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Spontaneous rectus sheath hematoma is a rare condition. It encompasses a wide spectrum of severity (self-limiting to fatal) depending of its size, etiology, and the development of complications. It enters into the differential diagnosis of abdominal pain but it's frequently difficult to diagnose and often radiologic imaging is required. Authors report a series of five patients admitted at emergency room within a 2-year period. Patient were between 63 to 78 years old. One of them was in therapy with warfarin, one was in therapy with acetilsalicililate and clopidogrel and in an another patient a coagulation disorder was detected. Diagnosis was suspected in all cases by clinical exam and ultrasonography, but CT-scan was necessary in three cases. All patients underwent conservative treatment, mainly pain relief and rest. In two cases blood transfusion was performed and in two cases clotting abnormalities were corrected with vitamin K and fresh frozen plasma. Average ospedalization was 10 days (range 5-17). One patient developed late seroma and was treated with ultrasound-guided aspiration. Rectus sheath hematoma is a rare but important entity in the differential diagnosis of abdominal pain. The difficulties in the correct diagnosis frequently lead to delay in treatment or unneeded surgery. CT-scan is the gold-standard investigation. Treatment options are variable and include conservative treatment, intravascular embolization and surgery Frequently an interdisciplinary team approach is needed.

Magnetic resonance (MR) imaging technique and findings in the setting of athletic pubalgia, including injury at the rectus abdominis/adductor aponeurosis, are becoming widely recognized. A subset of these patients is treated with various pelvic floor repairs, mesh reinforcements, and tendon releases. Most of these patients do well after intervention, but some have persistent or refractory groin pain, and others eventually develop new injuries in the pubic region or elsewhere about the pelvic girdle. This review describes the expected and some unexpected MRI findings in patients with recurrent or persistent groin pain after a "sports hernia" repair., (© Thieme Medical Publishers.)

Parasitism in skeletal muscles and myositis are commonly observed during experimental Trypanosoma cruzi infection. The effect of T. cruzi infection on contractile properties of skeletal muscles in consecutive periods of the acute infection in BALB/c mice was studied. Albarrada strain (clone 4) which was isolated in Mexico and has demonstrated a high level of blood parasitemia and parasitism in skeletal muscles was used. Isolated strips of rectus abdominis muscle were subjected to direct electrical field in vitro. Alternatively, plantaris muscles were stimulated in situ through the sciatic nerve. The peak amplitudes of a single twitch and tetanus contractions were considered to estimate the mechanical properties of muscles. Histopathological analysis was performed to correlate functional changes with the evolution of tissue parasitism and tissue injury. Contractile properties of muscles were significantly attenuated during acute T. cruzi infection. The percentage of damaged muscles rather than the character of tissue pathology affected their contractile properties significantly., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Scar endometriosis is an under-appreciated or misdiagnosed phenomenon in general surgery and may eventually be more common than reflected in the literature. We herein report five cases of scar endometriosis that were treated in our surgical department one to five years after Caesarean section. Scar endometriosis should be considered when the symptoms are present in a cyclic manner mostly after gynaecological operations and worsening during menstruation. Diagnosis is mainly based upon a high index ofsuspicion. The treatment of choice is surgical resection.

