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Background: Any protrusion through the anterior abdominal wall with the exception of hernia through the inguino-femoral region is defined as ventral hernia. Incisional hernia and primary defects in the abdominal fascia, which can cause umbilical hernia, epigastric hernia, para-umbilical hernia and spigelian hernia are grouped under the definition of ventral hernia. Objective: To evaluate the recurrence rate of laparoscopic ventral hernia repair with closure and non-closure of the hernia defect in non-complicated ventral hernia cases. Patients and Methods: This prospective randomized study was conducted from March, 2015 till December, 2019 in General Surgery Department, Mansoura University Hospital. It involved 50 patients with ventral hernia, who were classified randomly into 2 groups by computer generated sampling technique after retrieval of the calculated sample size according to inclusion and exclusion criteria. Results: The mean age of the non-closure group and of the closure group was 39.96 ± 6.52 and 39.84 ± 7.48 years respectively. The males were 36.0% and females were 64.0% in non-closure group, while in the closure group males were 24.0%, and the females were 76.0%. The mean BMI in the non-closure group was 31.44 ± 3.76 kg/m2, while in the closure group was 30.88 ± 3.70 kg/m2. In the non-closure group, the most common hernia sites were epigastric (60.0%), followed by umbilical (40.0%) while in the closure group, the most common hernia sites were umbilical (96.0%). Conclusion: Laparoscopic ventral hernia repair is a safe and feasible technique. The great advance in abdominal laparoscopic surgery and advance in the equipments and instruments as well as individual skills make closure of the hernia defect represents a good alternative to conventional laparoscopic ventral hernia repair (LVHR) with mesh only.

Objective: To evaluate the efficacy of intra-operative wound irrigation with normal saline in reducing surgical site infections in gynaecological surgeries. Methods: It is a prospective cohort study carried out at Obstetrics and Gynaecology Department, Pak-Emirates Military Hospital, Rawalpindi from 1st November 2019 to 30th April 2020. A total of 400 patients undergoing abdominal surgery for gynecological reasons were recruited by consecutive non-probability technique. Patients with known comorbidities were excluded. Participants of study were allocated cohort and control groups at the end of the surgery after closing the abdominal fascia. In cohort group, the subcutaneous soft tissue was irrigated with 1000 ml of Normal saline solution before skin closure and sterile dressing. No intra-operative wound irrigation was performed in the control group. The primary and secondary endpoint measures (SSI up to 10th Post-Operative day) and (SSI up to 30th Post-Operative day) respectively, were assessed clinically. Results: The study included 400 patients, with 200 in the cohort group and 200 in the control group with Mean Age of (Mean ± SD) 33.6±8.1 years. Majority of the patients had Pre-Op Hemoglobin of >11 g/dl (216)54%. Most common surgeries were Caesarean section (324)81% and Hysterectomy (40)10%. Maximum surgeries were performed between 30-30 min (312)78% with mean hospital stay of (Mean ± SD) 2.9±0.5 days. Analysis of the results showed that Intra-operative wound irrigation with normal saline significantly lesser rate of postoperative SSIs in comparison to no irrigation at both primary outcome measure that was SSI at 10th Post-operative day (POD)(RR=0.417, 95 % CI [0.15;1.161]) and secondary outcome measure that was SSI at 30th POD(RR=0.286, 95 % CI [0.060;1.359]). Conclusion: Intra-operative wound irrigation with Normal Saline decreases the risk of SSI by 58.3% (AR) at 10thPOD and by 71.4% (AR) at 30th POD in otherwise healthy women with no comorbidities.

Highlights • Lipids change overtime in normal fascial healing in the early post-surgery period. • Specific lipid species are correlated with the changes of inflammation cells and fibroblasts. • Lipid species in the present study are considered as predictive markers for the formation of incisional hernia., Background Failure of fascial healing in the abdominal wall can result in incisional hernia, which is one of the most common complications after laparotomy. Understanding the molecular healing process of abdominal fascia may provide lipid markers of incisional hernia or therapeutic targets that allow prevention or treatment of incisional hernias. Purpose This study aims to investigate temporal and in situ changes of lipids during the normal healing process of abdominal fascia in the first postoperative week. Methods Open hemicolectomy was performed in a total of 35 Wistar rats. The midline fascia was closed identically for all rats using a single continuous suturing technique. These animals were sacrificed with equal numbers (n = 5) at each of 7-time points (6, 12, 24, 48, 72, 120, and 168 h. The local and temporal changes of lipids were examined with mass spectrometry imaging and correlated to histologically scored changes during healing using hematoxylin and eosin staining. Results Two phosphatidylcholine lipid species (PC O-38:5 and PC 38:4) and one phosphatidylethanolamine lipid (PE O-16:1_20:4) were found to significantly correlate with temporal changes of inflammation. A phosphatidylcholine (PC 32:0) and a monosialodihexosylganglioside (GM3 34:1;2) were found to correlate with fibroblast cell growth. Conclusion Glycerophospholipids and gangliosides are strongly involved in the normal healing process of abdominal fascia and their locally fluctuating concentrations are considered as potential lipid markers and therapeutic targets of fascial healing.

Summary Background A previous abdominal scar is generally considered as a challenge for breast reconstruction using abdominal flaps. Since it may interfere with the perfusion of abdominal tissue and weaken the abdominal fascia, many plastic surgeons are concerned about the theoretical risk of postoperative complications. This study aims to assess the effects of previous scar on complications in abdominal flap–based breast reconstruction. Methods This systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline using MEDLINE, Ovid, and Cochrane databases in March 2020. All studies comparing the complication rates between patients with previous abdominal scars and control group without a scar were included. However, articles such as case series fewer than 10 patients, letters and animal studies were excluded. Results A total of 2109 patients underwent 2792 abdominal flap tissue transfers for breast reconstruction in the 11 studies reviewed. A previous scar increased the risk of overall flap complications (RR 1.12; 95% CI, 0.95–1.32; fixed-effect model, I2 = 13%) and donor-site complications (RR 1.35; 95% CI, 1.13–1.62; fixed-effect model, I2 = 42%, p > 0.05). In particular, the risk of donor-site wound problem was significantly higher than that in the control group (RR 1.83; 95% CI, 1.35–2.46; fixed-effect model, I2 = 19%, p > 0.05). Conclusions This study result showed that the previous scar increased the risk for all types of complications compared with the control group. In patients with a vertical midline scar, it requires careful preoperative planning with CT angiography and attentive follow-up. However, with careful preoperative planning and an appropriate strategy, it is possible to overcome the detrimental effect of previous scar. Level of evidence I

Background Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) has improved urinary function compared with standard robotic-assisted radical prostatectomy (S-RARP). As RS-RARP spares the dorsal vascular complex, pelvic fascia, and anterior abdominal fascia, it may also lower the incidence of “neglected” postprostatectomy sequelae such as penile shortening, Peyronie’s disease, and inguinal hernias. Objective To determine whether there are patient-perceived differences in penile shortening, Peyronie’s disease, and inguinal hernia rates among men undergoing RS-RARP versus S-RARP. Design, setting, and participants Researchers uninvolved in clinical care and blinded to surgical approach surveyed 60 RS-RARP versus 57 S-RARP men with validated patient-reported items to assess penile shortening, Peyronie’s disease, and inguinal hernia sequelae following surgery. Intervention RS-RARP versus S-RARP. Outcome measurements and statistical analysis Univariate differences between the two cohorts were analyzed using Student t test. Logistic regression was used to analyze variables associated with postoperative penile shortening. Cox proportional hazards models were used to assess the risk of developing Peyronie’s disease and inguinal hernia postoperatively. Results and limitations RS-RARP was associated with less patient-reported penile shortening (41.7% vs 64.9%, p = 0.012), Peyronie’s disease (0% vs 8.7%, p = 0.020), and inguinal hernia (0.0% vs 13.0%, p = 0.004). In adjusted analyses, RS-RARP (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09–0.63, p = 0.004) was associated with lower odds of penile shortening, while a higher body mass index was associated with increased odds of penile shortening (OR 1.13, 95% CI 1.01–1.26, p = 0.037). RS-RARP was not associated with a decreased risk of Peyronie’s disease on Cox proportion hazard model; however, these models are limited due to a limited number of events in our cohort. Limitations include retrospective design, patient-reported outcomes, and small cohorts. Conclusions RS-RARP is associated with less patient-reported penile shortening and may decrease the risk of Peyronie’s disease and postoperative inguinal hernia development. These new findings add to research, showing improved urinary continence and quality of life following RS-RARP; however, a prospective study is needed to validate these findings. Patient summary Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment, which has shown improved postoperative urinary control compared with the standard technique, likely due to preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia., Take Home Message Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment that has shown improved postoperative urinary control compared with the standard technique, likely due to the preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia.

