Kenneth K. Meyer

RETROPERITONEAL DUODENAL RUPTURE. PROPOSED MECHANISM, REVIEW OF LITERATURE AND REPORT OF A CASE.

Abstract The surgeon should be aware of this problem and should carefully observe patients who have a history of blunt abdominal trauma for progression of clinical manifestations of a perforated viscus. If a diagnosis is made, laparotomy should be performed immediately. Complete duodenal visualization and mobilization must be done. Closure in two layers is usually all that is necessary. Thorough irrigation of the peritoneal and retroperitoneal area is recommended. Drainage and parenteral administration of antibiotics are optional. If the lesion is not recognized and not surgically corrected, or if the patient is operated on and the perforation not found, the patients chances for survival are slim.

A critical review of a century’s progress in surgical apparel: how far have we come?1

Price is the dominant factor in sales of surgical apparel. Do most surgeons know this? Does a lower price mean less protection against microbial penetration and place patients at greater risk of developing surgical-site infections (SSIs)? Ironically, in the 5-year span between 1993 and 1998, the most recent period for which statistics are available, the reported SSI rate in comparable clean-clean operations decreased from 1.5% to 0.75% in hospital surgical procedures in the United States. These figures admittedly may reflect inadequate followup reporting of SSIs associated with ambulatory and 1-day-stay operative procedures. Data recently released by the American Hospital Association indicate that of the 24 million hospital surgical operations performed in 1997, 60% (14,700,000) were outpatient or 1-day-stay procedures, and the reported SSI rate dropped by 50%. The amount of outpatient and 1-day-stay surgery appears to be rising each year and does not include the increasing number of surgical procedures performed in nonhospital facilities. As to the accuracy of statistics on nonhospital surgical procedures, a method has yet to be devised to obtain such information with any degree of dependability. Concomitant with the development of more protective surgical materials, recent years have seen changes in surgical practices, which logically could have played a role in these statistics. Although there has been a marked increase in the number of extensive procedures in cardiovascular, thoracoabdominal, orthopaedic, transplant, and reconstructive surgery, this growth has been outdistanced by an even sharper increase in minimally invasive, lower blood-loss operations resulting from a marked increase in laparoscopic, endoscopic, and other smallincision procedures both in hospitals and ambulatory surgery centers. Additional factors are the judicious use of antibiotics and other related advances in perioperative care. Cause and effect are difficult to ascribe, not only because of the multiplicity of concurrent advances, but also because of the difficulty in quantifying the proportional contributions of each to the lowering of SSI rates. Except for the relatively few surgeons interested in the characteristics of surgical materials, most surgeons have no say in the choice of gowns and drapes provided to them by the hospital or ambulatory surgery center. According to a Gallup poll conducted in 1994 by a prominent surgical gown manufacturer, more than half of the surgeons and operating room (OR) nurses wanted more say about the gowns they wore. Only 16% of surgeons and 26% of OR nurses were involved in the selection of surgical apparel. Purchase of such items in the current economic structure of health care is usually the responsibility of a hospital purchasing agent or group purchasing service, the OR nurse supervisor, or other administrative personnel who may or may not be familiar with performance characteristics in relation to cost. In addition, a surprisingly high number of surgeons and nurses were unclear about the difference between liquid-resistant and liquid-proof apparel. No competing interests declared.

Gown-Glove Interface: A Possible Solution to the Danger Zone

The gown-glove interface is the weakest point in the present barrier system of gown and glove protection for the surgeon and other healthcare professionals who come into direct contact with body liquids. Try it yourself: put on a fluid-resistant gown and surgical gloves. See that the glove cuff is well proximal to the stockinette. Hold your wrist and forearm for a moment under running water. Wait a minute to see if your forearm is wet. A wet forearm during surgery would be a blooded one. We propose a gown redesign that creates a dart at the terminal forearm, sealed by a liquid-proof method, and then similarly sealing the proximal end of the glove to the sleeve.

Thrombosis prophylaxis and the pill

In light of the increased risk to many women using oral contraceptives of contracting thromboembolic disease it is suggested that patients with mild venous disease and significant reasons for using oral contraceptives should wear compressive support stockings. Though this regimen is obviously not for serious disease conditions which would rule out oral contraceptive use anyway it appears to be a convenient and simple prophylaxis that should increase the velocity of blood flow by reducing the volume of the venous bed without discomfort to the patient.