- Email: [email protected]
Basic surgical research
Letters to the editors
Small bowel obstruction after laparoscopie cholecystectomy as a result of a Maydl's herniation of the small bowel through a t r o c a r site
A high index of suspicion in the postlaparoscopic patient with small bowel obstructive symptoms is necessary for p r o m p t diagnosis and treatment.
To the Editors: We are reporting an unusual case of a patient with a small bowel obstruction caused by a Maydl's hernia after a laparoscopic cholecystectomy. Small bowel obstruction after laparoscopy was first reported in 1974.1 Larger series of this complication have reported an incidence of 0.1% in 1977 to 1% in 1995. 2 All of these reports described small bowel obstruction association'with Richter's hernia. An 65-year-old obese woman was admitted to Mercy Hospital with colicky abdominal pain 7 days after a laparoscopic cholecystectomy with cholangiogram that was performed at another hospital; The trocar site fascia had been closed with #1 polyglactin 910 sutures. Abdominal x-ray films on admission were constitent with a partial bowel obstruction; a computed tomography scan performed at the referring hospital was significant only for an ileus. A subsequent gastrointestinal series revealed a complete obstruction at the level of midjejunum. The patient underwent an operation, and a Madyl's hernia consisting of small bowel through the l0 m m trocar site was found. The bowel was viable and easily reduced into the peritoneal cavity, and the incision including the fascia was closed. The patient had an uneventful recovery and was discharged on postoperative day 4. All prewous reports of small bowel obstruction after laparoscopic cholecystectomy have describe a Richter's hernia as the cause of the obstruction. I A Maydl's hernia is one in which the hernial sac contains two loops of bowel with another loop of bowel being intraabdominal. 2 The intraabdominal closed loop may become gangrenous in the presence of viable loops in the hernial sac. Trocar site herniations with small bowel obstruction are usually Richter's hernias; however, other types of hernias are possible including Maydl's hernia. 3 It has been found to occur through large trocar sites (10 to 12 ram). It is thought to take place as the a b d o m e n decompresses at the end of the procedure. The typical patient is obese and presents with obstructive symptoms 3 to 7 days after a laparoscopic procedure. Computed tomography scan has been reported to be diagnostic in obese patients (not present in this patient). Suggestions to avoid this complication have included (1) the use of smaller trocars (5 ram) whenever possible. (2) creating a Z-plasty type pathway through the fascia with trocar insertion, (3) repairing the fascia u n d e r direct vision (often difficult in obese patients), and (4) desufflating the abdominal cavity through the subxiphoid site.
Elizabeth Bender, MD Harry Sell, MD Department of General Surgery Mercy Department of Pittsburgh 1400 Locust St. Pittsburgh, PA 15219
480
SURGERY
References 1. Hass B. Small bowel obstruction due to Richter's hernia after laparoscopic procedures, J Laparoendosc Surgery 1993;4:421-3. 2. Ganesaratnam M. Maydl's hernia: report of a series of seven cases and review of the literature. BrJ Surg 1985;72:73%8. 3. Boike G. Incisional bowel herniations after operative laparoscopy: a series of nineteen cases and review of the literature. Am J Obstet Gynecol 1994;172:1726-30.
11/59/69227
Basic surgical research To the Editors: I read with interest the address by Graham 1 about surgical research, and I totally agree with her opinion. Indeed, basic surgical research is a universal problem. In France this research was underdeveloped. Two reasons were the small n u m b e r of surgical laboratories and a confusion that existed between training for surgical techniques and surgical research. Therefore it has been a top priority to develop surgical research in laboratories. The first step was to train the young residents and the chief residents for basic research. However, the n u m b e r of surgical departments with a research program was too small to develop a substantial n u m b e r of residents for training; The only way was to train them in other laboratories such as the Health National Institute for Medical Research or the National Center for Scientific Research or in foreign laboratories, mainly in the United States. It was also necessary to arouse the interest of surgical residents in surgical research and training in the laboratory. Contributing to this is the fact that, since 1985, to become associate professor in France it has been necessary to possess a Dipl6me d'Etudes Approfondies.2 In 1986 we created a National Dipltme d'Etudes Approfondies in Surgical Sciences, the aim of which was to allow young surgeons to train in research by working full-time in a laboratory for 1 year. 3 To be eligible for the diploma, candidates have to run a research project in accordance with the diApril 1996
Surgery Volume 119, Number 4
Letters to the editors
