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Introduction: Enlargement of the ilioinguinal nerve distal to the inguinal ring is common in primary open inguinal herniorrhaphy and is histologically consistent with compression neuropathy. However, the origin of this neuropathy has not been thoroughly studied in primary inguinal hernia., Methods: In this prospective study, 143 primary inguinal herniorrhaphies were performed. Prior to surgery, all patients completed a preoperative pain questionnaire from the Carolina Comfort Scale and Visual Analog Scale-evaluating pain with various activities. Pain scores were statistically compared with several different anatomical surgical observations., Results: When each variable is individually compared with pain scores, a significant positive correlation exists between nerve enlargement and increased pain compared to those without enlargement for preoperative "most of the time pain" (P < 0.0017). There is also a statistically significant positive correlation between nerve enlargement and external ring fibrosis (P < 0.001). 81% of patients with enlargement have histological abnormalities., Conclusion: Preoperative pain in primary inguinal hernia is correlated with ilioinguinal nerve enlargement, which is also correlated with fibrosis of the external oblique fascia at the external ring., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to analyze the constituents of total and types I and III collagen fibers in the transversalis fascias of patients with indirect inguinal hernias, compared with samples removed from nonherniated cadavers., Methods: Biopsy samples from 26 patients and 26 cadavers were analyzed. Hematoxylin-eosin and picrosirius staining techniques were used. The images obtained were analyzed using a video morphometric technique to determine the constituents of total collagen and types I and III collagen in the transversalis fascia. The picrosirius-stained tissues were submitted to observation under polarized-light microscopy., Results: The results showed 17.3% less total collagen in patients with hernias compared with the control group (P < .01). Type I collagen in patients with indirect inguinal hernias was 23.7% less than the control group (P < .01), type III collagen was 6.4% less in the controls (P < .01)., Conclusion: The lower percentages of total collagen and type I collagen in the transversalis fascias of patients with indirect inguinal hernias could be a factor in hernia formation.

Background: Restoration of the abdominal wall's integrity after postoperative wound dehiscence is frequently performed in a delayed fashion, necessitating a temporary dressing of the dehisced wound., Methods: The Vacuum Assisted Closure (VAC) system (Kinetic Concepts, Inc., San Antonio, TX) was used in 21 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. The VAC device was used in conjunction with sharp debridement and it was maintained on a continuous mode with a negative pressure of -75 to -125 mm Hg. The dressing was changed every 2 days. VAC therapy was continued until the integrity of the abdominal wall was reestablished by surgical procedures or secondary healing., Results: Thirteen patients had fascial dehiscence, and 9 of them had frank bowel exposure. Definitive fascial closure was performed in 9 of 13 patients with fascial dehiscence. Stable cutaneous coverage was subsequently achieved in all patients by local abdominal skin flap advancement (6), skin grafting (9), or secondary intention healing (6). Seven patients had part of their VAC therapy as outpatients. The complications included a low-output small bowel enterocutaneous fistula in 2 patients and partial skin graft loss in 1 patient. The fistulae resolved after operative treatment (1) or conservative treatment (1)., Conclusion: Integration of the VAC system in the management of post-laparotomy wound dehiscence in patients with compromised wound healing appears to be successful and should be considered in such patients to provide a stable, healed wound.

