The Mirizzi syndrome consists of the obstruction either of the common hepatic duct or the choledocus, secondary to the extrinsic compression due to the impact of calculus in the cystic duct or in the gallbladder infundibulum4. The first description is due to Pablo Mirizzi (1948), when he observed some factors which could cause extra hepatic cholesthasis in certain groups of patients carrying cholelithiasis9. It generally occurs in female with advanced age. Depending on the degree of involvement of the biliary tract, the patients may be grouped into five distinct groups according to the new rating of the Mirizzi syndrome1 , 6.
The goal of this report is to present a case of a patient carrying type IV, surgically treated through the laparotomy approach.
A 56-year-old woman was admitted into the Service of Surgery of Getúlio Vargas Hospital with history of pain in the right hypochondrium with dorsal irradiation, daily evening fever during three months, and a previous episode of choluria lasting 10 days. The physical examination of admission was normal; laboratory tests demonstrated transaminases changes: glutamic oxalacetic transaminase: 75U/L and glutamic pyruvic transaminase: 62U/L; and the canalicular enzymes: alkaline phosphatase: 1924 U/L, and gama glutamil transferase: 884 U/L; the bilirubins were normal. The abdomen ultrasound showed cholelithiasis, bile duct of increased caliber measuring 1.7 cm, showing the "double barreled" with the portal vein, with presence of hyperechoic image measuring 1.1 cm, compatible with calculus; intra-hepatic biliary tract had normal sonographic appearance. The magnetic cholangiography showed cholelithiasis with intra and extra-hepatic biliary tract dilation up to the level of the distal common bile duct, which measured 1.6 cm.
The patient underwent surgical procedure through the laparotomy approach with right subcostal incision. Intraoperatively, there were adhesions of the transverse colon, duodenum and stomach in the gallbladder, which was found to be scleroatrophic and full of calculus. It was decided to perform anterograde cholecystectomy (Torek´s). During the procedure, it was observed the presence of fistula between the gallbladder infundibulum and the choledocus, with erosion of its entire anterior wall covering from the implantation of the cystic duct to the proximity of the duodenum, which was classified as type IV Mirizzi. Choledocoscopy through the fistula was performed with flexible choledocoscope, and a single calculus in the distal choledocus, was identified and removed. The irrigation of the biliary tract with physiological saline solution without elimination of aditional calculus, and endside choledocojejunal anastosomosis in Roux-en-Y was performed with ligature of the distal choledocus. The peritoneal cavity was drained with latex laminar drain. The diet was released on the second day after surgery, with good acceptance. The drain debit oscillated between 20 and 755 ml, showing bilious secretion until the 10th day, when it was removed due to the volume reduction. The patient was discharged on the 12th day after surgery.
Mirizzi syndrome is a rare complication and it occurs approximately on 0.5 to 4% of the patients carrying cholelithiasis. It's more frequent on women between 21 to 90 years old, probably a reflection of the gallstones preponderance in this group. It is the complication of long standing cholecistolithiasis5 , 6.
The constant compression of the calculus associated to the inflammation of the involved structures may result in fistula between the gallbladder infundibulum or the cystic duct, and the extra hepatic biliary tract. In the cholecystobiliary fistula, the calculus may migrate to the main biliary tract, while in the coloentericystic fistula the patient may show intestinal obstruction called biliary ileus9.
The importance of the recognition the Mirizzi syndrome derives from the high risk of lesions of the biliary duct during the surgical procedures. Summing up to this fact is the difficulty for the preoperative diagnosis because there is no specific clinic and laboratory presentation4 , 7 , 10. The most frequent signs and symptoms are abdominal pain followed by jaundice and cholangitis. Nausea, vomits, choluria, itch, hepatomegaly and, less frequently, acute pancreatitis, gallbladder perforation and weight loss3 , 4 , 5 , 8.