rector of the laboratory. The projects for a scientific publican o n are examined by referees. Candidates also have to attend two seminars of 2 days each, one about scientific writing a n d communication and the other o n methodology in surgical research. During the year for diploma, theoretical teaching completes the work in laboratory. Because the laboratories are located in various French universities, this theoretical teaching is organized in two 4-day seminars. T h e first seminar deals with general problems on surgical research in laboratories. T h e participants may then choose one of four options according to the t h e m e of their research: transplantation, oncology, biomaterials and artificial organs, and, since 1990, neurosciences. For the year of research residents are paid by university hospitals or through grants. At the end of the year of research residents have to present a report on their work to a board of examiners and are tested o n theoretical matters in the option they have chosen. From this experience two strategies may be considered. The first one to consider is that university surgeons, heads of departments, should r u n surgical research laboratories where young residents may be trained. Because this activity is timeconsuming, they will perform only highly specialized surgery. T h e training for general surgery therefore has to be performed in general hospitals as is the case in Japan. T h e other strategy is to perform in university departments all types of surgery that will ensure adequate training for residents. Research trmning will then be performed in nonsurgicai laboratories. The French experience with such a system shows that it is possible in collaboration with immunologists, biochemists, or other colleagues of basic sciences. Furthermore, the residents who spent 1 year in a laboratory created ties between research restitutions and surgical teams that were considered to be vital both by the departments of surgery a n d by the laboratories. Michel Huguier, MD Professor of Surgery Universit~ Pierre et Marie Curie H6pital Universitaire Tenon 4 Rue de la Chine 75020 Paris, France References 1, Graham LM. Presidential address: surgical research--facing new realities. SURGERY1995;118:1232-9. 2, D6cret du 24 f6vrier 1984 portant statut des personnels enseignants et hospitaliers des centres hospitaliers et universitaires. Paris: Journal Officiel, 25 f~vrier 1984 (article 61). 3. Huguier M, Poitout D. Diplome d'etudes approfondies (DEA) en Sciences Chirurgicales. Ann Chir 1986;40:449-53.
11/59/70917
Reply To the Editors: I appreciate Professor Huguier's thoughtful comments a n d insights into training surgeons in research. T h e steps taken to improve surgical research training in France provide valuable ideas that may be useful in other centers. Clearly, the problems faced in the United States are not unique, a n d sharing ideas
481
within the international surgical community will lead to better training programs. Linda M. Graham, MD Professor of Surgery Division of Vascular Surgery Case Western Reserve University 111 O0 Euclid Ave. Cleveland, OH 44106
11/59/70916
Use o f somatostatin analogm the management o f traumatic parofid fistula To the Editors: Numerous methods including complete fasting, parasympatholytic drugs, a n d irradiation have b e e n advocated for treating salivary fistulas, b u t n o n e of these was f o u n d to be totally satisfactory. We report a case of successful use of octreotide in the treatment of traumatic parotid fistula. A 33-year-old m a n sustained an 8 cm long cut wound to the left Side of his face. Clinically the facial nerve was intact and the main duct was too anterior to be involved. Exploration and careful suturing were performed. A sialocele was detected 4 days after the injury. Siaiographic study showed no major ductal injury. The wound was explored and the collection was drained. A closed suction drain was placed. Bacterial culture of the drained fluid showed no growth. The amylase concentration of the drained fluid was greater than 1800 units/L (normal, 30 to 110 units/L). He was treated conservativelywith complete fasting. By the e n d of 1 week it was evident that the salivary output was persistently high (60 to 80 ml/day). Furthermore. the patient f o u n d fasting difficult to tolerate. Administration of octreotide 0.1 mg three times per day subcutaneously was started, and a p r o m p t and remarkable response in the daily salivary output was observed. The output decreased to 10 to 20 ml per day after 2 days of treatment. We took off the drain o n day 10. T h e fistula healed completely after 2 weeks of octreotide treatment, even though h e h a d eaten a normal oral diet: T h e treatment was well tolerated without any side effects. The patient was well 9 months after the treatment. The pathophysiology of healing of a parotid fistula was well described by Arupragasam.1 A dynamic situation occurs at the site of a healing fistula. T h e granulating tissue attempts to grow over a n d heal the leaking acini a n d ducts. This is counteracted by the leaking pressure built u p as a result of saliva secretion especially at meals. Therefore when the rate of secretion of saliva is suppressed or stopped, healing is allowed to proceed with a m u c h greater tendency. Somatostatin can reduce the volume of salivary secretion in h u m a n beings without affecting the salivary amylase concentration, 2 although the mechanism of its action is still unknown. Nonetheless, it avoids the unpleasant r e q u i r e m e n t of complete fasting, side effects of parasympathetic inhibition, a n d potential hazards of irradiation. Spinell et al. 3 first reported the use of octreotide in the m a n a g e m e n t of postoperative salivary fistula in one patient. A similar clinical course a n d outcome were observed as in our
Small bowel obstruction after laparoscopie cholecystectomy as a result of a Maydl's herniation of the small bowel through a t r o c a r site
A high index of suspicion in the postlaparoscopic patient with small bowel obstructive symptoms is necessary for p r o m p t diagnosis and treatment.
