Parietal hernias, often also known as Littre's hernia and Richter's hernia, are a special kind of inguinal hernias. In this type of hernia, part of the abdominal (intestinal) wall is strangulated in "calotte form" in the hernial orifice; as a result, parietal hernias often cause only mild complaints and are surgically treated only in the late stage of enterocutaneous faecal fistula. In contrast to incarcerated inguinal hernias resulting in diffuse faecal peritonitis via infarction and necrosis, parietal hernia of the Richter type is locally restricted in extension because of the narrow hernial orifice, as far as the extension into the abdominal cavity is concerned; intestinal patency is usually maintained. The possibility of the existence of a perforated parietal hernia should always be considered in necrotising inflammations in the inguinal and vulvar regions, even if abdominal signs and symptoms are absent.
Between 1958 and 1979, 48 neonates with gastrointestinal perforation were treated in the University Clinic, Mainz. The high rate of premature births (c. 40%) was noteworthy, as were the frequent complications in the perinatal period. An accurate diagnosis was made more difficult by the peculiarities of this age, and the multipilicity of possible causes of perforation. The first clinical symptoms were non-specific. In only 36% of the patients was the so-called "pathognomonic" pneumoperitoneum diagnosed on X-ray. The most common site of perforation was the ileo-coecal region, the commonest causes of perforation were intestinal obstruction (atresias, Hirschsprung's disease) and necrotising enterocolitis. In almost 1/3 of all children, the exact causes of perforation could not be determined from the history, intra-operative findings, or histology. The operative procedure depends on the individual case. It must be suited to the site and cause of the perforation, and to the subsequent disturbances. Of the post-operative complications, those related to paediatric intensive-care proved to be more serious than the directly surgical complications. The total mortality was, at 63%, high. The main cause of death was found to be septicemia, and septic complications. An improvement in the results can only be attained through early diagnosis, immediate operation and peri-operative intensive care.
Ultrasound and computed tomography have been used routinely over the last five years in the diagnosis of acute pancreatitis. This has made classification as to degrees of severity easier. In addition to the direct imaging of destruction of pancreatic parenchyma, these imaging methods also (preoperatively) make an exact assessment of the extension of peripancreatic necrosis and necrosis paths possible, as well as the presence of any gallstone disease or pancreatic abscess. Under the influence of these imaging procedures the indications for operation and the extent of surgical intervention has become more limited. High-risk "early operation" has been drastically reduced in number and is indicated only in very severe disease with organ complications. The "delayed operation" in the postacute stage of disease is largely restricted to local septic complications. Here excision of necrotic tissue and drainage is now largely preferred to resection, previously practised more frequently. Extensive necrotising processes with only minor clinical symptoms have now been observed as a result of early employment of ultrasound and computed tomography. The successful conservative treatment of these uncomplicated disease processes has contributed to an overall reduction in the mortality of postacute pancreatitis.
In 95 patients with acute necrotising pancreatitis the clinical severity of the disease was compared with morphological criteria of operative specimens. In addition, various morphological phenomena, typical in acute and chronic pancreatitis, were investigated in 3 aetiologically different groups. In these groups pathohistologic alterations, associated with aetiological factors, were seen frequently. Furthermore, there was a good correlation between classifications according to gravity criteria in the assessment of the underlying disease. About 90% of cases clinically classified as acute pancreatitis proved, on the basis of the morphology, to be chronic recurrent pancreatitis. It thus follows that "genuine" acute pancreatitis is a rather rare syndrome.
The following are the specifications for intraoperative sonography equipment: Small, easy-to-manipulate 7-10 mHz probes which can be gas-sterilised. The sound head contact surface should be 2 X 3 X 1 to 2 cm. Three probes of different shape. Transmission cable 2-3 m in length. Gas-sterilisable ultrasound unit, cable and plug. Large screen monitor. Control panel which can be encased with a plastic foil according to sterility requirements. 8 step gray scale. Integrated image storage. Documentation possibility using videotape and/or photographic unit. For intraoperative sonography the body parts to be examined are sonographed at a distance of 1-2 cm using a precursor water gap. Interpretation of sonographic images can be performed only in connection with the palpation findings of the surgeon.
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