Search

KEY MESSAGE Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essential for understanding the mechanisms of action of the various CS techniques, the changes observed on computed tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who have undergone CS. Purpose Component separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps most importantly, the anatomic and physiologic changes following CS techniques. Methods A systematic review of the literature was conducted using the PubMed database and other sources to identify articles describing abdominal wall changes after CS Results After excluding non-pertinent articles, 14 articles constituted the basis for this review. Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the muscles' overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3) Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postoperative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and posterior CS are underway.

Background The aims of this study were to present the concept of original technique in the management of major incisional subcostal hernias and to evaluate short- and long-term outcome. Method Between January 2010 and January 2020, 280 patients underwent hernia repair surgery for incisional lateral abdominal hernia at Clinic for Digestive Surgery, Clinical Center of Serbia. Among them, 37 patients underwent the modified sublay technique for major incisional subcostal hernia with minimal hernia defect surface of 100 cm2 or greater or minimal hernia defect width or height of 10 cm or greater. The operative techniques are as follows: retromuscular dissection of rectus muscle from posterior sheath on the both sides of hernia defect, external oblique muscle dissection from internal oblique muscle in a circle around hernia defect at the side of the hernia defect, complete reconstruction of the posterior myofascial layer, large heavyweight polypropylene mesh placement in a sublay position, and complete or partial reconstruction of anterior myofascial layer. Results A median (range) hernia defect surface was 150 (100-500) cm2. A median operative time was 130 (90-330) minutes. The morbidity rate was 18.9%. A median (range) postoperative hospital stay was 7 (2-24) days. After the median follow-up of 50 (1-108) months, 2 patients (5.4%) developed recurrent hernia. Conclusions The modified sublay technique using large heavyweight polypropylene mesh provides good results in the management of major subcostal abdominal wall defects.

Background. Inguinal hernias in children are a common problem. They occur in 520 cases of 1000 newborns, with the prevalence in males of about 10 times. Therefore, they present a very important problem in pediatric surgery. Materials and methods. This prospective study was performed from 2019 to 2020 and included 30 patients with diagnosed inguinal hernias. Video-assisted percutaneous hernia sac ligation was performed in all patients. Results. The mean operating time was 10.3 2.7 min in patients with unilateral inguinal hernias and 14.7 1.6 min in patients with the bilateral variant. No complications or recurrences were observed during the six-month follow-up period. In one case, an additional 3 mm port setting was performed in an eight-month-old child. The main reason for doing this was the fibrous transformation of the parietal peritoneum because of the existence of incarcerations in the anamnesis. Conclusion. This technique garners all the advantages of a minimally invasive surgical treatment of inguinal hernias using the Tuohy needle. However, the conductor application allows us to create the same approach using a Touhy needle. This means that we can perform an isolated hernia sac ligation without getting under the preperitoneal tissue ligature, parts of the internal oblique and transverse muscles, aponeurosis of the external oblique muscle, and subcutaneous fat. This presented video-assisted percutaneous hernia sac ligation method seems like a potential minimally invasive way to treat inguinal hernias in children.

[Purpose] This study aimed to clarify the required number of measurements to calculate trunk muscle thickness at each position. [Participants and Methods] The participants were 30 elderly males aged >65 years. The right lumbar multifidus (L2), lumbar multifidus (L5), erector spinae, transversus abdominis, internal oblique, and external oblique muscle thicknesses were measured on longitudinal images obtained using ultrasonography in the lying, sitting, and standing positions. Two measurement values for each muscle thickness was used to calculate the intraclass correlation coefficient (1.1–1.5). [Results] The intraclass correlation coefficients of the abdominal muscle thickness measurements with “great reliabilities” were as follows: 1.3–1.5 for the external oblique muscle and 1.2–1.5 for the internal oblique and transversus abdominis muscles in the lying position; 1.3–1.5 for the external oblique and transversus abdominis muscles and 1.2–1.5 for the internal oblique muscle in the sitting position; the intraclass correlation coefficient in the standing position was 1.5 for the external oblique muscle 1.1–1.5 for the internal oblique muscle and 1.3–1.5 for the transversus abdominis muscle. In all the positions, the intraclass correlation coefficient of the measurements of the back-muscle thicknesses ranged from 1.1 to 1.5 for the right lumbar multifidus (L2), lumbar multifidus (L5), and erector spinae. [Conclusion] Depending on the posture, the abdominal muscles require multiple measurements, whereas the back muscles only require a single measurement.

Although changes in lateral abdominal wall musculature after posterior component separation with transversus abdominis release have been investigated, the effects of endoscopic subcutaneous anterior component separation (ES-ACS) on postoperative muscle anatomy have not been evaluated. The purpose of this study was to evaluate changes in the lateral abdominal muscles after ES-ACS. Computed tomography (CT) images of patients who underwent ES-ACS were retrospectively evaluated. Lateral abdominal wall thickness and external oblique displacement were measured at the level of fixed retroperitoneal structures. Measurements on the ES-ACS side were compared with those on the contralateral undivided side or with preoperative images in patients with bilateral procedures. Fifteen patients met the criteria for study inclusion. Most patients (n = 13, 86.7%) underwent unilateral ES-ACS. The most commonly performed procedure was laparoscopic intraperitoneal onlay mesh-plus hernia repair (n = 12, 80.0%; the remaining patients underwent open repair). The Mean defect width was 8.4 cm (range 6–15 cm). There was no difference in the thickness of the lateral abdominal musculature between ES-ACS and undivided sides. There was a significant lateral displacement of the external oblique muscle from the lateral edge of the rectus abdominis on the ES-ACS side (mean distance 3.7 cm; p = 0.0006). No midline hernia recurrences, iatrogenic linea semilunaris hernias, or lateral eventrations were observed during a mean follow-up period of 2.6 years (range 0.5–7.4 years). ES-ACS resulted in no atrophy of the lateral abdominal muscles in long-term CT follow-up. The procedure is a safe and effective adjunct to complex hernia repair in selected patients.