The Mirizzi syndrome, which was previously classified into four types, currently the coloentericystic fistula is being included in as complication (type V)1 (Figure 1). The types are: I) extrinsic compression of the common/choledocus hepatic duct by calculus in the gallbladder infundibulum or cystic duct; II) presence of cholecystoenteric biliary fistula with erosion of the diameter less than 1/3 of the common/choledocus hepatic duct circumference; III) presence of cholecystoenteric biliary fistula with a diameter bigger than 2/3 of the common/choledocus hepatic duct circumference; IV) presence of cholecystoenteric biliary fistula involving the entire common/choledocus hepatic duct circumference; V) any type, plus cholecystoenteric biliary fistula (Va - without biliary ileus, and Vb - with biliary ileus).
The surgical treatment of the Mirizzi syndrome requires ability and care in the dissection of the biliary tract in order to perform the cholecystectomy, a safe operation of the biliary tract can be avoided and the removal of the calculus so can avoid any iatrogeny in the biliary tract, as in this particular case, where was opted to dissect the biliary tract incompletely through the Torek technique due to the intense inflammatory process3 , 5.
Intraoperatively, perivisceral firm adhesions is found, the gallbladder in most of the cases is scleroatrophic, with or without cholecystoenteric fistula, the Calot's fibrous triangle should arouse the suspicion of this entity. The cholangiography performed by puncture or by Kehr drain as the first procedure is mandatory so that can outline the anatomy of the biliary tract 2 , 5 , 11.
Some authors do not consider laparoscopy as first option due to the intense inflammatory process caused by the disease, being even considered a contraindication to the treatment minimally invasive, but it can be safely performed by experienced surgeons in some cases1 , 3 , 5 , 6.
In the absence of cholecystobiliary fistula (Type I), the cholecystectomy and the removal of the biliary calculus constitute the treatment of choice. In the presence of lithiasis of common biliary duct, and when the choledocostomy shows technical difficulties, endoscopic retrograde cholangiopancreatography in the postoperative with the removal of the calculus may be a safe alternative10 .
In types II and III, the dissection of the cystic duct and the exposure of the Calot triangle may lead to the opening a fistulous orifice in the common biliary duct. In such situation, one of the alternatives is to use technique on which partial cholecystectomy is performed through anterograde via with preservation of the infundibulum, followed by opening of the gallbladder, removal of the calculus of its interior, and choledocoplasty with suture of the fistulous orifice on the remaining wall of the gallbladder. The Kehr drain is introduced into the common hepatic duct over the repair site. The closing of the orifice must be made with no tension and with the stump mucosal of the gallbladder juxtaposed to the duct mucosal. The use of the gallbladder infundibulum to close the orifice of the common hepatic duct is good because it consists of vascular tissue and it has mucosal similar to biliary duct. However, there is a tendency for the formation of fibrosis and stenosis on the suture lines of the biliary duct, even when it is carefully performed10 (Figure 2).
If the fistula cannot be primarily corrected with the techniques stated above, the biliodigestive anastomosis can be performed. For the reconstruction of the biliary duct in the Mirizzi syndrome type IV, a choledochal and hepaticojejunal anastomosis in Roux-en-Y is usually necessary as a first act, as in the case of the patient here reported6 , 10. According Mirizzi classification, there is a well defined protocol of surgical treatment for different types: type I - partial cholecystectomy; type II - closing of the fistula with suture or choledocoplasty; type III - choledocoplasty; type IV - biliodigestive anastomosis. The biliodigestive anastomosis has been performed for some of the cases of type II when the erosion of the biliary duct was considered significative5.
The organs that can be involved in the cholecystoenteric fistula are the stomach, the duodenum and the colon. The choosing procedure for the cholecystoenteric fistula with biliary ileus is the enterolithotomy and the closing of the fistula, and the one for the fistula without biliary ileus is the closing of the fistula orifice.
The gastroesophageal reflux disease is chronic and common condition that affects about 10% of the population in general22 and corresponds to about 75% of esophageal disorders, with a progressive increase in incidence over the years18. Surgical treatment is permanent, in most cases, since the fundoplication restores the competence of the lower esophageal sphincter and the hiatoplasty reduces and treats the associated hiatal hernia. This is old procedure, firstly described in 1956 by Nissen through laparotomy and in 1991 by laparoscopy done by D'Allemagne. The laparoscopic surgical treatment proved to be better over the years for its significant improvement of postoperative pain, shorter hospital stay, faster return to activities and better aesthetic results4 , 8 , 13 , 30.