Background: The etiology of inguinal hernia remains unclear. Research data indicate the presence of pathologic alterations within the connective tissue; their exact character remains the subject of dispute. The search for new methods to diagnose connective tissue abnormalities, and thoroughly explain the character of the ultrastructural alterations, continues., Materials and Methods: The study group included 10 male patients aged 18-60 y (five with primary inguinal hernia and five with acute appendicitis with no history of hernia). A specimen of the rectus muscle sheath was harvested from all of them upon surgery. The tissue samples were fixed and examined by spectrofluorometry and fluorescence microscopy, yielding fluorescence spectra and microscopic fluorescence images., Results: Both techniques have demonstrated significant differences between the biopsy samples harvested from hernia patients and healthy controls. The groups of fluorescence spectra were shifted relative to each other and showed maximum emission at different wavelengths after excitation with 350 nm light (arbitrarily chosen for one of the cross-link proteins). The spectra obtained for healthy controls were more homogenous, while the spectra of the hernia samples differed even between each other. In microscopic images, the difference was a more chaotic distribution of fluorophores in the samples obtained from hernia patients., Conclusions: The evidence of significant differences between the samples harvested from the same location from hernia patients and healthy controls, found by fluorescence techniques, indicates the presence of abnormalities in the connective tissue forming the rectus muscle sheath. This area is not a part of the hernial defect, therefore, we can assume that the changes can be attributed to a generalized process., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Apoptosis and myostatin are major mediators of muscle atrophy and might therefore be involved in the wasting of uremia. To examine whether they are expressed in the skeletal muscle of patients with chronic kidney disease (CKD), we measured muscle apoptosis and myostatin mRNA and their related intracellular signal pathways in rectus abdominis biopsies obtained from 22 consecutive patients with stage 5 CKD scheduled for peritoneal dialysis. Apoptotic loss of myonuclei, determined by anti-single-stranded DNA antibody and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assays, was significantly increased three to fivefold, respectively. Additionally, myostatin and interleukin (IL)-6 gene expressions were significantly upregulated, whereas insulin-like growth factor-I mRNA was significantly lower than in controls. Phosphorylated JNK (c-Jun amino-terminal kinase) and its downstream effector, phospho-c-Jun, were significantly upregulated, whereas phospho-Akt was markedly downregulated. Multivariate analysis models showed that phospho-Akt and IL-6 contributed individually and significantly to the prediction of apoptosis and myostatin gene expression, respectively. Thus, our study found activation of multiple pathways that promote muscle atrophy in the skeletal muscle of patients with CKD. These pathways appear to be associated with different intracellular signals, and are likely differently regulated in patients with CKD.

Purpose: To assess the collagen content and types in the rectus abdominis muscle of cadavers of different ages., Methods: Forty fresh adult male cadavers, at room temperature, were obtained from the Institute of Legal Medicine of Franca and dissected within 24 hours of death. The cadavers were divided into two groups: Group A (n=20), 18 to 30 years of age, and Group B (n=20), 31 to 60 years of age. Bilateral incisions were made in the middle portion of anterior rectus sheath 3 cm superiorly and 2 cm inferiorly to the umbilicus and four fragments of the rectus abdominis muscle were dissected. The samples were fixed in 10% buffered formalin and sent for immunohistochemical analysis to determine collagen content and types., Results: Immunohistochemical results revealed higher amounts of type I and type III collagen in Group A. However, no difference in the amount of type IV collagen was found between the groups., Conclusion: The amount of type I and type III collagen was higher in group A.

Objectives: Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion., Methods: A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction., Results: The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months., Conclusions: Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.

Pseudosarcomatous nodular fasciitis and desmoid tumors can be very similar at physical examination. Although their behaviours and cytologic aspects are very different, they both undergo the same surgical approach. Nevertheless, only desmoid tumors - because of their high rate of local recurrence - require a strict follow-up and further therapies when radicality of primary surgery could not be likely performed.

Introduction: The study assessed whether there is a greater incidence of divarication of the recti and whether between-recti distance is greater in patients with abdominal aortic aneurysm (AAA)., Patients and Methods: The study consisted of two parts: a radiological and a clinical assessment. All patients with a confirmed AAA on computerised tomography were included and compared with patients in whom AAA was excluded with imaging. Between-recti distance was measured using a computerised image viewer and clinical divarication was assessed by a surgical registrar or consultant., Results: In the radiological part of the study, 108 patients with AAA were compared with 84 with colorectal cancer. Median between-recti distance was 38 mm (range, 25-59 mm) in the AAA group and 27 mm (range, 20-44.5 mm) in the non-AAA group (P=0.006). AAA diameter did not correlate with between-recti distance. The clinical study included 50 patients (25 AAA). The groups were well matched, with only a greater incidence of diabetes in the AAA group (20% vs 0%; P=0.018). AAA patients were more likely to have clinically detected divarication of the recti (76% vs 36%; P=0.004)., Conclusions: Patients with AAA have greater radiological and clinical evidence of divarication. It is suggested that patients with divarication be screened for AAA.