Introduction At the moment, there is an ongoing debate regarding the controversial issue of the ideal reservoir placement (RP) surgical technique during implantation of a 3-piece inflatable penile prosthesis, but a definitive winner has not yet emerged. Aim In this light, we herein describe our modified technique for RP into the space of Retzius through the external oblique muscle fascia and present its results. Methods In total, 253 inflatable penile prosthesis procedures (110 AMS 700 and 143 Coloplast Titan) via a single transverse penoscrotal incision were retrospectively reviewed. 2 Kocher-Langenbeck retractors were placed over the right side of the penoscrotal incision and were used to retract the incision superior to the pubic bone. Then, the external oblique muscle fascia was incised medially to the spermatic cord which was retracted laterally. Next, a “W”, Vicryl 1, stay suture was placed to the incision, and under direct visualization, external oblique muscle fibers were dissected and fascia transversalis was perforated using a Metzenbaum scissor. A Foerster lung grasping clamp was then used to dissect further into the extraperitoneal space and create the reservoir space. The reservoir was placed into the created space and fascia incision was closed using the prepositioned stay suture. The procedure was then completed in a standard fashion. Outcomes The main outcome measures were intraoperative or postoperative complications of our modified RP technique. Results All 253 patients were available for short-term follow-up (average 9.1 months, range 3–22 months). No intraoperative or postoperative complications were reported. Reservoir-related prolonged pain (1 month) was reported by 1 patient, resolving completely after treatment with non-steroidal analgesics. Conclusion We are, surely, not proposing that our modified RP technique should supplant all other methods; rather, it should be considered another useful option for RP in the implanter’s armamentarium.

Using autologous common femoral artery and external oblique muscle fascia is a simple and reliable option for repairing infected aortic pseudoaneurysms. Reoperation of infected pseudoaneurysms is challenging and requires secure aortic repair with complete infection eradication. Here, we report two cases of infected pseudoaneurysms in the ascending aorta cannulation site after cardiac surgeries. Common femoral arteries and fascia were harvested in the same lesion as repair materials. The aortic pseudoaneurysms were repaired under deep hypothermic circulatory arrest. Femoral arterial patches were reinforced with circumferential aponeurosis strips. There was no infection recurrence or repair site dilatation in the long-term follow up of both patients.

BACKGROUND AND AIMS: The eventration involves a highly variable surgical entity with a wide range of possible surgical techniques for its repair, without having found a “Gold Standard” technique. With these animal study, we propose a possible and useful surgical procedure for hernia repair. MATERIALS AND METHODS: We present a modified technique of the anterior component separation (ACS) based on a release of the external oblique muscle from a posterior anatomical approach, accessing the space from the retrofascial space of the anterior sheath of the rectus abdominis muscle. The technique was performed in an experimental animal model with pigs of the “Large White” breed of 20-25 kg since the pig is a good representative model of human anatomy and its abdominal wall. RESULTS: The technique was performed in an experimental animal model with pigs of the “Large White” breed. The procedure through the anterior retrofascial space of the rectus abdominal muscle was easily done, allowing the access to the inter-oblique space and facilitating the release of the external oblique muscle. CONCLUSION: Waiting for its clinical application, the ACS by its external retrofascial space approach could be an interesting surgical resource for incisional hernia repair.

A progressive, generalized loss of skeletal muscle mass and associated deterioration in muscle strength and performance increases with age. Aging affect the respiratory muscle performance on respiratory system due to anatomical and physiological changes in muscle strength as well as thickness of the respiratory muscles. During resting breathing the limitation of movement is more evident in expiration than inspiration were the FEV1/FVC% falls in older people. There are lot of study on peripheral muscle thickness and muscle torque among elderly population, but not much study on respiratory muscle training. This made us to conduct a study on pulmonary function and muscle thickness in elderly population by training the expiratory muscles. To determine the effects of external oblique muscle training on pulmonary function and muscle thickness in elderly population. 60 geriatric voluntary subjects were assigned to experimental and control group as (n=30) each. Experimental group subjected to 16 weeks of external oblique strengthening along with incentive spirometer training. Control group subjected to incentive spirometer alone. Pre and post training muscle thickness and pulmonary parameters were assessed. The paired t test found there is significant difference (P

Amaç:Analjeziklerin yetersiz veya yüksek doz kullanımı giderek önem kazanmaktadır;bu yüzden analjezi yöntemleri her gün geçtikçe gelişmektedir. Transversusabdominis plan (TAP) bloğu ultrasoneşliğinde batın cerrahilerinde ağrı kontrolü için yapılan bir yöntemdir.Çalışmamızda Ultrason eşliğinde farklı bölgelerden ölçümler alarak TAP bloğununhangi bölgeden uygulanması gerektiğini araştırmayı amaçladık.Materyal ve Metot:Çalışmaya 18-65 yaş arası 30 hasta çalışmaya alındı. Ön karın bölgesindenultrason’nun lineer probu subkostal bölgeden ve krista iliyakanın üstündenanterior aksiler bölge ve mediyal aksiler hatta denk gelecek bölgeden internaloblık kas, eksternal oblik kas, ve transversus abdominal plan kılıf genişliğikaydedildi. Yine bu bölgelerin görüntü netliği (kötü, iyi ve çok iyi olarak )değerlendirilip kaydedildi.Bulgular: Kristailiyaka üzerinden anterior aksiler hattın (A1) median aksiler hat (A2) ilekarşılaştırılmasında alınan ölçümlerde internal oblik kas, eksternal oblik kas,transversus abdominus kası genişlikleri ve transversus abdominus fasiya dahadüşük çıkmış ve istatistiksel olarakolarak anlamlı bulunmuştur (P, Background:Inadequate or overdose use of analgesics is becoming increasingly important;therefore, analgesia methods are developing day by day. Transversus abdominisplan (TAP) block is a method for pain control in abdominal surgeries underultrasound guidance. In our study, we aimed to investigate the area where TAPblock should be applied by taking measurements from different regions underultrasound guidance.Methods: Thirty patientsaged between 18-65 years were included in the study. Linear oblique muscle,external oblique muscle, and transverse abdominal plan sheath width from theanterior axillary region and medial axillary line from the anterior abdominalregion, from the subcostal region of the ultrasound to the anterior abdomen,and from the upper iliac crest were recorded. The image sharpness of theseregions (poor, good and very good) was evaluated and recorded.Results: Internal obliquemuscle, external oblique muscle, transversus abdominus muscle widths andtransversus abdominus fascia were found to be lower and statisticallysignificant (P

Objective To determine the value of shear wave elastography (SWE) in assessing abdominal wall muscles, including rectus abdominis (RA), external oblique muscle (EO), internal oblique muscle, and transversus abdominis (TrA) in patients with diastasis recti abdominis (DRA) and healthy controls. Methods From October 2018 to December 2019, 36 postpartum DRA patients and 24 nulliparous healthy women were identified. Inter-rectus distance (IRD) measurements were taken by B-mode ultrasound. Shear wave speed (SWS) values were acquired by one operator at ten specific locations. Clinical and ultrasound variables, including demographics, IRD, muscle thickness, and muscle SWS, were compared between the two groups using Student’s t test or Fisher's exact test. Pearson correlation analyses were conducted for the variables of IRD, muscle thickness, and SWS in the 36 DRA patients. Results The maximum diameter of recti abdominus separation was located at the umbilicus in DRA patients (4.59 ± 1.14 cm). The SWS value was significantly lower in the RA (p = 0.003) and higher in the TrA muscle (p p p = 0.001). Conclusions The application of SWE to abdominal wall muscles in DRA patients is feasible. The correlation between SWS value and IRD in RA should be interpreted with caution.

