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This study involves the design, development and evaluation of a new multifunctional prosthetic mesh for treatment of abdominal wall defects without complications. The developed prosthetic mesh is a hybrid platform of both synthetic and natural materials with its backbone consisting of a synthetic commercial polyester fabric (CPF) to provide the required mechanical integrity. The CPF mesh was coated by a natural biodegradable, biocompatible and antimicrobial layer of chitosan (CS) incorporating phenytoin (PH)-loaded pluronic nanomicelles for healing promotion, and ciprofloxacin (CPX)-alginate polyelectrolyte complex-based microparticles as antibacterial agent. The prosthetic mesh was optimized and evaluated in-vitro and in-vivo. The optimum PH-loaded micelles had particle size of 95.42 nm, polydispersity index of 0.41, zeta potential of -18 and entrapment efficiency of 89.4%, while the optimum CPX microcomplexes had particle size of 1292.0 nm, polydispersity index of 0.8, zeta potential of -20.1, complexation efficiency of 81.1%, and minimum inhibitory concentration of 0.25 μg/ml and 0.125 μg/ml against Staphylococcus aureus and Pseudomonas aeruginosa, respectively. In-vivo study on abdominal wall defect dog model was conducted, followed by implantation of the proposed prosthetic meshes. The developed mesh depicted an efficient healing with excellent biocompatibility, and could be an ideal and feasible alternative prosthesis with many advantages such as low cost, inertness, mechanical stability, pliability, low infection rate, limited modification by body tissues, sterilizability, non-carcinogenicity, limited inflammatory reaction, hypoallergenic as well as minimal complications., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Actinomycosis, a chronic suppurative and granulomatous infection, is caused by Actinomyces israeli. The common clinical presentations are cervicofacial, abdominal, and thoracic regions. Abdominal wall actinomycosis following pelvic or intraperitoneal involvement is known, but isolated abdominal wall involvement is extremely rare and can mimic malignancy. We report a case of primary actinomycosis of anterior abdominal wall, diagnosed on fine needle aspiration cytology (FNAC). Identifying fluffy colonies and branching swirling filaments positive for fungal and Gram stain on cytology smears aid correct diagnosis. FNAC is an effective and reliable tool for early diagnosis of actinomycosis. The treatment is centered around antibiotics, and thus it is essential to diagnose accurately and avoid unnecessary surgery.

Competing Interests: Competing interests: None declared.

A 33-year-old postpartum patient, who had an uncomplicated repeat caesarean section 4 weeks prior, presented with a 2-day history of acute right lower quadrant, incisional and groin pain. She was found to have a palpable tender lump in the right groin. A CT scan with contrast identified fluid along the anterior abdominal wall of the right lower quadrant (inguinal region) measuring about 1.7 cm, a preliminary diagnosis of an incarcerated inguinal hernia was made and the patient underwent immediate surgery. The hernia sac was dissected free and had chocolate cyst that was confirmed to be endometrioma on histopathology. The hernia defect was repaired. Postoperative, the patient did well and was discharged home. We emphasise to consider this differential diagnosis of extrapelvic inguinal endometrioma in reproductive-aged women with or without history of endometriosis especially in a post-caesarean patient who has atypical presentations., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare four types of mesh regarding visceral adhesions, inflammatory response and incorporation., Methods: Sixty Wistar rats were divided into four groups, with different meshes implanted intraperitoneally: polytetrafluoroethylene (ePTFE group); polypropylene with polydioxanone and oxidized cellulose (PCD); polypropylene (PM) and polypropylene with silicone (PMS). The variables analyzed were: area covered by adhesions, incorporation of the mesh and inflammatory reaction (evaluated histologically and by COX2 immunochemistry)., Results: The PMS group had the lowest adhesion area (63.1%) and grade 1 adhesions. The ePTFE and PM groups presented almost the total area of their surface covered by adherences (99.8% and 97.7% respectively) The group ePTFE had the highest percentage of area without incorporation (42%; p <0.001) with no difference between the other meshes. The PMS group had the best incorporation rate. And the histological analysis revealed that the inflammation scores were significantly different., Conclusions: The PM mesh had higher density of adherences, larger area of adherences, adherences to organs and percentage of incorporation. ePTFE had the higher area of adherences and lower incorporation. The PMS mesh performed best in the inflammation score, had a higher incorporation and lower area of adherences, and it was considered the best type of mesh.