Currently there is no doubt that surgical treatment of reflux disease by laparoscopy is safe and effective, with success rates above 85%2 , 6 , 7 , 11 , 12 , 17 , 21 , 26 , 28 being considered the "gold-standard" of laparoscopic surgery. However, some complications and failures have been reported in postoperatively3 , 9 , 16 , 23 , 24, among them the stenosis of the esophagogastric junction, dysphagia due to the very "tight" valve or fundoplication performed with the gastric body or its migration to the mediastinum. Additionally, recurrent gastroesophageal reflux valve migration resulting in total or partial dehiscence of suture may occur. However, not always these anatomic alterations produce symptoms of reflux disease20, but atypical ones.
It is the aim of this study is to describe and report the diagnostic methods employed in the occurrence of persistent postoperative dysphagia after laparoscopic surgery for repair of hiatal hernia and reflux disease, as well as the therapeutic approach employed in these cases.
Three patients, two men aged 33 and 53 years and a woman aged 24 who underwent four years, two years and eight months before the surgical treatment of reflux disease, who developed persistent dysphagia were studied. All had undergone multiple postoperative endoscopies, with no conclusive diagnosis. So, it was indicated and performed in all cinedeglutogram, which revealed difficulty in emptying the barium contrast to the stomach (Figure 1), with formation of diverticular appearance formation on the gastric fundus image, emptying cascade like to the stomach (Figure 2).
All were re-operated on, again by laparoscopy, and was recognized that de Nissen fundoplication was done with the gastric body instead the fundus. The operation was to undo the fundoplication and rebuild a new one Lind or Toupet (270°) partial fundoplication.
All patients recovered uneventfully and were discharged in 48 hours. The evolution in two years later showed disappearance of dysphagia symptoms and absence of gastroesophageal reflux.
After laparoscopic or conventional surgical correction of gastroesophageal reflux some complaints are common like postprandial bloating, difficulty on burp and vomit, and sometimes disphagia1 , 10 , 14 , 25. In most cases, dysphagia symptom is intermittent and tends to disappear within 30 days after the procedure, without the need for specific or new intervention15 , 19.
However, in case of persistent dysphagia, especially when associated with weight loss or dysphagia also important to liquids, diagnostic investigation must be done30. Persistent dysphagia occurs in approximately 3% of cases after surgical treatment of GERD by laparoscopy. It often leads to loss of quality of life, weight loss and of course a lot of dissatisfaction among patients5 , 29.
Postoperative investigation should include endoscopy and always contrasted study of the upper digestive tract, preferably with cineradiography of the esophagus, stomach and duodenum. Endoscopy not always points to the real cause of dysphagia, but can prove difficulties in passing the endoscope from the esophagus into the stomach or a twisted or migrated fundoplication to the chest. The dynamic contrast radiographic study, evaluating the anatomy and function of the upper digestive tract, aids to recognize the anatomical and functional changes of the esophagogastric junction. The normal radiological appearance, in the case of successful antireflux operation, can show the rapid passage of contrast material from the esophagus to the stomach without failure or retentions, the preview image of the fundoplication with air bubble and absence of gastroesophageal reflux on technical maneuvers20. In the case of anatomical changes of the transition they are easily evidenced by the difficulty of oesophageal emptying, upstream dilation of the esophagus with functional achalasia or the formation of gastric diverticulum on fundoplication.
The anatomical reasons that justify the persistent postoperative dysphagia are the realization of tight hiatoplasty and/or fundoplication and bad positioning of the valve made erroneously with the body of the stomach rather than with the fundus on trying to perform a 360º valve27. In the studied cases were observed diverticula formation just below the transition with cascade-like emptying. During the examination can also be noticed the correlation of the act of swallowing with the clinical picture, referring or not dysphagia and pain upon swallowing.
Once diagnosis is made, it is appropriate to indicate surgical correction of the defect, that can also be performed by laparoscopy; cavity inventory often reveals the anatomical cause of dysphagia.