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials., (Copyright 2010 Mosby, Inc. All rights reserved.)

The abdominal wall is an uncommon site of extrapelvic endometriosis, which usually develops in a previous surgical scar and it should be considered in the differential diagnosis of any abdominal swelling. Endometriosis involving the rectus abdominis muscle is a very rare event and its rarity explains the incomplete nature of the reports in the literature. Up to the present, 18 cases with lesions contained entirely within the rectus abdominis muscle were clearly documented in medical literature with only four cases as a primary location. We report a case, which came to our observation, of primary endometriosis of the rectus abdominis muscle. The patient underwent only surgery without any medical treatment. Currently, the patient is in follow up for four years with no recovery of the disease. In our experience, surgery is the treatment of choice and it is decisive. We reviewed the literature and summarized all reported cases.

Background: We describe a novel approach for treating end stage abdominal wall failure using isolated abdominal wall allotransplantation in a porcine model., Methods: Full thickness abdominal wall transplants were performed in 13 pairs of genetically mismatched pigs. All recipients received daily immunosuppresion after transplantation. Rejection was assessed by visual inspection and skin biopsies. At the end of the 28 d study period, thickness, stiffness, and tensile strength of the transplanted rectus muscle was measured and compared with native rectus muscle., Results: Eight grafts were viable and showed no signs of herniation. Four grafts failed within the first week secondary to vascular thrombosis. One animal had viable graft but was euthanized due to an incarcerated inguinal hernia. Rejection was minimal in six of the eight recipients. At necropsy, the gross thickness of the transplanted muscle flap was reduced compared with the native muscle (4.3 mm versus 7.7 mm, P < 0.001). Histologically, the diameter of the muscle fiber decreased from 0.15 mm to 0.09 mm (P < 0.0001). While the stiffness measurements between the transplanted and native muscles were comparable, the transplanted muscles had significantly lower tensile strength than the native muscles., Conclusion: This study demonstrates the feasibility of isolated abdominal wall allotransplantation to provide a potential solution for end stage abdominal wall failure. Based on the model set forth, future work will evaluate the biomechanical properties of the composite allograft to provide a suitable dynamic abdominal wall replacement., (Copyright 2010 Elsevier Inc. All rights reserved.)

Rectus sheath hematoma (RSH) is a rare, but important potential cause of acute upper abdominal pain in pregnancy. We report a patient with history of hemolysis, elevated liver enzymes, low platelets syndrome who presented with upper abdominal pain, hypotension, elevated hepatic transaminase levels, and a visibly enlarging right costal margin mass at 33 weeks' gestation. She underwent emergent cesarean delivery and upper abdominal exploration with findings of a large hematoma involving the entire right rectus sheath. The current case illustrates that the diagnosis of an RSH in pregnancy can be difficult as its presentation can mimic many common causes of abdominal pain seen outside of pregnancy, as well as many specific to pregnancy. Review of the published cases from the past 20 years shows that correct diagnosis remains difficult in pregnancy despite advances in diagnostic imaging. Although management of an RSH outside of pregnancy is frequently conservative, it is very often treated surgically in pregnant patients and often leads to preterm delivery.

Endometriosis is defined as the presence of ectopic functional endometrial tissue outside the uterine cavity. The most common locations are within the pelvis. Unusual sites ofendometriosis outside the pelvis have been reported, including the bladder, intestine, appendix, surgical scars, hernia sac, lung, kidney, and extremities. The diagnosis of scar endometriosis is usually not difficult and is based on history and physical examination. We report here two cases who developed endometriosis on the abdominal wall in the rectus abdominis muscle and were treated with local excisions.