Study Objective: To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient., Design: A descriptive study approved by our local Institutional Review Board. Consent was given from the patient., Setting: A university hospital in Ashdod, Israel., Patient: On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her β-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas., Intervention: Owing to an extrauterine pregnancy with high β-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The β-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac., Measurement and Main Results: This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall., Conclusion: Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety., (Copyright © 2019. Published by Elsevier Inc.)

Background: Laparoscopic gastric banding (LGB) is associated with high rate of failure (Stenard and Iannelli. World J Gastroenterol; 21:10348-57 2015, Lazzati et al. Ann Surg. 2016). In case of failure, conversion to Roux-en-Y gastric bypass (RYGB) is preferred (Noel et al. Surg Obes Relat Dis;10:1116-22; 2014, Schneck et al. Surg Obes Relat Dis;12:840-8, 2016)., Methods: We present the case of a 63-year-old woman with a BMI of 57 kg/m 2 who underwent LGB in 2011. In 2015, she consulted for intolerance of the banding and weight regain, with a BMI of 52. The gastric band was removed, and 6 months later conversion to RYGB was performed., Results: The main technical problem of conversion of LGB to RYGB is where to staple the stomach, either below or above the band-related scarring tissue. Stapling below the band in a fresh non-scarring area often results in the creation of a large pouch; furthermore, the vertical part of the pouch stapling is done on scarring tissue, with a risk of leak. Stapling above the band leaves a very small part of stomach and may be technically challenging. The present video shows the conversion of LGB to RYGB. The hiatal region is dissected, and a small pouch stapling above the band-related scarring tissue is fashioned. An RYGB with a 150-cm alimentary limb and a 50-cm biliopancreatic limb is confectioned., Conclusions: For conversion of LGB to RYGB, a small gastric pouch above the gastric band scar tissue is confectioned, after dissection of the hiatal region and abdominal esophagus. The small pouch ensures the restriction, and all the stapling and suturing are done on healthy, fresh tissue.

The incidence of endometriosis, including atypical forms of the disease, has been continuously growing, thus increasingly challenging for the imaging specialists as well. We conducted a retrospective study to analyze the results of ultrasound-guided interventions between 2016 and 2018. All interventions were performed in female patients due to uncertain abdominal wall lesions at the University of Szeged, Hungary. The abdominal wall lesions were incidentally detected, one by CT, the others by ultrasound examinations. We identified 12 cases during the study period. The average age of the patients was 59 years (29-79), 8 of them had abdominal surgery in their medical history. The mean diameter of the masses was 34.4 mm (20-49 mm). Since the indication of imaging examinations was the evaluation of a known or suspected malignancy, four patients had undergone an MRI prior to the biopsy. In addition, ultrasound-guided biopsy was not performed in another two patients, and the diagnosis was established by histological examination of the surgically removed specimens. The histological examination revealed malignant primary serous epithelial tumor in one case, metastases in six cases, endometriosis in six patients and abdominal wall abscess was found in one patient. Endometriosis was more frequent in the younger patients. The likelihood of endometriosis as a cause of abdominal wall lesions of younger, premenopausal female patients is rather high, especially with obstetrical or gynaecological operations in the medical history. Ultrasound plays a primary role in the detection and therapy planning of these lesions. Orv Hetil. 2019; 160(35): 1395-1403.