According to Lafullarde et al.16 reoperation for failure of the fundoplication occurred in 15% of patients due to postoperative paraesophageal hiatal hernia, severe and persistent dysphagia and recurrence of GERD symptoms.
In fundoplication improperly made with the gastric body, cineradiography and/or videodeglutogram is important to guide the diagnosis.
It can be concluded that severe and persistent postoperative dysphagia in antireflux surgery is a symptom that may indicate failure in the operation and should be carefully evaluated with endoscopy and dynamic contrast radiological examinations; reoperation with valve reconstruction is indicated to control symptoms and re-treat GERD.
Endometrial tissue localized outside the uterine cavity is defined as endometriosis. It commonly has been demonstrated in the ovaries, peritoneal surfaces, vagina, scar tissues, cervix, fallopian tubes, rectum, urinary tract, pouch of Douglas and possibly any organ in the abdomen15. The estimated prevalence reported in literature ranges from 8-15%5 , 9. Extra-pelvic localization of endometriomas are relatively rare. Especially abdominal wall placements are very infrequent. Usually such cases are associated with surgical scars5. The proposed mechanisms that have been put include retrograde menstruation, venous or lymphatic dissemination or metastasis, and mechanical transplantation into scars at the time of surgery8.
Herein, is presented a case of endometrioma localized in the rectus abdominis muscle.
A 31 year old female with a history of two cesarean sections, the last one of them three years prior, presented with a painful mass in the left lateral side of the Pfannenstiel incision which had been steadily growing. The same patient went a month ago to our institution's urology clinic with pain in the inguinal region. After a detailed history and physical examination an ultrasonography was performed that revealed a 20X12 mm hypo-echoic nodular mass, neighboring the rectus abdominis muscle, with minimal vascularization. The differential diagnosis included endometriosis and a possible desmoid tumor. The patient was referred to our clinic for further evaluation. The pain started on the left lower quadrant and radiated towards the inguinal region, and was associated with menstruation. In physical examination a 2 cm wide mass was palpated in the previously described localization. Magnetic resonance imaging was performed which revealed a 20x11 mm mass which is slightly hyper-intense in the T1 sequence, and contrast enhanced after IV gadolinium injection in the T2 sequence, with increased signal intensity and nodular appearance in diffusion weighted sequences. These were found to be consistent with an endometrial implant (Figures 1A and 1B). Examination of the uterine cavity showed effusion which was at most 15 mm in width when measured. A little free fluid, indicating peritoneal irritation was present in between the intestinal loops. No pathological lymph nodes were present in the lower abdomen.
Ectopic endometrial tissue localized in the rectus abdominis tissue is a very rare occurrence. Previously there have been only 20 reported cases in literature5. The first one of these cases was presented by Amato et al.2, in 1984. Giannella et al.7 has reviewed the previously reported cases extensively; their clinico-pathological characteristics, summarized, were: endometriosis with rectus abdominis placement usually is seen in premenopausal women, aged 27-42y, and history of previous surgery (77%), similarly to this patient. The average size of the endometriomas were 4X4 cm in diameter. This case had a much smaller dimension. The imaging studies' measurements were 2 cm at the greatest width. While CT scan has most commonly been used, in this case imaging diagnosis preferred to use ultrasound followed by an MRI7. Fine needle aspiration has also been tried in these cases; however, failed to prove effective in establishing diagnosis3.
Cesarean section is very frequently associated with abdominal wall endometriosis. The incidence, as reported in previous literature, can be as high as 1%. One of the proposed theories for how this occurs, takes into consideration the possibility that during the operation, endometrial cells may escape through the incision in the uterus and implant themselves within the abdominal incision site3.
This patient presented with cyclic symptoms that were associated with menstruation. The differential diagnosis of cyclic pain in general include lymphadenopathy, mesenteric lymphadenitis, lipoma, abscesses, hernias, hematomas, soft tissue sarcomas, desmoid tumors (which was considered in differential diagnosis) and even metastatic cancer. Previously some studies have looked into the utility of biochemical markers for tracking endometriosis. These markers include CA-125, C-reactive protein, anti-mullerian hormone, follistatin6 , 11 , 12 , 13.
