Risk to surgeons is of great concern in in areas of high HIV prevalence .... ('Kalashnikov') compared with the M16 ('Armalite'). It is misleading of Gregori to label ...
Com m ent
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with the Notice printed on the inside back cover. Tables and figures should be included only if absolutely essential and no more than five references should be given. The Editor reserves the right to shorten letters and to subedit contributions to ensure clarity
How long do patients convalesce after inguinal hemiorrhaphy? Current principles and practice
Non-woven, disposable theatre gowns for 'high-risk' surgery
Having had a long-standing special interest in hernia surgery (1), I would like to add my comments to those already made on the article by Robertson et al. (Annals, January 1993, vol 75, p30) regarding rehabilitation after herniorrhaphy. The topic is of some socioeconomic importance as operations for inguinal hernia are among the commonest carried out all over the world. In the USA over 1 million are performed annually, of which 10% are for recurrences. Views on timing of return to work and other normal activities are disparate as the article and comments reveal. My own approach is to tell my patients that they can, with confidence, do whatever they want with immediate effect without jeopardising the success of the operation. I have held this view and implemented this policy since I abandoned operations based on the Bassini principle of uniting the conjoint tendon to Poupart's ligament in 1968 and introduced primary prosthetic hernioplasty (2,3) using polypropylene mesh, since when I have carried out a personal series of some 700 of these hernia repairs without recurrence. The essential difference between the Bassini operation and utilising a mesh prosthesis for the primary reconstruction of the inguinal canal for hernia, and which affects attitudes to postoperative rehabilitation and recovery, is that the former is carried out by coapting structures with distortion and under tension, as witnessed the tension-relieving manoeuvres that have been advocated as adjuncts to the Bassini repair such as the Tanner slide, whereas the latter is accomplished without distorting the normal anatomical lie of the structures comprising the inguinal canal with consequent absence of tension. The integrity of the repair in the prosthetic operation does not depend on a protracted healing process but is mechanically sound from the moment the mesh prosthesis is sutured into position and before the patient leaves the operating table. Patients are reassured to this effect. It is this freedom from distortion and tension in the wounds that explains, in my opinion, the relative comfort of prosthetic hernioplasty patients postoperatively as several of my patients, who have had previous experience of a Bassini operation and who have thus been able to compare, have spontaneously observed. Finally, patients of mine would not know what constituted the 'gentle sexual intercourse' [sic] allowed by Mr Gilmore (Annals 1993, vol 75, p216) in the second postoperative week. I say to all of them, quite simply, go for it, and they do!
I would like to comment on the article by Jones et al. (Annals, May 1993, vol 75, p154). Risk to surgeons is of great concern in in areas of high HIV prevalence such as sub-Saharan Africa. Unfortunately, the disposable seamless gowns advocated by the authors are unlikely to be readily available in such areas and are likely to be prohibitively expensive. Much of the risk can be removed by wearing a non-sterile apron under the surgeon's gown for all cases. This protects the trunk and legs. Obstetric gauntlets, which protect the forearm, can be worn for cases where the risk of contamination of the forearm is present. R S DREW FRCS Medical Superintendent Elim Mission Hospital Zimbabwe
LAURENCE TINCKLER TD MD ChM FRCS FACS
Lieutenant Colonel RAMC (V)
Jamestown Hospital Island of St Helena South Atlantic Ocean References 1 Tinckler LF. Pre-peritoneal prosthetic herniorrhaphy. Br MedJ7 1968; 4: 832. 2 Tinckler LF. Pre-peritoneal prosthetic herniorrhaphy. Postgrad Med 7 1969; 45: 664-7. 3 Tinckler LF. Pre-peritoneal Prosthetic Herniorrhaphy. A Monograph in the series Advancing with Surgery. Ethicon Ltd., 1972.
Comparative vascular audit using the POSSUM scoring system
I read the above article with interest (Annals, May 1993, vol 75,
p175). I would like to draw your attention, and the attention of readers of the Annals, to the fact that POSSUM is a computerised database which has been developed in Australia for the diagnosis of multiple malformations in children both with dysmorphic features and intellectual disabilities. The acronym is as follows: P -Pictures O-Of S -Standard S -Syndromes U-Unknown M-Malformations This product is now being marketed worldwide to 44 countries and a number of systems are also in use in the United Kingdom. For those who are interested, additional details can be obtained by writing to Dr Agnes Bankier, Project Manager, POSSUM Program, The Murdoch Institute for Research into Birth Defects Limited, Royal Children's Hospital, Parkville, Victoria 3052, Australia. N A MYERS AM MD FRCS FRACS Royal Children's Hospital Melbourne, Australia
An improved method for oesophageal intubation We found it difficult to understand why Bramhall et al. (Annals, May 1993, vol 75, p189) describe their modified technique for prosthetic intubation of oesophageal malignancy as 'an improvement', when it causes a perforation rate of over 20%, higher than any previously recorded in the literature. This is a high cost for the slight advantages of a possibly shorter procedure and avoiding the use of radiology, though the patients are still subjected to general anaesthetic rather than simple sedation. Even if mortality was not excessive, these perforations increase the hospital stay of these terminally ill patients, which is inadvisable on social and financial grounds. Controlled introduction of a tube under radiological guidance using a device such as the Nottingham Introducer (1) gives
450
Comment
Table I
Series Atkinson et al. (1978) Bennett et al. (1981) Watson (1982) Gasparri et al. (1987) Bueset et al. (1987) van den Brandt-Gradel et al. (1987) Bramhall et al. (1993) Our series
GA or sedation
Perfor- MorX-ray Number ation tality
GA or Yes sedation Sedation Yes GA or Yes sedation
820
9
?