Background: Desmoid tumors are rare locally invasive, benign neoplasms that develop along aponeurotic structures. Current treatment is complicated by associated morbidity and high recurrence rates., Methods: A retrospective, single-institution review identified 23 patients (age: 16-77) with extra-abdominal desmoid tumors who received CT-guided percutaneous cryoablation as either a first-line (61%) or salvage (39%) treatment in 30 sessions between 2014 and 2018. Median maximal lesion diameter was 69 mm (range: 11-209). Intent was curative in 52% and palliative in 48%. Contrast-enhanced cross-sectional imaging was obtained before and after treatment in addition to routine clinical follow-up., Results: Technical success was achieved in all patients. The median follow-up was 15.4 months (3.5-43.4). Symptomatic improvement was demonstrated in 89% of patients. At 12 months, the average change in viable volume was  -80% (range -100% to  + 10%) and response by modified response evaluation criteria in solid tumors (mRECIST) was CR 36%, PR 36%, and SD 28% No rapid postablation growth or track seeding was observed. Four patients underwent repeat cryoablation for either residual or recurrent disease. Two patients sustained a major procedural complication consisting of significant neuropraxia., Conclusion: Cryoablation for desmoid tumors demonstrates a high degree of symptom improvement and local tumor control on early follow-up imaging with relatively low morbidity., (© 2019 Wiley Periodicals, Inc.)

Purpose: To Compare the extent and intensity of adhesions formed between the intra-abdominal organs and the intraperitoneal implants of polypropylene mesh versus polypropylene/polyglecaprone versus polyester/porcine collagen used for correction of abdominal wall defect in rats., Methods: After the defect in the abdominal wall, thirty Wistar rats were placed in three groups (ten animals each) for intraperitoneal mesh implant: polypropylene group, polypropylene/polyglecaprone group, and polyester/porcine collagen group. The macroscopic evaluation of the extent and intensity of adhesions was performed 21 days after the implant., Results: The polypropylene group had a higher statistically significant impairment due to visceral adhesions (p value = 0.002) and a higher degree of intense adherence in relation to polypropylene/polyglecaprone and polyester/porcine collagen groups (p value<0.001). The polyester/porcine collagen group showed more intense adhesions than the polypropylene/polyglecaprone group (p value=0.035)., Conclusions: The intraperitoneal implantation of polypropylene meshes to correct defects of the abdominal wall caused the appearance of extensive and firm adhesions to intra-abdominal structures. The use of polypropylene/polyglecaprone or polyester/porcine collagen tissue-separating meshes reduces the number and degree of adhesions formed.

Background: Incarceration of primary and incisional hernias often results in emergency surgery. The objective of this study was to evaluate the relation of defect size and location with incarceration. Secondary objectives comprised identification of additional patient factors associated with an incarcerated hernia., Methods: A registry-based prospective study was performed of all consecutive patients undergoing hernia surgery between September 2011 and February 2016. Multivariate logistic regression was performed to identify risk factors for incarceration., Results: In total, 83 (3.5%) of 2352 primary hernias and 79 (3.7%) of 2120 incisional hernias had a non-reducible incarceration. For primary hernias, a defect width of 3-4 cm compared to defects of 0-1 cm was significantly associated with an incarcerated hernia (OR 2.85, 95% CI 1.57-5.18, p = 0.0006). For incisional hernias, a defect width of 3-4 cm compared to defects of 0-2 cm was significantly associated with an incarceration (OR 2.14, 95% CI 1.07-4.31, p = 0.0324). For primary hernias, defects in the peri- and infra-umbilical region portrayed a significantly increased odds for incarceration as compared to supra-umbilical defects (OR 1.98, 95% CI 1.02-3.85, p = 0.043). Additionally, in primary hernias age, BMI, and constipation were associated with incarceration. In incisional hernias age, BMI, female sex, diabetes mellitus and ASA classification were associated with incarceration., Conclusion: For primary and incisional hernias, mainly defects of 3-4 cm were associated with incarceration. For primary hernias, mainly defects located in the peri- and infra-umbilical region were associated with incarceration. Based on patient and hernia characteristics, patients with increased odds for incarceration may be selected and these patients may benefit from elective surgical treatment.

Competing Interests: Competing interests: None declared.

There are a number of papers discussing medical and mechanical aspects of ventral hernia management. Despite intensive work on the problem understanding, recurrences of the sickness still happen too often. For that reason, new aspects of the problem must be considered. In this article, a change in the abdominal implant's stiffness is discussed, which is caused by cyclic loading. Such loading influence abdominal implant, for example, while patient is coughing or exercising. For the first time, this stiffness change is quantitatively described for a selected knitted mesh. The influence of mesh stiffness changes on repaired hernia persistence is studied. Then, ex vivo experiments on a repaired hernia model under cyclic pressure loading are performed. Finally, numerical simulations of the experiments are made in which stresses and forces in the system are calculated. The two following cases are considered. In the first case, the mesh has its baseline stiffness, and in the second case, the mesh is preconditioned by former loading; thus, it is stiffened. Reaction forces at the mesh fixation points appear to be approximately twofold higher in the second case than in the first case. That may be a reason for a fixation damage in operated hernia system. The results presented shed new light on the necessary strength of mesh fixation in the abdominal wall. They enlarge the state of the art on laparoscopic hernia management with the use of a synthetic implant. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1400-1409, 2019., (© 2018 Wiley Periodicals, Inc.)