Objective: Mechanisms of sepsis-induced myocardial and diaphragmatic alteration are multiple and remain largely unknown, particularly in humans. In the present study, we compared the inducible nitric oxide synthase (NOS-2) expression, the peroxynitrite production and the expression and activation of the ubiquitin proteolytic pathway in the wall of the 4 cardiac chambers, in the diaphragm, and in the rectus abdominis., Patients: Seven patients who died from septic shock associated with a myocardial depression and 5 nonseptic (control) patients., Measurements and Results: We evaluated protein expression by Western blot. Nitrotyrosin and ubiquitin residues were localized by immunofluorescence. NOS-2, nitrated proteins, free ubiquitin, and ubiquitinated proteins are overexpressed in the wall of the four cardiac cavities, in the diaphragm and in the rectus abdominis of septic patients at a similar level. Ubiquitinated proteins with a molecular mass of 50, 35, 30, and 25 kD were consistently detected in heart, diaphragm, and rectus abdominis of septic shock patients but lacking in nonseptic patients. In situ immunolabelling of ubiquitin showed a colocalisation with nitrotyrosine residues at the sarcomeric level of cardiac myocytes in septic patients., Conclusions: This study showed the first evidence for the activation of the proteolytic ubiquitin-proteasome pathway in human heart and diaphragm in septic shock., (Copyright 2010 Elsevier Inc. All rights reserved.)

Desmoid tumor is a rare, benign fibroblastic tumor that is characterized by highly aggressive local invasiveness. The authors report the case of a 35-year-old male who presented with a 20 cm para-umbilical tumor invading the right rectus abdominis muscle. This required a wide excision of the abdominal wall. The resulting defect was closed with a single-stage latissimus dorsi myocutaneous free flap in combination with a prosthetic mesh reconstruction. The authors discuss the therapeutic options for management of these rare tumors and the variety of available techniques for coverage and reconstruction after extensive parietal loss of substance., (Copyright (c) 2010 Elsevier Masson SAS. All rights reserved.)

Objective: To evaluate skeletal muscle biopsy from asymptomatic patients affected with newly diagnosed colorectal cancer and to identify pathological features which may be indicative of tumor-associated muscle disorders, potentially leading to cachexia., Methods: Patients affected with newly diagnosed colorectal cancer at clinical onset of disease underwent biopsy of the rectus abdominis muscle during elective laparoscopic tumor resection, before chemotherapeutic treatment. Morphometric analyses, ATPase histochemistry and immunohistochemical studies using antibodies directed to N-CAM and to MHC-emb, two sound makers of muscle denervation and injury-induced muscle regeneration, were performed on intraoperative muscle biopsies from ten patients. Muscle biopsies from rectus abdominis of seven subjects affected with non-neoplastic condition, which underwent laparoscopic surgery, were used as controls., Results: In patients' biopsies, we observed a surprisingly high percentage of myofibers with internalized or central nuclei compared to controls (9.15 +/- 8.9 versus 0.6 +/- 0.9, p<0.0003). In addition, in the 30% of patients, small myofibers expressing the MHC-emb have been identified (0.4 +/- 0.5 positive fibers/mm(2)), while in 50% of patients, larger fibers positive for N-CAM have also been detected (0.7 +/- 1.1 positive fibers/mm(2)), suggesting that investigated muscle biopsies exhibit other evidence of muscle fiber injury/regeneration and/or denervation. Among the 10,000 analysed myofibers in control biopsies, no MHC-emb and N-CAM-positive muscle fibers have been detected. Thus, patients affected with newly diagnosed colorectal cancer at clinical onset of disease display early signs of a subclinical myopathy., Discussion: Factors and mechanisms of this cancer-associated myopathy are yet unknown. The facts that the great majority of the abnormally nucleated myofibers are of the fast type and that regenerating myofibers are present, suggest a myogenic response to the colorectal cancer and not to the laparoscopic modalities of the biopsy harvesting. Follow-up of the patients will elucidate the clinical relevance of our observation, and further studies investigating the molecular mechanism underlying this early cancer-associated myopathy will hopefully provide some pathogenetic clues leading to the identification of potential specific targets for therapeutic intervention to prevent tumor cachexia.