Objective Incisional hernia is a frequent complication of midline laparotomy. The suturing technique is an important determinant of the risk of developing an incisional hernia. Moreover, IL-6 has crucial roles in the wound-healing process. We aimed to compare the large stitch vs. small stitch technique for abdominal fascial closure on IL-6 expressions in rats. Results Twenty rats were used. The small stitch group received small tissue bites of 5 mm and the large stitch group received large bites of 10 mm. The incisions of fascia were closed by running sutures. Animals were euthanized on days 4 and 7. Histological sections of the tissue-embedded sutures were analyzed for IL-6 expressions. Two-way ANOVA showed that rats in the small stitch group had similar IL-6 expressions on days 4 and 7 to those in the large stitch group (p = 0.36). In conclusion, the IL-6 expressions are similar between the small and the large stitch groups, implying that different suturing techniques might not have an impact on the incisional hernia occurrence.

Altered composition of collagen and elastin in abdominal fascia has been linked with the pathogenesis of hernias. This has not been studied amongst Africans who have hernia presentations which vary significantly from Caucasian cohorts. The aim of this study was to determine, and compare, the collagen and elastin contents of the transversalis fascia and rectus sheath of inguinal hernia patients with non-hernia controls. Twenty-five patients with solitary, primary, uncomplicated inguinal hernia and twenty-five non-hernia controls were evaluated. Biopsies of the transversalis fascia and anterior rectus sheath were stained with Masson Trichrome and Verhoeff van-Gieson to isolate collagen and elastin respectively, which were quantified using the ImageJ/Fiji® image analysis software. Inguinal hernia patients were aged 19–85 years with a mean age of 45.2 years, mean body mass index (BMI) of 23.3 kg/m2 and mean duration of hernia of 42.5 months. Lateral hernias with no hernia defect or posterior wall defect [PL0] were the predominant clinical type. There were significantly lower collagen and higher elastin content in the transversalis fascia and rectus sheath of inguinal hernia patients [P

Introduction Chronic, large, and old incisional hernias often lead to surgical complications and major hindrances during emergent laparotomies. The most challenging stages of the laparotomy in such cases occur during opening and fascial closure. Case presentation This article explains the novel surgical technique employed for the complex abdominal closure upon concluding an emergent laparotomy on a 68-year-old female patient. This innovative technique is appropriate for patients with contaminated abdominal cavities and scant fascia who require abdominal operations in cases where biological mesh is not available or is not a viable option. Conclusion This surgical technique can help surgeons restrict abdominal contents and organs (particularly the bowel loops) and prevent migration out of the abdominal cavity during the early post-operative stages, hence, reducing post-surgical complications. The discussed surgical technique ensures that the abdominal fascia defect is limited using skin flaps. This defect later develops into a small hernia sac within a few weeks. Patients then need to have a secondary delayed elective operation on this significantly smaller sized hernia for repair using synthetic mesh., Highlights • In repairing large hernias, if there is no contamination, the best method is to repair with mesh. • In the presence of contamination and small hernia, initial repair seems reasonable. • If there is a large hernia, the use of biological mesh is a good option if possible. • In our country, due to the existence of sanctions in such circumstances, using the proposed method can be a good alternative.

BackgroundParastomal hernia (PH) is a common long-term complication in persons with an ostomy. Although the cause of PH may be multifactorial, the surgical technique employed for the creation of a stoma may be a risk factor for the development of PH. The traditional technique of cruciate fascia incision may predispose to increased pressure zones at the ostomy exit site, thereby increasing the risk of PH. A circular excision of the abdominal fascia at the ostomy exit site enables a uniform pressure distribution, thereby reducing the risk of PH. This hypothesis was tested in this in vitro experimental simulation study.MethodsThe effect of the surgical technique for ostomy creation on the risk of PH development was investigated in this in vitro experimental simulation study. The pressure development at the stoma site was compared for the traditional cruciate incision vs. circular fascia excision.ResultsThe pressure at the ostomy site was about four-times higher in the tradition cruciate incision technique compared to the circular excision technique. This finding was independent of unilateral (e.g. peritoneal) pressure application.ConclusionThe main finding from this study suggests that the traditional cruciate incision of the abdominal fascia for the creation of an intestinal ostomy predisposes to increased pressures at the ostomy site, thus increasing the risk of PH. This effect is not seen in the experimental setting following a circular excision of the fascia. Thus, this surgical aspect may be adopted as a possible means of reducing the risk of parastomal hernia in patients undergoing ostomy surgery.

Background An open abdomen is often necessary for survival of patients after peritonitis, compartment syndrome, or in damage control surgery. However, abdominal wall retraction relieves delays and complicates abdominal wall closure. The principle of the newly fascia preserving device (FPD) is the application of anteriorly directed traction on both fascial edges over an external support through a longitudinal beam to relieve increased abdominal pressure and prevent fascial retraction. Methods Twelve pigs were randomly divided into two groups. Both groups underwent midline laparotomy under general anesthesia. Group one was treated with the new device, group two served as controls. The tension for closing the abdominal fascia was measured immediately after laparotomy as well as at 24 and 48 h. Vital parameters and ventilation pressure were recorded. Post mortem, all fascial tissues were histologically examined. Results All pigs demonstrated increases in abdominal circumference. In both groups, forces for closing the abdomen increased over the observation period. Concerning the central closing force after 24 h we saw a significant lower force in the FPD group (14.4 ± 3 N) vs. control group (21.6 ± 5.7 N, p

Background and aim of the study Cardiac implantable electronic device (CIED) implantation is associated with an increase in CIED infection. For pacemaker-dependent patients, temporary pacemaker leads are implanted until infection remission, which allows new CIED implantation. We compared the outcome of pacemaker-dependent patients with infected CIED based on whether a combined single procedure of epicardial pacemaker implantation with system extraction or a temporary transjugular pacemaker implantation with interval system implantation was performed. Methods This retrospective study included pacemaker-dependent patients with CIED infection who were divided into two groups: the Tempo and Epi groups. The Tempo group received temporary transvenous pacemaker connected to an external pulse generator. After infection remission, a new permanent pacemaker was implanted, and the temporary pacemaker leads were removed. The Epi group received implantable epicardial right-ventricular pacemaker through infrasternal inferior pericardiotomy, and a permanent pulse generator was implanted through the same incision between the subcutaneous tissue and abdominal fascia. Results Sixty-six patients were included. Forty-two patients with epicardial pacemakers were discharged after 9.5 ± 8.8 days without infection of the newly implanted epicardial pacemaker. Patients with temporary transjugular pacemaker lead were discharged 23 ± 15 days after receiving permanent pacemakers. No serious complications were recorded in the Epi group. Conclusions CIED infections in pacemaker-dependent patients can be treated through epicardial pacemaker implantation that allows early patient mobility and reduces hospital stay with no risk of epicardial pacemaker infection. Epicardial pacemakers can be used as a bridge until permanent intravenous CIED is implanted or as a replacement for permeant intravenous CIED.

Breast reconstruction by abdominal flap has evolved to ensure minimal donor-site morbidity with the description of Deep Inferior Epigastric artery Perforator flap (DIEP flap). Being of the same thickness and the same surface, the Superficial Inferior Epigastric Artery flap (SIEA flap) does not require, for it harvesting, to open the abdominal fascia or to dissect through the muscles minimizing again donor-site sequelae. However, it is little used because of the variability of its vascularization and a higher failure rate than the DIEP in the literature. We believe that it is reasonable, in some cases, to harvest a SIEA flap instead of DIEP flap in mammary reconstruction. We present a technical note explaining our operative strategy for reliably taking a SIEA when the caliber of the vessels allows.

