A. Ebru Salman

Efficacy of ultrasonography in identification of non-recurrent laryngeal nerve

BACKGROUND The aim of this prospective study was to identify the arterial anomalies constantly associated with nonrecurrent inferior laryngeal nerve by preoperative ultrasonography and impact on recurrent inferior laryngeal nerve palsy (RILN). METHOD The study included 332 patients who underwent thyroidectomy or parathyroidectomy between 2009 February and 2011 October. Preoperative ultrasonography was performed to all patients to identify vascular anomalies related to NRILN. CT was performed only in patients with NRILN predicted with preoperative ultrasonography. Systematic nerve dissection was performed surgically. Patient characteristics, type of NRILN, preoperative and postoperative vocal cord mobility and morbidity were recorded. RESULTS The NRILN was identified in 6 patients on the right side (1.94%). Preoperative ultrasonography predicted NRILN in all cases (accuracy 100%). CONCLUSION Ultrasonography is a very reliable and simple method to be used in preoperative assessment to identify vascular anomaly associated with NRILN to make optimal surgical decisions against nerve damage in patients undergoing thyroidectomy or parathyroidectomy. Adequate surgical technique is of great importance.

The efficacy of the semi-blind approach of transversus abdominis plane block on postoperative analgesia in patients undergoing inguinal hernia repair: a prospective randomized double-blind study

Purpose In this prospective, randomized, double-blind study, our aim was to compare the analgesic efficacy of the semi-blind approach of transversus abdominis plane (TAP) block with a placebo block in patients undergoing unilateral inguinal hernia repair. Methods After receiving hospital ethical committee approval and informed patient consents, American Society of Anesthesiologists (ASA) I–III patients aged 18–80 were enrolled in the study. Standard anesthesia monitoring was applied to all patients. After premedication, spinal anesthesia was administered to all patients with 3.5 mL heavy bupivacaine at the L3-L4 subarachnoid space. Patients were randomly allocated into 2 groups. Group I (n = 32) received a placebo block with 20 mL saline, Group II (n = 32) received semi-blind TAP block with 0.25% bupivacaine in 20 mL with a blunt regional anesthesia needle into the neurofascial plane via the lumbar triangle of Petit near the midaxillary line before fascial closure. At the end of the operation, intravenous (IV) dexketoprofen was given to all patients. The verbal analog scale (VAS) was recorded at 2, 4, 6, 12, and 24 hours postoperatively. Paracetamol IV was given to patients if their VAS score > 3. A rescue analgesic of 0.05 mg/kg morphine IV was applied if VA S > 3. Total analgesic consumption and morphine requirement in 24 hours were recorded. Results TAP block reduced VAS scores at all postoperative time points (P < 0.001). Postoperative analgesic and morphine requirement in 24 hours was significantly lower in group II (P < 0.01). Conclusion Semi-blind TAP block provided effective analgesia, reducing total 24-hour postoperative analgesic consumption and morphine requirement in patients undergoing elective unilateral inguinal hernia repair.

Management of fistula of ileal conduit in open abdomen by intra-condoit negative pressure system

INTRODUCTION We aimed to present the management of a patient with fistula of ileal conduit in open abdomen by intra-condoid negative pressure in conjunction with VAC Therapy and dynamic wound closure system (ABRA). PRESENTATION OF CASE 65-Year old man with bladder cancer underwent radical cystectomy and ileal conduit operation. Fistula from uretero-ileostomy anastomosis and ileus occurred. The APACHE II score was 23, Mannheim peritoneal index score was 38 and Björck score was 3. The patient was referred to our clinic with ileus, open abdomen and fistula of ileal conduit. Patient was treated with intra-conduid negative pressure, abdominal VAC therapy and ABRA. DISCUSSION Management of urine fistula like EAF in the OA may be extremely challenging. Especially three different treatment modalities of EAF are established in recent literature. They are isolation of the enteric effluent from OA, sealing of EAF with fibrin glue or skin flep and resection of intestine including EAF and re-anastomosis. None of these systems were convenient to our case, since urinary fistula was deeply situated in this patient with generalized peritonitis and ileus. CONCLUSION Application of intra-conduid negative pressure in conjunction with VAC therapy and ABRA is life saving strategies to manage open abdomen with fistula of ileal conduit.

Intrarectal negative pressure system in the management of open abdomen with colorectal fistula: A case report

INTRODUCTION To present the management of open abdomen with colorectal fistula by application of intrarectal negative pressure system (NPS) in addition to abdominal NPS. PRESENTATION OF CASE Twenty-year old man had a history of injuries by a close-range gunshot to the abdomen eight days ago and he had been treated by bowel repairs, resections, jejunal anastomosis and Hartmans procedure. He was referred to our center after deterioration, evisceration with open abdomen and enteric fistula in septic shock. There were edematous, fibrinous bowels and large multiple fistulas from the edematous rectal stump. APACHE II, Mannheim Peritoneal Index and Björck scores were 18, 33 and 3, respectively (expected mortality 100%). After intensive care for 5 days, he was treated by abdominal and intrarectal NPS. NPS repeated for 5 times and the fistula was recovered on day 18 completely. Fascial closure was facilitated with a dynamic abdominal closure system (ABRA) and he was discharged on day 33 uneventfully. There was no herniation and any other problem after 12 months follow-up. DISCUSSION Management of fistula in OA can be extremely challenging. Floating stoma, fistula VAC, nipple VAC, ring and silo VAC, fistula intubation systems are used for isolation of the enteric effluent from OA. Several biologic dressings such as acellular dermal matrix, pedicled flaps have been used to seal the fistula opening with various success. Resection of the involved enteric loop and a new anastomosis of the intestine is very hard and rarely possible. In all of these reports, usually patients are left to heal with a giant hernia. In contrast to this, there is no hernia in our case during one year follow up period. CONCLUSION Combination of intra and extra luminal negative pressure systems and ABRA is a safe and successful method to manage open abdomen with colorectal fistula.