Necrosis in TRAM (transverse rectus abdominis myocutaneous) still occurs in flap breast reconstruction. Blood flow may be improved by vascular endothelial growth factor (VEGF), an endogenous protein that stimulates neovascularization. Experimental studies of gene therapy with plasmid vector expressing human VEGF (hVEGF) presented inadequate results. Low level of gene expression could be the cause. To prove that high level of VEGF gene expression can minimize necrosis of TRAM flap, electroporation of VEGF plasmid was tested.Forty-two adult, male, Wistar-EPM rats were randomly distributed in 6 groups of 7 animals and 50 microg of vectors were injected in the intradermal layer of TRAM flap donor region, by electroporation: LacZ (beta-galactosidase gene); CG (no substance injected and flap elevated); P2G (empty gT plasmid in area 2); PV2G (gT-VEGF165 in area 2); P4G (empty gT plasmid in area 4); PV4G (gT-VEGF165 in area 4). Five days after flap elevation, the animals were euthanized and the degree of necrosis was analyzed by histology and paper template method.Dermal X-gal staining after electroporation with pSV2lacZ proved high rate of gene transfer. Mean values of necrosis by the paper template method were: CG (74.5%), P2G (62.2%), PV2G (41.1%), P4G (76.6%), and PV4G (59%). Degree of necrosis, preservation of muscle layer, and degree of infiltrates seen by histology were in accordance with mean values of necrosis.Intradermal injection of gT-VEGF165 in area 2, by electroporation, was effective in reducing unipedicle TRAM flap necrosis, in rats.

Study Design: Case report., Objectives: To enhance the early recognition of buried bumper syndrome in patients with tetraplegia requiring percutaneous endoscopic gastrostomy (PEG)., Setting: Inpatient unit, Massachusetts, USA., Methods: A 44 year-old man with C2 American Spinal Injury Association grade A tetraplegia with a relatively recent PEG insertion secondary to poor nutritional intake., Results: Several months after PEG placement, patient became febrile, hypotensive and complained of abdominal pain. Plain films showed a dilated bowel suggestive of ileus. Abdominal and pelvic computed tomography with and without contrast revealed PEG tube dislodgement, and a 21 cm x 2.8 cm left anterior abdominal wall collection consisting of air and contrast. Upon surgical intervention, the left rectus abdominis sheath and muscle were found to be necrotic., Conclusion: Buried bumper syndrome is a serious complication related to PEG tubes. For many people with tetraplegia, PEG is a life-saving procedure with minimal risks. However, emergencies do occur, making prompt recognition imperative to prevent a fatal sequela.

We present a case of rectus hematoma occurring in the setting of transfemoral cardiac catheterization. This is a potentially deadly complication that is under-reported and under-diagnosed. The goal of this article is to present a case of rectus hematoma alongside a comprehensive review of the literature.

We report 2 rare cases of endometriosis on the rectus abdominal muscle diagnosed incidentally during an operation for inguinal hernia repair in women with no surgical history. Two women sought medical attention for a mass found in the pubic abdominal wall. Only 1 woman reported occasional pain. At physical examination in both women, an ovoid swelling in the right pubic area was felt. One woman experienced pain on palpation, and one reported slight discomfort. Ultrasonography demonstrated a heterogeneous hypoechogenic formation with indistinct edges; diagnosis was difficult. Routine clinical and instrumental (pelvic ultrasonography) gynecologic examination in both patients performed shortly before hospitalization had not revealed any macroscopic focus of endometriosis in the pelvic region. At surgery, a lesion consistent with the diagnosis of endometriosis was found, which was confirmed at histologic analysis. These cases could represent the consolidation of different theories of endometriosis diffusion. We suggest including endometriosis in the differential diagnosis of a symptomatic mass in the abdominal wall in women with and without a surgical history.