Highlights • The open abdomen is a useful resource for treating patients with abdominal hypertension and abdominal compartment syndrome. • Multiple techniques have been described in the literature. • Adequate application of negative pressure therapy in combination with fascial retraction, has proved to be the most convenient approach in the management of the open abdomen., Introduction The open abdomen is a useful resource for treating patients with abdominal hypertension and abdominal compartment syndrome. Currently, early closure assisted with negative pressure devices is considered standard of treatment, and its use has demonstrated favorable outcomes and a decreased rate of complications. Presentation of a case We present a case of a 32-year-old male patient with diagnosis of non-seminomatous germinal testicular tumor (Stage IIIB (T3-N3-M1), which was summited to surgery, as a complication he presented massive bleeding, that culminated in acute compartment syndrome. With the aforementioned findings the patient re entered the operating room and was managed with open abdomen combined with a medial retraction technique of the abdominal fascia. Currently, the patient has not presented recurrence or late complications after a year. Discussion The use of negative pressure techniques for open abdomen management began to be generalized in 1995. Subsequently, this technique evolved to V.A.C therapy (Vacuum-assisted closure therapy). Currently, these negative pressure techniques have become the most used method for the temporary closure and management of open abdomen. Controversies continue to limit its widespread use and effectiveness. Conclusion Adequate application of negative pressure therapy in combination with techniques of medial retraction of the abdominal fascia, have proved to be useful in management for patients with open abdomen.

Objective: Endometriosis is defined as the presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity. It is most commonly located in the pelvis but it is also rarely observed in the gastrointestinal tract, lung, liver, kidneys, central nervous system and abdominal wall. Abdominal wall endometriosis (AWE) commonly occurs following a caesarean section or pelvic surgery. The patients consult the physician mostly with complaints of cyclic abdominal pain and a palpable mass in the abdomen. The basic methods in diagnosing AWE are anamnesis and physical examination but ultrasound, computerized tomography, and sometimes magnetic resonance imaging of the abdomen are also used. Material and Methods: In our study, we retrospectively analyzed 9 patients who underwent surgery at Avcılar State Hospital General Surgery Service between January 2015 and December 2018 with a preliminary diagnosis of AWE and confirmation through pathology results. Results: Median age of the patients was 32 ± 4.66 and median body mass index (BMI) was 24.6 ± 1.15. Every patient except 1 had a history of cesarean section history. One patient was operated because of recurrence. Patients consulted the hospital with complaints of pain during menstruation and abdominal swelling. The start of the complaints was 4.1 years following C-section. Mostly ultrasound was used for imaging. For treatment, they all received en-bloc mass excision and their pathological diagnosis were compliant with endometriosis. Average surgery time was 40 minutes and average endometriosis lesion dimension was 3.4 cm. It was observed that the lesion extended to the anterior abdominal fascia in 6 of the patients, and 2 patients underwent fascia repair with propylene mesh because of the excessive defect size. No postoperative complication occured in any patient and no recurrence is observed. Conclusion: In patients with periodic abdominal pain and swelling on the abdominal wall, AWE could be suspected and early diagnosis can be realized by carefully taking medical history and following physical examination, and appropriate radiological examinations and necessary surgical intervention can be performed. The method of diagnosis and treatment is to remove the lesion through wide excision.

Endometriosis is a common clinical problem in women of reproductive age. Endometriosis usually involves pelvis, peritoneum, ovaries, pouch of Douglas, and uterosacral ligaments, in addition to abdominal wall, albeit rarely. Meshes are frequently implanted today for the purpose of hernia repair. Synthetic mesh placement has been growing in number with an intent of improving success of certai n surgical procedures and prolonging treatment response. With increasing use of meshes, however, mesh-associated complications are coming to light. Such complications cover a broad spectrum including chronic erosion, dyspareunia, pain, infection, injury to rectum, bladder, and vessels. Here, we present a case who previously had undergone surgery due to umbilical hernia and was implanted with a mesh for whom total laparoscopic hysterectomy was indicated as she had uterine myoma and menometrorrhagia refractory to medical treatment. During her surgery, mesh in- fection was suspected upon which excision was performed and pathology report, in turn, revealed endometrioma.

BackgroundPrimary closure of the fascia at the conclusion of a stage laparotomy can be a challenging task. Current techniques to medialize the fascial edges in open abdomens entail several trips to the operating room and could result in fascial damage. We conducted a pilot study to investigate a novel non-invasive device for gradual reapproximation of the abdominal wall fascia in the open abdomen.MethodsMechanically ventilated patients ≥16 years of age with the abdominal fascia deliberately left open after a midline laparotomy for trauma and acute care surgery were randomized into two groups. Control group patients underwent standard care with negative pressure therapy only. Device group patients were treated with negative pressure therapy in conjunction with the new device for fascial reapproximation. Exclusion criteria: pregnancy, traumatic hernias, pre-existing ventral hernias, burns, and body mass index ≥40 kg/m2. The primary outcome was successful fascial closure by direct suture of the fascia without mesh or component separation. Secondary outcomes were abdominal wall complications.ResultsThirty-eight patients were investigated, 20 in the device group and 18 in the control group. Primary closure of the fascia by direct suture without mesh or component separation was achieved in 17 patients (85%) in the device group and only 10 patients (55.6%) in the control group (p=0.0457). Device group patients were 53% more likely to experience primary fascial closure by direct suture than control group patients. Device group showed gradual reduction (pConclusionsThe new device applied externally on the abdominal wall promoted reapproximation of the fascia in the midline, preserved the integrity of the fascia, and improved primary fascial closure rate compared with negative pressure therapy system only.Level of evidenceI, randomized controlled trial.

Background Incisional hernia is a frequent complication of abdominal wall incision and has a high rate of recurrence. Most of the studies stated that non-absorbable sutures decreased incisional hernia incidences, but some stated otherwise. We aimed to compare the collagen type I/III ratio between monofilament non-absorbable sutures and multifilament absorbable sutures for abdominal fascia closure in Wistar albino rats. Methods Forty rats were divided into four groups. Groups 1 and 3 were sutured with monofilament non-absorbable (polyvinylidene fluoride). Groups 2 and 4 were sutured with multifilament absorbable (polyglycolide). Then, groups 1 and 2 were euthanized on day 4 (POD 4), while groups 3 and 4 were euthanized on day 7 (POD 7). Samples of fascia (1 × 0.5 cm) were taken for analysis. Collagen I/III ratios were measured using immunohistochemistry staining methods. Results While the expression of collagen I was not significantly different between monofilament non-absorbable and multifilament absorbable at POD 4 and 7 (p = 0.45 and 0.81, respectively), the expression of collagen III reached a significant level with p-values of 0.0003 and 0.0004 for POD 4 and 7, respectively. Moreover, the collagen I/III ratio was also significantly different between the two groups either at POD 4 (0.88 ± 0.23 vs. 0.53 ± 0.08; p = 0.0003) and 7 (1.77 ± 0.65 vs. 1.03 ± 0.28; p = 0.004). Conclusions Monofilament non-absorbable sutures show a significantly higher collagen I/III ratio than multifilament absorbable sutures for abdominal fascia closure in rats. Our findings imply that the usage of monofilament non-absorbable sutures might have a beneficial effect on decreasing the incisional hernia occurrence., Highlights • One of the most important factors that influences the occurrence of incisional hernia is suturing material. • Collagen is a major component of the extracellular matrix and plays an important role in maintaining tissue elasticity and tensility. • The usage of monofilament non-absorbable sutures might have a beneficial effect on decreasing the incisional hernia occurrence.

Purpose Alteration in fascial tissue collagen composition represents a key factor in hernia etiology and recurrence. Both resorbable and non-resorbable meshes for hernia repair are currently used in the surgical setting. However, no study has investigated so far the role of different implant materials on collagen deposition and tissue remodeling in human fascia. The aim of the present study was to develop a novel ex vivo model of human soft tissue repair mesh implant, and to test its suitability to investigate the effects of different materials on tissue remodeling and collagen composition. Methods Resorbable poly-4-hydroxybutyrate and non-resorbable polypropylene mesh implants were embedded in human abdominal fascia samples, mimicking common surgical procedures. Calcein-AM/Propidium Iodide vital staining was used to assess tissue vitality. Tissue morphology was evaluated using Mallory trichrome and hematoxylin and eosin staining. Collagen type I and III expression was determined through immunostaining semi-quantification by color deconvolution. All analyses were performed after 54 days of culture. Results The established ex vivo model showed good viability at 54 days of culture, confirming both culture method feasibility and implants biocompatibility. Both mesh implants induced a disorganization of collagen fibers pattern. A statistically significantly higher collagen I/III ratio was detected in fascial tissue samples cultured with resorbable implants compared to either non-resorbable implants or meshes-free controls. Conclusion We developed a novel ex vivo model and provided evidence that resorbable polyhydroxybutyrate meshes display better biomechanical properties suitable for proper restoration in surgical hernia repair.

