence after repair. In addition, the squeezing and plugging action of the cremasteric muscle and binding effect of the strong cremasteric fascia, also play an important role in the prevention of hernia.
PMCID: PMC155644  PMID: 12697071
Inguinal hernia repair; physiology; inguinal canal; protective mechanism
13.  Poorly differentiated carcinoma arising from adenolymphoma of the parotid gland 
BMC Surgery  2003;3:1.
There is only one previous case report of a poorly differentiated carcinoma arising from an adenolymphoma of the parotid gland (Warthin's tumour). The absence of clinical symptoms, and the aspecificity of the radiological pattern make the diagnosis very difficult.
Case presentation
We here report the case of a 73-year-old man with Warthin's tumour who was brought to our attention because of a swelling in the parotid region.
In this case with an atypical clinical presentation, the intra-operative examination of a frozen section of the parotid mass allowed us to diagnose the malignant tumour correctly and consequently undertake its radical excision.
PMCID: PMC149357  PMID: 12533195
Warthin's tumour; malignant adenolymphoma; parotid gland; salivary gland carcinoma

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