An alternative anterior tension free preperitoneal patch technique by help of the endoscope for femoral hernia repair

BACKGROUND Femoral hernias are relatively uncommon and have a higher risk for strangulation and incarceration. We introduce an alternative anterior tension free inlay patch technique by help of the endoscope for femoral hernia repair. METHOD Characteristics of patients undergoing femoral hernia repair between March 2006-April 2011 and description of the surgical technique is presented. RESULTS We analyzed our experience with this technique in 26 consecutive patients with femoral hernias (1 bilateral, 15 right, 10 left femoral hernia) in 5 year period. Seven of these 26 femoral hernias were recurrent and 2 of them were concomitant with inguinal hernia. Mean operation time was 30.0 ± 12.1 min. Seroma was seen in 2 patients at postoperative 1st week. There were no; hematoma, wound infection and separation of wound edges and early recurrence at postoperative 1st week and 1st month. The mean follow up period was 41.8 ± 18.2 months. All of 22 patients who were contacted were satisfied with the operation. There was no recurrence, chronic pain and foreign body feeling in any patient at the end of the follow-up period. CONCLUSION This feasible and safe alternative anterior inlay patch repair might be used in all femoral hernias with the exception of the ones requiring intestinal resection.

The importance of clinical suspicion in the diagnosis of a successfully managed case with De Bakey Type 1 acute aortic dissection: A case report.

Type 1 aortic dissection is a catastrophic clinical entity originating from the ascending aorta. Clinical suspicion in patients with epigastric pain, chest pain and gastrointestinal symptoms might be life saving. Aortic dissection and acute mesenteric ischemia might be confusing in diagnosis of patients with epigastric pain, chest pain, gastrointestinal symptoms and high white blood cell count and D-dimer. In this case report of a patient who was admitted to the emergency room with a presentation resembling acute mesenteric ischemia, this diagnosis was excluded within the first 24 hours as a result of clinical suspicion. In this case report, the successful management in diagnosis and treatment of a 30-year-old male patient with type 1 aortic dissection is discussed in light of the literature.

Fusion of a cervical sympathetic ganglion with the recurrent inferior laryngeal nerve: a case of false positive non-recurrent inferior laryngeal nerve.

An anastomosis between the recurrent inferior laryngeal nerve (RILN) and the cervical sympathetic ganglion is seen rarely and might be confused with non-recurrent inferior laryngeal nerve (NRILN) in patients undergoing thyroidectomy and parathyroidectomy. In spite of the fact that NRILN is rarely seen and is an important anatomical structure, when damaged, the quality of life of the patient is negatively affected. This case report describes a connection between the RILN and the sympathetic nerve ganglion encountered during nerve dissection in a 43 year old female patient undergoing thyroidectomy and central zone dissection. Key points in the differential diagnosis are discussed.

Management of Septic Open Abdomen in a Morbid Obese Patient with Enteroatmospheric Fistula by Using Standard Abdominal Negative Pressure Therapy in Conjunction with Intrarectal One

Introduction. Management of open abdomen (OA) with enteroatmospheric fistula (EAF) in morbid obese patient with comorbid disease is challenging. We would like to report the management of septic OA in morbid obese patient with EAF which developed after strangulated recurrent giant incisional hernia repair. We would also like to emphasize, in this case, the conversion of EAF to ileostomy by the help of second Negative Pressure Therapy (NPT) on ostomy side, and the chance of new EAF occurrence was reduced with intrarectal NPT. Case Presentation. 62-year-old morbid obese woman became an OA patient with EAF after strangulated recurrent giant hernia. EAF was converted to ostomy with pezzer drain by the help of second NPT on ostomy. Colonic distention was reduced with the third NPT application via rectum. Abdominal reapproximation anchor (ABRA) system was used for delayed abdominal closure. Conclusions. Using the 2nd NPT on ostomy side may help in the maturation of the ostomy created in a difficult condition in an open abdomen. Using the 3rd NPT through rectum may decrease the chance of EAF formation by reducing the pressure difference between intraluminal pressure and extraluminal pressure in hollow viscera.

Effects of rosiglitazone pretreatment on blood glucose, lipid levels, urea, and microalbuminuria in rats undergoing 70% pancreatectomy

1Yozgat Bozok University Hospital, General Surgery Department, Yozgat, 2Department of Surgery, Faculty of Veterinary Medicine, Ankara University, Ankara, 3Department of Medical Biochemistry, Gazi University, Ankara, 4Department of Endocrinology, Bozyaka Research and Training Hospital, Izmir, 5Department of Anesthesiology and Reanimation, 6Department of General Surgery, Ataturk Research and Training Hospital, Ankara, Turkey