BACKGROUND Negative pressure wound therapy (NPWT) has been described for closure of complex neonatal abdominal wounds, but advanced techniques for stoma or fistula control, skin protection, and the use of high pressure therapy not as well established. CASES We identified neonatal patients at our institution who received NPWT for a complex abdominal wound, defined as a wound associated with a stoma or fistula with partial or complete dehiscence of the abdominal fascia or skin. We then reviewed techniques for decreasing wound contamination and protecting the newborn's skin. One patient had an especially complex wound; she was born at ∼23 weeks' gestational age (birth weight 580 g). She developed necrotizing enterocolitis and strictures, requiring multiple surgeries to relieve obstruction, ultimately resulting in an end ileostomy with mucous fistula. She suffered from wound dehiscence and retraction of her surgically created stoma, resulting in a complex abdominal wound with significant damage to the surrounding skin. We used advanced NPWT techniques to heal her wound, including topical skin protectants, placement of an adhesive dressing over the skin prior to placement of negative pressure dressing, placement of a negative pressure sponge directly on the wound bed and stoma, diversion of enteric contents away from the wound using a Malecot catheter, and an increase in the negative pressure applied. CONCLUSION Complex neonatal abdominal wounds can be treated effectively using NPWT. The techniques we describe divert enteric contents away from the wound bed while maintaining negative pressure and protecting the surrounding skin. In addition, we used negative pressure up to -125 mm Hg and found it was well tolerated by our patients.

Background Preeclampsia is among the most common medical complications of pregnancy. The clinical utility of invasive hemodynamic monitoring in preeclampsia (e.g., Swan-Ganz catheter) is controversial. Thoracic impedance cardiography (TIC) and Doppler echocardiography are noninvasive techniques but they both have important limitations. NICaS™ (NI Medical, PetachTikva, Israel) is a noninvasive cardiac system for determining cardiac output (CO) that utilizes regional impedance cardiography (RIC) by noninvasively measuring the impedance signal in the periphery. It outperformed any other impedance cardiographic technology and was twice as accurate as TIC. Methods We used the NICaS™ system to compare the hemodynamic parameters of women with severe preeclampsia (PET group, n = 17) to a cohort of healthy normotensive pregnant women with a singleton pregnancy at term (control group, n = 62) (1/2015–6/2015). Heart rate (HR), stroke volume (SV), CO, total peripheral resistance (TPR) and mean arterial pressure (MAP) were measured 15–30 min before CS initiation, immediately after administering spinal anesthesia, immediately after delivery of the fetus and placenta, at the abdominal fascia closure and within 24–36 and 48–72 h postpartum. Results The COs before and during the CS were significantly higher in the control group compared to the PET group (P

Introduction Loss of abdominal domain is an unsolved problem in many complex abdominal procedures. We report three patients who underwent weighted traction and use of retention sutures to prevent fascial retraction. Cases Our first patient had esophageal metaplasia and a recalcitrant esophageal stricture after having esophageal atresia repair as an infant. Due to vascular congestion of his new conduit, his abdomen was left open. Respiratory compromise was noted on attempted closure, so the patient's abdominal fascia was placed on 20 pounds of traction to prevent fascial retraction. His abdomen was able to be closed after 7 days. Our second patient had a caustic ingestion and underwent a jejunal interposition. Due to the length of the procedure, the abdomen was left open. The fascia was sutured to a silastic silo and placed on 30 pounds of traction. After 8 days, the patient's abdomen was able to be closed primarily. Our third patient presented with persistent aspiration after esophageal atresia repair. Due to concern for her jejunal conduit, her abdomen was left open and placed on weighted traction. Once the abdomen was suitable for closure, an abdominal vac was placed, and continuous fascial tension was applied using #5 Ethibond sutures. Her abdomen was fully closed 10 days later. Discussion One of the concerns with temporary abdominal closure is retraction of the fascia. We report three cases where the fascia and abdominal wall were placed on weighted traction, which allowed for retention of abdominal domain and delayed primary closure without grafts or mesh. This approach adds to the options available to aid in closure of the complex abdomen.

Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.

Resumen La ascitis es la complicación más común en los pacientes con cirrosis hepática. Las hernias umbilicales (HU) ocurren en 20% de estos pacientes y 40% en aquellos con ascitis severa. La HU ocurre debido al aumento de presión intraabdominal, al debilitamiento de la fascia abdominal y la pérdida de masa muscular. Además, tienen tendencia a aumentar rápidamente y presentar alto riesgo de complicaciones que amenazan la vida del paciente. El tratamiento de la HU no complicada es controversial, tanto el manejo quirúrgico (herniorrafia) como el manejo conservador (control de ascitis) presentan alta tasa de complicaciones, en consecuencia incrementa la morbimortalidad. Actualmente, se recomienda herniorrafia umbilical con previo control de la ascitis en el manejo de HU no complicada, reduce el riesgo de infección de herida operatoria, evisceración, drenaje de ascitis, peritonitis y reduce hasta 41% la recidiva de HU. El éxito de este enfoque también depende del grado de disfunción hepática. El tratamiento de la HU complicada es quirúrgico (herniorrafia sin malla), con menor tasa de mortalidad respecto al manejo conservador. Estudios revelan ventajas de la herniorrafia umbilical laparoscópica (mínimamente invasiva y sin tensión) en comparación a la cirugía abierta, sin embargo, aún no hay evidencia al respecto.

Surgical site infection (SSI) is a frequent complication in dirty surgery, reaching rates of up to 40%. The incidence of SSI might be influenced by the suture used for closure of the abdominal fascia. Sutures coated with antibacterial substances may reduce the bacterial load in the incision.A retrospective study of patients with intra-operative diagnosis of fecal peritonitis undergoing a laparotomy in three Spanish hospitals was performed. Fascial closure consisted in running loop suture of Polyglactin (Vicryl loopOne hundred four patients were included. There were no differences in age, gender, comorbidities, etiology of peritonitis, and mortality among groups. Surgical site infection rate was 34.6% in group 1; 8% in group 2; 33% in group 3; and 10% in group 4 (p = 0.029). The use of triclosan-coated sutures is associated with lower risk of SSI (risk ratio [RR]: 9; p = 0.003). Evisceration rate was 0% in groups 1 and 2; 15.2% in group 3; and 10% in group 4 (p = 0.05). All patients suffering from evisceration presented previous SSI. The use of monofilament sutures is associated with higher risk of evisceration (RR: 6.35; p = 0.033).Triclosan-coated sutures reduce SSI rate in fecal peritonitis, without differences between braided and monofilament type. The use of monofilament sutures is related to higher risk of evisceration, independent of a triclosan coating.

Tension-free repair (TFR) is hernioplasty using prosthetic mesh or device to replace or reinforce abdominal wall defect, without forceful pull between tissues or tissue-prosthesis junction with sutures. Open tension-free repair (TFR) is the most common groin hernia repair, representing 70% of all hernia repairs performed in the developed countries (Lomanto et al., Asian J Endosc Surg 8:16–23, 2015), the procedure is easy to learn, quick to perform, safe and cost-effective, and can be done without general anesthesia (Awad and Fagan, Am J Surg 188:9S–16S, 2004). With triple-triangles of the myopectineal orifice treated as a whole, the prosthetic mesh material could replace or reinforce the attenuated abdominal fascia and muscles without tension, resulting in minimized postoperative pain and recurrences (Jacobs, N Engl J Med 350:1895–7, 2004). The 2009 and 2014 European Hernia Society guidelines also recommend open TFR (Lichtenstein, Plug and Patch, Prolene Hernia System) and endoscopic repair as the choices for unilateral primary groin hernia for adult patients (Simons et al., Hernia 13:343–403, 2009; Miserez et al., Hernia 18:151–63, 2014).