Background The management of large abdominal wall defects, such as omphalocele or gastroschisis, remains a challenge for pediatric surgeons. Though several techniques have been described to repair those conditions, there is no procedure considered to be the standard worldwide. We report an infant girl with a giant ventral hernia after staged surgery for omphalocele in whom delayed closure of a large abdominal wall defect was performed successfully using “endoscopic component separation technique (ECST)” without serious complications. Case presentation A baby girl was admitted to our hospital because of a giant omphalocele, which had been prenatally diagnosed. The omphalocele was supraumbilical and included the entire liver. After staged surgery, a large abdominal wall defect was closed by skin, creating a giant ventral hernia. We performed endoscopic separation component technique (ECST) for the closure of her abdominal wall defect when she was 11 months of age. ECST was initiated with placement of a 5.0-mm port just above the inguinal ligament and under the external oblique muscle. The space between the external and internal oblique muscles was created by the insufflation pressure, and a second 5.0-mm port was placed at 1.0 cm below the inferior edge of the rib into the space. As the further dissection was carried, the aponeurosis of the external oblique muscle was identified as a white line, running vertically from the epigastrium to inguinal ligament. It was transected longitudinally using electrocautery over its full length. The same procedure was performed on the contralateral side and the abdominal wall was successfully closed. Postoperative course was uneventful. Conclusions The technique of ECST, described here, is simple and safe for infants, and the cosmetic result is satisfactory.

This chapter illustrates a technique of free muscle flap harvesting and its subsequent transfer with revascularization. The second part of the chapter demonstrates an experiment with neovascularization of the abdomen’s external oblique muscle wrapped around the superficial lower epigastric vessels. Latissimus dorsi and neovascularized flap rectus abdominis are excellent training and experimental interventions, especially for experienced microsurgeon.

There have been no studies in which the change in lateral abdominal muscle thickness was compared with shear modulus and electromyography during isometric contraction. Thus, the aim of this study was to compare the change in external oblique muscle (EO) thickness in relation to shear modulus and electromyography during isometric contraction. The case report was conducted on a healthy man, 46 years of age, without any low back pain symptoms within two years prior to the study. An Aixplorer ultrasound was used in SSI mode to measure muscle thickness and shear modulus in the EO on the right side of the body. The eMotion EMG system was used to control EO muscle activity. The expected force (0 kg, 4 kg, 6 kg, 7 kg) was controlled by a force gauge coupled with an external S-Type load cell. Relative to EO rest thickness during an isometric contraction, EO muscle thickness decreased for each force used. Compared to the rest stage (0 N), the EO shear modulus during an isometric contraction systematically increased, which suggested diminished elasticity during the generation of more force. Similarly, EO activity for Chanel 1 and 2 increased during isometric contraction. Changes in the thickness of the lateral abdominal muscles using ultrasound imaging should not be equated with a change in their function or force generation ability.

The components separation technique (CS) is used for the reconstruction of complex abdominal wall defects. Release and undermining of the rectus abdominis muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline, reducing recurrence of ventral hernia, but causes major changes in the physiology of abdominal wall. The purpose of the study was to determine which muscle release and undermining produces the lowest tension on the midline.Twenty fresh cadavers were dissected and the anterior and posterior layers of the rectus sheath were isolated in the midline. The forces necessary to advance the layers of the rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after release and undermining of the right RAM and left EOM; and after release and undermining of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for the different muscles involved, layers of the rectus sheath, measurement points, and stages of separation.Tension on the abdominal midline after the release and undermining of both the RAM and EOM was reduced by 56% (p0.05), 42% after the release and undermining of the EOM alone (p0.05), and 35% after release and undermining of the RAM alone (p0.05).Release and undermining of the EOM by CS led to lower tension on the abdominal midline compared to that associated with the release of the RAM alone.

Background Over the last few years, various concepts of applying core stabilization mechanisms in the formation of human motor function have come to existence. The objective of the research was to assess the influence of two types of core stability training on deep abdominal muscle thickness and on global trunk mobility. Methods The study involved 108 individuals divided into 3 groups: LT (local training), performing the stability training based on locally isolated work of the transversus abdominis muscle; GT (global training), performing the training based on global movement patterns; and CG (control group), who did not undergo the training. The workout programs comprised 4 weeks of the exercise, 4 times a week. The measurement of the observed muscle thickness was carried out by means of ultrasound imaging. Trunk mobility was evaluated based on the toe-touch test, as well as the measurement of lateral flexion ranges. All the measurements were performed before the workout programs, right after finishing and 2 weeks after the end of the training cycle. Results Both training concepts have an impact on deep abdominal muscle thickness; however, in the LT group, significant improvement was noted with regard to the transversus abdominis, whereas in the GT group the improvement concerned the external oblique muscle. Both training methods also improved trunk mobility in the sagittal and frontal plane. Conclusions The results we have obtained imply that both concepts of core stability training affect the human body at a structural as well as functional level. The application of the described training methods may not only provide measurable benefits in the field of clinical physiotherapy, for instance in the treatment of spine-related back pain, but also in motor training designed to improve athletes' performance and to minimize the risk of injury.

Highlights • We present three cases of incisional hernia repair using onlay self-gripping mesh. • The mesh was placed following the anterior component separation technique. • Self-gripping mesh enhances tissue adhesion and requires minimal suture fixation. • The advantages are more sufficient reinforcement and technical simplicity. • The disadvantages are risk of decreased blood flow, infection, fistula, and pain., Introduction Incisional hernia (IH) is a common postoperative complication that affects 10% of the patients who undergo abdominal surgery. The component separation (CS) technique is suitable for large and/or complex hernias; however, CS alone may not eliminate recurrence and is associated with an increased incidence of wound complications. Self-gripping mesh enhances tissue adhesion and contributes to a reduced risk of migration, chronic pain, and other complications. Here, we present three cases of IH that were successfully repaired by anterior CS (ACS) using onlay self-gripping meshes. Case presentation All three patients underwent surgery using the following technique: Briefly, a skin flap was created with release of the external oblique muscle and preservation of the perforating vessels. The linea alba was closed with absorbable interrupted sutures. A self-gripping mesh was trimmed and placed with a 4–5 cm overlap bilaterally from the closed linea alba using an onlay technique. For all patients, the postoperative courses were uneventful and there were no complications at the 3-month follow-up. Discussion The advantages of our technique include more sufficient abdominal reinforcement, technical simplicity, and minimal time required for mesh placement. The disadvantages are the potential risk of decreased blood flow of the skin flaps, wound infection, intestinal fistula, persisting or chronic pain, and difficulty with subsequent abdominal surgery. Conclusion The use of self-gripping mesh with ACS can be performed without increasing the operative time or causing short-term surgical complications. This technique may be recommended for large IH because of its simplicity and secure abdominal reinforcement provided.

