847
EFFECT OF A SUNSCREEN IN PHOTOSENSITIVE
PATIENTS
and Dr
SIR,-Dr Farr Diffey (Feb 25, p 249) describe
polymorphic light eruption, which I am prone. However, the
to
’Invisible Total Sunblock’ (Roc), which is factor 15 + for ultraviolet
A/B, does protect effectively if not totally and is cosmetically
acceptable. Patients with this disorder may therefore be advised to
try this sunscreen. If not available in the UK, the sunscreen may be
obtained in the Netherlands or France.
Wilhelminapark 34,
2342 AH Oegstgeest, Netherlands S. P. VERLOOVE-VANHORICK
ABDOMINAL INCISION
SIR,-Dr Cahalane and colleagues (Jan 21, p 146) discuss
abdominal incisions. We wish to correct their misconception about
our repair of incisional hernias. The repair does not rely largely on
the strength of the posterior sheath and peritoneum. These are
brought together in the midline when constructing the new linea
alba from the strips split off the medial part of the anterior rectus
sheaths in the reconstruction. This first line of sutures creates a new
midline anchor for the sheet muscles of the abdominal wall and
returns the unopened hernial sac and contents into the abdominal
cavity. In so doing, the peritoneum and posterior rectus sheaths
cover the hernia but they do not cure it. There is still a bulge over the
reduced hernia which only disappears when the next line of
"shoelace" sutures is placed in the anterior rectus sheaths. This
substitutes anatomically and functionally for the missing parts of the
anterior rectus sheaths and has the dominant role in the repair,
though the posterior rectus sheaths possibly contribute. The
operation aims to restore the normal balance of the tonic
contractions of the sheet muscles pulling against each other at the
linea alba, which act as a natural, live girdle holding back the
abdominal contents.
Cahalane and his colleagues stress the importance of suturing the
peritoneal layer, yet no-one would seriously rely on suturing a
flimsy layer one cell thick. The peritoneum and the posterior rectus
sheaths may be sutured as two separate layers or as one layer. To
suture the peritoneum but not the posterior rectus sheaths has not
been suggested. Cahalane and colleagues also say that "the greatest
holding power lies in the anterior rectus sheath or linea alba". This
is opposite to the conclusion they reach about our operation.
Furthermore, since the one variable is whether the peritoneum is
sutured, the only conclusion from these data is that suturing or not
makes no difference. Cahalane et al use "suture of the peritoneum"
as synonymous with "suture of the peritoneum and posterior rectus
sheath in one layer".
Their statement that "At reoperation after omission of peritoneal
closure... we have often found that the small intestine becomes
intimately and broadly adherent either to the rectus muscle in
paramedian incisions or to the under-surface of the linea alba in
midline incisions" is not relevant since Cahalane and colleagues fail
to mention how often these adhesions occur when the peritoneum is
sutured. In their discussion on midline incisions, it is no use
lumping all closures of midline incisions in one group and then
blaming the midline incision for having an excess incidence of
incisional hernias. Incompetent closures must be separated from
competent ones.
We do not mean to criticise the lateral paramedian incision, which
can prove useful, even though it needs more time and a longer
incision is needed to achieve equivalent exposure to the midline
incision. One of us (J. A.) abandoned the standard paramedian
incision about 28 years ago and since then uses the midline approach
almost exclusively when a vertical incision is indicated. There is
nothing wrong with the midline incision, but there is a lot wrong
with the incompetent way it is closed in many cases. It is a quick,
easy, and almost bloodless incision, especially if passed straight
down through the midline of the umbilicus. It gives excellent
universal exposure and can be readily extended. If properly closed,
healing is perfect and no muscular weakness will occur. We use
interrupted stainless steel sutures, taking large bites of the anterior
and posterior rectus sheaths and inevitably of the rectus muscles as
well, on both sides at about 2.5-3 cm from the would edge and about
1 5-2 cm apart. The sutures are carefully tied to avoid any pressure
between the suture and the tissues, to prevent ischaemia. The
needle is passed between the posterior rectus sheath and the
peritoneum to avoid the peritoneum and the extra-peritoneal fat.
