The management of flail chest continues to evolve as scientific evidence and surgical experience accumulates. Flail chest injuries that span the sternum present a rare and complicated injury pattern that can be challenging to manage both medically and surgically. Our patient is a 69-year-old involved in a high-speed motor vehicle crash with respiratory failure secondary to an anterior flail chest. Tomographic examination confirmed a sternal fracture with bilateral sternochondral dislocations and multiple rib fractures. The rib fractures created a lateral flail segment which extended towards the right side. An open Pectus exposure with a right anterolateral extension (modified Ravitch approach) and osteosynthesis plates accomplished stabilization of the chest wall, and contributed to weaning from mechanical ventilation.

BackgroundTraumatic abdominal wall hernias (TAWHs) are a rare clinical entity that can be difficult to diagnose and manage. There is no consensus on management of TAWH due to its low incidence and complex concomitant injury patterns. We hereby present the largest single-center case series in the USA to characterize associated injury patterns, identify optimal strategies for hernia management, and determine outcomes.MethodsPatients who presented with a TAWH from blunt trauma requiring operative management were retrospectively identified over a 14-year period. Demographic data, Injury Severity Score (ISS), associated injuries, type of repair, durability of repair, and complications were collected, and descriptive statistics were calculated.ResultsFifteen patients were identified. The average age was 31±11 years, ISS 15±9, and body mass index 33.4±7.1 kg/m2. Mechanisms included falls (13%), motor vehicle collisions (60%), motorcycle accidents (20%), and pedestrian versus motor vehicle collisions (7%). The most commonly associated injuries included colonic injuries (53%), long bone fractures (47%), pelvic fractures (40%), and small bowel injuries (33%). Nineteen hernia repairs were performed: 6 underwent primary suture repair (32%) and 13 used mesh (68%). There were four recurrences. We could not find any significant relationship between contamination and mesh use or recurrence. There was one mortality related to sepsis.DiscussionTAWHs have an associated injury pattern involving fractures and abdominopelvic visceral injuries where a tailored approach is advisable. Without hollow viscous injuries and gross contamination, these hernias can be repaired safely with mesh in the acute setting. However, in patients with gross contamination or hemodynamic instability, the risk of recurrence with primary repair must be weighed against the risk of infection and prolonged surgery with mesh repair. In those cases, a delayed reconstruction in the elective setting may be optimal.

Amyand's hernia was coined after Claudius Amyand (1660–1740), who was the first to describe the presence of a perforated appendix in a hernial sac and also was the first to perform a successful appendectomy in 1735. It is an exceptionally rare condition in which the hernia itself contains the appendix, which may not necessarily be inflamed. The presence of an inflamed appendix further contributes to the rarity of this case. We report a case of acute appendicitis brought on by its incarceration in the inguinal hernia.

Objective: To determine the optimal volume of abdominal irrigation that will prevent surgical site infections (both deep and superficial), eviscerations and fistula formations; and improve 30-day mortality in trauma patients. Methods:We conducted a three-arm parallel clinical superiority randomized controlled trial comparing different volumes of effluent (5, 10 and 20 liters) used in trauma patients (both blunt and penetrating) age 14 and above undergoing an emergency laparotomy between April 2002 and July 2004 in a busy urban Level 1 trauma center. Results: After randomization, a total of 204 patients were analyzed. All patient groups were comparable with respect to age, gender distribution, admission injury severity score, and mechanism of injury, estimated blood loss and degree of contamination. The mortality rate overall was 1.96% (4/204).No differences were noted with respect to contamination, wound infection, fistula formation, and evisceration. The twenty liter group (Group III) showed a trend toward an increased incidence of deep surgical site infections when compared to the five liter (Group I) (p=0.051) and ten liter (Group II) (p=0.057) groups. This did not however reach statistical significance. Conclusion: The old surgical adage "the solution to pollution is dilution" is not applicable to trauma patients. Our results suggest that using more irrigation, even when large amounts of contamination have occurred, does not reduce post-operative complications or affect mortality; and it may predispose patients to increased incidence of abscess formation. (Trial registration number: ISRCTN66454589)