Technical note - NCBI

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* Do not rely too much on powered tools. * The arthroscopist must be gentle. Avoid iatrogenic injury, especially with the more cumbersome tools, e.g. meniscal repair sets.

Documentation * Very important and should allow another surgeon to review accurately the findings of the operation. * Should document both the examination under anaesthetic (EUA) and the arthroscopy. * Needs to be systematic, noting both positive and negative findings. * A standardised sheet is very useful and can save time and ensure findings are not forgotten. * Attach photographs or videos to the written note. Give patients copies of films as they appreciate the information they offer. * It can be useful to take photographs both before and after surgery, e.g. a meniscal resection. However, remember that the photographs are not as important as the surgery!

Dressings * Can be varied, and are individual to each surgeon. * Most arthroscopists do not use stitches - I use adhesive strips. * Supplementary anaesthesia at the time of dressing reduces postoperative pain considerably. introduce 10 mg morphine and 20 ml 0.5% marcaine with adrenaline into the knee and wounds at the end of the procedure. * If the patient bleeds postoperatively, change the dressings prior to discharge or else painful blistering and irritation of the skin may occur.

Postoperative management * rarely use a drain, except for lateral releases. * The patient is charted for oral analgesia and anti-inflammatories (if not contra-indicated). * Advise your patient to rest whilst moving around to a reasonable extent to prevent thrombo-embolism. I do not use chemical chemothromboprophylaxis unless the patient is at high risk. * The dressings remain in place for 3-5 days. * Physiotherapy is important postoperatively, as there is a reflex quadriceps inhibition after surgery The knee can feel very 'vulnerable' if the quadriceps are not strengthened. I advise against the use of open chain exercises as part of rehabilitation. * always tell the patient that it takes about 3 months for the knee to attain optimal function after an arthroscopy. The knee can be swollen and the portal sites painful over this period. If you warn the patient of this, they will not worry when it happens! Condusion Arthroscopy of the knee is a beautifully simple procedure, made complicated by poor technique and preparation. Employment of identical methods for each arthroscopy performed allows for a safe and effective 'system', so that the surgeon's attention can be best directed to the pathology present within the knee.

Correspondence to: Mr Andrew Unwin, Consultant Orthopaedic Surgeon, The Windsor Orthopaedic Clinic, Phoenix House, Nightingale Walk, Windsor, Berkshire SL4 3HS, UK. Tel +44 1753 868622; Fax: +44 1753 868642

Technical note The small bowel wrap - an effective way of packing small bowel in the surgical field V Munikrishnan*, NJ Keeling Department of Colorectal Surgery, West Suffolk Hospital, Bury St Edmunds, UK Background The key to any surgical procedure is good access. At laparotomy it may be difficult to keep the small bowel away from the operative field. On occasion, loops of small bowel may slip from under the retractor and hinder the view of the surgeon, or exteriorising the bowel may result in unnecessary traction on the root of the mesentery causing haematomas or ischaemia.1 We describe a technique of packing the small bowel, which in our experience is very effective during colonic and pelvic surgery. Technique After a systematic exploration of the abdominal cavity and organs, the operative field is approached with adequate retraction of the abdominal wall. A large pack is spread under Ann R Coll Surg Engl 2002; 84

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Figure 1 Top two corners of pack sutured with single stitch.

the root of the small bowel mesentery. The loops of small bowel are then laid over the pack. The two top corners of the pack are sutured together with a single stitch such that it forms a loose sleeve around the root of mesentery (Fig. 1). The stitch secures the pack in place and helps to control the small bowel loops as detailed below. The left and right margins of the pack are partially unrolled to accommodate 139

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tip of the guide wire to negotiate even the most tortuous fistula tract. The wire can be passed from the external opening, but works especially well when passed from the internal opening, where this can be identified with confidence.