Previously conducted sonographic studies have determined that abdominal wall endometriomas (which were first demonstrated via ultrasound in 197914) are commonly hypo-echoic, well defined, solid masses; this is consistent with sonographic findings of this case1. Medical treatment for these conditions, which have been previously utilized in literature, include danazol and progesterone; however, this treatment is frequently inefficacious, and therefore must be reserved for cases in which surgical treatment is not preferred10.
To summarize, in masses which present with cyclic pain and growth, localized to the abdominal surface, endometriomas must be considered in the differential diagnosis. Surgical removal, as evidenced previously reported cases, is successful, especially when limited and localized within in the rectus abdominis muscle. Sonography followed by resonance, provides the most definitive imaging. Molecular markers are currently not established enough to be considered as a standard of diagnosis. Further large-scale studies or reviews are necessary to determine which approach is the best, with consideration of the patient's request.
Laparoscopic cholecystectomy is the surgical procedure of choice for symptomatic gallstones. The incidence of bile duct injury following laparoscopic cholecystectomy is around 0.62% and, when vascular injuries also occur, the surgeon is faced with is a serious complication1.Morbidity and mortality increase drastically when bile-duct and vascular injuries occur simultaneously and a successful outcome is unlikely when diagnosis of these is delayed. The extent of liver damage and the need for liver resection or transplant significantly influence the progress of patients with such injuries.
A 36-year-old female with symptomatic colelithiasis was referred for elective laparoscopic cholecystectomy. During the surgery, the chronic inflammatory process deforming the anatomy of the porta hepatis and the appearance of bleeding and bile in the surgical field obliged the surgeons to revert to the conventional procedure (open cholecystectomy), which involves a subcostal incision on the right hand side. Extensive hemostasis was carried out using sutures, clips and diathermy. The assistant surgeon decided to call in the surgeons from the hepato-biliary surgery group. The new team immediately increased the size of the incision (extending it to the subcostal area on the left hand side). Almost complete damage to the elements of the porta hepatis was found: ligature and section of the right portal branch; ligature and section of the right hepatic artery; ligature and section of the common hepatic duct on bifurcation; ligature and almost complete section of the left hepatic artery.
Ilmo. Sr. Prof. Dr. Osvaldo Malafaia Editor da Revista Arquivos Brasileiros de Cirurgia Digestiva
Comentando a Carta ao Editor escrita pelo professor Fabio Gonçalves Ferreira, de São Paulo: "A indexação da ABCD no PubMed e a cirurgia da hipertensão portal esquistossomótica no Brasil" (Arq Bras Cir Dig 2013;26(3):248-251)1, também gostaria de parabenizar o Corpo Editorial da Revista por sua recente promoção pelo índice Qualis, na área de Medicina III, quando esta foi elevada a B3.
Considero necessário parabenizar o Editor pela opção de publicar os artigos também na língua inglesa, aumentando consideravelmente o alcance e impacto da publicação, assim como pela presteza, pela forma desburocratizada e cordial de contato com o periódico e mesmo com o Editor. Para ilustrar a qualidade dos Revisores da Revista, informo que uma publicação recente da ABCD: "Aspectos ultrassonográficos e anatomia da aponeurose do músculo transverso do abdome" (Arq Bras Cir Dig 2013;26(3):184-189)2, recebeu o prêmio de melhor Pôster do 29th International Congress of the Medical Women's International Association, realizado em Seul, na Coréia, entre 31 de julho e 3 de agosto de 2013.
Ao avaliarmos os periódicos indexados disponíveis em nosso país, que aceitam artigos sobre Cirurgia Experimental, encontramos uma grande carência de opções. O Grupo de Pesquisa que represento tem artigos revisados pelo Conselho Editorial de periódicos que estão aguardando publicação por períodos próximos de dois anos.
The surgical and anatomical basis for using the colon as a substitute for the esophagus were established in 1911 by Kelling and Vuillet1 and for many years was the technique of choice for esophageal replacement2. Its use is helpful in benign diseases, such as caustic or peptic strictures, and malignancies1 , 3, especially when the stomach cannot be used, and also in children with congenital anomalies2 , 4. However, this procedure is subject to early complications, as ischemia of the colon and leakage5, or late problems as anastomosis stenosis, ischemic colitis, fistula due to diverticulitis and malignant lesions4.
