Search

Summary: Background: A pancreatic fistula is one of the most devastating complications following a Whipple's procedure. Fistula rates remain high despite various modifications to surgical techniques. We propose the use of a vascularised muscle flap in the primary prevention of pancreatic fistulas. Method: A distal pancreatectomy was performed on 5 pigs in our porcine model. A pancreaticojejunal (PJ) anastomotic leak was simulated. The pigs were divided into treatment (4 pigs) and control groups (1 pig). A left pedicled rectus abdominis flap was wrapped around the PJ anastomosis for the treatment group and omitted for the control group. Serum and drain amylase levels were recorded. The PJ-rectus abdominis flap complex was evaluated histologically. Results: There was no biochemical evidence of anastomotic leak in the treatment group. The drain-serum amylase ratio was less than 1.5 in the treatment group (p=0.006). Microscopically, the muscle adjacent to the anastomotic leak showed mild necrotic changes with an affected muscle depth of less than 10%. Conclusion: The vascularised rectus abdominis muscle is a durable flap to withstand proteolytic pancreatic enzymes. It is able to provide a water-tight seal around the PJ anastomosis and mitigate intraperitoneal haemorrhage and infection caused by erosion from the pancreatic fistula.

In cases of lacrimal gland carcinoma requiring surgical excision of the orbital contents, skull base, and surrounding bones, definitive blockage of the cranial cavity and reconstruction of the anterior skull base with irradiation-acceptable tissue (for possible subsequent radiotherapy) is necessary. However, considerations for quality of life, including cosmetic aspects, such as artificial eye placement and contour morphology, make reconstruction challenging. In three cases of advanced lacrimal gland carcinoma, we performed a reconstruction surgery following an en bloc resection of the orbital contents and lateral orbital bones. A rectus abdominis flap was used, considering both function and morphology. This flap, characterized by reliable anatomical structure and good blood flow, adequately filled the three-dimensional dead space. In our case, the flap fully survived, and no complications such as cerebrospinal fluid leakage or meningitis were observed. Six months after surgery, the flap volume was 31.7-73.3% of its initial size. Considering potential flap shrinkage in the future, it was deemed beneficial to use a slightly excessive volume., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ueda et al.)

Introduction: Reconstruction of anterior thoracic wall are considered a challenge regarding restoration of form and function. Sternum dehiscence represents a possible complication after cardiac surgery especially in non-compliant, multiple-operated patients. Muscular flaps provide an excellent option for stable soft tissue defects coverage as well as a well vascularised surface. Case Report: This paper presents the case of a 75-year-old male patient with a complex medical record of multiple cardiovascular and lung diseases who was transferred from IUBCvT to Plastic and Reconstructive Surgery Compartment of Târgu-Mureş for a post sternotomy wound dehiscence. Previous interventions that required this maneuver consisted in aortic valve replacement and coronary artery bypass followed by sternal osteosynthesis using stainless steel wires. The first intervention was minimal due to patient post-surgical complications (osteitis, mediastinitis, bilateral pachypleuritis) and consisted in soft tissue debridement, eschilectomy, thoracentesis for bilateral pneumothorax performed by thoracic surgeon and sutures inanatomical planes. Reintervention was required due to poor post-operative care after hospital discharge and recurrence of the initial dehiscence. Reconstruction of the thoracic wall was tempted using two local advancement cutaneous flaps with unfavourable results and flaps necrosis. Substantial debridement of the necrotising tissue with sternal osteotomy were necessary to create a favourable ground for reconstructive methods. For proper coverage of the exposed mediastinum a rectus abdominis muscle flap rotated on its proximal pedicle was placed over the sternum. After a midline incision was performed, the muscle was dissected from its fascial layer with the visualisation of superior epigastric artery and deep inferior artery, the latest being ligatured after suprapubic muscle sectioning. After rising the flap over the defect, coverage was ensured by a skin graft harvested from the anterior aspect of the left tight and the abdominal fascia was reinforced using a polypropylene surgical mesh. Postoperative the patient is admitted to the ICU for supportive treatment. Discussions : After a 5-day follow-up the muscular flap was viable, with minimal 4/2cm marginal skin graft necrosis for which negative pressure wound therapy (Vivano) was applied. Sutures were removed progressively at 2-3 weeks after the surgery without any further complications and spontaneous epithelization of skin graft necrosis site. Conclusions: A notable improvement in clinical results and patient improving health condition was made possible by the effective use of a multimodal therapy strategy. The significance of proper reconstructive techniques and preparation in the management of intricate postoperative complications is demonstrated by the notable final result of the presented case. [ABSTRACT FROM AUTHOR]

The use of robotic surgical systems to perform abdominoperineal resection (APR) has recently become more prevalent. This minimally invasive approach produces fewer scars and potentially less morbidity for the patient. The rectus abdominis muscle is often used for reconstruction after APR if primary closure is not feasible or the surgical site is at high risk of wound complications. Since the traditional open harvest of this flap creates large incisions that negate the advantages of minimally invasive APR, there has been growing interest in harvesting the rectus abdominis in a similarly robotic fashion. This article reviews the technique, benefits, and limitations of this robotic technique. Compared to the traditional open harvest, robotic harvest of the rectus abdominis leaves smaller scars, provides technical benefits for the surgeon, and offers possible morbidity benefits for the patient. These advantages should be weighed against the added expense and learning curve inherent to robotic surgery., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)