0Fig. 1. Training of technical skills on models.4
included probing on worm-eaten wood and incision on vegetables (such as watermelon, gourd and cucumber).4
Sushruta specified that 'a surgeon who has set out on this path should have witnessed operations. He must be licensed by the ruler of the land. He should be clean and keep his nails and hair short. He should be cheerful, well-spoken and honest'. He constantly emphasized that an improper surgical intervention without knowledge and natural history of the disease process was highly unfavourable. Furthermore, greed for money or lack of judgement led only to complications. These sentiments are highly relevant to this day.
References
1. Halsted WS. The training of the surgeon. Bull. Johns Hopkins Hosp. 1904; 15: 267-75.
2. Das S. Urology in ancient India. Indian J. Urol. 2007; 23: 2-5.
3. Samhita S. An English translation of the Sushruta Samhita [English translation by Kaviraj Kunja Lal Bhishagratna], Chapter 16. Calcutta, West Bengal, India: the Bharat Mihir Press, 1907; 152-4.
4. Saraf S, Parihar RS. Sushruta: the first plastic surgeon in 600 B.C. Texas: USA [updated 13 February 2009; cited November 2008]. Available from: www.ispub.com/journal/the_internet_journal_of_plastic_surgery/volume_ 4_number_2_40/article/sushruta_the_first_plastic_surgeon_in_600_b_c. html
Kamran Ahmed MRCS Hutan Ashrafian MRCS Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital Campus, London, UK
doi: 10.1111/j.1445-2197.2010.05229.x
Dear Editor,
Hepatic portal venous gas
Hepatic portal venous gas (HPVG) is an unusual entity associated with a variety of abdominal events. There is usually a grave prog-
Fig. 1. Abdominal computed tomography scan showing gas in the intra-hepatic portal vein.
nosis when HPVG is associated with ischaemic bowel disease. We present a case of a 67-year-old woman with HPVG (Fig. 1) associated with ischaemic changes of the small bowel. At laparotomy, we noted localized ischaemic changes of the ileum. The pulse was present in the trunk of the superior mesenteric artery. The patient received promptly full-dose heparin. Application of warm serum in the ischaemic bowel ameliorated its viability, and no resection was performed. Patient was discharged on oral anticoagulants.
HPVG is a rare but important radiographic finding whose patho-genesis is still not fully understood. HPVG is thought to be caused by mesenteric ischaemia, but it can also occur under nonischaemic conditions that may not require emergency exploratory laparotomy.1-4 Gas in the portal vein was initially detected on plain radiographs of the abdomen and was associated at that time with a mortality rate of 75%. Since the introduction of computed tomography (CT), the clinical outcome of HPVG has improved, and its mortality rate has dropped to 29% because of earlier diagnosis of the disease.2 Recent studies have dealt with various nonischaemic conditions and even with incidental findings of HPVG, some of which could be cured with conservative management alone.2,4 The major predisposing factor for the development of HPVG is damage to the intestinal mucosa combined with bowel distension or bacterial gas production. Approximately 15% of HPVG cases, however, are idiopathic.1-3 The diagnosis of HPVG is usually made by plain abdominal radiography, sonography, colour Doppler flow imaging or CT scan. HPVG can occur alone or in association with pneuma-tosis intestinalis. When associated with pneumatosis intestinalis, it usually indicates the presence of mesenteric ischaemia. However, the coexistence of HPVG and pneumatosis intestinalis unrelated to mesenteric ischaemia is also reported.2 CT findings of pneumatosis intestinalis and HPVG do not generally allow prediction of transmural bowel infarction because they may also be observed in patients with only partial ischaemic bowel wall damage.
References
1. Chiu HH, Chen CM, Lu YY, Lin JC, Mo LR. Hepatic portal venous gas.
Am. J. Surg. 2005; 189: 501-3.
2. Schindera ST, Juergen Triller J, Vock P, Hoppe H. Detection of hepatic portal venous gas: its clinical impact and outcome. Emerg. Radiol. 2006; 12: 164-70.
3. Sebastia C, Quiroga S, Espin E, Boye R, Alvarez-Castells A, Armengol M. Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. Radiographics 2000; 20: 1213-24
4. Wiesner W, Mortele KJ, Glickman JN, Ji H, Ros PR. Portal-venous gas unrelated to mesenteric ischemia. Eur. Radiol. 2002; 12: 1432-7.