Correspondence to: Mr JG Williams, Consultant Colorectal Surgeon, New Cross Hospital, Wolverhampton WV10 OQP, UK

Response to paper by T Agarwal, J Refson & S Gould

The Tellytubby Tummy', a novel technique for laparostomy management Ann R Coil Surg Engl 2001; 83: 440 Richard J Guy, David Lloyd, Heah Sieu Min Figure 2 Lower two corners of pack brought to lie on the joined top end.

the proximal small bowel and the distal ileo-caecal junction, respectively. Now the other two corners are brought to lie on the joined top end such that the pack effectively wraps up all the loops of small bowel (Fig. 2). The roll can now be safely controlled using a large self-retaining retractor. Conclusion We have used the small bowel wrap in more than 200 patients undergoing colonic and pelvic surgery. We have found it to be an extremely effective technique in controlling the highly mobile small bowel and would recommend its use routinely.

Reference 1. Masters A. Retraction for pelvic surgery. In: Walsh CJ, Jamieson NV, Fazio VW. (eds) Top rips in Gastrointestinal Surgery. Oxford: Blackwell Science, 1999; 19.

Correspondence to: NJ Keeling, Consultant Surgeon, Department of Colorectal Surgery, West Suffolk Hospital, Bury St Edmunds, UK *Present address: V Munikrishnan, Clinical Research Fellow, Department of Surgery, University College London, UK

Technical tip

Department ofColorectal Surgery, Singapore General Hospital, Singapore W le read with interest the 'Tellytubby Tummy' technique for A laparostomy management described by Agarwal et al., but the authors seem to have overlooked quite a significant literature on the topic. This is a well-established technique in trauma surgery, primarily in the context of the 'abbreviated laparotomy' when rapid 'damage-control' surgery followed by temporary abdominal closure by this so-called 'Bogota Bag' method is combined with other resuscitative measures.1 Temporary closure of the chest following thoracotomy for trauma also be achieved in the same way.2 Another recent article describes the technique in 75 patients (using a total of 320 plastic bags) following laparotomy for peritonitis intestinal obstruction, pancreatitis and aortic surgery as well as for trauma.3 We recently used the method successfully in a 71-year-old man who developed extensive full-thickness necrotising fasciitis of the anterior abdominal wall following anterior resection. After radical debridement, temporary closure was achieved using a split 3 11.5% glycine irrigation bag sutured to the fascial edges. Subsequent definitive cover using a fascia lata flap and split skin grafting proceeded uneventfully 1 week later after resolution of sepsis. Although previously reported for a similar indication,4 our case differs in that definitive closure was achieved early with an autologous graft rather than prosthetic material.

References

Roadrunner to the rescue JG Williams, M Washer

Department of Colorectal Surgery, Royal Wolverhampton Hospitals NHS Trust, Newv Cross Hospital, Wolverhampton, UK Probing an anal fistula at surgery is usually a simple procedure. However, there are instances where it is not possible to follow the fistula tract, particularly if the tract is long and follows a horseshoe course. One solution to this frustrating problem is a Roadrunner ureteric guide wire (Cook Urological Incorporated, Spencer, IN 47460, USA). The shaft of the guide wire is fairly rigid, but the tip is very flexible. This flexibility, coupled with the hydrophilic coating which is very slippery when wet, allows the

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1. Hirshberg A, Walden R. Damage control for abdominal trauma. Surg Clin North Am 1997; 77: 813-20. 2. Wall Jr MJ, Soltero E. Damage control for thoracic injuries. Surg Clin North Am 1997; 77: 863-78. 3. Ghimenton F, Thomson SR, Muckart DJJ, Burrows R. Abdominal content containment: practicalities and outcome. BrJ Surg 2000; 87: 106-9. 4. Howard CA, Turner Jr WW. Successful treatment of early, postoperative, necrotizing infection of the abdominal wall. Crit Care Med 1989; 17: 586-7.

Correspondence to: Mr RJ Guy, Department of General Surgery, Colorectal Unit, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK. Tel: 01733 875126; Fax: 01733 875013 Ann R Coll Surg Engl 2002; 84