Purpose: The purpose of this study was to evaluate the effect of task-oriented exercise and abdominal muscle contraction using functional electrical stimulation (FES) on abdominal muscle thickness and balance of stroke patients. Methods: Ten stroke patients who met the selection criteria were assigned randomly into two groups of five. One group received FES therapy before task-oriented training (experimental group), while the other group received a FES placebo before task-oriented training (control group). The Mann-Whitney U test was used to compare the groups, and the Wilcoxon Signed-ranks test was used to compare differences between the groups before and after intervention. The Mann-Whitney U test was used to compare the rate changes of each item before and after intervention, between the two groups. Results: In the rectus abdominalis and external oblique muscle thickness tests that used ultrasound, there was a statistically significant difference in the experimental group (p .05). There was also a significant difference between the groups (p .05). Conclusions: FES therapy before task-oriented training increases the thickness of abdominal muscles and improves balance abilities.

Introduction Camptocormia (severe bending of the spine) is a debilitating complication of Parkinson’s disease (PD) without established treatment. Botulinum toxin (BT) may be beneficial, but data is scarce regarding the efficacy of administration of BT into the bilateral external oblique (EO) muscle for treatment of camptocormia in PD. Methods Six patients with PD and camptocormia, with flexion of the thoracic spine, were enrolled in the study. BT (75 or 90 units, onabotulinum toxin A) were injected into each EO bilaterally under sonographic guidance. Camptocormia angle (CA) was defined as the angle between the acromion-greater trochanter line and a vertical line. CA and disabling symptoms were evaluated during the treatment course. Results Two weeks after the injection of BT, the mean CA showed significant attenuation [median (interquartile range); 38° (23.5°) vs. 18° (21°), p = 0.028]. Subjective relief was present in cases 1–3 and 6, and absent in cases 4 and 5. Cases 1–3 received repeated injections to maintain the amelioration; in cases 1 and 2, this was for 1 year or longer, while falls of case 3 limited the amelioration. Conclusion Botulinum therapy into bilateral EO attenuated the angle of thoracic-level camptocormia in six patients with PD over the observation period of 2 weeks. The reproducibility of the results, long-term efficacy, and subjective relief of symptoms require further examination.

Introduction Development of indirect inguinal hernias through the inguinal canal is usually prevented by the shutter and the sphincteric mechanisms, which are known to be destroyed by almost all anterior herniorrhaphies. Objective A new preperitoneal repair, which uses a bipedicled external oblique oponeurotic flap, has been recently introduced and was suggested to change the mechanics of this area. In this hernia repaires, the biomechanics of the inguinal region were assessed in healthy individuals and in patients with hernia after new repair and after other conventional anterior hernial repairs. Methods The study included 20 patients with inguinal hernias and 5 non-hernia control cases (group A). Ten of the hernia cases were repaired by the new preperitoneal repair (group B) wheareas the other 10 were repaired by convemtional anterior repair (modified Bassini) (group C). The 5 control cases were selected from patients without hernia, who were scheduled for inguinal surgery for excision of symptomatic varicoceles. During surgery in all cases, two ligaclips were inserted into the ileopubic tract. After sound healing, all cases were radiographed to detect any change in the position of the ligaclips, on contraction of the external oblique muscle. Any displacement of the inserted ligaclips was considered in this study as a sort of mobility at the floor of the inguinal canal, induced by the contracted muscle. Results The study showed that contraction of the external oblique muscle induced, in all cases, a degree of an upward displacement of the floor of the inguinal canal, which could be called a reversed shutter movement. The magnitude of this reversed shutter mobility was nearly identical in normal controls and in cases that underwent conventional anterior hernial repairs. Conclusion The new preperitoneal repair, with the bipedicled external oblique oponeurotic flap, was found to augment this reversed shutter movement significantly. The possible explanation and the forces that possibly induced this reversed shutter mechanism are herein presented and discussed.

The external oblique musculo-aponeurotic complex is an important contributor to the strength of the inguinal canal. The present case report describes the bilateral absence of the external oblique muscle in a patient. A 40-year-old male patient presented with a history of intermittent lower abdominal pain for 15 years which had increased over the past 2 years. Abdominal examination revealed bilateral reducible, incomplete, direct inguinal hernia. Elective bilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the bilateral absence of the external oblique musculo-aponeurotic complex. The isolated absence of the external oblique musculo-aponeurotic complex in adults is an exceedingly rare anomaly. The possibility of such an anomaly should be considered in patients without other risk factors for hernia.

Aim Cardiopulmonary resuscitation is vital for survival after cardiac arrest, and chest compressions are an important aspect of this. When performing chest compression in a hospital setting, the rescuer often has to kneel on the bed to overcome inconvenient differences in height between the rescuer and the bed. However, as yet no study has evaluated the quality of chest compressions in this position. The aim of this study was to examine the impact on the quality of chest compressions while kneeling on the bed. Methods Fifteen female students performed 2‐min chest compressions on a manikin placed on the floor and a bed. Measurement parameters included compression depth, heart rate, integrated electromyogram, and a visual analog scale. The parameters were measured every 30 s and were statistically compared between the conditions. Results Compression depth at 30, 60, 90, and 120 s differed significantly between the conditions. Heart rate values at 150 and 210 s of recovery significantly differed between the conditions. Integrated electromyogram values for the trapezius, rectus femoris, and biceps femoris differed between the floor and bed conditions during 2‐min chest compressions, whereas the external oblique muscle significantly differed at 60 and 120 s. Visual analog scales for fatigue, effectiveness, and stability significantly differed between the conditions. Conclusion Kneeling on the bed does not enable grounding of the toe, causing the upper body to be unstable and limiting generation of the power required for chest compression. Our results suggest that rotation every minute is necessary to maintain effective cardiopulmonary resuscitation while kneeling on the bed.

The abdominal wall provides rigid protection to the abdominal viscera. Moreover, the abdominal musculature is responsible for core strength and agility. The detailed anatomy of the musculature of the abdominal wall extends beyond the scope of this chapter as it is rarely required to extirpate a skin tumor in that depth. In rare cases, one must master the knowledge of the anterolateral musculature of the abdominal wall as components separation of the abdominal wall may be used in order to provide closure. Thus, the anterolateral musculature will be portrayed in detail. It is worth mentioning the superficial fascia as it is common knowledge that the superficial vessels, nerves, and lymphatics course within it near the groin. The superficial fascia is comprised from two anatomically distinct layers. It consists of the superficial (Camper’s fascia) and deep layer (Scarpa’s fascia). Camper’s fascia is thick, and it passes over the inguinal ligament and is continuous with the superficial fascia of the thigh. Scarpa’s fascia is continuous with Colles fascia and does blend with the tensor fascia lata. Moreover, it is loosely adherent to the aponeurosis of the external oblique muscle and to the linea alba and symphysis pubis.