Introduction: Giant ovarian cysts are rarely described in the literature, owing to the availability of advanced imaging technologies in developed countries leading to early treatment. In resource-limited settings, various factors lead to late presentation., Case Presentation: We present a case of a 48-year-old black African woman with a giant mucinous cystadenoma who presented to a tertiary hospital with massive abdominal distention 5 years after being referred from a district hospital for the same problem. Surgical management resulted in fatal complications., Conclusions: The surgical management of these huge tumors is associated with many life-threatening complications. Transvaginal ultrasound should be used in resource-limited settings to delineate ovarian masses. Community health workers must be involved in scouting and follow up of community members with unusual abdominal swellings in developing countries to avoid delays in care.

Self-adhesive meshes are being developed to avoid complications due to traumatic fixation methods. LifeMesh™ is a novel self-adhesive mesh with a biodegradable gelatin adhesive layer developed for hernia repair. The aim of this study was to assess the safety and biodegradability of LifeMesh in Sprague-Dawley (SD) rats for 6 weeks, in comparison to a bare polypropylene (BPP) mesh fixed with sutures. LifeMesh was tolerated well and its implantation did not result in any adverse local reaction, and its adhesive layer was substantially degraded after 4 weeks. Histopathological examination revealed that the presence of the adhesive contributed to a uniform thickness of the granulation tissue surrounding the mesh, in contrast to a nonuniform granulation tissue with BPP. Nonuniform granulation tissue suggests that there will be poorer integration of the mesh to the abdominal wall. The use of LifeMesh also resulted in less adhesions of internal organs with a smaller surface area of involvement. These findings lend support to the potential benefit of LifeMesh for hernia repair in humans and expand the available information on the typical histopathological findings expected with biodegradable implants in the peritoneal cavity of SD rats.

Background: Massive weight loss can notably affect patients' health-related quality of life (HRQoL) and body image. Yet, no body contouring specific instruments to assess HRQoL and body image after massive weight loss have been validated in Finnish. The BODY-Q includes 26 independently functioning scales and a single checklist that measure appearance, HRQoL, and experience of care. The aim of the present study was to translate and validate a Finnish version of the BODY-Q among patients who underwent abdominoplasty., Methods: The BODY-Q was translated into Finnish using recommended guidelines. Eighty-two patients who underwent abdominoplasty due to massive weight loss were identified from hospital records using procedure codes. A postal survey including the BODY-Q, the 15D, and general health and pain instruments was used. Criterion validity, Cronbach's alpha, and floor and ceiling effects were analyzed., Results: The BODY-Q translated well into Finnish. Fifty-three patients returned the questionnaires (response rate 65%) and were included. All but the Scars subscale correlated significantly with the 15D mean score, thus indicating strong criterion validity against a generic HRQoL tool. The Excess Skin and the Physical Function scales reached the ceiling effect (>15% of maximum points) in our postoperative sample. No floor effects were observed. Internal consistency of the BODY-Q scales was high (Cronbach's alpha range, 0.81-0.95)., Conclusions: The Finnish version of the BODY-Q instrument is equivalent in terms of content, accuracy, and comprehensiveness to the original English version. The findings of the present study indicate that the BODY-Q has psychometric properties suitable for assessing outcomes and treatment effectiveness of abdominoplasty., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

