Faculty Bibliography

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20(th) century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4(th) century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.

RATIONALE AND OBJECTIVES: Cellulitis is a common cause for emergency department (ED) presentation and subsequent hospital admission. Underlying fracture, osteomyelitis, or foreign body is often considered in the clinical evaluation of these patients. Accordingly, plain radiographs (XRs) of the affected extremity are often ordered during the initial work-up. The utility of these imaging studies in the treatment of uncomplicated lower-extremity cellulitis, however, remains unclear. In an effort to treat this common problem more efficiently, we evaluated our imaging practices and results in a cohort of consecutive patients admitted to a large public city hospital for treatment of uncomplicated lower-extremity cellulitis. MATERIALS AND METHODS: Retrospective cohort study of 288 consecutive ED admissions for treatment of uncomplicated cellulitis, of which 214 met the inclusion criteria for this study. Patient demographics, history, vitals, laboratory values, and test results were evaluated with univariate and multivariate statistical analyses. RESULTS: XRs of the affected lower extremity were obtained in 158 patients (73.8%). Positive XR findings were present in 19 patients (12.0%) and positively correlated with a history of acute trauma to the extremity (P < .001) or the presence of a chronic wound (P < .01). Multivariable logistic regression analysis revealed a history of trauma (P < .001) or the presence of a chronic wound (P < .05) to be independent predictors of positive XR findings with relative risks of 6.24 and 2.98, respectively. CONCLUSIONS: The establishment of evidence-based guidelines for the treatment of lower-extremity cellulitis has potential to significantly improve clinical efficiency and reduce cost by eliminating unnecessary testing. Based on our results, patients without a recent history of trauma to the affected extremity or the presence of a chronic wound do not appear to warrant XRs. When applied to our cohort, only 48 of 158 patients had a history of trauma or chronic wound. This means that 110 patients unnecessarily had plain films taken as part of their initial work-up. In a largely uninsured inner city patient population such as this cohort, that extra cost falls on the public hospital system.

Composite resins have been routinely used for posterior cavities due to a phasedown on amalgam as a restorative option. However, clinical problems related to polymerization shrinkage demands careful and specific techniques for placement of the composite layers. New low shrinkage composites are now marketed for bulk filling of cavities without the need of a traditional layering. With this new concept, the restoration can be built in one or two layers, depending on the classification of the bulk fill material. This article discusses and presents two alternative techniques using the low shrinkage composites, suggesting a called "amalgam-like sculpting technique," one using a flowable bulk fill and other a regular bulk fill material. Clinical cases illustrate these two alternatives compared with the layered technique. CLINICAL SIGNIFICANCE: New techniques using low shrinkage composites for bulk filling can provide a simpler technical approach for the clinician in sculpting and generating highly esthetic posterior composites.

Agnathia-otocephaly complex (AOC) is characterized by mandibular hypo- or aplasia, ear abnormalities, microstomia, and microglossia. Though rare and often fatal, this is the first report detailing various reconstructive strategies beyond infancy as well as longitudinal follow-up into adulthood.All patients with AOC treated at our institution over a 30 year period were reviewed. Four patients were identified, one with agnathia, one with micrognathia. Two males with nanognathia (defined as a symphyseal remnant without body nor ramus) were also included. The mean follow-up was 17 years. All four underwent perinatal tracheostomy and gastrostomy-tube placement. Commissuroplasties were typically performed before 3 years of age and repeated as necessary to allow for oral hygiene. Mandibular reconstruction was most successful with rib between ages 3 and 8, after which time, free fibula transfer was utilized. Due to some resoprtion or extrusion, all patients underwent repeated bone grafting procedures. Tissue expansion of the neck was used to restore the lower third of the face, but was most successful in the teenage years. At last follow-up of the eldest patients, one was in college while another was pursuing graduate education.AOC need not be a fatal nor untreatable condition; a reasonable quality of life can be achieved. Although the lower-facial contour may be improved, and a stoma created, the lack of musculature make deglutition virtually impossible with current therapies. Just as transplantation has emerged as a modality for facial restoration following severe trauma, so too may it be a future option for congenital deformities.

OBJECTIVES: The objective of this histologic study was to determine the effect of three drilling protocols (oversized, intermediate, and undersized) on biologic responses to a single implant type at early healing periods (2 weeks in vivo) in a beagle dog model. MATERIALS AND METHODS: Ten beagle dogs were acquired and subjected to surgeries in the tibia 2 weeks before euthanasia. During surgery, each dog received three Unitite implants, 4 mm in diameter by 10 mm in length, in bone sites drilled to 3.5, 3.75, and 4.0 mm in final diameter. The insertion torque was recorded during surgery, and bone-to-implant contact (BIC), and bone area fraction occupied (BAFO) measured from the histology. Each outcome measure was compared between treatment conditions with the Wilcoxon signed-rank test. Bonferroni-corrected statistical significance was set to 95%. RESULTS: Insertion torque increased as an inverse function of drilling diameter, as indicated by significant differences in torque levels between each pair of conditions (P = 0.005). BIC and BAFO levels were highest and statistically similar in the recommended and undersized conditions and significantly reduced in the oversized condition (P < 0.01). CONCLUSIONS: Reduced drilling dimensions resulted in increased insertion torque (primary stability). While BIC and BAFO were maximized when drilling the recommended diameter hole, only the oversized hole resulted in evidence of statistically reduced integration.

We present a case of rapidly ascending left ventricular assist device driveline and tunnel infection in a patient with a long length of driveline buried beyond the distal velour coating. Device salvage with radical debridement, exit site relocation, and local tissue advancement is described. The findings in this case suggest that the interface between nonvelour covered driveline and subcutaneous tissue can become the nidus of a virulent ascending infection because of poor tissue ingrowth.