To the Editors: We are reporting an unusual case of a patient with a small bowel obstruction caused by a Maydl's hernia after a laparoscopic cholecystectomy. Small bowel obstruction after laparoscopy was first reported in 1974.1 Larger series of this complication have reported an incidence of 0.1% in 1977 to 1% in 1995. 2 All of these reports described small bowel obstruction association'with Richter's hernia. An 65-year-old obese woman was admitted to Mercy Hospital with colicky abdominal pain 7 days after a laparoscopic cholecystectomy with cholangiogram that was performed at another hospital; The trocar site fascia had been closed with #1 polyglactin 910 sutures. Abdominal x-ray films on admission were constitent with a partial bowel obstruction; a computed tomography scan performed at the referring hospital was significant only for an ileus. A subsequent gastrointestinal series revealed a complete obstruction at the level of midjejunum. The patient underwent an operation, and a Madyl's hernia consisting of small bowel through the l0 m m trocar site was found. The bowel was viable and easily reduced into the peritoneal cavity, and the incision including the fascia was closed. The patient had an uneventful recovery and was discharged on postoperative day 4. All prewous reports of small bowel obstruction after laparoscopic cholecystectomy have describe a Richter's hernia as the cause of the obstruction. I A Maydl's hernia is one in which the hernial sac contains two loops of bowel with another loop of bowel being intraabdominal. 2 The intraabdominal closed loop may become gangrenous in the presence of viable loops in the hernial sac. Trocar site herniations with small bowel obstruction are usually Richter's hernias; however, other types of hernias are possible including Maydl's hernia. 3 It has been found to occur through large trocar sites (10 to 12 ram). It is thought to take place as the a b d o m e n decompresses at the end of the procedure. The typical patient is obese and presents with obstructive symptoms 3 to 7 days after a laparoscopic procedure. Computed tomography scan has been reported to be diagnostic in obese patients (not present in this patient). Suggestions to avoid this complication have included (1) the use of smaller trocars (5 ram) whenever possible. (2) creating a Z-plasty type pathway through the fascia with trocar insertion, (3) repairing the fascia u n d e r direct vision (often difficult in obese patients), and (4) desufflating the abdominal cavity through the subxiphoid site.
Elizabeth Bender, MD Harry Sell, MD Department of General Surgery Mercy Department of Pittsburgh 1400 Locust St. Pittsburgh, PA 15219
480
SURGERY
References 1. Hass B. Small bowel obstruction due to Richter's hernia after laparoscopic procedures, J Laparoendosc Surgery 1993;4:421-3. 2. Ganesaratnam M. Maydl's hernia: report of a series of seven cases and review of the literature. BrJ Surg 1985;72:73%8. 3. Boike G. Incisional bowel herniations after operative laparoscopy: a series of nineteen cases and review of the literature. Am J Obstet Gynecol 1994;172:1726-30.
11/59/69227
Basic surgical research To the Editors: I read with interest the address by Graham 1 about surgical research, and I totally agree with her opinion. Indeed, basic surgical research is a universal problem. In France this research was underdeveloped. Two reasons were the small n u m b e r of surgical laboratories and a confusion that existed between training for surgical techniques and surgical research. Therefore it has been a top priority to develop surgical research in laboratories. The first step was to train the young residents and the chief residents for basic research. However, the n u m b e r of surgical departments with a research program was too small to develop a substantial n u m b e r of residents for training; The only way was to train them in other laboratories such as the Health National Institute for Medical Research or the National Center for Scientific Research or in foreign laboratories, mainly in the United States. It was also necessary to arouse the interest of surgical residents in surgical research and training in the laboratory. Contributing to this is the fact that, since 1985, to become associate professor in France it has been necessary to possess a Dipl6me d'Etudes Approfondies.2 In 1986 we created a National Dipltme d'Etudes Approfondies in Surgical Sciences, the aim of which was to allow young surgeons to train in research by working full-time in a laboratory for 1 year. 3 To be eligible for the diploma, candidates have to run a research project in accordance with the diApril 1996
Surgery Volume 119, Number 4
Letters to the editors