Bassam Abboud,* MD Ronald Daher,* MD Raymond Sayeght MD Departments of *General Surgery and tGastroenterology,y
Hotel-Dieu de France Hospital, Faculty of Medicine, Saint-Joseph
University, Beirut, Lebanon
doi: 10.1111/j.1445-2197.2010.05230.x
Dear Editor,
Splenosis and accessory spleens
Kok and colleagues provide an interesting insight on splenosis.1 The authors do not mention accessory spleens as possible differentials. Both are ectopic splenic tissues. Table 1 illustrates the difference of such tissues.2
References
1. Kok J, Lin M, Lin P et al. Splenosis presenting as multiple intraabdominal masses mimicking malignancy. ANZJ. Surg. 2008; 78: 406-7.
2. Fremont RD, Rice TW. Splenosis: a review. South. Med. J. 2007; 100: 589-93.
Weekitt Kittisupamongkol, MD Hua Chiew Hospital, Bangkok, Thailand
doi: 10.1111/j.1445-2197.2010.05231.x
Table 1 Comparison between splenosis and accessory spleens
Splenosis Accessory spleens
The corresponding author is not a recipient of a research scholarship. The paper is not based on a previous communication to a society or meeting.
Dear Editor,
Congenital unilateral absence of the vas deferens
We report the case of a baby born with an anorectal malformation and cutaneous fistula treated by anoplasty. Investigations on admission showed an absent left kidney and undescended left testis. Orchi-dopexy at seven months of age revealed the testis inside the processus vaginalis. However, dissection of the hernial sac was complicated as the vas could not be identified. Exploration of the internal ring revealed no vas deferens proximally, and delivery of the testis demonstrated absence of the epididymis.
Congenital absence of the vas deferens was first described by John Hunter in 1737.1 It can be caused by failure of Wolffian duct development, often with ipsilateral renal agenesis and is estimated to occur in up to 1% of the male population.2
Embryologically, the mesonephric duct gives rise to both the Wolffian duct, which forms the ipsilateral vas deferens, seminal vesicle and distal 2/3 of the epididymis, as well as the ureteric bud, which becomes the renal pelvis, calyces, collecting tubules and ureter. The testis is unaffected, arising from the genital fold. The ureteric bud forms at seven weeks and foetal injury at or before this time may result in congenital absence of the vas in conjunction with renal anomalies. After seven weeks, injury will only affect one of the two mesonephric derivatives. Therefore, it is not surprising that patients with congenital absence of the vas may also have renal malformations, as reported by Donohue and Fauver, who found that 79% of patients with congenital unilateral absence of the vas defer-ens had ipsilateral renal agenesis.3
Another well-documented cause of absence of the vas deferens is cystic fibrosis, where there is often bilateral secondary atresia.4
This case highlights the need to identify the vas deferens at inguinal herniotomy or orchidopexy, and a strategy to find it if it cannot be identified, either at the internal ring or around the testis. Using this approach, augmented by ultrasound, it should be possible to distinguish whether absence of the vas deferens is related to the Rokitansky sequence with absence of the ipsilateral kidney or whether it is part of the spectrum of cystic fibrosis gene mutations.
References
1. Hunter J. On the glands called vesiculae seminales. In: Palmer JF (ed.). Complete Works, Vol. 4. London: Longman, Reese, Orm, Brown, Green & Longman, 1737; 23.
2. Mulhall JP, Oates RD. Vasal aplasia and cystic fibrosis. Curr. Opin. Urol. 1995; 5: 316-9.
3. Donohue RE, Fauver HE. Unilateral absence of the vas deferens - a useful clinical sign. JAMA 1969; 261: 1180-2.
4. Popli K, Stewart J. Infertility and its management in men with cystic fibrosis: review of literature and clinical practices in the UK. Hum. Fertil. (Camb.) 2007; 10: 217-21.
This paper is not based on a previous communication to a society or meeting.
The corresponding author is not the recipient of a research scholarship.
Aetiology Acquired Congenital
Number More than100 Six or less
Histology A poorly formed capsule Normal splenic
and distorted architecture histology
with no hilum
Blood supply From surrounding From a branch of
tissues and vessels a splenic artery
Location Any intraperitoneal or Near splenopancreatic
extraperitoneal or gastrosplenic
location ligament
Prevalence Lower Higher
