Informed Consent

http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/ml_guides/consent_guide/com_cg_practicalconsiderations-e.cfm

Adequacy of informed consent is judged by what a "reasonable patient" would want to know about a procedure.

Inguinal hernia tissue repairs

McVay repair:
- for direct and femoral hernias
- transversalis aponeurosis and fascia sutured laterally to Cooper's ligament.
- sutures are placed beginning medially at the pubic tubercle and extending as far laterally as the femoral vein
- next suture (transition stitch) placed deeply into the pectineus fascia and more laterally through the anterior layer of the femoral sheath
- if conjoined to coopers stitches carried out too far lateral before transition stitch then patient can get femoral vein thrombisis
- treatment of femoral vein thrombosis involves anti-coagulants, recanalization and collateral venous formation usually occurs

Condon Repair:
- anterior approach similar to McVay repair but you are suturing the conjoined tendon to coopers and to iliopubic tract/poupart's ligament
- ?higher risk of femoral vein compression
- double closure of femoral canal
- but does this neccessarily add anything beyond a McVay repair?

Nyhus repair:
- Preperitoneal approach to hernia repair
- from posteriorly similar to a condon repair you close femoral canal by suturing iliopubic tract to cooper's ligament

Poupart's ligament is the reflection of the external oblique aponeurosis
iliopubic tract extends from ASIS to the pubic tubercle

Stages of wound healing

Physiological Stages

Physiological Stages of Wound Repair

1.) Inflammatory Phase

• Initial response to injury
• Day 1-4 post injury
• Characterized by rubor, tumor, dolor, calor
• Platelet aggregation and activation
• Leukocyte (PMNs, macrophages) migration, phagocytosis and mediator release
• Venule dilation
• Lymphatic blockade
• Exudative
• In wounds closed by primary intention, lasts 4 days
• In wounds closed by secondary or tertiary intention, continues until epithelialization is complete

2.) Proliferative Phase

• Day 4-42
• Fibroblast proliferation stimulated by macrophage-released growth factors
• Increased rate of collagen synthesis by fibroblasts
• Granulation tissue and neovascularization
• Gain in tensile strength

3.) Remodeling Phase

• 6wks-1 year
• Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation
• Characterized by increase in tensile strength
• Type III collagen replaced with type I
• Scar flattens

Imperforate Anus

Low vs high.
Low perineal procedure.
High colostomy and pull through

Best to wait 24 hrs to define high or low.
- invertogram
>1 cm high
<1cm low High create colostomy then come back in 3 mos. Low cutback anoplasty High posterior sagital anorectal pullthrough Cloaca. Combined uretral and anal opening. Need to separate all and create new openings

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Rectal surgery sexual and bladder function

Since advent of TME, impotence reported ~10-30% of patients.
- hypogastric plexus. Sympathetic innervation, ejaculation
- Nervi erigentes. Parasympathetic function. Erection and urinary dysfunction.


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Rectal cancer margins

Distal margins.
- traditionally 5 cm. However no difference in local recurrence rateswhethwr 5, 2 or <2 cm distal margins.

Current recommendations. NCI
- proximal margin 5cm
- distal margin of >= 2 cm
- however, if 1cm margin needed to preserve sphincters then acceptable.
- distal spread beyond 1cm associated with aggressive disease or advanced stage tumors and a longer distal margin will not improve prognosis.

CRM: circumferential radial margin.
- most important determinant of local recurrence.
- TME has largely ensured that adequate circumferential margins routinely obtained.
- preTME era local recurrence was in the realm of 15-30%
- now recurrence rates should strive for 4-7%
- if mesorectal margin involved then local recurrence rates 11 vs 5%

Nodal clearance:
- 12 LNs required for adequate pathological staging. NCCN.
- can be challenging in pts who have had neoadjuvant therapy.

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