Com ment
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with the Notice printed on the inside back cover. Tables and figures should be included only if absolutely essential and no more than five references should be given.
Aortic aneurysms-who should do them? I am writing with reference to the article by Vella et al. (Annals, July 1990, vol 72, p215). In the article, the authors provide figures in support of operations on ruptured abdominal aortic aneurysms being performed in a district general hospital as opposed to major centres. The work they refer to is that by Jenkins et al. (1), who state that ruptured aortic aneurysms are better managed by a specialised vascular team and not necessarily in a major vascular centre. Jenkins et al. stress that the key points are that, 1 The surgeons should be trained in vascular surgery; 2 The surgery should be performed by senior staff; and 3 That there should be a coordinated team of surgeons, anaesthetists and nurses in the theatre. Although Vella et al. state under the heading Patients and methods that the patients are all the patients undergoing aortic aneurysm repair in the Royal Gwent Hospital between the years 1983 and 1987, they later go on to say that the load is in fact the aneurysm repairs carried out by 'one general surgical team'. If the latter is the case, and as is later revealed the surgeon has a vascular interest, then this is in accordance with the generally accepted guidelines on the management of ruptured abdominal aortic aneurysms. That is, improved mortality figures are due to who does the surgery, and not where the surgery is done. It would have been of more interest to compare their results with those of the other general surgeons, without a vascular interest, at the Royal Gwent Hospital within the specified dates. I NYAMEKYE Senior House Officer Royal Hallamshire Hospital Sheffield
Reference I Jenkins AMcL, Ruckley CV, Nolan B. Ruptured abdominal aortic aneurysms. BrJ7 Surg 1986;73:395-8.
The presentation of malrotation of the intestine in adults Regarding the article by Gilbert and Armstrong (Annals, July 1990, vol 72, p239). There are several points in the article with which we disagree. The classification of 'malrotation' is very confused, and terms like non-rotation, malrotation and partial rotation mean different things to different people. The definitive work on 'malrotation' was done by Grob (1) and it is unfortunate that his treatise has never been translated into English and accepted as standard. According to Grob, 'non-rotation' refers to a persistence of the primitive embryological gut configuration, which is anatomically a straight tube from oesophagus to anus, with the duodenum running straight down in the midline. This is extremely rare. The 'classic' form of malrotation, which is not the commonest form, is the +900 malrotation, in which the duodenum runs straight down the right side of the abdomen, and with the colon on the left side. The commonest form is actually the +1800 malrotation, in which the duodenum lies near, but to the right of, the midline, does not pass beneath the superior mesenteric artery and is most commonly associated
with Ladd's Bands. After a Ladd's procedure, the configuration of the bowel resembles that of a +900 malrotation. We also disagree with the authors' concept of an exomphalos. The most accepted explanation of exomphalos is that it is caused by failure of the migration of the para-axial mesoderm, causing ventral defects, which may extend rostrally or caudally to involve other organs. A failure of the intestine to return completely to the abdomen results in a condition known as a herniation of the bowel into the cord, where the bowel is actually within the cord, as this is where the extra-embryonic coelom lies. Finally, we disagree strongly with the authors' statement that "no operative intervention can be justified if the patient is free of symptoms". No one can predict when a volvulus may occur, and neither can it be prevented without an operation. A midgut volvulus is potentially a catastrophic event, often misdiagnosed, and to leave a known malrotation alone is courting disaster. In expert hands, an elective operation is safe and should be performed whenever malrotation is diagnosed. I B KERN Visiting Paediatric Surgeon B G CURRIE Staff Paediatric Surgeon Prince of Wales Children's Hospital Sydney, Australia
Reference I Grob M. Uber Lageanomalien Des Magendarmtractus Infolge Storungen Der Fetalen Danndrehung. Basle: Benno Schwabe & Co, 1953.
Suturing of digital lacerations: digital block or local infiltration? It is unfortunate that the authors did not state the type of injuries that they were suturing (Annals, November 1990, vol 72, p360). For example, whether they were dealing with crush injuries, eg door-jam or simple incised wounds. The indications for suturing crushed fingers at all are extremely restricted. However, assuming that all the cases they reported were incised injuries, it may be that this paper is based on a false premise. The authors state that there was no tendon, nerve or arterial damage. The implication is therefore that these are simple skin wounds and they are volar surface injuries. (Ring block would not be effective for dorsal injuries.) Under such circumstances the modern adhesive dressings are extremely effective ways of treating these minor injuries, especially in the expectation that there will be no other major factor causing hand dysfunction. If, however, the wounds are more complicated and irregular, then even in the apparent absence of injury to the structures mentioned, there may still be an obligation to explore the wounds properly, in which case they should be done under regional anaesthesia with proper tourniquet control. Natul-Ily one is pleased at the conclusion that it is not necessary to inject into the wounded area. However, one might be forgiven for saying that such a technique should never have been considered, given the state of modern day practice. Most regions in Britain have access to advice from either a hand surgery service or a specialist hand surgeon. Had the authors or their seniors taken advice from such a source, I
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with the Notice printed on the inside back cover. Tables and figures should be included only if absolutely essential and no more than five references should be given.