Critically-ill patients may have their abdomens opened as a result of primary pathology (damage-control laparotomy in trauma, soiled peritoneum from perforated hollow viscus, necrotizing pancreatitis), or as treatment for abdominal compartment syndrome (defined as new organ dysfunction associated with intra-abdominal hypertension). The incidence and implications of intra-abdominal hypertension and abdominal compartment syndrome (ACS) in particular, are currently debated. Intra-abdominal hypertension (IAH) is defined as a sustained intra-abdominal pressure ≥ 12 mmHg. Grading is possible; Grade I = IAP 12 to 15 mmHg, Grade II = IAP 16 to 20 mmHg, Grade III = IAP 21 to 25 mmHg, Grade IV = IAP >25 mmHg. Management principles include reduction of intra-abdominal gas (NGT and flatus) and intra-abdominal fluid (the latter may be interstitial or intra-peritoneal), and ensuring the abdominal wall is as compliant as possible. Definitive management is to open the abdomen however, the benefits and use of the open abdomen (OA) approach are unclear. The rates of OA appear to be reducing worldwide. The reduction in the incidence of ACS requiring laparostomy may be related to global changes in resuscitation targets1, rather than changes in surgical techniques. In particular, the notion of ‘fluid de-resuscitation’ may be implicated in improved outcomes. The decision to leave the abdomen open after emergent laparotomy seems to be dependent on the surgical specialty of the operating surgeon, and is a common approach applied in victims of blunt abdominal trauma2. Complications of the open abdomen relate mainly to nutritional status and long-term abdominal complications. The most feared abdominal complication relates to the inability to close the abdominal fascia, with associated increases in mortality, fistula formation, and ventral hernias. Current critical care focus is on the prevention of the open abdomen. For intra-abdominal hypertension and acute compartment syndrome, medical management aimed at reduction of abdominal wall pressure and evacuation of intra-abdominal contents (including fluid) are cornerstone strategies. The use of neuromuscular blocking agents is controversial; short-term benefit may be outweighed by long-term complications. For the de novo open abdomen, current research suggests a possible role for more aggressive early closure (primary or before day 5, latest day 8). Further research is required to confirm whether primary closure is safe. Temporary closure techniques using a combination of negative abdominal wall pressure in combination with partial mesh reduction seems to be helpful in increasing successful abdominal closure rates3. Aggressive infection control and nutritional support after 72 hours is key. Common to both scenarios is the need for careful, judicious fluid management; organ perfusion must be optimized, but not at the expense of massive bowel and abdominal wall edema. The latter complicates healing and closure4. A final question is whether extubating patients with an open abdomen is safe and feasible. The literature provides a resounding yes to this issue5.

Purpose: Incisional hernias after laparotomy are associated with significant morbidity and increased costs. Recent research on prevention of incisional hernia formation suggests that a laparotomy closure technique using a slowly absorbable monofilament suture with small fascial steps and bites in a continuous, single layer with a suture length to wound length (SL/WL) ratio of at least 4:1 is effective in lowering morbidity. Little is known about application of this evidence in daily practice. Therefore, a survey was performed among Dutch surgeons.Methods: All members of the Dutch Surgical Society were invited to participate in a 24-question online survey on techniques and materials used for abdominal wall closure after midline laparotomy. Subgroup analysis was performed based on surgical subspecialty, type of hospital and experience.Results: Response rate was 26% (402 respondents), representing 97% of all Dutch surgical departments. More than 90% of participants closed the abdominal wall in a single mass layer, using a slowly absorbable monofilament running suture The SL/WL ratio of > 4:1 is practiced by only 35% of participants and preferred suture size was variable among participants. Risk factors for incisional hernia development were generally identified correctly but more than half of the participants were unaware of the incidence and time of occurrence of incisional hernia. Subgroup analysis found that gastrointestinal and oncologic surgeons preferred smaller diameter sutures and higher suture-length to wound-length ratios. Trauma, vascular and pediatric surgeons had lower estimates of incidence of incisional hernia than other subspecialties. Surgeons employed in academic hospitals were more likely to use small fascial steps and smaller suture sizes than their colleagues in non-academic hospitals. Correct estimates of incisional hernia incidence decreased when surgeons perform less than 10 laparotomies annually.Conclusion: Implementation of the latest evidence regarding closure techniques of the abdominal wall is not widespread. Only 35% of surgeons close the abdominal fascia using a suture length to wound length ratio of 4:1, which is recommended based on the latest evidence. Surgical trainees, gastrointestinal and oncological surgeons are most familiar with the recommended technique and use it in their daily practice. Efforts should be directed at improving spreading of this technique.

PurposeInguinodynia or chronic post-herniorrhaphy pain, defined as pain lasting longer than 3 months after open inguinal hernia repair, has become the most important complication after inguinal surgery and therefore compromises the patient´s quality of life. A major reason for inguinodynia might be the lack of neuroanatomical knowledge and suboptimal “management” of the nerves during surgery.MethodsWe present a detailed neuroanatomic mapping of the inguinal region by dissection including the most important surgical landmarks with all nerves confirmed by immunohistochemistry, ultrasound guided visualization of the iliohypogastric, ilio-inguinal, and genital branch of the genitofemoral nerve, and a practical (preoperative) algorithm for clinical management.ResultsSurgically and ultrasonographically relevant structures (“landmarks”) in open hernia repair are the anterior–superior iliac spine, pubic tubercle, Camper´s fascia (superficial layer of the superficial abdominal fascia), External oblique aponeurosis, Internal oblique muscle, Transversus abdominis muscle, superficial inguinal ring, external spermatic fascia, cremasteric fascia with cremaster muscle fibers, internal spermatic fascia, cremasteric vein (=external spermatic vein = “blue line”), ductus deferens, pampiniform plexus, inguinal ligament and the inferior epigastric vessels.ConclusionA detailed understanding of inguinal anatomy is an indispensable basic requirement for all surgeons to perform inguinal ultrasonography as well as open inguinal hernia repair, avoiding complications, especially postoperative inguinodynia.

Usage of "large-for-size" left lateral segment (LLS) liver grafts in children with high graft to recipient weight ratio (GRWR) is controversial due to concerns about increased recipient complications. During the study period, 77 pediatric living donor liver transplantations (LDLTs) with LLS grafts were performed. We compared recipients with GRWR ≥2.5% (GR-High = 50) vs GRWR 2.5% (GR-Low = 27). Median age was higher in the GR-Low group (40 vs 8 months, P .0001). Graft (GR-High: 98%, 98%, 98% vs GR-Low: 96%, 93%, 93%) and patient (GR-High: 98%, 98%, 98% vs GR-Low: 100%, 96%, 96%) survival at 1, 3, and 5 years was similar between groups (P = NS). Overall complications were also similar (34% vs 30%; P = .8). Hepatic artery and portal vein thrombosis following transplantation was not different (P = NS). Delayed abdominal fascia closure was more common in GR-High patients (17 vs 1; P = .002). Subgroup analysis comparing recipients with GRWR ≥4% (GR-XL = 20) to GRWR 2.5% (GRWR-Low = 27) revealed that delayed abdominal fascia closure was more common in the GR-XL group, but postoperative complications and graft and patient survival were similar. We conclude that pediatric LDLT with large-for-size LLS grafts is associated with excellent clinical outcomes. There is an increased need for delayed abdominal closure with no compromise of long-term outcomes. The use of high GRWR expands the donor pool and improves timely access to the benefits of transplantation without extra risks.

Introduction. There are no reported survivors of gastroschisis with complete liver herniation. We describe a case report of two patients, one of whom survived. Case #1. The patient was born with gastroschisis and herniation of the entire liver. Along with silo placement, the abdominal fascia was attached to an external traction system for growth. Complete closure was achieved at 5 months. Due to pulmonary hypoplasia, high-frequency ventilation was required. The patient is doing well, on a home ventilator wean, at 20 months. Case #2. The patient was born prematurely with gastroschisis, total liver herniation, and a defect extending to the pericardium. A silo was attached to the fascia to provide growth of the abdominal cavity. The patient developed respiratory failure, diffuse anasarca, and renal failure. She died at 38 days of life. Discussion. We report the first survivor of gastroschisis with complete liver herniation, contrasting it with a death of a similar case. The associated pulmonary hypoplasia may require long-term ventilation, the inflammatory response can lead to anasarca, and renal injury can occur from acute-on-chronic compartment syndrome. Conclusion. External fascial traction systems can help induce growth of the abdominal wall, allowing closure of the challenging abdomen. While critical care management is complex, survival is possible.