We investigated whether likely pathogenic variants co-segregating with gastroschisis through a family-based approach using bioinformatic analyses were implicated in body wall closure. Gene Ontology (GO)/Panther functional enrichment and protein-protein interaction analysis by String identified several biological networks of highly connected genes in UGT1A3, UGT1A4, UGT1A5, UGT1A6, UGT1A7, UGT1A8, UGT1A9, UGT1A10, AOX1, NOTCH1, HIST1H2BB, RPS3, THBS1, ADCY9 , and FGFR4 . SVS-PhoRank identified a dominant model in OR10G4 (also as heterozygous de novo), ITIH3, PLEKHG4B , SLC9A3 , ITGA2 , AOX1 , and ALPP , including a recessive model in UGT1A7 , UGT1A6 , PER2 , PTPRD , and UGT1A3 . A heterozygous compound model was observed in CDYL, KDM5A , RASGRP1 , MYBPC2 , PDE4DIP , F5 , OBSCN , and UGT1A . These genes were implicated in pathogenetic pathways involving the following GO related categories: xenobiotic, regulation of metabolic process, regulation of cell adhesion, regulation of gene expression, inflammatory response, regulation of vascular development, keratinization, left-right symmetry, epigenetic, ubiquitination, and regulation of protein synthesis. Multiple background modifiers interacting with disease-relevant pathways may regulate gastroschisis susceptibility. Based in our findings and considering the plausibility of the biological pattern of mechanisms and gene network modeling, we suggest that the gastroschisis developmental process may be the consequence of several well-orchestrated biological and molecular mechanisms which could be interacting with gastroschisis predispositions within the first ten weeks of development.

Background: The treatment of abdominal wall metastasis presents a challenge, because resection can be followed by poor healing and external radiotherapy is associated with serious adverse events. This study aimed to evaluate the efficacy and safety of interstitial 125 I seed implantation under ultrasound (US) guidance for treating abdominal wall metastasis. Materials and Methods: The cases of 21 patients with 28 abdominal wall metastases who received brachytherapy with 125 I seeds at the department from August 2010 to March 2015 were retrospectively reviewed. 125 I seeds were implanted in the abdominal wall lesions under US guidance and with the help of a treatment planning system. Follow-up was performed using computed tomography at 1 d and at 3, 6, and 12 months after implantation. The lymphocyte count before the surgery was compared with the 3-month postoperative count. The main indicators observed were changes in tumor size, side effects, and complications. Results: All 21 patients were successfully treated with 125 I seed implantation under US guidance. The median follow-up since 125 I seed implantation was 15 months (range 6-23 months). The response rates and local tumor control after 3, 6, and 12 months were 78.6% and 89.3%, 64.3% and 85.7%, and 52.4% and 71.4%, respectively. The mean preoperative lymphocyte count was 0.262 ± 0.117 × 10 9 /L, which did not differ significantly from the postoperative count, which was 0.259 ± 0.094 × 10 9 /L ( p  = 0.122). Procedure-related complications included fever, bleeding, and pain, but all these were Grade 1-2. No severe side effects or complications were noted. Conclusions: Percutaneous interstitial implantation of 125 I seeds under US guidance is safe and feasible for abdominal wall metastases. However, its long-term efficacy requires further investigation.

Recent advances have now made it possible to speak of gastroschisis narrowly in morphogenetic terms invoking the Rittler-Beaudoin (R-B) model. This proceeds from the appreciation of gastroschisis as a congenital intestinal herniation (without cover or liver) within the primordial umbilical ring, mostly to the right side of a normally formed umbilical cord. Presently, it is unresolved whether this visceral prolapse represents failure of ring closure before return of the physiological hernia into the abdomen or rupture of the delicate amniotic/peritoneal membrane at the ring's edge to the right of the cord. Animal observations and experiments will be required to address this question effectively. If gastroschisis is, in fact, a primary malformation with the primordial umbilical ring as the developmental field involved, then homology implies potential gastroschisis in all amniotes with corresponding nourishment from yolk sac (aka omphalomesenteric) vessels going into the embryo and excretory products out via the ancient umbilical connection. It also implies homology of corresponding morphogenetic signal transduction cascades. We review the history of gastroschisis, its presumed pathogenesis, and the developmental biology of the amniotic umbilical ring from this perspective. Therefore, based on the animal and human evidence to date, we propose that gastroschisis is a primary midline malformation that involves the umbilical canal from amniotic to peritoneal space and its primordial umbilical ring, either through nonclosure or rupture of the membrane covering the area, mostly to the right, between the cord and the edge of the ring., (© 2019 Wiley Periodicals, Inc.)

