The long posterior flap amputation designed by Kendrick ( I ) and subsequently widely applied by Burgess and Romano (2) in conjunction with an immediate peroperatively fitted prosthesis or without, as reported by Hunter-Craig (3), has now established the place of below-knee amputation in the treatment of patients with an ischaemic extremity which cannot be salvaged by a vascular surgical procedure.Despite its success in permitting this level of amputation in patients who would otherwise have had their amputation at above-knee level, there are a few drawbacks to the surgical technique. The operation is time consuming as considerable shaping of the soft tissue is required, and even in the hands of an experienced operator the stump can be initially unsatisfactory. While much reduction in prominent soft tissue can occur with use of the immediate peroperatively fitted prosthesis, subsequent bandaging to produce late reshaping of the stump entails a delay before a cast can be made for a patellar tendonbearing socket, which adds to the time that the patient may wait or need to stay in hospital before he or she can receive an initial prosthesis.A method of below-knee amputation is described in which the advantage of the long posterior flap technique is maintained but the operation is simplified to produce a durable stump with parallel sides and a hemispherical end from the conclusion of the operation, so that early casting and the provision of a patellar tendon-bearing socket can be achieved. This has been used in amputation for both ischaemia and orthopaedic conditions. Patients and methodsThe limb is shaved and is prepared by an application ofpovidone iodine solution in the ward 2 h before surgery. The foot and any septic lesion is isolated in a sealed polythene bag. The whole limb is wrapped in a dry sterile sheet. The perineum is covered by a large wool pad held in place with orthopaedic briefs or a T bandage. Penicillin and mptronidazole prophylaxis is used routinely. Benzyl penicillin 600 mg is given intramuscularly 1 h before operation and 6-hourly for 5 days, with metronidazole suppositories I g 4 h before operation and &hourly also for 5 days.The operation is performed under a general anaesthetic with a muscle relaxant or with a regional anaesthetic technique. either spinal or epidural anaesthesia being frequently used in our patients. A tourniquet is not applied in those patients with degenerative vascular disease.The skin flaps are marked on the skin before any incision. (Figs. I and 2). The skin flaps are semicircular. based on a line around the limb at right angles to its long axis, drawn at the plane of bone section 10-12cm from the joint line at the tibial plateau.The circumferential mark is bisected by a diameter rotated by 20 from the vertical axis. achieved by marking a point overlying the middle of the anterior tibial compartment and using a thread or tape to measure the circumference. which is then halved to indicate the opposite point on the posteromedial aspect of the limb. Thc anterior junction bet...

A prospective randomized trial was conducted on 301 adult males undergoing inguinal herniorrhaphy to assess the value of postoperative suction drainage. Hernias were classified into 'complicated' and 'simple'. In the 'complicated' group suction drainage for 24 h significantly reduced the incidence of wound haematoma, seroma or infection from 48.7 per cent to 17.6 per cent (P < 0.01); there was also a noticeable effect on the postoperative morbidity in the 'simple' hernias, although this just failed to achieve significance (4.5 per cent in the suction group compared with 9.8 per cent in the controls). It is concluded that suction drainage should be employed postoperatively following repair of hernias where dissection may be difficult or where other complicating factors are present.

Two cases of successful vein patch repair of the common bile duct are reported, with follow-up periods of 9 years and one year respectively.

resin while three remained untreated. Anticoagulation was achieved with heparin and blood flow maintained at 200 ml/min throughout haemoperfusion (two hours).Both forms of haemoperfusion significantly reduced plasma paraquat levels (P<0 05) compared with control values (see fig.), cation exchange resin being more effective than activated charcoal (P < 0.05). Plasma paraquat clearances remained consistently high using cation exchange but were lower and more variable with activated charcoal. After haemoperfusion plasma paraquat concentrations increased in both treated groups. Paraquat concentrations approached control values 30 minutes after charcoal haemoperfusion but took 90 minutes after cation exchange haemoperfusion. Conversion: SI to Traditional Units-Paraquat: 1 ,Lmol/ 0-26 mg/l. Activated charcoal reduced blood platelet concentrations by 40% and cation exchange resin reduced them by 50%. The cation exchange resin was equilibrated before haemoperfusion with electrolyte solutions, and subsequently plasma calcium, magnesium, sodium, and potassium remained normal. DiscussionProgressive lung fibrosis leading to respiratory failure remains the most important lethal complication of paraquat poisoning in man, though renal failure is also common. Early reports suggested that paraquat exerts its toxic effect in a "hit and run" fashion.3 Recently, however, paraquat has been shown in vivo to accumulate selectively in rat lung2 and in vitro in rat and human lung by similar mechanisms.After oral dosage of paraquat to rats sustained plasma paraquat concentrations of about 3-9 tmol/l (1 mg/l) resulted in paraquat accumulating in the lung and in death.2 Repeated oral doses of sorbents (bentonite, Fuller's earth) effectively reduce gastrointestinal absorption of paraquat resulting in reduced plasma paraquat concentrations and preventing lung damage and death.2In man paraquat removal has been attempted using forced diuresis,' peritoneal dialysis,4 and haemodialysis.5 The treatment we propose for rapid and efficient reduction of paraquat concentrations combines the haemoperfusion methods described here with forced diuresis and repeated administration of oral sorbents. The platelet falls we saw are acceptable.The rebound in plasma paraquat concentration after haemoperfusion may be partly due to the method of paraquat administration, but may indicate the necessity for prolonged haemoperfusion, especially when renal excretion is impaired by concomitant acute renal failure. Though proximal gastric vagotomy is generally regarded as a safe operation' occasional complications have occurred.2 Of particular importance is necrosis of the lesser curve of the stomach which may be accompanied by fatal peritonitis. We describe a patient who underwent routine proximal gastric vagotomy and developed a gastric fistulaa previously unrecorded complication of this procedure. Case ReportA previously fit 41-year-old man was admitted for elective surgery for a chronic duodenal ulcer. He had a 15-year history of recurrent dyspepsia. Barium meal exa...

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