Background and aims Ultrasound guided (USG) ‘the blockade of ThoracoAbdominal nerves through Perichondrial Approach’(TAPA) is a new block we recently described. Its sensory block was reported between Th5-Th12 dermatomes from the mid-axillary line to mid-abdomen/sternum. The modification of TAPA (M-TAPA) was also effectively used in major abdominal surgeries. In this case series, we present TAPA and M-TAPA applied for postoperative analgesia in abdominal surgery patients. Methods We performed TAPA and M-TAPA blocks unilaterally and bilaterally in abdominal surgery patients in our clinic after obtaining written informed consent. In M-TAPA, 20–30 mL of local anesthetic (LA) was applied interfascially between lower surface costochondral tissue and the upper fascia of the transversus abdominis muscle in the 9th and 10th midclavicular line. In TAPA, additional to this injection supplementary 10–20 mL of LA is applied between the upper surface of the condrium and the deep fascia of the external oblique muscle. Results In 8 different operations, 4 patients had right, 9 patients had bilateral TAPA and 9 patients had M-TAPA. The types of surgery, ASA scores, 24-hour analgesic requirements, the numeric rating scale (NRS) scores followed for patients’ pain level are presented in table 1 and figure 1. The mean paracetamol and tramadol consumption were 2.36 ± 0.84 g/day 62.72 ± 49.29 mg/day respectively. Conclusions USG guided TAPA and M-TAPA blocks are an effective regional anesthetic technique in laparoscopic and open abdominal surgeries when selected by considering sensory innervation of the surgical field.

In large congenital diaphragmatic hernias (CDHs), direct suture of the diaphragm is impossible. Surgeons can use a triangular internal oblique muscle (IOM) plus transverse abdominis muscle (TAM) flap. Its caudal limit faces the medial extremity of the 11th rib. Clinical studies show that the flap is not hypotonic but that the procedure could expose patients already presenting a hypoplastic lung to external oblique muscle (EOM) hypotonia. The aims of this study were to study EOM innervation by the 10th intercostal nerve (ICN) and ICN innervation to the IOM and TAM. Forty cadaveric abdominal hemi-walls were dissected. The number of branches and the trajectory of each specimen's 10th ICN were studied medially to the medial extremity of the 11th rib (MEK11) using surgical goggles and a microscope (Carl Zeiss®). The 10th ICN was consistently found between the IOM and TAM. There was a median of nine branches from the 10th ICN to the EOM, 77% of them medial to the MEK11. Median values of nine and 12 branches for the IOM and TAM were found, 60% and 51%, respectively, medial to the MEK11. These results argue in favor of good innervation to the IOM plus TAM flap but also indicate postoperative abdominal weakness exposing patients to herniation risks, as more than 75% of the branches from the 10th ICN to the EOM were sectioned or pulled away during flap detachment. Clin. Anat., 33:759-766, 2020. © 2019 Wiley Periodicals, Inc.

BACKGROUND: While researchers have investigated low back pain (LBP) and its association with the thickness of trunk muscles in the general population, few articles have studied this relationship in athletes. HYPOTHESIS/PURPOSE: To compare the lateral abdominal muscle thickness and other possible functional risk factors in young soccer players with and without LBP. STUDY DESIGN: Cross-sectional study METHODS: Thirty young male soccer players, with and without LBP, from the Premier League participated in this study. The thicknesses of the external oblique, internal oblique and transversus abdominis muscles were measured via musculoskeletal ultrasound imaging, bilaterally. In addition, hamstring flexibility, lumbar spine flexion range of motion, and trunk extensor muscle endurance were measured and were compared in those with and without the history of LBP. RESULTS: The mean age of the subjects was 17.4 (+/- 1.1) years. There was no statistically significant difference between groups (p > 0.05). Subjects with a history of LBP during their lifetime of sports participation (sports life), within the prior year, and within the prior month had statistically significant lower external oblique muscle thickness bilaterally (p

Graphical abstract, A young women presented with iliac vein thrombosis, as extrapelvic endometriosis complication. Endometriosis mass had a subfascial position at the level of external oblique muscle and extended to the iliac vein. This paper reviewed the literature on endometriosis cases localized into striated muscles and cases of deep vein thrombosis due to this disease. There are not similar cases in the literature. The diagnostic role of ultrasound, in obtaining the definitive histological diagnosis, may be further enhanced through Elasticity Imaging Techniques and ultrasound-guided biopsy.

We aimed to characterize rectus abdominis, internal oblique, and external oblique muscle activity in healthy adults under expiratory resistance using surface electromyography. We randomly assigned 42 healthy adult subjects to 3 groups: 30%, 20%, and 10% maximal expiratory intraoral pressure (PEmax). After measuring 100% PEmax and muscle activity during 100% PEmax, the activity and maximum voluntary contraction of each muscle during the assigned experimental condition were measured. At 100% PEmax, the external oblique (p

Background: Inguinal herniotomy is the most common surgery performed by paediatric surgeons.Methods: 100 Male and female cases with congenital inguinal hernia aging from one month till the age of two years. randomly allocated into two groups for undergoing two types of hernia repair techniques, with and without opening the external oblique muscle fascia. Surgical complications such as fever, scrotal oedema and hematoma, and wound infections classified as early complication. The rates of mentioned early complications and operative time were compared in the two interventional groups. In this study, 100 cases were selected and allocated to the two interventional groups.Results: The prevalence of early complications in two studied groups were not different significantly in two interventional groups. Operation time was significantly shorter in inguinal repair techniques without opening the external oblique muscle fascia than the other studied techniqueConclusions: The findings of our study indicated that though early complications of the two repair methods were similar, but the time of procedure was shorter in herniotomy without opening the external oblique muscle both methods are safe and feasible, choosing one of them depend on surgeon prefer.

Introduction. Schwannomas or neurilemmomas are rare, benign, and usually solitary lesions that arise from the nerve sheath. In the majority of cases, these tumors involve the extremities, head, neck, and trunk. Case Presentation. In the present study, a 52-year-old man presented to our surgical department for the evaluation of a symptomatic lump in his left lateral abdominal wall. CT and MRI confirmed the presence of a cystic mass located between the external and internal oblique muscles. Histopathology and immunohistochemistry confirmed it to be benign schwannoma. Discussion. Schwannomas have rarely been reported in the abdominal wall. To the best of our knowledge, this is the first case of schwannoma located in the left upper abdominal wall and the fifth case of abdominal wall schwannoma reported according to the reviewed medical literature. Conclusion. Benign schwannoma should be included in the differential diagnosis of cystic and symptomatic lesions of the abdominal wall. The treatment of choice is surgical excision, and recurrence is extremely rare.