Objective: To assess the value of electromyography ( EMG) of rectus abdominis muscle in the diagnosis of polyneuropathy., Methods: 109 patients with polyneuropathy were studied. The routine nerve conduction study was done and standard EMG was recorded from rectus abdominis muscle, first dorsal interosseous muscle and tibialis anterior muscle. The parameters studied included spontaneous activity fibrillation potentials (fib) and positive sharp waves (psw); duration, amplitude and percentage of polyphasic wave of motor unit action potential (MUAP) and pattern of recruitment. A group of controls and patients with amyotrophic lateral sclerosis (ALS) were studied at the same time. EMG parameters of rectus abdominis muscles were compared among patients with polyneuropathy, patients with ALS and the controls., Results: EMG of rectus abdominis muscle in the patients with polyneuropathy showed neurogenic change. The amplitude of motor unit potential in patients with polyneuropathy (451.67 +/- 75.01) microV was higher than that of the controls (373.78 +/- 56.46)microV(t = 2.01, P < 0.04) and lower than that of patients with ALS (537.19 +/- 159.04) microV (t = 2.32, P < 0.03)., Conclusion: EMG of rectus abdominis muscle might be used to find the lesion of intercostal nerve in polyneuropathy.

Spiegelian hernias account for less than 1% of all hernias diagnosed in the adult population. The most important factors in the proper diagnostic process are detailed physical examination combined with imaging procedures. Two cases of Spiegelian hernias are presented. The anatomical background of the pathology, as well as diagnostic procedures and surgical treatment, is discussed.

No investigation has yet been accomplished to screen the detrimental effects of cigarette smoke condensate (CSC) and total particular matter solution (TPMS) on embryonic development of extraocular and intraocular structures. In this report, chicken embryo assay was utilized to undermine diverse ocular pathologies produced by exposure of CSC and TPM. Extraocular anomalies triggered after exposure of CSC and TPMS include degeneration of optic chiasma, medial rectus muscle, and inflammatory lesions in forebrain. Histological investigations of CSC and TPMS-treated embryos also exposed delayed differentiation of photoreceptor layer, degeneration of retinal ganglion and nerve cell layer. In addition, corneal thickness, deterioration and complete loss of hyaloid vasculature were observed. Extraocular and intraocular regions of TPMS-treated embryos also revealed widespread hemorrhages in the entire cephalic, optic disc, ganglion cell layer and vitreous humor area. The findings of our experiment demonstrate, for the first time, that exposure to CSC and TPMS is hazardous for developing embryos and it has potential detrimental effects on several underlying events of ocular development. Moreover, it was also intriguing that toxicity profile of TMP was much more higher than CSC with more profound detrimental effects on ocular development.

Background: Desmoid tumors are benign neoplasms that most often arise from muscle aponeurosis and have been associated with both trauma and pregnancy. The etiology of desmoids has not been determined., Clinical Characteristics: We present here four almost identical cases with desmoids occurring in the same location, the right rectus abdominus muscle in young post partum females. All were over the age of 30 at the time of diagnosis. Three of them had previously used oral contraceptive agents for an average of 3 years. None had a history of trauma to the area of involvement. Three had early surgical resection and one was treated with tamoxifen and imatinib without response and then had surgical resection., Discussion: All four patients are disease free at a median follow-up of 2.5 years. The possible etiology of desmoids tumors in this location in postpartum females is discussed.

Desmoid tumours are uncommon benign tumours but with aggressive behaviour, resulting from the proliferation of well-differentiated fibroblasts. Clinically, they present as a painless firm soft tissue mass. They can be solitary or multiple and have potential infiltrative capacity. When planning treatment, it is important to assess the correct tumour extent to permit curative radical surgery minimizing possible local recurrence. Different imaging techniques help to characterise these tumours. At present, magnetic resonance is the tool of choice for studying these tumours. The role of nuclear medicine techniques, such as bone scintigraphy, or more recently FDG-PET, has not been defined in the evaluation of these neoplasms. We present the case of a patient with a desmoid tumour of the abdominal-chest wall and we review the related literature.

