This review examines the incidence and implications of overwhelming infection in patients who have undergone splenectomy following trauma.Few topics have been so widely discussed in the last 10 years as the treatment of splenic trauma. Although splenectomy was considered the treatment of choice until recently, it is now held responsible for the onset of overwhelming postsplenectomy infection (OPSI) immediately or many years after surgery'.A large number of experimental and clinical studies from all over the world have contributed to our understanding of the physiology of the spleen and its role in the immunological defence against bacterial Several alternatives to splenectomy (non-operative treatment, splenic embolization, ligation of the splenic artery, splenorrhaphy, partial splenectomy, spleen autotransplantation) have been suggested and adopted after careful experimental studies5-'. Far from clarifying the ideal treatment for splenic trauma, the great mass of data render the choice of surgical treatment even more confusing. This is mainly due to failure to define the precise incidence of OPSI after splenectomy for trauma. The aim of this review is to stimulate a rational approach to resolve these problems. Definition of OPSIAlthough it is believed that Morris and Bullock were the first to hypothesize a n increased incidence of infection after splenectomy in 19199, it was not until 1952 that OPSI became seriously considered. In fact in that year King and Shumacker reported that two of five children who underwent splenectomy for spherocytosis died from the sudden onset of OPSI1o.The onset is sudden, the patient presenting with nausea, vomiting and mental confusion. He then goes into a coma and death occurs within a few hours of the onset of symptoms. Disseminated intravascular coagulation, severe hypoglycaemia, electrolyte imbalance and shock are frequently associated with OPSI'4. In our view, this clinical picture should be present when OPSI is diagnosed. On the contrary many authors have included under the heading OPSI other pathologies, such as subphrenic abscesses and laparotomy wound infections. These are related to the trauma but we d o not think that they should be part ofthe OPSI syndrome as they are not 'specific' septic events linked to splenectomy. In fact, they can also be observed after trauma to the liver, pancreas and especially to the large bowel.It is not easy t o give a precise evaluation of the incidence of OPSI despite the wealth of published information. In our opinion an exact definition of OPSI must be established, especially in the immediate postoperative period as fever, leucocytosis and pulmonary infections frequently occur also after other types of surgery. It is also vital to differentiate between data concerning OPSI incidence and mortality rate inThe clinical picture of OPSI is generally patients splenectomized for splenic trauma and those operated on because of haematological diseases. Incidence of OPSIO'Neal and McDonald reported 256 adults who had undergone ~plenectomy'~; 187 of...

Internal hernias account for 0.2-0.9 % of all small bowel obstructions and are associated with a mortality rate of 50 % when strangulation is present. Congenital mesocolic hernias, traditionally called paraduodenal hernias, caused by an abnormal rotation of the primitive midgut, are the most common type of internal hernia. They can be divided into three types: the right and the left congenital mesocolic hernias, accounting for the 25 and 75 % of all cases, respectively, and the extremely rare transverse congenital mesocolic hernia. A high preoperative misdiagnosis rate has been reported and a surgical exploration is recommended to identify strangulation. The present case report describes a case of small bowel obstruction due to an unusual variant of congenital mesocolic hernia never previously reported in the literature. We discuss the clinical appearance, pathogenesis, diagnosis, and treatment of the case, with a brief review of the literature focused on the pathogenesis and management of mesocolic congenital hernias.

Complex abdominal wall defects (CAWDs) can be difficult to repair and using a conventional synthetic mesh is often unsuitable. A biological mesh might offer a solution for CAWD repair, but the clinical outcomes are unclear. Here, we evaluated the efficacy of a cross-linked, acellular porcine dermal collagen matrix implant (Permacol) for CAWD repair in a cohort of 60 patients. Here, 58.3% patients presented with a grade 3 hernia (according to the Ventral Hernia Working Group grading system) and a contaminated surgical field. Permacol was implanted as a bridge in 46.7%, as an underlay (intraperitoneal position) in 38.3% and as a sublay (retromuscolar position) in 15% of patients. Fascia closure was achieved in 53.3% of patients. The surgical site occurrence rate was 35% and the defect size significantly influenced the probability of post-operative complications. The long-term (2 year) hernia recurrence rate was 36.2%. This study represents the first large multi-centre Italian case series on permacol implants in patients with a cAWD. our data suggest that permacol is a feasible strategy to repair a CAWD, with acceptable early complications and long-term (2 year) recurrence rates.

It is a common opinion that general surgery is the first step for whoever approaches a surgical discipline, and that whoever practices training in general surgery should learn the rudiments of each surgical branch. The role of microsurgery in the training of the general surgeon has not been well-established. Clinical applications of microsurgery in general surgery are few and are rarely required, and have been connected strictly to restricted indications. However, we think that microsurgery could be very useful to the general surgeon because it allows the execution of experimental research on rats, the only possibility permitted by law. In these studies the microsurgeon can perform many times and in a short time the same surgical operation, thus improving his skill, and easily getting familiarity with surgical instruments and sutures.

The authors report their experimental studies on early nutritional changes in 30 gastrectomized rats where intestinal continuity was restored by three different reconstruction methods, i.e., exclusion of the duodenum from alimentary transit (Sweet-Allen method), or duodenal recanalization (Longmire method) or double duodenal and jejunal recanalization (Moricca method). Ten sham operated rats were used as controls. Results showed that the group of rats which underwent Longmire's reconstruction presented better nutritional parameters (body weight gain, daily food intake, feeding efficiency, albuminemia) than the Moricca and Sweet-Allen reconstruction groups. These results became statistically significant when follow up was extended to 18 months by using an actuarial method. However, perioperative mortality rate was highest in the Longmire reconstruction group.