The aim of the study was to compare the one-armed vs. two-armed American kettlebell swing on trunk muscle activation. Fifteen resistance-trained men performed ten repetitions of both exercises using a 14-kg kettlebell. Surface EMG from the erector spinae, rectus abdominis and external oblique muscles were collected on both sides of the trunk. The erector spinae activation during the one-armed swing was 14–25% higher on the contralateral compared to the ipsilateral side in both exercises (Cohen’s d effect size [ES]=0.41–0.71, p ˂ 0.001–0.034). Further, the contralateral side was 14% more activated during the two-armed swing compared to the ipsilateral side during the one-armed swing (ES=0.43, p=0.009). For the rectus abdominis muscle, the two-armed swing induced higher activation of the rectus abdominis compared to the one-armed swing on both the contralateral (40%, ES=0.48, p=0.040) and ipsilateral side (59%, ES=0.83, p=0.002). There were no differences for the external oblique muscle (p=0.495–0.662). In conclusion, the trunk activation patterns of the two exercises were different, which could be explained by different biomechanics in the two exercises, and could thus have complimentary effects. We recommend that both unilateral and bilateral execution of the American kettlebell swing is included over time. Open Access. CC BY-NC-ND 4.0 · Sports Med Int Open 2019; 03(01): E12-E18

Objective The purpose of this study was to systematically review the literature regarding which condition (task, position, or contraction type), changes in muscle thickness could be interpreted as muscle activity of trunk muscles. Methods Studies that assessed the correlation between changes in muscle thickness measured with ultrasonography (US) and electromyography (EMG) activity were included. Only the data related to abdominal and lumbar trunk muscles in participants with or without low back pain were extracted. The PubMed, ScienceDirect, Ovid MEDLINE, Scopus, Springer, and Cumulative Index to Nursing and Allied Health Literature databases were searched from inception to August 2018. Two independent raters appraised the quality of the included studies using the Critical Appraisal Skills Program checklist. Results Fourteen studies were included. The results revealed significant correlations between US and EMG measures for the lumbar multifidus and erector spinae muscle during most contraction levels and postures. For transverse abdominis and internal oblique, US and EMG measures were correlated during low load abdominal drawing or bracing. The correlations were influenced by trunk position for higher intensities of contraction. For the external oblique muscle, correlation was observed only during trunk rotation. Conclusion Changes in muscle thickness should not be interpreted as muscle activity for all tasks, positions, and contraction types. Only during prime movement tasks performed with isometric contraction could muscle thickness change be considered as muscle activity. Also, upright postures influenced the relationship between changes in muscle thickness and muscle activity for abdominal muscles.

Background Hypopressive exercises are suggested for the prevention and conservative treatment of pelvic floor dysfunction. The aim of hypopressive exercises is to strengthen abdominal and pelvic floor muscles (PFM) through the descent of the intra-abdominal pressure. Transabdominal ultrasound imaging is a helpful procedure for assessing the abdominal muscle and PFM activity during the performance of a hypopressive exercise. Methods A sample of nineteen non-pregnant women was recruited. All the participants had previously finished a two-month individual physiotherapy treatment based on hypopressive exercises. The women were instructed to perform a hypopressive repetition that involved a maintained apnea after a forced expiration. The apnea was held for 10 s during which participants tried to expand their ribs and to rise the abdominal wall. Transabdominal ultrasound assessment was performed in supine position, with a 12 MHz straight linear array ultrasound transducer (Model L14 6Ns, Mindray, Shenzen). In order to measure the increase of the cross-sectional area of abdominal muscles, the probe was placed transversely on the right side of the abdominal wall. The PFM action was recorded above the pubis bone in midtransversal and midsagittal planes. Results The whole sample achieved a PFM rise during the hypopressive exercise. The transverse abdominis muscle increased it cross-sectional area, whereas the other abdominal muscles showed different behaviour among the participants. The mean (standard deviation) age of the women was 44.64 (±8.23) with a body mass index of 23.13 (±3.09) kg/cm2. A 78.9% of women presented at least one pelvic floor dysfunction. The PFM lifted a median (interquartile range) of 6.6 (±4.8) cm in transversal plane and 4.4 (±4.6) cm in sagittal plane. The cross-sectional area increase of abdominal muscles was 1.7 (±1) cm in transverse abdominis muscle, 1.1 (±2.2) cm in internal oblique muscle, 0.4 (±1.6) cm in external oblique muscle and 0.2 (±1.8) cm in rectus abdominis muscle. However, in seven women, the external oblique and rectus abdominis muscles showed a decreased area, and the same phenomenon occurred to five participants in the internal oblique muscle. Conclusions Hypopressive exercises produced the elevation of PFM without a direct contraction command. Transversus abdominis muscle also contracted indirectly during a hypopressive exercise, whereas the other abdominal muscles response was not regular.

The purpose of this study was to investigate effects of three pelvic floor muscle (PFM) exercises on the thickness of PFM and transverse abdominal muscle (TrA), the internal oblique muscle, and the external oblique muscle. The PFM and trunk muscles were measured using ultrasonography in 4 conditions—rest, conventional PFM contraction (Ex A), PFM contraction with hip adductor contraction (Ex B), and PFM contraction with real-time ultrasound imaging (Ex C). The thickness of PFM in Ex C showed a significantly more decrease compared to rest and others (all comparisons, p

The components separation technique (CST) was first described in 1990 and involves elevating the external oblique muscle and medially advancing the muscle complex to close abdominal wall defects. Because this procedure is straightforward and does not require prosthetic materials to repair the defect, many surgeons have adopted it. However, some patients who undergo this technique develop Spigelian herniation or "lateral bulging", which is a projection deformity of the lateral abdominal wall. These patients may require prosthetic reinforcement to strengthen the abdominal wall due to the relaxing incision that is made during the CST. In this report, we describe a simple modification to improve the relaxing incision by substituting several short incisions for the traditional single, long incision in the external oblique fascia. These short incisions create a mesh-like pattern in the fascia, which preserves the strength of the lateral abdominal wall and may help prevent Spigelian herniation or lateral bulging. Although the separation of the external oblique muscle from the internal oblique muscle is slightly cumbersome compared to the traditional CST, the plane is avascular and sparsely connected, which allows separation using a finger or tools in our modified technique. Further studies are needed to confirm whether this technique is effective for large defects, although this simple modification may preserve the strength of the lateral abdominal wall without the need for prosthetic materials.