Background: The purpose of this study was to determine whether imbrication of native fascia versus excision and closure of new raw fascia forms a stronger union., Methods: We utilized the anterior rectus sheath fascia of Sprague-Dawley rats as the model. Sixty rats underwent fascial tightening procedures. Each rat had the anterior rectus sheath shortened by 1 cm, 30 by imbrication and 30 by excision and closure. Ten of each group were harvested at 7 days' healing, 10 at 14 days, and 10 of each group at 28 days' healing. The anterior rectus sheath was removed, a "dumbbell" shape constructed, and the cross sectional area at the point of interest determined. The fascia was placed on an Instron tensiometer to determine the breaking strength. Tensile strength was calculated and the data analyzed by ANOVA and the Kruskall-Wallis test. Tissue samples of the closures were histologically analyzed for fibroblast counts, degree of inflammation, and presence of dense fibrous connective tissue. Tissue samples were also analyzed for enzymatic collagen crosslinking., Results: There was a statistically significant difference in tensile strength between the two groups at 7, 14, and 28 days. Results show that at 7 days the mean tensile strength of excision was 0.133 kg/mm2 +/- 0.056 and the mean tensile strength of imbrication was 0.083 kg/mm2 +/- .048 (P < 0.05); at 14 days the mean tensile strength of excision was 0.105 kg/mm2 +/- 0.033 and the mean tensile strength of imbrication was 0.057 kg/mm2 +/- 0.014 (P < 0.002), and at 28 days the mean tensile strength of excision was 0.279 kg/mm2 +/- 0.143 and the mean tensile strength of imbrication was 0.145 kg/mm2 +/- 0.061 (P < 0.03). Histologic findings showed no statistical significance between the two closure methods when comparing degree of inflammation or the number of fibroblasts present. However, at 7 and 14 days there is a significantly greater presence of dense fibrous connective tissue in the excision group (P < 0.03 at 7 days and P < 0.044 at 14 days by ANOVA). Collagen crosslink analysis showed that by day 28 there is a significantly greater amount (P < 0.05 by ANOVA) of the difunctional crosslink dihydroxylysinonorleucine (DHLNL) and a greater ratio between DHLNL and the difunctional crosslink hydroxylysinonorleucine (HLNL) in the excision and closure group., Conclusion: We conclude that at 7, 14, and 28 days healing, excision provides a significantly stronger closure than imbrication. According to the crosslinking analysis, it is likely that this strength advantage may continue to increase over time. These findings suggest that excision and closure may be the preferred method for fascial tightening procedures.

A study of 5 patients and 10 mastectomy specimens was performed to identify the extent of surgery necessary to completely remove all breast tissue in patients having prophylactic mastectomies. A standard total mastectomy performed for breast cancer was shown to frequently leave breast tissue within the superficial pectoralis major muscle and the lower skin flap. Frozen section analysis of margins was found to be essential to clear the axillary extension of the breast and lower skin flap in particular. The value of more extensive surgery to remove all glandular elements of the breast in the high-risk patient remains to be demonstrated.

Sixteen patients with necrotizing fasciitis were observed under clinical and laboratory conditions for collection, preservation, and culture that permitted optimal retrieval of anaerobes. The clinical observations of necrosis of fascia, subcutaneous fat and skin with thrombosis of the microvasculature, and absence of myonecrosis were clearly apparent in these patients. Two clear-cut groups of culture and gram stain results were found, suggesting that the clinical entity of necrotizing fasciitis can occur after infection by different infecting organisms. The cultivation of Streptococcus pyogenes (group A), either alone or in combination with staphylococcus, in three patients conforms to the culture results found by Meleney [1] in his original description.

Attention if directed to explanation of the endothoracic fascia in several operations described by pioneer thoracic surgeons. The extrapleural plane was extensively and successfully employed in a number of these operations. Re-emphasis of its use seems advisable even today when open thoracotomy is the rule rather than the exception. In selected cases the extrapleural plane can and should be dissected in the aggressive management of relatively localized empyema, with complete enucleation of the infected sac (empyemectomy). This operation can reduce morbidity and prevent prolonged external drainage. The surgical advantage of the extrapleural plane is also apparent in complete parietal pleurectomy for effective palliation of repeated fluid formation. Other instances of intrathoracic disease are mentioned for which dissection in the extrapleural plane can be a safe and time-saving method of treatment. The anatomic considerations relating to the rapid, safe, and effective dissection of the major hilar vessels are also emphasized.

This review of recurrent inguinal hernia evaluates the possible causes of recurrence and the most effective operative procedures for successful repair. Emphasis is placed upon precise dissection technic so that whatever fascia is available after the primary operation may be utilized for the subsequent repair. A detailed study is devoted to the histologic features of fascia, emphasizing its lack of vascularization as the possible reason for its strength and permanency throughout life. In operations for recurrent inguinal hernia, rectus sheath pedunculated grafts should be used more frequently, and in extreme cases cord excision may be required. A follow-up study of one hundred postoperative cases, with a failure rate of 7 per cent, is presented.