The transposed colon cancer is a rare complication. Since 2007, six new cases were reported and two reviews published. Hwang et al6 found 10 reported cases of adenocarcinoma in the transposed colon and Bando et al7 also reviewed 10 cases in the literature, encompassing adenomas and adenocarcinomas.
The aim is to report an unique case of synchronous adenocarcinoma of the transposed colon.
Woman with 53-years-old diagnosed with congenital esophageal atresia, underwent to several surgical procedures in childhood, the latest was a cervical retrosternal esophagocoloplasty at 11 years old. After 42 years she was evolved with cervical dysphagia, and an initial diagnosis of stenosis of the esophagocolic anastomosis was performed, treated with endoscopic dilation without improvement. Later, biopsies were performed in the area of stenosis in proximal colonic segment (Figure 1) and polypectomy of sessile polyp of 10 mm, 5 cm distal to the stenosis (Figure 2). The pathological assessment showed tubular-villous intramucosal adenocarcinoma at the resected polyp and the area of stenosis was a invasive adenocarcinoma in colonic mucosa. Colonoscopy of remained colon was normal. Staging performed with CT scan showed an eccentric wall thickening of proximal colon transposed with luminal reduction target of left innominate vein; densification of mediastinal fat plane adjacent and regional lymph nodes up to 1.9 cm.
Marking of colonic lesions which require surgical resection prior to surgery is of extreme importance, especially since laparoscopic approach is becoming increasingly common in colonic resections. Endoscopic tattooing of lesions, using dyes such as India ink, is recommended in such cases1, and is currently the most commonly used marking technique. This procedure was found to be both effective and safe in several studies.2 , 3
Several side effects and complications of India ink tattooing have been reported. Among them are localized leakages of ink into the peritoneal cavity, which were mostly asymptomatic3, and transmural injection of India ink into adjacent structures, such as small bowel4 and rectus muscle.5 However, we were not able to find any reports describing transmural injection of India ink into adjacent segments of large bowel, which prompted us to submit our case.
We present the case of a patient who underwent endoscopic tattooing of a colonic lesion prior to surgery. At laparotomy we noticed that the India ink was injected through the colon wall into an adjacent segment of large bowel, thus leading to inaccurate marking of the lesion.
A 75 year old woman, with a history of hypothyroidism and essential hypertension, underwent a screening colonoscopy for the first time in her life. It is worth noting that the patient was asymptomatic. Colonoscopy revealed two polyps which were deemed endoscopically unresectable: one at the cecum and one at 40 cm from the anus. Both were biopsied, and a marking with India ink was made distal to the lesion at 40 cm in order to easily locate it at surgery. Both biopsies showed tubulovillous adenoma with areas of high grade dysplasia.
Mesenteric cyst is defined as a cystic lesion located between the leaflets of the mesentery from the duodenum to the rectum , being most commonly found in ileum level. Since its first description in 1507 by Benevienae until 1993 there are only about 820 cases reported in the literature4 - 6.
Lymphangiomas are benign tumors, probably congenital, are more common in the cervical and axillary regions. They are unusual in abdominal and pancreas location. Its incidence is estimated at around 1:100,000 and 1:20,000 admissions in adults and in children. The first excision was performed by Tillaux (quoted Chung) only in 18025. Despite the long recognition of this disease, its origin classification and pathology remain controversial. The highest incidence is between the third and fourth decades of life, with 75% of those diagnosed after ten years with a slight female predominance. The term lymphangioma is appropriately used when there is hemodynamic isolation, or the injury is not related to the blood system10 - 13. Lymphangiomas are a major group of so-called vascular hamartomas, which result from a failure in the evolutionary development of the vascular system, including lymphatic and/or arteries and veins3.
These lymphatic tumors are divided in: 1) simple, with capillary lymphatic channels; 2 ) cavernous, with dilated lymphatics and the presence of capsule; and 3) macrocystic malformations, clinically termed "cystic hygroma"6. This is the most common type, and the most affected sites are head and neck. The main differential diagnosis is hemangioma, branchial cysts, lipomas and rabdmiossarcoma. Diagnosis is made by biopsy of suspicious nodules, and the main treatment is surgical excision.