Background Despite guideline-compliant prophylaxis, an increased rate of deep venous thrombosis (DVT) formation has been reported following autologous versus implant-based breast reconstruction. We hypothesized that tight abdominal fascia closure might decrease lower extremity venous return and promote venous stasis. Methods An observational crossover study of patients who underwent autologous breast reconstruction using transverse rectus abdominis musculocutaneous/deep inferior epigastric artery perforator flaps was conducted. Ultrasonographic measurements of the left common femoral vein (CFV) and right internal jugular vein (IJV) were performed preoperatively, in the postanesthesia care unit, and on postoperative day (POD) 1. Parameters of interest included vessel diameter, circumference, area, and maximum flow velocity. Results Eighteen patients with a mean age and body mass index of 52.7 years (range, 29–76 years) and 31.3 kg/m2 (range, 21.9–43.4 kg/m2) were included, respectively. A 29.8% increase in CFV diameter was observed on POD 1 (p Conclusion Postoperative changes observed in the CFV reflect increased lower extremity venous stasis after microsurgical breast reconstruction and may contribute to postoperative DVT formation.

The advancement of liposculpturing and fascial flaps in reconstructive surgery has renewed interest in the superficial fascia of abdomen. Its histological and biochemical composition may play a vital role in maintaining strength and elasticity of the fascia. Hence, study of abdominal fascia for the elastic, collagen, and hydroxyproline contents is desirable to understand asymmetrical bulges and skin folds and in improving surgical treatment of obesity. Samples of superficial fascia were collected from of upper and lower abdomen from 21 fresh cadavers (15 males and 6 females). Samples were stained using Verhoeff–Van Gieson stain. Digital images of superficial fascia were analyzed using TissueQuant software. The samples were also subjected to hydroxyproline estimation. The superficial fascia was formed by loosely packed collagen fibers mixed with abundant elastic fibers and adipose tissue. Elastic contents and collagen contents of superficial fascia were significantly more in the upper abdomen than that in the lower abdomen in males. Hydroxyproline content of superficial fascia of upper abdomen was significantly more than that of lower abdomen in both males and females. The elastic, collagen and hydroxyproline contents of superficial fascia of upper abdomen were higher compared to the lower abdomen. This may be a reason for asymmetric bulging over abdomen and more sagging fold of skin in the lower abdomen than in the upper abdomen. This study may therefore be helpful in finding new ways to manage obesity and other body contour deformities.

Background: In emergency and elective settings, some surgeons prefer continuous or interrupted closure of abdominal fascia, because in a continuous suturing, cutting out of even a single bite of tissue leads to opening of the entire wound and high risk of burst abdomen, whereas in interrupted method, they found much lower risk of burst abdomen. The aim is to assess the complication rate with the same closure technique between two different sutures. The best suture is one that maintains tensile strength throughout the healing process with good tissue approximation and less wound infection, is well tolerated by patient and is technically simple and expedient. The aim was to compare the non-absorbable sutures (nylon) and delayed absorbable sutures (polydioxanone (PDS)) for abdominal wall closure in cases of peritonitis. We used a different technique to close the abdominal wall fascia and study the postoperative complications. Methods: This was a prospective study carried out in the Department of Surgery, MMIMSR, Mullana, Ambala from March 2014 to April 2015, a single unit by a single surgeon. A total of 60 patients underwent interrupted closure of abdominal fascia by figure of eight techniques with polyamide (nylon No. 1) suture in group A and polydiaxanone (PDS No. 1) suture in group B. The incidence rates of wound infection, dehiscence, suture sinus formation and incisional hernia were recorded. Patients were followed up for a period of 1 year. Results: Out of the 60 patients, the rates of wound pain, discharge and dehiscence in group A were 30%, 23.3% and 26.7% and in group B were 6.7%, 16.6% and 23.3%. There was 0 burst abdomen in group A compared to one burst abdomen in group B. Suture sinus formation, chronic wound infection and stitch granuloma was one each in group A and was 0 in group B. Incisional hernia was not found in any of the group. We have concluded that condition of the wound depends on the comorbidity of the patient like smoking, malnutrition, and old peritonitis. It also mainly depends on the technique used for closure of the wound and also on the material used. Conclusion: Though wound complications were found more in non-absorbable suture but the rate of wound complications between the two sutures was found insignificant. The purpose of the study is to assess the presence of differences in abdominal wall closure in patients with risk criteria, with the same closure technique between slowly absorbable sutures and non-absorbable sutures. Sutures were placed and tied such that fascial edges were well approximated but not compressed tightly together. J Curr Surg. 2016;6(3-4):65-72 doi: https://doi.org/10.14740/jcs306e

Hernia management is a common component of surgical practice; however, the treatment of this problem is complex in the setting of cirrhosis and requires a thorough understanding of the pathophysiology of end-stage liver disease to maximize outcomes in those patients that would benefit from operative repair. Multiple aspects of the pathophysiology of cirrhosis can alter outcomes in these patients. Increased intra-abdominal pressure from ascites exacerbates weakening of abdominal fascia, resulting in umbilical hernias or worsening of incisional defects. Malnutrition in these patients can lead to muscle wasting which further undermines abdominal wall architecture (Eher et al. Surgery 150:542–546, 2011). Perioperative management may be complicated by variceal bleeding, exacerbation of hepatic encephalopathy, elevated risk of infectious complications given these patients’ relative immunocompromised state, and fulminant hepatic failure.

Background Experiencing a ventriculoperitoneal (VP) shunt complication is a major obstacle in the management of hydrocephalus. Degradation of a shunt catheter associated with surrounding tissue calcification could be 1 reason for a difference in facture rates. Furthermore, tissue reactions around cerebrospinal fluid shunts may be a sign of bacterial shunt infection, which is not uncommon. Case Description A 31-year-old man was living with a ventriculoperitoneal shunt since childhood. Consequently, his cerebrospinal fluid absorption was supposed to be modified by the shunt. Shunt malfunction later occurred concomitant with symptoms of headache and repeated vomiting. He had undergone shunt revision a year before presentation, but examination revealed that a new, extremely rare calcified lesion had formed in the aponeurosis of the abdomen, compressing the shunt tube. We removed it and replaced the shunt tube, thus relieving his symptoms. Conclusions We treated a rare case of shunt dysfunction caused by calcification of the aponeurosis coinciding with significant weight gain over the course of a year. To the best of our knowledge, this is the first report to describe a case of shunt malfunction caused by calcification of the aponeurosis.

Open abdomen indicates the abdominal fascia is unclosed to abbreviate surgery and to reduce physiological stress. However, complications and difficulties in patient care are often encountered after operation. During May 2008 to March 2013, we performed a prospective protocol-directed observation study regarding open abdomen use in trauma patients. Bogota bag is the temporary abdomen closure initially but negative pressure dressing is used later. A goal-directed ICU care is applied and primary fascial closure is the primary endpoint. There were 242 patients received laparotomy after torso trauma and 84 (34.7%) had open abdomen. Twenty patients soon died within one day and were excluded. Among the included 64 patients, there were 49 (76.6%) males and the mean Injury Severity Score was 31.7. Uncontrolled bleeding was the major indication for open abdomen (64.1%) and the average duration of open abdomen was about 4.2 ± 2.2 days. After treatment, 53(82.8%) had primary fascia closure, which is significant for patient survival (odds ratio 21.6; 95% confidence interval: 3.27–142, p = 0.0014). Factors related to failed primary fascia closure are profound shock during operation, high Sequential Organ Failure Assessment Score in ICU and inadequate urine amount at first 48 hours admission.

Incisional hernias to the subxiphoid region are rare and anatomically challenging, with bony and cartilaginous structures attaching, as well as conflating abdominal fascia. The repair of hernias in this region is, therefore, difficult and prone to recurrence. The surgical treatment can be done by open or laparoscopic repair but very little is known about which method is superior. We, therefore, reviewed our data of patients undergoing repair of subxiphoid hernias. Between January 2010 and June 2015 twenty-eight patients were treated by laparoscopic (n = 8) or open (n = 20) hernia repair due to an incisional hernia in the subxiphoid region. Patients with ventral hernias with an origin more distal than the M1-area only extending into the subxiphoid region and those undergoing suture hernia repair were excluded. The hernia sizes, in terms of length, width and EHS classification, did not vary between open and laparoscopic repair. The duration of laparoscopic surgery was significantly shorter than the mean operative time for an open subxiphoid hernia repair (168.1 min vs. 96.1 min, respectively; p = 0.012). The groups did not differ significantly in terms of overall postoperative complications (p = 0.568) but the grade (Clavien–Dindo) of complications was higher following open repair leading to three reoperations. Within the follow-up time, we diagnosed significantly (p = 0.031) more subxiphoid hernia recurrences after laparoscopic repair (37.5%, n = 3) than after open repair (0%). Laparoscopic and open repair of subxiphoid incisional hernias are both technically challenging compared to other midline hernias. Referring to our results laparoscopic repair has shorter operative times, lower postoperative morbidity with a higher recurrence rate compared to open repair but the sample size is too small for an overall conclusion.