A 54-year-old woman was transferred to our hospital with disseminated intravascular coagulation, and was treated with heparin. On hospitalization day 13, she developed lower abdominal pain and mass followed by circulatory shock. She became oliguric and laboratory tests showed serum creatinine of 3.5 mg/dL and hemoglobin of 7.4 g/dL. Computed tomography showed hematoma in the left rectus sheath, compressing the urinary bladder exteriorly, which resulted in worsening of bilateral hydronephrosis. Conservative treatment resulted in resolution of the rectus sheath hematoma and improvement of renal function. Rectus sheath hematoma can be treated conservatively without surgical intervention even in complicated cases.

The operative management of midline full-thickness abdominal wall gaps is difficult, often requires several surgical procedures and is associated with significant short- and long-term complications. A rectus abdominis-posterior sheath (RAPS) flap with skin grafting provides a tension-free one-step repair which was used in three patients successfully with midline abdominal wall (including the skin) gaps who had multiple previous operations related to intra-abdominal malignancy. No complications occurred in these patients in relation to this procedure.

Objective: Endometriosis is defined as functioning endometrial tissue outside the uterine cavity. It occurs in up to 15% of menstruating females and in most cases is located within the pelvis. Endometrial implants, however have been described in soft tissues, particularly in the skin and subjacent tissues of surgical scars, and diagnosis might be problematic., Case Study: A 32 aged female presented with a suprapubic abdominal mass, which appeared suddenly after exercise. Fine needle aspiration was performed., Results: Epithelial sheets were shown in direct aspirates. No evident endometrial stromal cells were seen. CD10 immunostaining in additional cell block preparations using a commercial antibody gave positive results. The cell pattern and immunocytochemical profile suggested a cytodiagnosis of endometriosis. The patient was administered with leuprolide acetate. She experienced adverse effects related to estrogen deficiency. Medical treatment was discontinued and the patient underwent surgical excision. Histological sections revealed endometrial glands surrounded by stroma and embedded in fibrous connective tissue., Conclusion: With optimal preparations a confident cytological diagnosis of endometriosis may be established easily, allowing correct treatment of the disease and, in selected cases, planning of preoperative pharmacologic therapy.

Aims and Background: Diagnostic technologies which penetrate the abdominal wall in an attempt to definitively diagnose an intraabdominal malignancy by biopsy can contaminate the abdominal wall by cancerous cells. With follow-up these entrapped cancer cells may progress as an abdominal wall recurrence of the disease process. Frequently, laparoscopy is the definitive diagnostic study which results in the abdominal wall cancer progression., Methods: We examined recurrences within the abdominal wall and attempted to establish a surgical approach to this problem which would maximize a functional result and minimize the incidence of disease persistence within the abdominal wall., Results: Eighteen patients with abdominal wall recurrence were studied. Laparoscopy port sites resulted in the abdominal wall disease in eight patients, in four the recurrence was at a previous ostomy site, in three it was in a Pfannenstiel incision and in three it was in a McBurney incision site. All of these patients were treated by total resection of the rectus abdominis muscle. This resulted in a complete removal of visible disease that was dissecting along the fibers of the rectus abdominis muscle., Conclusions: No patients required reoperation for abdominal wall hernia and mesh repair was not used in any of these patients. Disease control within the abdominal wall has been excellent.

The diagnosis of endometriosis is usually established by a biopsy. Since endometriotic lesions can present as a mass lesion, it seems feasible to investigate them by the noninvasive method of fine-needle aspiration cytology (FNAC). In this study, seven cases (5 from a cesarean scar and 2 from rectus sheath) are presented in which FNAC was indicative of endometriosis. The aspirate was obtained using a disposable 10 ml syringe and 22 gauge needle. The material was collected as syringe and needle washings in a cytology container in which 30% ethyl alcohol was present. From half of this material, filter preparations were made on size 3 mum filters and stained by Papanicolaou method, while the remaining aspirate was spun and a cell block was made from the sediment and sections cut and stained with hematoxylin-eosin stain. In all cases the cytologic preparations showed tubular structures indicative of endometrial tissue and stromal cells indicative of endometriosis. This was further confirmed on examination of cell blocks, which showed histologic features of endometriosis characterized by endometrial glands separated by endometrial stroma and rare siderophages. The seven cases described are interesting, since the cytohistological finding in FNAC sample and cell block not only were indicative of the diagnosis of endometriosis, but also obviated the need for an invasive surgical procedure., ((c) 2008 Wiley-Liss, Inc.)