Fifty-eight years man came to San Francisco Hospital in Taquaral of Goiás, Brazil, after previous medical care without diagnosis or treatment. He had a history of a large mass over a year of slow evolutionary character. He denied pain, headache, fever, diarrhea and other symptoms. Physical examination revealed good general condition, acyanotic, afebrile, hydrated, normotensive, rhythmic, symmetrical heart sounds without murmur. His abdomen had a moving mass of 10 cm in diameter, painless to superficial and deep palpation. Ultrasonography showed an intraperitoneal cyst apparently mesenteric (Figure 1).
The technique of elastic suture was described by Raskin4 in a review article on acute vascular lesions in the upper limbs after crushing arm and forearm with the development of compartment syndrome. This author used an elastic suture to approximate the edges of fasciotomy and prevent bloody retraction. Leite et al.3 added in the application of subcutaneous and superficial fascia, in order to avoid additional suffering the edge of the skin, which could worsen the condition of the wound to this technique. This modification improved the aesthetic appearance and location prevented the formation of the lateral wound scars.
The objective of this report is to present a new technique for closure of extensive surgical wounds through elastic suture, using circular elastic rubber bands.
Woman with 49 years old was admitted in Santa Casa de Belo Horizonte, Brazil, in good general condition but with a tumor in hypogastric region with dimensions of 25x15 cm in diameter and 12 cm high. The evolution of neoplasia was 10 years and had a bleeding ulcer on its top. A CT scan showed that the tumor has not plagued the muscle layer or other deep structures. Physical examination and additional imaging tests showed no signs of metastases. A biopsy of this lesion diagnosed dermatofibrosarcoma. The tumor was completely removed with wide lateral and deep margins, including muscle fascia, which was macroscopically free of disease. The remaining wound area was of 20x15 cm in diameter and 4 cm deep. The approximation of the wound edges was done by means of elastic suture. Two thin circular rubber bands - usually used to hold bundles of cash - were sterilized by autoclaving and sutured to the edges of the wound, 1 cm from the wound area. Simple 2-0 nylon was used in suturing. These tapes were zigzag positioned. This procedure was performed under local anesthesia with 1% lidocaine. After five days, the wound edges were already very close to each other and the two rubber strips failed to exert traction on them. With local anesthesia, they were replaced by a single circular rubber tape, which kept the draw for the approximation of the edges. On the 20th postoperative day, the skin closure was completed and there was no need to suture the skin. The patient was discharged on that day, with the wound closed and showing good healing aspect. She continues to be followed on an outpatient basis after over 14 months and is very pleased with the outcome of the treatment. No recurrence or metastasis sarcoma were recorded.
Rectus sheath hematoma is an uncommon and frequently misdiagnosed cause of acute abdominal pain3. Although the exact incidence is unknown, Klingler et al.6 observed 23 cases (1.8%) of rectus sheath hematoma among 1257 patients evaluated by ultrasound for acute abdominal disorders. It is defined as spontaneous in patients without history of abdominal trauma. In these cases, anticoagulation therapy is considered an important predisposing factor. Many series have described the association between spontaneous rectus sheath hematoma and anticoagulant agents, especially warfarin and heparin1,3,9. However, there are few reports of spontaneous rectus sheath hematoma occurring in patients exclusively on antiplatelet medications, such as acetylsalicylic acid. The authors report a case of spontaneous rectus sheath hematoma in a patient on low dose of acetylsalicylic acid.
A 62-year-old woman presented to the emergency department with a 12-hour history of a sudden onset abdominal pain in the left lower quadrant after an episode of sneeze. The pain increased gradually and a mass in the left lower quadrant was noted 30 minutes after the initial pain. Her past medical history included obesity, hypertension, coronary artery disease and diabetes. She was on captopril, glibenclamide and low dose of acetylsalicylic acid (100 mg daily). She had no trauma history and denied fever, nausea, vomiting, cough or any change in urinary output. Stool passage was as usual.
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