Purpose: The objective of this study was to demonstrate a new suturing technique in reference to fascia closure after laparotomy in an experimental setup to increase the tearing force of the fascia. Methods: Two ordinary DIN A4 papers, which represents the fascia were sutured at the edges in a length of approx. 5 cm with the known continuous technique in the abdominal surgery and with the new technique, we called it: Spider suture. A bucket arranged on the interconnection was filled with sand until the sutures teared. Measuring the final weight of the bucket allowed comparing the carrying capacities of the paper of the two techniques. Results: A significant (Fisher’s test, p=0.017) increase of mean carrying capacity from 1776.5g (classic continuous suture) to 5101.75g (basic Spider suture) was found. The carrying capacity of the paper was increased to 287% compared to the classic continuous suture. Conclusion: Spider suture could be an effective improvement in closure of the abdominal wall in abdominal surgery to minimize the risk of developing of incisional hernia. This method allows the surgeon to perform an abdominal closure adapted to the quality of patient’s fascia. Further clinical studies will show the effectiveness of this method.&nbsp

Background Insufflation of the abdomen during laparoscopy improves surgical space, but may cause post-operative shoulder pain. The incidence of shoulder pain is reduced using a lower insufflation pressure, but this may, however, compromise the surgical space. We aimed at investigating whether deep neuromuscular blockade (NMB) would enlarge surgical space, measured as the distance from the sacral promontory to the trocar in patients undergoing gynaecologic laparoscopy. Methods Fourteen patients were randomised in an assessor-blinded crossover design. The distance from the sacral promontory to the trocar was measured during deep NMB and without NMB at pneumoperitoneum 8 and 12 mmHg both. Additionally, we assessed surgical conditions while suturing the abdominal fascia using a 4-point subjective rating scale. Deep NMB was established with rocuronium and reversed with sugammadex. Results At 12 mmHg pneumoperitoneum, deep NMB improved surgical space with a mean of 0.33 cm (95% confidence interval 0.07–0.59) (P = 0.01, paired t-test) compared with no NMB. At 8 mmHg pneumoperitoneum deep NMB improved surgical space with a mean of 0.3 cm (95% confidence interval, 0.06–0.54) (P = 0.005) compared with no NMB. Deep NMB resulted in significantly better ratings of surgical conditions during suturing of the fascia (P = 0.03, Mann–Whitney U-test). Conclusion Deep NMB enlarged surgical space measured as the distance from the sacral promontory to the trocar. The enlargement, however, was minor and the clinical significance is unknown. Moreover, deep NMB improved surgical conditions when suturing the abdominal fascia.

BackgroundTemporary abdominal closure (TAC) is increasingly common after military and civilian major trauma. Primary fascial closure cannot be achieved after TAC in 30 per cent of civilian patients; subsequent abdominal wall reconstruction carries significant morbidity. This retrospective review aimed to determine this morbidity in a UK military cohort.MethodsA prospectively maintained database of all injured personnel from the Iraq and Afghanistan conflicts was searched from 1 January 2003 to 31 December 2014 for all patients who had undergone laparotomy in a deployed military medical treatment facility. This database, the patients' hospital notes and their primary care records were searched.ResultsLaparotomy was performed in a total of 155 patients who survived to be repatriated to the UK; records were available for 150 of these patients. Seventy-seven patients (51·3 per cent) had fascial closure at first laparotomy, and 73 (48·7 per cent) had a period of TAC. Of the 73 who had TAC, two died before closure and two had significant abdominal wall loss from blast injury and were excluded from analysis. Of the 69 remaining patients, 65 (94 per cent) were able to undergo delayed primary fascial closure. The median duration of follow-up from injury was 1257 (range 1–4677) days for the whole cohort. Nine (12 per cent) of the 73 patients who underwent TAC subsequently developed an incisional hernia, compared with ten (13 per cent) of the 77 patients whose abdomen was closed at the primary laparotomy (P = 1·000).ConclusionRates of delayed primary closure of abdominal fascia after temporary abdominal closure appear high. Subsequent rates of incisional hernia formation were similar in patients undergoing delayed primary closure and those who had closure at the primary laparotomy.

The open abdomen is an increasingly used technique that is applied in a wide variety of clinical situations. The ABThera Open Abdomen Negative Pressure Therapy System is one of the most common and successful temporary closure systems, but it has limited ability to close the fascia in approximately 30% of patients. The abdominal reapproximation anchor system (ABRA) is a dynamic closure system that seems ideal to manage patients who may not achieve primary fascial closure with ABThera alone. We report on the use of the ABRA in conjunction with the ABThera in patients with an open abdomen.We retrospectively analyzed patients with an open abdomen managed with the ABThera and ABRA between January 2007 and December 2012 at the Halifax Infirmary, QEII Health Science Centre, Halifax, Nova Scotia.Sixteen patients had combination therapy using the ABRA and ABThera systems for treatment of the open abdomen. After removing patients who died prior to closure, primary fascial closure was achieved in 12 of 13 patients (92%).We observed a high rate of primary fascial closure in patients with an open abdomen managed with the ABThera system in conjuction with the ABRA. Applying mechanical traction in addition to the ABThera should be considered in patients predicted to be at high risk for failure to achieve primary fascial closure.La laparotomie, ou « abdomen ouvert », est une technique de plus en plus employée dans une grande diversité de contextes cliniques. Le système ABThera (thérapie par pression négative pour abdomen ouvert) est l’un des systèmes de fermeture temporaire de l’abdomen les plus fréquemment utilisés et efficaces, mais sa capacité de refermer le fascia apparaît limitée chez environ 30 % des patients. Le système ABRA est un système de fermeture dynamique qui semble idéal pour la prise en charge des patients qui pourraient ne pas obtenir une fermeture primaire du fascia avec le système ABThera seul. Nous faisons rapport de l’utilisation du système ABRA en conjonction avec le système ABThera chez des patients soumis à une laparotomie.Nous avons analysé rétrospectivement des patients soumis à une laparotomie et pris en charge au moyen des systèmes ABThera et ABRA entre janvier 2007 et décembre 2012 au Halifax Infirmary du Centre des sciences de la santé QEII d’Halifax, en Nouvelle-Écosse.Seize patients ont subi un traitement concomitant par les systèmes ABRA et ABThera pour leur laparotomie. Après exclusion des patients décédés avant l’obtention de la fermeture primaire du fascia, cette dernière a été réussie chez 12 patients sur 13 (92 %).Nous avons observé un taux élevé de fermeture primaire du fascia chez les patients soumis à une laparotomie et traités au moyen du système ABThera en conjonction avec le système ABRA. L’application d’une traction mécanique en plus du système ABThera est à envisager chez les patients présumés à risque élevé d’échec de la fermeture primaire du fascia.

Pedicled transverse rectus abdominis myocutaneous (TRAM) breast reconstruction is associated with increased abdominal wall morbidity. We present a method of abdominal wall reconstruction using an adjunct technique to validated procedures of hernia repair. This study is a retrospective, single-surgeon analysis of 21 patients between 2005 and 2012. Patients had bony suture anchoring of synthetic polypropylene mesh to the anterior superior iliac spine bilaterally and the pubic symphysis after the abdominal fascia was reconstructed. Patient mean follow-up was 62 months. Of the series, five patients underwent bilateral pedicled TRAM breast reconstruction. None of the 21 patients developed abdominal wall hernias. One patient developed postoperative bulging, which was retreated successfully. Two patients developed mesh infections; none required radical removal of mesh. There were no flap failures or loss in the series. The BARS technique for abdominal wall reconstruction provides excellent reinforcement of abdominal reconstruction in conjunction with pedicled TRAM breast reconstruction. Level of Evidence: Level IV, therapeutic study.