Immediately above and below the umbilicus, the peritoneum is
intimately adherent to the posterior rectus sheath and may have to
be included within the suture. We can see no advantage in suturing
the peritoneum and several good reasons for not doing so. For the
same reasons we no longer suture or ligate the sac when repairing an
inguinal hernia. We simply invert the unopened sac when it is short,
or transect long or complete sacs close to the internal ring and
invaginate the stump.
A good alternative is continuous mass closure with a heavy
monofilament nylon thread at least four times the length of the
incision. Here too the posterior rectus sheath is included but the
peritoneum is avoided. Results are similar except that mild
separation of the recti on long-term follow-up can occur.
The midline incision when properly opened and closed is near to
being ideal.
Department of Surgery,
Lady Davis Carmel Hospital, JACK ABRAHAMSON
Haifa, Israel 34 362 SAMUEL ELDAR
1 Abrahamson J, Eldar S. ’Shoelace’ repair of large postoperative ventral abdominal
hernias: a simple extrapentoneal technique. Contemp Surg 1988; 32: 24-34.
INNOCENT ELEVATION OF ASPARTATE
AMINOTRANSFERASE
SiR,-Serum aspartate aminotransferase (AST) activity is a
common investigation for liver disease or myocardial infarction. We
have encountered an individual in whom innocent elevation of AST
led to multiple hospital attendances.
The patient, a 36-year-old woman, presented with mild
abdominal pain. Clinical evaluation was unimpressive but routine
blood testing showed AST at 391 IU/1 (reference range 13-34)
Between October, 1987, and February, 1989, her AST was
measured nine times. Every time AST was raised, but all other liver
function tests were normal.
The possibility of a "macro AST" analogous to the creatine
kinase BB immune complex was considered. Gel exclusion
chromatography showed the enzyme activity to be associated with a
protein fraction of greater than normal size. Subsequent
investigations with protein A and anti-human IgG antibodies
showed the AST activity to be an enzyme/IgG complex.
We have been able to find only five reportsls of macro AST
relating to nine cases, although two other cases have been cited. Of
those nine cases, in one (a patient with bronchogenic carcinoma) the
macro forms of AST contributed a very small proportion to the
serum AST activity. In the other eight cases (six females, two males)
the increased AST activity was a cause of unnecessary hospital
attendances for investigations. The enzyme form was identified in
four of those cases as an IgG-AST complex.
Circulating immune enzyme complexes for amylase and creatine
kinase BB are well known.6 However, we suspect that most clinical
and laboratory staff are unaware of this cause of raised AST.
M.S. CONNELLY
Division of Medicine,
United Norwich Hospitals H. J. KENNEDY
C. M. DAWSON
Department of Chemical Pathology,
Norfolk and Norwich Hospital, G. D. HOWE
Norwich NR1 3SR T. R. TICKNER
1. Konttinen A, Murros J, Ojala K, et al. A new cause of increased serum aspartate
aminotransferase activity. Clin Chim Acta 1978; 84: 145-47.
2. Nagamine M, Okchi K. Complexes of immunoglobulins A and G with aspartate
aminotransferase isoenzymes in serum. Clin Chem 1983; 29: 379-81.
3. Weider N, Lott JA, Yale VD, et al. Immunoglobulin-complexed aspartate
aminotransferase Clin Chem 1983; 29: 382-84.
4. Fex G, Berntorp K. A circulating complex between ASAT and IgG in serum in an
apparently healthy woman. Clin Chim Acta 1987; 164: 11-15.
5. Litin SC, O’Bnen JF, Prunett S, et al. Macroenzyme as a cause of unexplained
elevation of aspartate aminotransferase. Mayo Clin Proc 1987; 62: 681-87.
6. Klonoff DC. Macroamylasemia and other immunoglobulin-complexed enzyme
disorders. West J Med 1980, 133: 392-407.