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Fri Feb 24 05:14:50 GMT 2006

Dean

The idea is to always suture hernia prone tissue with a permanent suture. The diaphragm is partly muscle, but mostly tendonous and this tissue does not heal as well. There have been reports of re-herniation / breakdowns. So yes, I would alwys use a non-absorbable, even if I use PDs for midline sheath.

Tim

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dean Lutrin
Sent: Friday, February 24, 2006 12:34 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: A woman shot by her husband

Hi Tim

Do you really think that it is necessary to use non absorbable suture on the
diaphragm?

After a few weeks, I am sure that the muscle has fibrosed shut and the
suture is no longer important. I think that the preoccupation with non
absorbable suture for the diaphragm predated sutures like PDS and hence non
absorbable was the way to go.

Disagree?? Keen on hearing your opinion

Dean Lutrin
Surgical Registrar
JHB, SA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Hardcastle Tim, Dr <tch at sun.ac.za>
Sent: 23 February 2006 02:15 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: A woman shot by her husband

Dr Georgio

The first principle of diaphragm repair is NON-ABSORBABLE suture,  we
usually use Ethibond or Tychron. The second is that you need healthy tisse
to be approximated. I would have placed some form of mesh over the thoracic
surface of the diaphragm. The usual options are Polipropolene or PTFE, with
the latter havinng a higher sepsis rate, but better functional result.

Contamination that is "washable" is not shown to increase the rates of
sepsis - so the mesh should be safe. Afterall, most gastric juice is sterile
if cultured soon after trauma. I presume the stomach was simply sutured??
The liver should be left alone. the left lung, if not bleeding is best left
to heal by itself - no need to remove all the pellets!!

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (SU)
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Department of Surgery Room 4064
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of geokgeo at otenet.gr
Subject: A woman shot by her husband
 A woman 64y/o ,120 Kgr ,was shot by her husband while she was sleeping.
(He approached the barrel of a hunting -gun under her left breast and he
shot)
Left breast sheared off the thoracic wall. The pellets entered in the
abdomen ,shattered a part of the left hemidiaphragm and
perforated  the stomach .A linear quite superficial laceration of the liver
across the attachment of the round ligament was also
present. Spleen was intact as was the myocardium .Pellets were found on the
lower lobe of the left lung.

A question arised while taking care of the  diaphragm. We repaired it with
horizontal mattress sutures of 1-0 Vicryl reinforced with running suture.
Due to the destruction of the diaphragmatic muscles the sutures in some
places were not full thickness and they simply approximated the peritoneum
Should we had use prothetic mesh ? We preferred not ,  while pellets were
everywhere and we thought the trauma to be potentially contaminated.
Questions.
-Is it safe to use mesh in such cases ?
-Is the lack of full thickness approximation of the muscles going to cost to
the integrity of the diaphragm ?
I will  appreciate your comments .
Thanks in advance.
G.C.Georgiou
Xanthi General Hospital
Greece

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A woman shot by her husband