Parastomal hernia formation is common following formation of an abdominal stoma, with the risk of subsequent incarceration, obstruction and strangulation. Current treatment options include non-operative management, stoma relocation and fascial repair with or without mesh. The purpose of this systematic review was to evaluate the effectiveness and safety of open mesh repair of a parastomal hernia and to compare open non-mesh fascial repair with mesh techniques of parastomal hernia repair. Electronic databases were searched for studies comparing the two surgical techniques in accordance with preferred reporting items for systematic reviews and meta-analyses. The primary outcome of the study was the comparison of recurrence rates of parastomal hernia for each technique. Secondary outcomes included comparison of mortality, wound infection, mesh infection and any other complication. Twenty-seven studies of parastomal hernia repair were included and divided into two subgroups for open mesh repair and non-mesh fascial repair. Non-mesh fascial repair resulted in a high recurrence rate (around 50%). Reported recurrence rates for mesh repair were substantially lower, at 7.9-14.8%, depending on the position of the mesh in relation to the abdominal fascia and the length of follow-up. Morbidity and mortality did not differ significantly between the techniques used to repair a parastomal hernia. This study shows that mesh repair of a parastomal hernia is safe and significantly reduces the rate of recurrence compared with sutured repair, which should only be used in exceptional circumstances. There is insufficient evidence to determine which mesh technique (onlay, sublay or underlay) is most successful in terms of recurrence rates and morbidity.

Up to the present, the optimal time to close an open abdomen remains controversial. This study was designed to evaluate whether early fascial abdominal closure had advantages over delayed approach for open abdomen populations. Medline, Embase, and Cochrane Library were searched until April 2013. Search terms included “open abdomen,” “abdominal compartment syndrome,” “laparostomy,” “celiotomy,” “abdominal closure,” “primary,” “delayed,” “permanent,” “fascial closure,” and “definitive closure.” Open abdomen was defined as “fail to close abdominal fascia after a laparotomy.” Mortality, complications, and length of stay were compared between early and delayed fascial closure. In total, 3125 patients were included for final analysis, and 1942 (62%) patients successfully achieved early fascial closure. Vacuum assisted fascial closure had no impact on pooled fascial closure rate. Compared with delayed abdominal closure, early fascial closure significantly reduced mortality (12.3% versus 24.8%, RR, 0.53,P<0.0001) and complication incidence (RR, 0.68,P<0.0001). The mean interval from open abdomen to definitive closure ranged from 2.2 to 14.6 days in early fascial closure groups, but from 32.5 to 300 days in delayed closure groups. This study confirmed clinical advantages of early fascial closure over delayed approach in treatment of patients with open abdomen.

BACKGROUND: Wounds and their management are fundamental to the practice of surgery.Surgical wound dehiscence after laparotomy remains a serious complication.To evaluate the effect of prophylactic retention sutures in patients with a high risk for wound dehiscence who underwent midline laparotomy. Patients and methods:One hundred fifty(150) cases were randomized to form two groups with 75 patients each: a prophylactic group by using retention sutures and an non prophylactic group. A central randomization for both hospitals was performed. Two patients in the non prophylactic group and three patients in the prophylactic group In the non prophylactic(control) groupStandard midline incision and continuous mass closure technique was used in each case using a running looped 1/0 nylon string located 1 cm from the edge of the lineaalba.In the prophylactic group, the fascia was sutured using the same technique as the non prophylactic group; however, retention sutures were added using a 1/0 nylon string every 10 cm and contained 5 cm of the skin, subcutaneous tissue, rectus muscle, and abdominal fascia (except peritoneum) on each side. All fascia closures were performed by tow attending surgeons who adhered strictly to the protocol.Occurrence of abdominal dehiscence was assesseddaily by precise examination of the wound. Results:The incidence of abdominal wound dehiscence was 3 patients (4%) in the prophylactic group and 10 patients (13.3%) in the control (nonprophylactic )group (P = 0.007 ) therefore it is significantConclusion:Ourconclsion that prophylactic retention sutures can decrease the incidence of abdominal wound dehiscence but although there is decrease incidence of post operative evisceration ,wound infection and post operative pain , there was no significant difference.

Background: Laparotomy is a major surgical procedure in emergency settings. There is paucity of data regarding abdominal fascia closure in emergency laparotomies in Indian population. This study was planned to compare two techniques of fascial closure namely continuous and interrupted using polydioxanone in patients undergoing midline emergency laparotomies in our institute.Methods: This prospective study was conducted in Surgery Department, MMC&H, Muzaffarnagar, from January 2017 to June 2018. 60 patients undergoing emergency laparotomies were divided into two groups of 30 each. Group I (study group) patients underwent interrupted suture abdominal closure; Group II (control group) patients underwent continuous suture closure.Results: Commonest diagnoses were duodenal and enteric perforations. Mean closure time in Group 1 was 31.6 minutes and in Group 2 -17.3 minutes. Mean hospital stay in Group I and II were 12.88 and13.76 days respectively. 4 Group I patients developed wound discharge versus 6 patients in Group II. Burst abdomen occurred in 3 out of 60 patients. One Group I patient had localised fascial burst. One Group II patient had localized while one had complete fascial burst. One incisional hernia was observed in each group at 3rd month of follow up. Three patients in Group 1 and one in Group 2 developed suture sinus.Conclusions: Major complication is wound dehiscence leading to increased morbidity, hospital stay and cost. In our study, we used continuous and interrupted PDS sutures and found that interrupted suturing method of abdominal wall closure is better, though it takes more time.

Purpose Combined heart and liver transplantation is a live saving procedure for patients with advanced dual organ failure. Although described 35 years ago, less than 20 cases are performed every year, reflecting the complexity of the procedure. We present the first case series of adult patients receiving En-Bloc Heart-Liver Transplant (En-Bloc HLTx). Methods A present a retrospective analysis of our experience with En-Bloc HLTx in five adult patients, including demographic characteristics, indications, surgical course with operative data, surgica outcomes, and long term follow up with evaluation of rejection by myocardial biopsy results. Results Five patients received En-Block HLTx between June 2016 and December 2017. Mean recipient age was 43 years (26-63), and 3 (60%)patients were male.Indication for dual organ transplantation included hereditary ATTR amyloidosis (n=1), gestations cardiomyopathy with cardiac cirrhosis (n=2), and idiomatic dilated cardiomyopathy with cryptogenic cirrhosis (n=1) or coexistent NASH (n=1).All patients presented NYHA FC IV symptoms, and 4 were admitted to the hospital awaiting transplantation for 63 days (51-89) as status 1A, while 1 patient was on home inotropic support. Sodium MELD score ranged from 8 to 28 (mean = 17.6). Total operative time was 430 min (393-480), and ischemic times (IT) were equal for both organs, with cold IT of 85 min (32-136), and warm IT of 37.5 min (31-47). Patients required CPB support for 107 min (80-138), and aortic cross-clamp of 58 min (52-72). Abdominal fascia remained open in 4 patients, and sternum in 3 patients, with planned definitive wound closure within 48 hours in all patients. Thirty day operative survival was 100%, and 4 (80%) patients were discharged alive from the hospital on POD 36 (17-67). One patient expired on POD 55, due to fungemia and multi system organ failure. Mayor postoperative complications included prolonged ventilation requiring tracheostomy on 3 patients, and renal insufficiency requiring dialysis in 2 patients. Follow up was complete all 4 patients for up to 18 months, All patients remained on low immunosuppression regimen, and there was no evidence of grade 2 or higher rejection on anyone. Conclusion En-Bloc HL Tx is a safe procedure for patients requiring dual organ transplantation. Operative times are significantly decreased, and mid-term outcomes are comparable to single organ transplantation.

Objective To investigate the presence of widespread pressure pain sensitivity in cancer patients following partial colorectal resection in the abdominal and lower back area and to describe the presence of abnormalities in abdominal and lower back muscle morphology. Methods Twenty colon cancer survivors (eight females, mean age 56.60 ± 7.76 years) and 20 matched healthy controls (10 females, mean age 54.22 ± 8.12 years) participated. Abdominal and lower back pain was assessed after undergoing surgery using a Visual Analogue Scale (VAS) and Brief Pain Inventory (BPI). Pressure pain thresholds (PPTs) were bilaterally assessed over the supraumbilical, infraumbilical, and lower back areas and the second metacarpal. Ultrasound imaging was used to measure the depth of the abdominal muscles, the width of the midline abdominal fascia and the width of the lumbar multifidus. Results Ten months after finishing oncological treatments, patients who underwent partial colorectal resection reported significantly higher pain levels in the low-back area (P = 0.003) but not in the abdominal area (P = 0.426) compared with the matched controls. After surgery, the colon patients reported significantly higher BPI-intensity (P