Background: Hyaluronic acid fillers (HAFs) and energy-based devices are frequently used sequentially. However, the effect of using fractional devices directly over HAF is unclear., Objective: To evaluate histologic changes after fractional laser and radiofrequency (RF) therapies applied over preinjected HAF., Materials and Methods: Abdominoplasty skin samples were divided into 8 zones. Intradermal injections of HAF were performed to 7 zones with 1 zone as untreated control. Six of 7 HAF injected zones were then treated with the following devices: 1,540-, 1,550-, 1927-, and 10,600-nm fractional lasers, and fractional bipolar RF delivered through insulated and noninsulated microneedles. After treatment, biopsies were collected for H&E staining., Results: Histology revealed HAF in the mid to deep dermis. Treatment with 1,540-, 1,550-, 1927-, and 10,600-nm lasers did not result in any morphologic changes of HAF, although thermal changes from 1,540- and 1,550-nm lasers were in very close proximity to the filler. The RF devices demonstrated thermal damage of HAF along the microneedle tracks., Conclusion: Hyaluronic acid filler is unaffected by fractional lasers in this model. Fractional RF devices, which produce deeper dermal penetrations, will cause thermal damage of HAF. Caution is advised in using microneedle RF over recently injected filler. Study limitations include use of nonfacial skin and lack of inflammatory response in an ex-vivo model.

The pathophysiology underlying the formation, progression, and surgical healing of incisional hernia (IH) that develops as a major complication associated with abdominal laparotomy is poorly understood. The proposed mechanisms include the switch of collagen phenotype and the proliferation of abnormal fibroblasts after surgery. The focus of this article was to critically review the cellular, biochemical, and potential molecular events associated with the development of IH. The disturbance in collagen homeostasis with alterations in the expression of collagen subtypes, including type 1, type 3, type 4, and type 5, and impairment in the transdifferentiation of fibroblasts to myofibroblasts are discussed. The phenotype switch of wound-repair fibroblasts results in mechanically compromised extracellular matrix that triggers the proliferation of abnormal fibroblasts. High-mobility group box 1 could be involved in wound progression, whereas signaling events mediated by tumor necrosis factor β1, connective tissue growth factor, lysyl oxidase, and hypoxia-inducible factor 1 play significant role in the wound healing response. Thus, the ratio of tumor necrosis factorβ1: high-mobility group box 1 could be a critical determinant of the underlying pathology. Potential target sites for therapeutic intervention in the management of IH are recognized., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This case report describes the use of a three-dimensional reconstruction technique to plan the abdominal incision in order to avoid incision-related complications in a 53-year-old female patient who had had a cystic mass in the liver for 16 years and had undergone four previous surgeries. The patient presented with a recurrent cyst. The surgical team used three-dimensional reconstruction to model the liver mass, the area of abdominal wall weakness due to previous surgeries, bowel adhesions, skeletal structure and whole abdominal contour. The models were superimposed upon each other to reveal the relationship between the various features so that the optimum incision point could be selected so as to avoid the area of abdominal wall weakness, bowel adhesions and vital organs. The actual surgical incision was made based on the three-dimensional reconstruction models and the surgeon was able to avoid the area of abdominal wall weakness and bowel adhesions as planned. No incisional hernia and wound infection were observed postoperatively and the incision healed well. The three-dimensional reconstruction technique for preoperative surgical incision planning on patients with a history of multiple abdominal surgeries can minimize incision-related complications and achieve good therapeutic results.