rector of the laboratory. The projects for a scientific publican o n are examined by referees. Candidates also have to attend two seminars of 2 days each, one about scientific writing a n d communication and the other o n methodology in surgical research. During the year for diploma, theoretical teaching completes the work in laboratory. Because the laboratories are located in various French universities, this theoretical teaching is organized in two 4-day seminars. T h e first seminar deals with general problems on surgical research in laboratories. T h e participants may then choose one of four options according to the t h e m e of their research: transplantation, oncology, biomaterials and artificial organs, and, since 1990, neurosciences. For the year of research residents are paid by university hospitals or through grants. At the end of the year of research residents have to present a report on their work to a board of examiners and are tested o n theoretical matters in the option they have chosen. From this experience two strategies may be considered. The first one to consider is that university surgeons, heads of departments, should r u n surgical research laboratories where young residents may be trained. Because this activity is timeconsuming, they will perform only highly specialized surgery. T h e training for general surgery therefore has to be performed in general hospitals as is the case in Japan. T h e other strategy is to perform in university departments all types of surgery that will ensure adequate training for residents. Research trmning will then be performed in nonsurgicai laboratories. The French experience with such a system shows that it is possible in collaboration with immunologists, biochemists, or other colleagues of basic sciences. Furthermore, the residents who spent 1 year in a laboratory created ties between research restitutions and surgical teams that were considered to be vital both by the departments of surgery a n d by the laboratories. Michel Huguier, MD Professor of Surgery Universit~ Pierre et Marie Curie H6pital Universitaire Tenon 4 Rue de la Chine 75020 Paris, France References 1, Graham LM. Presidential address: surgical research--facing new realities. SURGERY1995;118:1232-9. 2, D6cret du 24 f6vrier 1984 portant statut des personnels enseignants et hospitaliers des centres hospitaliers et universitaires. Paris: Journal Officiel, 25 f~vrier 1984 (article 61). 3. Huguier M, Poitout D. Diplome d'etudes approfondies (DEA) en Sciences Chirurgicales. Ann Chir 1986;40:449-53.
11/59/70917
Reply To the Editors: I appreciate Professor Huguier's thoughtful comments a n d insights into training surgeons in research. T h e steps taken to improve surgical research training in France provide valuable ideas that may be useful in other centers. Clearly, the problems faced in the United States are not unique, a n d sharing ideas
481
within the international surgical community will lead to better training programs. Linda M. Graham, MD Professor of Surgery Division of Vascular Surgery Case Western Reserve University 111 O0 Euclid Ave. Cleveland, OH 44106
11/59/70916
Use o f somatostatin analogm the management o f traumatic parofid fistula To the Editors: Numerous methods including complete fasting, parasympatholytic drugs, a n d irradiation have b e e n advocated for treating salivary fistulas, b u t n o n e of these was f o u n d to be totally satisfactory. We report a case of successful use of octreotide in the treatment of traumatic parotid fistula. A 33-year-old m a n sustained an 8 cm long cut wound to the left Side of his face. Clinically the facial nerve was intact and the main duct was too anterior to be involved. Exploration and careful suturing were performed. A sialocele was detected 4 days after the injury. Siaiographic study showed no major ductal injury. The wound was explored and the collection was drained. A closed suction drain was placed. Bacterial culture of the drained fluid showed no growth. The amylase concentration of the drained fluid was greater than 1800 units/L (normal, 30 to 110 units/L). He was treated conservativelywith complete fasting. By the e n d of 1 week it was evident that the salivary output was persistently high (60 to 80 ml/day). Furthermore. the patient f o u n d fasting difficult to tolerate. Administration of octreotide 0.1 mg three times per day subcutaneously was started, and a p r o m p t and remarkable response in the daily salivary output was observed. The output decreased to 10 to 20 ml per day after 2 days of treatment. We took off the drain o n day 10. T h e fistula healed completely after 2 weeks of octreotide treatment, even though h e h a d eaten a normal oral diet: T h e treatment was well tolerated without any side effects. The patient was well 9 months after the treatment. The pathophysiology of healing of a parotid fistula was well described by Arupragasam.1 A dynamic situation occurs at the site of a healing fistula. T h e granulating tissue attempts to grow over a n d heal the leaking acini a n d ducts. This is counteracted by the leaking pressure built u p as a result of saliva secretion especially at meals. Therefore when the rate of secretion of saliva is suppressed or stopped, healing is allowed to proceed with a m u c h greater tendency. Somatostatin can reduce the volume of salivary secretion in h u m a n beings without affecting the salivary amylase concentration, 2 although the mechanism of its action is still unknown. Nonetheless, it avoids the unpleasant r e q u i r e m e n t of complete fasting, side effects of parasympathetic inhibition, a n d potential hazards of irradiation. Spinell et al. 3 first reported the use of octreotide in the m a n a g e m e n t of postoperative salivary fistula in one patient. A similar clinical course a n d outcome were observed as in our