32 248
9 2
15.6 7.6
Sedation Sedation
Yes Yes
144 400
7.8 7
GA
No
50
20.8
12
Sedation
Yes
50
4
6
4.3 4
acceptably low rates of perforation (see Table I). In our last 50 intubations our perforation rate has been 4%. There are several other available palliative techniques which are safe (2). Before changing to a technique with less control, operators should be sure that it offers true advantages in the desired end results-quick, effective and safe restoration of adequate swallowing. JOHN R BENNETT MD FRCP Consultant Physician MOUNEs DAKKAK PhD MRCP Consultant Physician (Locum)
Hull Royal Infirmary
References 2 Atkinson M, Ferguson R. Fibreoptic endoscopic palliative intubation of inoperable oesophagogastric neoplasms. Br Med7 1977; 1: 266-77. 2 Cox J, Bennett JR. Light at the end of the tunnel? Palliation for oesophageal carcinoma. Gut 1987; 28: 781-5.
Gunshot wounds of the colon: ballistic considerations While I agree with Gregori's assertion (Annals, May 1993, vol 75, p214) that some gunshot wounds to the colon are amenable to primary repair, I must take issue with his views on ballistics. He follows what Lindsey called 'the idolatry of velocity' (1) and further clouds the issue with a misleading statement on the velocity of bullets from various weapons. The crucial matter determining the damage caused by a bullet is not its velocity but the energy which it transfers in its path through the tissues. This is determined by the tissues encountered as well as the ballistic characteristics of the weapon (2). For example, the wound track through skin and muscle is associated with much less damage than when bone is struck. In the latter case, far more soft tissue is injured, in addition to the bony damage, since the bullet is rapidly retarded, destabilised and possibly fragmented in the tissues, giving up more energy. Bullets from some weapons have a tendency to become unstable earlier than others in their track through tissue; this contributes to their energy transfer and hence the extent of tissue damage
(3). It is the latter phenomenon which accounts for the differences in injury seen in some wounds from the AK47 ('Kalashnikov') compared with the M16 ('Armalite'). It is misleading of Gregori to label the AK47 as a low-velocity weapon. Its muzzle velocity (around 720 m/s) is less than that of the M16 (around 900 m/s) but is far greater than the velocity of the handgun bullets conventionally regarded as being 'low velocity' (less than 300 m/s). All of that being said, what does it matter to the surgeon? Not much-for in many cases the weapon is unknown, but the injury can be assessed clinically. Hence, if the extent of bowel disruption is felt to be compatible with primary repair then this approach may be followed (4), regardless of the mass or velocity of the projectile which has caused the injury. It is worth reiterating that surgeons should assess, and treat, the wound not the presumed weapon. G W BOWYER FRCS Lecturer in Military Surgery Royal Army Medical College London
References I Lindsey D. The idolatry of velocity, or lies, damned lies and ballistics. J Trauma 1980; 20: 1068-9. 2 Cooper GJ, Ryan JM. Interaction of penetrating missiles with tissues: some common misapprehensions and implications for wound management. BrJ Surg 1990; 77: 606-10. 3 Fackler ML, Bellamy RF, Malinowski JA. The wound profile: illustration of the missile-tissue interaction. J. Trauma 1988; 28 (Suppl): S21-9. 4 Demetriades D, Pantanowitz D, Charalambides D. Gunshot wounds of the colon: role of primary repair. Ann R Coll Surg Engl 1992; 74: 381-4.
Benign thyroid disease and vocal cord palsy Rowe-Jones et al. (Annals, July 1993, vol 75, p241) have rightly emphasised the importance of preoperative laryngeal assessment prior to thyroid surgery. Further, the apparent relationship of preoperative paresis to benign thyroid disease is illustrated well and evaluated. However, although depicting two patients as having an alternate paralysis (1), no attempt has been made to explain this unusual finding. Certainly, in one patient, the concept that a relatively rigid trachea is deviated by the solitary lesion against a somewhat resistant contralateral thyroid lobe leading to nerve compression is supported by one case, but not the other. In both recovery, and non-recovery groups, it is possible that some of the pareses may have been due to idiopathic paralysis (2) totally unrelated to the thyroid disease. In this situation it was shown that recovery, as well as a persistent paralysis, could occur, a possibility discussed in detail elsewhere (3). R T J HOLL-ALLEN FRCS
Consultant Surgeon
Birmingham Heartlands Hospital Bordesley Green East References 1 Holl-Allen RTJ. Laryngeal nerve paralysis and benign thyroid disease. Arch Otolaryngol 1967; 85: 121-3. 2 Faaborg-Anderson K. Idiopathic recurrent nerve paralysis. Acta Otolaryngol Scand Suppl 118 1954: 68-91. 3 Holl-Allen RTJ. A clinical investigation into the apparent relationship between recurrent laryngeal nerve paralysis and benign thyroid disease. 1972. MD Thesis, University of London.