Aortic aneurysms-who should do them? I am writing with reference to the article by Vella et al. (Annals, July 1990, vol 72, p215). In the article, the authors provide figures in support of operations on ruptured abdominal aortic aneurysms being performed in a district general hospital as opposed to major centres. The work they refer to is that by Jenkins et al. (1), who state that ruptured aortic aneurysms are better managed by a specialised vascular team and not necessarily in a major vascular centre. Jenkins et al. stress that the key points are that, 1 The surgeons should be trained in vascular surgery; 2 The surgery should be performed by senior staff; and 3 That there should be a coordinated team of surgeons, anaesthetists and nurses in the theatre. Although Vella et al. state under the heading Patients and methods that the patients are all the patients undergoing aortic aneurysm repair in the Royal Gwent Hospital between the years 1983 and 1987, they later go on to say that the load is in fact the aneurysm repairs carried out by 'one general surgical team'. If the latter is the case, and as is later revealed the surgeon has a vascular interest, then this is in accordance with the generally accepted guidelines on the management of ruptured abdominal aortic aneurysms. That is, improved mortality figures are due to who does the surgery, and not where the surgery is done. It would have been of more interest to compare their results with those of the other general surgeons, without a vascular interest, at the Royal Gwent Hospital within the specified dates. I NYAMEKYE Senior House Officer Royal Hallamshire Hospital Sheffield
Reference I Jenkins AMcL, Ruckley CV, Nolan B. Ruptured abdominal aortic aneurysms. BrJ7 Surg 1986;73:395-8.
The presentation of malrotation of the intestine in adults Regarding the article by Gilbert and Armstrong (Annals, July 1990, vol 72, p239). There are several points in the article with which we disagree. The classification of 'malrotation' is very confused, and terms like non-rotation, malrotation and partial rotation mean different things to different people. The definitive work on 'malrotation' was done by Grob (1) and it is unfortunate that his treatise has never been translated into English and accepted as standard. According to Grob, 'non-rotation' refers to a persistence of the primitive embryological gut configuration, which is anatomically a straight tube from oesophagus to anus, with the duodenum running straight down in the midline. This is extremely rare. The 'classic' form of malrotation, which is not the commonest form, is the +900 malrotation, in which the duodenum runs straight down the right side of the abdomen, and with the colon on the left side. The commonest form is actually the +1800 malrotation, in which the duodenum lies near, but to the right of, the midline, does not pass beneath the superior mesenteric artery and is most commonly associated
with Ladd's Bands. After a Ladd's procedure, the configuration of the bowel resembles that of a +900 malrotation. We also disagree with the authors' concept of an exomphalos. The most accepted explanation of exomphalos is that it is caused by failure of the migration of the para-axial mesoderm, causing ventral defects, which may extend rostrally or caudally to involve other organs. A failure of the intestine to return completely to the abdomen results in a condition known as a herniation of the bowel into the cord, where the bowel is actually within the cord, as this is where the extra-embryonic coelom lies. Finally, we disagree strongly with the authors' statement that "no operative intervention can be justified if the patient is free of symptoms". No one can predict when a volvulus may occur, and neither can it be prevented without an operation. A midgut volvulus is potentially a catastrophic event, often misdiagnosed, and to leave a known malrotation alone is courting disaster. In expert hands, an elective operation is safe and should be performed whenever malrotation is diagnosed. I B KERN Visiting Paediatric Surgeon B G CURRIE Staff Paediatric Surgeon Prince of Wales Children's Hospital Sydney, Australia
Reference I Grob M. Uber Lageanomalien Des Magendarmtractus Infolge Storungen Der Fetalen Danndrehung. Basle: Benno Schwabe & Co, 1953.
Suturing of digital lacerations: digital block or local infiltration? It is unfortunate that the authors did not state the type of injuries that they were suturing (Annals, November 1990, vol 72, p360). For example, whether they were dealing with crush injuries, eg door-jam or simple incised wounds. The indications for suturing crushed fingers at all are extremely restricted. However, assuming that all the cases they reported were incised injuries, it may be that this paper is based on a false premise. The authors state that there was no tendon, nerve or arterial damage. The implication is therefore that these are simple skin wounds and they are volar surface injuries. (Ring block would not be effective for dorsal injuries.) Under such circumstances the modern adhesive dressings are extremely effective ways of treating these minor injuries, especially in the expectation that there will be no other major factor causing hand dysfunction. If, however, the wounds are more complicated and irregular, then even in the apparent absence of injury to the structures mentioned, there may still be an obligation to explore the wounds properly, in which case they should be done under regional anaesthesia with proper tourniquet control. Natul-Ily one is pleased at the conclusion that it is not necessary to inject into the wounded area. However, one might be forgiven for saying that such a technique should never have been considered, given the state of modern day practice. Most regions in Britain have access to advice from either a hand surgery service or a specialist hand surgeon. Had the authors or their seniors taken advice from such a source, I
