INTRODUCTION The aim of this study was to carry out an independent evaluation of the efficacy and security of a number of vessel ligation devices and ligatures.MATERIALS AND METHODS A vascular ligation model was devised using fresh, ex vivo porcine internal carotid arteries of varying external diameters. Coloured normal saline was infused via a pressure/monitor device through the artery. The end lumen was occluded by five different techniques: (i) braided suture in a surgeon's knot; (ii) a monofilament suture in a granny knot; (iii) a metallic clip (Ligaclip, Johnson and Johnson); (iv) a bipolar diathermy system (Ligasure, ValleyLab); and (v) an ultrasonically activated scalpel (Harmonic Scalpel, Johnson and Johnson). The vessels were subjected to supraphysiological pressures. Loss of haemostasis was evident by leakage of coloured perfusion fluid.RESULTS Secure haemostasis was obtained with all the techniques in all vessels below 5m m in diameter. In vessels over 5m m, secure haemostasis was obtained with all modalities except harmonic scalpel. With the harmonic scalpel, leaks occurred in 3/27 (11%) vessels between 5-6 mm and 3/5 (60%) vessels over 6 mm, confirming the manufacturer's instructions.CONCLUSIONS In this first, independent, randomised study comparing vessel ligation devices and ligatures, the manufacturer's claims for each of the haemostatic methods were accurate. We find that all the modalities tested perform as well as the traditional surgeon's knot in vessels of 5 mm and below.

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A 41-year-old man was transferred by ambulance to the emergency department following a road traffic accident. The patient left his home to walk his dog when his wife heard a crash from inside the house and arrived outside to find him 2 m from the roadside and semi-conscious.On arrival at hospital, the patient was talking, had a GCS of 14 (E3, M6, V5) and was haemodynamically stable. On examination, he had severe generalised abdominal tenderness. Other injuries of note included open left tibial and fibula fractures and a left hip abrasion.The patient was stabilised and sent for a computed tomography (CT) scan of his head, neck, chest, abdomen, and pelvis. The CT showed a right renal haematoma with some extravasation of contrast at the level of the pelviureteric junction (Fig. 1). Bone views also showed a fracture through L3 transverse process on the right side (Fig. 2). Other injuries of note on CT scan were right superior and inferior pubic rami fractures and pulmonary contusions.Initially, he maintained good urine output with no haematuria and his renal function was normal. In accordance with local protocol, his open lower limb fractures were fixed on the day of injury. An ultrasound scan the following day, demonstrated no evidence of a perirenal collection/urinoma; therefore, a conservative approach for his urological injury as initially adopted. A follow-up CT scan was performed 2 days' post-injury due to worsening right-sided abdominal pain, tachycardia and hypertension. This showed a larger right pelvicalyceal system leak and likely urinoma (Fig. 3).Retrograde ureteric studies were performed on day 3 post-injury; however, attempts to pass the guide wire into Complete transection of the pelvi-ureteric junction in an adult DT WALKER, F MASSOUH, NJ BARBER Departments of General Surgery and Urology, Frimley Park Hospital, Frimley, UK ABSTRACTWe present a unique case report of a 41-year-old man involved in a hit-and-run accident. The patient suffered a complete disruption of the pelvi-ureteric junction along with a fracture of the L3 transverse process. Occasionally seen in children, we believe this to be the first reported adult case. The report details the presentation and symptoms, with subsequent radiology. This case also demonstrates how using an effective multidisciplinary team approach and the ATLS principles, uncommon injuries can be identified and managed successfully. We revisit the classification of ureteric trauma and the accepted best surgical management.

A 64-year-old woman presented to a dermatologist with male pattern hair loss and was found to have grossly elevated testosterone levels at 22.3 nmol/l (normal range, 0.0-2.9 nmol/l). The diagnosis of an androgen-secreting adrenal tumour was made and she underwent a laparoscopic retroperitoneal right adrenalectomy with an uneventful speedy recovery, being discharged in less than 48 h, underlining the clear advantage of this approach.