【PURPOSE: Bridge exercises are broadly used to develop trunk co-activation patterns that promote spine stability. This study was to analyze the trunk muscle activity during bridge exercise with various shoulder support surface(stable, sling, Swiss ball). METHODS: The subjects were 20 healthy subjects in their twenties. Subjects were performed bridge exercise on 4 different shoulder support surfaces using stable and labile instruments. 1) Bridge exercise on a stable surface. 2) Bridge exercise with their shoulder on a stable bench. 3) Bridge exercise with their shoulder on a sling. 4) Bridge exercise with their shoulder on a Swiss ball. Rectus abdominis, erector spinae, internal oblique, external oblique muscle activities were measured using electromyography. RESULTS: There were significant differences in RA, EO muscles between performing each of the 4 exercises(p】

The lateral "window" has previously been described as part of the ilioinguinal and anterior intrapelvic approaches for gaining access to the anterior aspect of the sacroiliac joint, the internal iliac fossa, and upper portion of the anterior column for reduction and placement of fixation. Surgical exposure of this window typically involves release of the external oblique muscle from the iliac crest and elevation of the iliacus muscle from the internal iliac fossa. This exposure is limited by the residual attachment of the external oblique muscle and inguinal ligament to the anterior superior iliac spine, particularly in patients with a large abdomen or in fractures that involve the anterior wall of the acetabulum and pubic root region. Herein, we describe the addition of an osteotomy of the anterior superior iliac spine for improved medial mobilization of the abdominal wall musculature to allow better visualization and access to the internal iliac fossa and anterior aspect of the sacroiliac joint.

Rib cartilage grafts are widely used in maxillofacial surgery, but not in orthopedic surgery. The aim of this technical note is to describe the technique used to harvest this graft and to report on donor site complications in the 136 cases we have published on up to now. Harvesting is carried out at the osteochondral junction of the eighth rib. The osteochondral junction is located under the external oblique muscle and a perichondrium layer, which is retracted to allow safe harvesting. The amount of cartilage harvested depends on the size of the area being grafted. Harvesting of a rib osteochondral graft is easy to carry out, provides a considerable amount of hyaline cartilage for the reconstruction of degenerative and traumatic lesions on a joint surface and results in few donor site complications.

Background: Considering that complications and outcome of each method of pediatric inguinal hernia repair are one of the determinants for pediatric surgeons for selection of the appropriate surgical technique, we compared the early and late complications of two inguinal repair techniques, with and without opening the external oblique muscle fascia. Materials and Methods: In this double-blind clinical trial study, boy children aged 1-month to 6 years with diagnosed inguinal hernia were included and randomly allocated into two groups for undergoing two types of hernia repair techniques, with and without opening the external oblique muscle fascia. Surgical complications such as fever, scrotal edema and hematoma, and wound infections classified as early complication and recurrence, testis atrophy and sensory impairment of inguinal area classified as late complications. The rates of mentioned early and late complications were compared in the two interventional groups. Results: In this study, 66 patients were selected and allocated to the two interventional groups. The prevalence of early and late complications in two studied groups were not different significantly in two interventional groups ( P > 0.05). Operation time was significantly shorter in inguinal repair techniques without opening the external oblique muscle fascia than the other studied technique ( P = 0.001). Conclusion: The findings of our study indicated that though early and late complications of the two repair methods were similar, but the time of procedure was shorter in herniotomy without opening the external oblique muscle, which considered the superiority of this method than inguinal hernia repair with opening the external oblique muscle.

The aim of this study is to investigate the cumulative incidence and risk factors of postoperative inguinal hernia (PIH) in patients undergoing radical prostatectomy, i.e., laparoscopic prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RARP). This study included 1124 patients who had undergone radical prostatectomy or transurethral resection of bladder tumor from 2011−2016. We compared the cumulative incidence of PIH in the radical prostatectomy groups (460; LRP 341, RARP 119) and the control group (664; transurethral resection of bladder tumor), and we then analyzed the risk factors (age, operative methods, previous abdominal operative history, thickness and width of external oblique muscle and rectus muscle, thickness of abdominal subcutaneous fat layer at Hesselbach’s triangle level, body mass index, prostate-specific antigen, operative time, specimen weight, Gleason score, and pathology T-stage) of PIH in the radical prostatectomy groups. The median follow-up period in this study was 39.6 months. In Kaplan–Meier curve analysis, the cumulative incidence of PIH was 5.3, 4.2, and 0.5% for the LRP, RARP, and control groups, respectively (p

金沢大学医薬保健研究域保健学系, [Purpose] It has been reported that exercises focusing upon the transversus abdominis (TrA) ameliorate low back pain (LBP). We investigated whether expiratory muscle training (EMT) can promote activity of the TrA to the same degree as the abdominal drawing-in manoeuvre (ADIM) in elderly individuals. [Subjects and Methods] Twenty-one elderly subjects (9 males, 12 females; mean age, 84.9 ± 6.6 years) without LBP symptoms were included. Using ultrasound imaging we measured changes in thickness of the lateral abdominal muscles, TrA, internal oblique muscle (IO), and external oblique muscle (EO) during ADIM and EMT. The load in EMT was set to 15% of maximal expiratory pressure. [Results] TrA showed a significant increase in muscle thickness during ADIM and EMT compared with at rest. A significant increase in muscle thickness was noted for EMT in comparison with ADIM. No significant differences were found for IO and EO. [Conclusion] In elderly people, EMT may be an effective alternative to ADIM for promoting activity of the TrA and can be used as an exercise to maintain TrA function. © 2018 The Society of Physical Therapy Science., 出版者照会後に全文公開

A Tc-MDP bone scintigraphy was performed in an 88-year-old man with a history of right external oblique muscle leiomyosarcoma, which was resected 8 months ago. The static images showed abnormal tracer uptake in the region of resection bed. SPECT/CT images demonstrated that the increased activity was from a partially calcified soft tissue mass in external oblique muscle. Subsequent pathological examination confirmed recurrent tumor.

Summary:. Breast asymmetry has a wide spectrum of presentations with several employable strategies for surgical correction. Historically, the external oblique muscle has proven to be a versatile flap option for the reconstruction of both local and distant defects. It has also been described for use in breast reconstruction for coverage of the lower pole of implant prostheses. The external oblique muscle flap can be harvested in several ways to capture overlying fat and skin. In this study, we describe the use of a superiorly based partial rectus and external oblique flap for surgical correction of lower pole breast hypoplasia. This flap provides vascularized autologous volume to the lower pole of the breast with minimal donor morbidity. Other advantages of this flap are that it can increase the nipple to inframammary fold distance and lower the inframammary fold. This technique represents an evolution of an under-utilized flap and is the first study describing the use of the external oblique flap in the management of breast asymmetry.

