Nicholas Greaves

The influence of skin substitutes upon angiogenesis during wound healing is unclear. To compare the angiogenic response in acute cutaneous human wounds treated with autogenic, allogenic and xenogenic skin substitutes to those left to heal by secondary intention. On day 0, four 5mm full-thickness punch biopsies were harvested from fifty healthy volunteers (sites 1-4). In all cases, site 1 healed by secondary intention (control), site 2 was treated with collagen-GAG scaffold (CG), cadaveric decellularised dermis (DCD) was applied to site 3, whilst excised tissue was re-inserted into site 4 (autograft). Depending on study group allocation, healing tissue from sites 1-4 was excised on day 7, 14, 21 or 28. All specimens were bisected, with half used in histological and immunohistochemical evaluation whilst extracted RNA from the remainder enabled whole genome microarrays and qRT-PCR of highlighted angiogenesis-related genes. All wounds were serially imaged over 6 weeks using laser-doppler imaging and spectrophotometric intracutaneous analysis. Inherent structural differences between skin substitutes influenced the distribution and organisation of capillary networks within regenerating dermis. Haemoglobin flux (p = 0.0035), oxyhaemoglobin concentration (p = 0.0005), and vessel number derived from CD31-based immunohistochemistry (p = 0.046) were significantly greater in DCD wounds at later time points. This correlated with time-matched increases in mRNA expression of membrane-type 6 matrix metalloproteinase (MT6-MMP) (p = 0.021) and prokineticin 2 (PROK2) (p = 0.004). Corroborating evidence from invasive and non-invasive modalities demonstrated that treatment with DCD resulted in increased angiogenesis after wounding. Significantly elevated mRNA expression of pro-angiogenic PROK2 and extracellular matrix protease MT6-MMP seen only in the DCD group may contribute to observed responses.

Single incision laparoscopic surgery (SILS) is a rapidly developing field that may represent the future of laparoscopic surgery. The major advantage of SILS over standard laparoscopic surgery is in cosmesis, with surgery becoming essentially scarless if the incision is hidden within the umbilicus. Only one incision is required so the risk of potential complications like port site hernias, haematomas and wound infection is reduced. The trade-off for this is a technically more challenging procedure with different underlying principles to that of traditional laparoscopic surgery. A wide variety of new equipment has been developed to support SILS and the range of procedures that are amenable to the technique is increasing. To date most of the published data relating to SILS are in the form of case series, with the first large randomised controlled trials due to be completed by the end of 2012. The existing evidence suggests that SILS is similar to standard laparoscopic surgery in terms of complication rates, completion rates and post-operative pain scores. However, the duration of SILS is longer than equivalent laparoscopic procedures. This article discusses SILS with regard to its applications in general surgery and reviews the evidence currently available.

We report the case of a 16 year old male who was the victim of a drive by shooting sustaining the rare but recognised complication of cardiovascular bullet embolism. He was seen as a trauma call in the emergency department and CT scanning revealed 70 shotgun pellets scattered throughout left sided sub-cutaneous tissues of the head and neck, and more significantly a single pellet within the right atrium. It is believed to have got there via injury to the left brachiocephalic vein which was demonstrated by extravasation of contrast on the CT scan. He remained stable throughout admission and the injury was managed conservatively. Serial scanning showed the pellet had subsequently migrated into the right ventricle where it has remained since, presumably having become epithelialised. This case report highlights the importance of repeated scanning for the possibility of projectile migration within the cardiovascular system in similar cases of penetrating injury.