Sunday, August 12, 2007

Sunday evening

Incarcerated umbilical hernia today. I've been using Ventralex mesh for these. It's a cool little product that allows a nice underlay repair without having to undermine and create huge ass subcutaneous flaps. No topic incites more debate amongst surgeons than ventral/incisional hernia repairs. I'm from the school of thought that underlay repairs are technically superior. Think of plugging a hole in a barrel with cork. Is the cork going to stay in longer if you stick it in from the inside or the outside? The answer is "on the inside", if you can't wrap your mind around that analogy. By the way "wrap my mind around" is the next hipster phrase. I had an old college buddy who lives in California drop it on me a few months ago. Since then, I keep hearing it more and more, as it works its way back to unhip, three months behind the times midwestern USA. In about two years it will be the punchline to some lame joke on According to Jim. So get in now while it's hot.

But about hernias. It's amazing how many gen surgeons simply close the fascia primarily and suture Marlex as an on-lay reinforcement. There's no doubt recurrences are higher. But the fear of having to go back into an abdomen with intraperitoneal mesh overrides those concerns. Anytime there's such a difference of opinion in surgery, it just means there's no good answer. I think, in the future, optimal repair is going to involve laparoscopic placement of some sort of biologic replacement tissue (like alloderm version-2020).....

Bourne Ultimatum- Go see this flick. Best action movie in years.

I have a guy lives not too far from me with a front lawn that literally looks like the 12th green at Augusta National. I find this highly troubling. Is there any reason for one to install bent grass into a private front lawn? To spend thousands of dollars a year on chemicals and watering regimens and professional upkeep? I mean it would be one thing if he was Jesper Parnevik out there chipping and putting before bed. But it's not. The guy is like 85 years old. If anything, maybe he naps on his luscious green soft grass after his morning enema. I'm tempted to sneak over there one night with my wedge and whack out a few divots....

Great article in the most recent New Yorker (not available on the website unfortunately) about Lesch-Nyhan disease. I'd forgotten what the hell it was. It involves some sort of mutation in the gene coding for purine metabolism and uric acid builds up in the blood. Afflicted individuals exhibit self mutilation, especially of the hands and face. If they live to adulthood, a lot of them have chewed off their lips and fingertips. One patient had removed his right eyeball. Another had gouged off his nose with a dinner fork. They live in a state of terror, from their own actions. And all from one protein being awry.

8 comments:

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Kellie said...

Thanks for the link to the Ventralex site. My youngest son had his incisional hernia repaired in Dec. '06 at Children's and I will have to ask his surgeon next visit if Ventralex was used. The incision was quite small (about 6cm) and Eli bounced back quickly. So far it looks like the repair is holding and there are no other areas of concern along his 16cm scar from his Nissen.

Oh...and by the way...GO BUCKS!

Buckeye Surgeon said...

16 cm scar? Was it an open Nissen or laparoscopic?

Sid Schwab said...

I'm an underlay guy for sure. In fact, I developed my own version of an open inguinal hernia repair using properitoneal placement before anyone was writing about it (or, as now, making special mesh for it.) I just had the surgicenter cut up big pieces of Marlex into a bunch of small ones, made a small opening in the transversalis fascia, and slid it under and unfolded it with a couple of deBakeys. Fifteen minutes, and comparatively painless. Pretty much the same with umbilical/ventral ones.

I agree about the movie. And the New Yorker article.

Kellie said...

His Nissen was open. Eli had prior abdominal complications from his extreme prematurity that necessitated the open vs. lap Nissen. They had to move his old GJ tube site d/t prior placement being too close to his ribs to allow for many years of growth. A new g-tube site was created during the Nissen operation and some old adhesions were also cleaned out. He was only about 7kg at the time of the Nissen.

Thankfully the Nissen helped save his lungs at the time from the terrible aspiration he was suffering from d/t GERD. We're now looking at a pH probe and bronch to see if he is refluxing and aspirating past his fundo. The upper GI, video flouro, endoscopy looked *okay* but his respiratory status is in decline once again. Gotta love complicated patients (especially when they end up being your own children).

Buckeye Surgeon said...

Congrats on the graduation Kellie. Hope the kids are doing better. Sounds like you'll make a great nurse.

Kellie said...

Thanks so much...I start orientation on the 10th. Can't wait for the Buckeye game on Saturday!

Anonymous said...

it is now 3 and 1/2 years later. do you still use ventralex?