Endometriosis is the abnormal existence of functional uterine mucosal tissue outside the uterus. It is a usual disorder of women in reproductive age, which is mainly located in the female genital tract. We report the cases of two women with endometriosis of the abdominal wall; the first one in the rectus abdominis muscle and the second one in the surgical scar of previous caesarian incision. The diagnosis was made by the histopathological analysis of the surgical specimens.

Perineal wound failure associated with infection is one of the intractable complications after abdominoperineal resection including pelvic exenteration. It is supposed that there is a strong possibility of this complication occurring in patients with infected perineal lesions after radiation therapy. We describe herein a case of a 56-year-old female who received pelvic exenteration for recurrent rectal cancer, the perineal wound of whom was successfully managed by a two-step operation using muscle flaps. The patient had a recurrent tumor in her pelvis after abdominoperineal resection for locally advanced rectal cancer. She had been treated with chemoradiotherapy for the recurrent tumor. The tumor was exposed to the perineum and was associated with bacterial infection. The tumor was curatively resected by total pelvic exenteration. The perineal wound infection was controlled by a lay-open method after reconstruction of the pelvic floor using a rectus abdominis muscle. The perineal wound was secondarily closed using gracilis mycocutaneous flaps 14 days after pelvic exenteration. She was discharged uneventfully 14 days after perineal closure. The strategy in the present report may be a useful option for perineal wound management in patients with a high risk of perineal wound failure due to infection after abdominoperineal resection.

Background: Deep sedation is often necessary after major reconstructive plastic surgery in the face and neck regions to prevent sudden spontaneous movements capable of inflicting mechanical injury to the transplanted musculocutaneous flap(s). An adequate positioning may help to optimize oxygenation and perfusion of the transplanted tissues. We hypothesized that dexmedetomidine, a central alpha2-agonist and otherwise potentially ideal postoperative sedative drug, may induce vasoconstriction in denervated flaps, and thus increase the risk of tissue deterioration., Methods: Two symmetrical myocutaneous flaps were raised on each side of the upper abdomen in 12 anesthetized pigs. The sympathetic nerve fibers were stripped from the arteries in one of the flaps (denervated flap), while nerve fibers were kept untouched in the other (innervated flap). After simulation of ischemia and reperfusion periods, the animals were randomized to deep postoperative sedation with either propofol (n = 6) or dexmedetomidine (n = 6). Flap tissue metabolism was monitored by microdialysis and tissue-oxygen partial pressure. Glucose, lactate, and pyruvate concentrations were analyzed from the dialysate every 30 min for 4 h., Results: Mean arterial blood pressure was higher in the dexmedetomidine group (P = 0.036). Flap tissue metabolism remained stable throughout the experiment as measured by lactate-pyruvate and lactate-glucose ratios (median ranges 14.3-24.5 for lactate-pyruvate and 0.3-0.6 for lactate-glucose) and by tissue-oxygen partial pressure, and no differences were found between groups., Conclusions: Our data suggest that dexmedetomidine, even if used for deep sedation, does not have deleterious effects on local perfusion or tissue metabolism in denervated musculocutaneous flaps.

Granular cell tumors (GCT) are found in virtually any body site, including the tongue, skin, subcutaneous tissue, breast, rectum and vulva. However, they are rarely seen in the abdominal wall. We report here on a rare case of GCT in the rectus muscle of the abdominal wall. A 44-year-old woman presented with a non-tender, hard mass in the right lower abdominal wall. Upon microscopic examination, the tumor was found to comprise of large polygonal cells with an abundant eosinophilic granular cytoplasm and round to oval nuclei. Upon immunohistochemical staining, the large cells showed S-100 and CD68 positive granular aggregates in the cytoplasm. Many lysosomes of variable size were observed in the cytoplasm.