Richard Stahl

Extensive wounds of the spine : a comprehensive approach to debridement and reconstruction

Extensive wounds involving the spine (greater than three vertebral segments exposed) may threaten its indispensable roles of biomechanical support and vital neurologic function. Although there have been select reports of specific flap applications in this body region in the reconstructive surgical literature, there has been a paucity of comprehensive descriptions of pertinent anatomy, pathophysiology, and the perioperative care of such patients—including the degree to which the spine is suited to aggressive debridement. Four patients with complex spine wounds involving greater than three vertebral segments were treated by the authors from 1986 through 1988. These patients ranged from 28 to 80 years of age. They were all found to have multiple risk factors, including neoplasm (4), severe nutritional depletion (3), advanced age (2), wound sepsis (2), and multiple other general medical problems (4). All patients underwent wide bony and soft-tissue debridement. A new clinically essential four-pillar concept of spinal support predicted spinal instability in two of the four patients. These patients could thus be protected from neurologic compromise with internal stabilization (1) or external orthotic support (1). Wound closure was achieved with skin graft (1) or traditional or extended musculocutaneous flap coverage (3). With 7 to 20 months of follow-up, wound healing has been complete in all patients despite a 100 percent complication rate and one late postoperative death. Multisegment spine wounds tend to arise in the setting of multiple medical problems or risk factors. Despite these risk factors and a high postoperative complication rate, gratifying results may be achieved in these patients with a comprehensive understanding of regional surgical anatomy and a multidisciplinary approach to their care.

Cutaneous angiosarcoma of the face and scalp

Cutaneous angiosarcoma is an infrequent but aggressive neoplasm involving the skin of the face and scalp. Unfamiliarity with the clinical manifestations of cutaneous angiosarcoma frequently leads to misdiagnosis and delay in treatment. Complete surgical resection requires the performance of preoperative staging biopsies to determine the true extent of the neoplasm. Intraoperative frozen section analysis to determine the adequacy of the surgical resection is unreliable due to the high false-negative rate. All patients should receive a full course of postoperative radiation.

Reconstruction of Infant Thoracic Wounds

From 1985 through 1987, five of eight infants with thoracic wounds at Yale-New Haven Hospital underwent chest-wall reconstruction. In total, the eight infants underwent 17 procedures (including multiple open resuscitations) exclusive of the reconstructive operations. Patients undergoing reconstruction ranged from 1 to 10 months of age and 3 to 7 kg in weight. All reconstructed patients underwent bilateral pectoralis major advancement flaps, with three of the five patients each requiring the simultaneous use of a rectus abdominis flap. With 2 to 18 months of follow-up, healing was complete in all five of the reconstructed patients, with two prosthetic pulmonary-systemic shunts and two outflow tract patches thus salvaged. These patients were found to be distinct from their adult counterparts, with special critical care requirements and expectedly delicate muscular anatomy. The gratifying results now expected in adults with sternal wound complications can be achieved in their infant counterparts. Furthermore, the group of patients whose chests cannot initially be closed owing to resultant cardiac compression may look to sternocostal debridement and flap reconstruction as a means of not only achieving wound closure, but of effectively increasing their mediastinal volume and compliance. Questions about skeletal development remain unanswered and demand further follow-up.

Reconstructive surgery in primary breast cancer treatment

The goal of breast reconstruction is achievement of symmetry and preservation or restoration of a positive body image. The two methods of reconstructive breast surgery are implantation of a prosthesis or a flap procedure using skin, with or without autologous tissue from a donor site. Factors that determine which method is most appropriate are based on predicted outcome, patient expectations, and patient risk factors associated with complications of surgery.

Elbow joint salvage with the transverse rectus island flap: a new application.

The transverse rectus island flap has gained wide acceptance in breast reconstruction. We introduce its use in reconstruction of extensive wounds of the elbow region. Three cases are presented. Its principal advantages over other methods are size, pedicle length, reliability, acceptable donor defect, and potential prevention of elbow and shoulder stiffness. Its disadvantages are bulk, weight, and required staged procedures.

Skin grafting for repair of a cardiac laceration

Rupture of the right ventricle has been reported as a complication of closed catheter irrigation in poststernotomy mediastinitis. We report the case of a right ventricular rupture that was repaired with a deepithelialized dermal skin graft. The technique is described and management options for these difficult wounds are discussed.

Major bleeding in patients with mediastinitis: a heartbreaking series.

Deep sternal wound infection (DSWI) is a life-threatening complication that develops in 5% of patients undergoing median sternotomy. One feared complication is major bleeding, associated with up to 50% mortality. We characterized a series of patients who experienced major bleeding following DSWI. We included eight patients with DSWI who experienced major bleeding at our institution from 1990 to 2012. The median age was 70.9 (range, 47-81) and the cohort consisted of seven male patients and one female patient. All eight patients required emergent surgical repair for the bleeding and all survived past 30 days postoperatively from the repair.

The protection of resident curriculum by work redesign

Abstract In recent years at the Yale School of Medicine, operative services work volume has increased dramatically, including a 24% increase in cases and a 17% increase in inpatient discharges. At the same time, ambulatory care has surged, reducing hospital length of stay by 26%. The institution has also been through 2 budget reviews, which reduced the operating budget by 10% each time. The result has been a rise in patient acuity, a rise in patient volume, an increase in outpatient work, and a reduction in hospital personnel available to participate in patient care. As a result, the hours of our residents have increased as they have assumed responsibility for both the volume increase and the decrease in hospital personnel. At the same time, the number of house staff positions has been reduced as a result of a training program amalgamation, and preliminary positions and time spent by specialty categorical residents in general surgery have decreased. Therefore, a work redesign project was undertaken to examine the activities of first-year trainees. The tasks of first-year trainees were divided into educational benefit (OR, rounds, conferences), service (paperwork, finding films), and tasks that were indeterminate. The service tasks were redistributed within a new service structure to include a physician associate (PA) role. The trainees were then available for educational activities, including the OR. The relationships among the nurse, PA, attending surgeon, senior resident, and patient were redefined to emphasize the role of the trainee. Under the new system, the PA spanned the roles of the attending surgeon, trainees, and nurses during the day to support managed care pathways, paperwork, nursing care plans, and questions that in the past were directed to the house staff. While reporting directly to the associate program director, the PA performed the patient care tasks on assignment from both the house staff and attending surgeons during the day, leaving little in the way of accumulated tasks for the evening. The PA also participated in the check-out rounds of the house staff and in the nursing shift meetings. Physician associates were hired for the major general surgery services and did not perform night duty. They were never perceived as replacements for house staff but rather as health care workers in a new role as defined by work redesign. The first-year trainees continued to perform 80–100 cases per year despite drastic changes in the work expectations that otherwise would have fallen to them. The evaluation of services by the residents increased substantially. Nursing evaluation of the program was completely positive, and the attending surgeons found the new system completely acceptable. Work redesign is a tactic that can preserve the educational aspects of resident training even in the face of severe resource constraints and conflicting demands on time.

Chest Wall Reconstruction: the Sternal Wound

A 25-year-old man with Down’s syndrome presented with constrictive pericarditis 6 weeks after surgical closure of a ventricular septal defect. Repeat sternotomy was necessitated for pericardiectomy to relieve his constriction.

Ischial Pressure Sore Reconstruction with V-Y Hamstring Advancement Flap Reconstruction

A 20-year-old college freshman was referred for a nonhealing ischial pressure sore. She had been paraplegic since childhood as a result of resection of a histologically benign spinal cord tumor. She had never previously suffered from pressure ulceration.