Scapular dyskinesis is the term used to describe changes in the positioning or movement of the scapula. Such dysfunction is associated with changes in the activation of the scapular muscles. However, the influence of the axial muscles on the scapular muscles activity of subjects with scapular dyskinesis is unknown. This study aimed to compare the electromyography (EMG) activity of periscapular muscles and its correlation with the external oblique muscle during the execution of push-up performed in different surfaces, in volunteers with and without scapular dyskinesis. Thirty-six men, divided in two groups (control and dyskinesis), performed push-up on stable and unstable surface. The EMG activity of serratus anterior (SA_5th and SA_7th fibers), upper (UT) and lower (LT) trapezius, external oblique (EO) was recorded during execution of each task condition. Statistical analyzes were performed using two way ANOVA repeated measures and Pearson correlation. It was observed effect of interaction between factors, being evidenced increased activity of UT, SA_7th and OE for the control group and decreased activity of SA_5th, SA_7th and EO for dyskinesis group during execution of push-up on unstable surface. In both groups positive correlations (r0.47) were observed between EMG activity of SA and EO. In the exercises tested, there seems to be an anatomical and functional relationship between the SA and EO muscles. The use of the unstable surface promotes increased neuromuscular demand, but the neuromuscular strategies appear to differ between groups.

In this report, we present a case of successful treatment of a bowel fistula in the open abdomen by perforator flaps and an aponeurosis plug. A 70-year-old man underwent total gastrectomy and developed anastomotic leakage and dehiscence of the abdominal wound a week later. He was dependent upon extracorporeal membrane oxygenation, continuous hemodiafiltration, and a respirator. Bowel fluids contaminated the open abdomen. Two months after the gastric operation, a plastic surgery team, in consultation with general surgeons, performed perforator flaps on both sides and constructed, as it were, a bridge of skin sealing the orifice of the fistula. The aponeurosis of the external oblique muscle was elevated with the flap to be used as a plug. The perforators of the flaps were identified on preoperative and intraoperative ultrasonography. This modality allowed us to locate the perforators precisely and to evaluate the perforators by assessing their diameters and performing a waveform analysis. The contamination decreased dramatically afterwards. The bare areas were gradually covered by skin grafts. The fistula was closed completely 18 days after the perforator flap. An ultrasoundguided perforator flap with an aponeurosis plug can be an option for patients suffering from an open abdomen with a bowel fistula.

Reconstruction of full-thickness abdominal wall defect is difficult and is usually done by regional flaps or free tissue transfers. This creates additional donor site morbidity. A 20 cm × 15 cm full-thickness defect in the right iliac fossa of a woman after tumor excision was reconstructed successfully with right-sided external oblique muscle flap and abdominoplasty in a hitherto undescribed fashion. External oblique muscle flap with abdominoplasty can be used for reconstruction of abdominal wall defects with minimum morbidity and satisfactory esthetic appearance.

BACKGROUND Abdominoplasty using a more superficial plane of dissection has several advantages. Previous studies described a trilaminar structure (superficial and deep fat compartments separated by the Scarpa fascia) in the lower abdominal wall. This study aimed to gain a clearer understanding of compartment dominance and changes with increasing adiposity. METHODS The study was performed on the surgical specimens of 41 female patients submitted to a full abdominoplasty. A morphometric study was performed on 82 sides to evaluate the thickness of the fat layers at predetermined locations (point A over the external oblique muscle and point B over the rectus abdominis muscle). A histologic study was performed in 31 samples to analyze the structure of the fat compartments and Scarpa fascia. RESULTS A trilaminar structure was always present, and the Scarpa fascia did not become vestigial with increasing adiposity. Total thickness at point B was significantly higher than that at point A; this difference was mainly attributable to the superficial compartment. The deep fat compartment was always thinner than the superficial, corresponding to 25 percent of total thickness in point A and 23 percent in point B. It was less susceptible to an increase in thickness in cases of obesity. Histologic analysis demonstrated constant morphology, with an average Scarpa fascia thickness of 0.29 mm (point A) and 0.28 mm (point B). CONCLUSIONS This study demonstrates a trilaminar structure with superficial compartment dominance and Scarpa fascia presence irrespective of adiposity in the lower abdominal wall. The deep fat compartment has a minor contribution to the lower abdominal wall thickness.

Background: The surgical treatment ofincisional hernia has changed rapidly during the last decade with the increasing use of mesh technique and the introduction oflaparoscopy. However, many questions concerning mesh type, mesh positioning, fixation method and operation type still remain unanswered. Methods: The study includes 100 cases of anterior abdominal wall hernias, including incisional hernia (cicatricial or paralytic types). The idea of the tension free repair of anterior abdominal wall hernia depends on repair of the defect by double layer onlay polypropylene mesh the deeper mesh is fixed to the free edge of the defect by polypropylene (No.1). The mean operative time was 2 hours (ranging between 1.5- 4 hours). Follow up of the patients was performed every 3 month with maximum follow up of two years and a minimum of six months. Results: The early postoperative course was uneventful in 96 patients (96%). Four patients presented with wound infection, two patients presented with superficial infection, the other two patients presented with deep infection and exposed mesh. The follow up revealed 8 cases of recurrent hernia (8%), two ofthese cases were associated with obesity, and one case was associated with bronchial asthma. Conclusion: In our study we modified the onlay technique for incisional hernia repair by using double layer onlay polypropylene mesh the deeper mesh is fixed to the free edge of the external oblique muscle, this modification insured a tension free repair of the hernia, the technique is universal and can be applied in both scar and paralytic insicional hernia.

The author presents a surgical procedure for chest-wall soft tissue reconstruction due to large losses based on a modified thoracoabdominal myocutaneous flap. Designed in a bilobed shape, it rests on the superior epigastric vessels and may include the cranial one fourth of the rectus abdominis muscle and the premuscular fascia of external oblique muscle and constitutes one of the largest flaps based on a single minor artery. Local recurrent breast tumors and adjuvant therapy associated to obesity, high blood pressure, type II diabetes, and tobacco abuse on previously debilitated patients render the usual reconstructive procedure difficulties. These become indications for this flap, whose safety is improved by maintaining the deep fascia of the external oblique muscle attached to the flap to preserve the network of the arteries close to the fascia and a wide-ranging interarterial choke anastomosis alongside the lateral projection of the flap on the thorax. Thus, a wide range of angles allows us to reach even the opposite site of the thorax over the sterna area with an easy closure of the donor site facilitated by the vertical portion of the abdominal donor site. The flap was used in 55 patients, and no serious complications, including necrosis, notable dehiscence, hematoma, seroma, or abdominal wall weakness, were observed. The overall aspect is acceptable with the visible scars over the upper part of the abdomen.