Background: Inguinal lymph node metastasis from rectum is uncommon but well-known occurrence, whereas that from colon adenocarcinoma is extremely rare. Inguinal lymph node metastasis from colon adenocarcinoma has only been reported in previous cases involving primary tumor invasion of the abdominal wall, or in those involving colon cancer metastasis to external iliac lymph nodes. We describe a case of inguinal lymph node metastasis from colon cancer without primary tumor invasion to the abdominal wall., Case Presentation: A 42-year-old female, who had undergone twice cesarean sections before, underwent open sigmoidectomy for sigmoid colon adenocarcinoma and received 12 cycles of FOLFOX regimen as adjuvant chemotherapy. Two years after sigmoidectomy, a follow-up CT scan revealed enlarged inguinal lymph nodes as well as growth of enhanced mass lesions on the abdominal wall at site of the cesarean section scar. Biopsy of both lesions revealed well-differentiated adenocarcinoma, and immunohistochemistry demonstrated positive expression of CDX2, substantiating its gastrointestinal origin. We therefore performed dissection of left inguinal lymph nodes and mass lesion of the abdominal wall. The patient died 51 months after lymph node dissection., Conclusions: This is the first reported case of inguinal lymph node metastasis from colon cancer without invasion of the primary tumor to the abdominal wall or without involvement of the external iliac lymph nodes, suggesting that the pathway of inguinal metastasis originated from the abdominal wall metastasis. When inguinal lymph node metastasis from colon cancer is suspected, if an R0 resection was possible, inguinal lymph node dissection may be a potentially effective treatment.

The stability and bioactivity of biologic implants rely mainly on the control of the crosslinking process of collagen. However, the most common methods have no control on the crosslinking degree producing it excessively. This study outlines the role of crosslinking of collagen-based implants with oligourethane on the host response following reconstruction of a rat full-thickness abdominal wall defect. We decellularized and crosslinked bovine pericardial tissue to achieve two crosslinking degrees. For the decellularized implants, named as non-crosslinked (N-CL), the collagen-amines were 0.42 ± 0.02 mmol/mg. Crosslinking by the oligourethane reduced the primary amine concentration to 0.28 ± 0.01 and 0.19 ± 0.01 mmol/mg; these values were classified as low (∼30%, L-CL) and medium crosslinking (∼50%, M-CL), respectively. By imaging the implants using second harmonic generation microscopy, we observed undulated bundles of collagen fibers organized in multi-directed layers localized in N-CL and L-CL samples. Post-implantation, a negligible change in the organization of collagen fibers in the crosslinked implants was observed, suggesting that the in vivo biodegradation was delayed. An enlargement of the implant area was also observed, without rupture, in all three (N-CL, L-CL, M-CL) materials, whereas adhesion to the omentum, but not to the bowel, was observed. The number of blood vessels after 90-day implantation in N-CL and L-CL was 13 ± 1 and 12 ± 1 per field, respectively, while the number significantly decreased to 2 ± 1 in M-CL. The results suggest that the controlled degree of crosslinking in oligourethane-modified biologic implants can be used as a strategy to balance biodegradation and remodeling in surgical repair of soft tissues.

A 57-year-old man presented with a 6-month history of pelvic fullness. He had no lower urinary tract symptoms or altered bowel habits. On examination, there was a non-tender pelvic mass which extended from the pubic symphysis to the level of the umbilicus. CT scan of the abdomen demonstrated a 22×11×11 cm cystic mass arising from the pelvis extending into the midline and superiorly to the umbilicus. Other than raised carcinoembryonic antigen of 7.6 ng/mL (<5.0), the remainder of his blood test were unremarkable. Flexible cystoscopy demonstrated a convex deformity of the bladder wall in keeping with the compression and displacement as seen on the CT. The patient underwent an open excision of the cystic structure (urachal remnant), partial cystectomy, partial excision of anterior abdominal wall and pelvic lymphadenectomy. A check cystogram performed 12 days following the initial operation was unremarkable., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cesarean scar endometriosis (CSE) is the most common type of abdominal wall endometriosis (AWE). The aim of this study was to systematically identify the clinical features of CSE and recommend precautionary measures., Methods: A large, retrospective study was undertaken with CSE patients treated surgically at our hospital between January 2005 and December 2017., Results: A total of 198 CSE patients were enrolled, with a mean age of 32.0 ± 4.0 years. The main complaint of the patients was abdominal mass (98.5%), followed by cyclic pain (86.9%). The latency period of CSE was 31.6 ± 23.9 months, and the duration between the onset of symptoms and this surgery was 28.3 ± 25.0 months. A majority (80.8%, n = 160) of the patients had undergone a Pfannenstiel incision, and a minority (19.2%, n = 38) a vertical midline incision. The latency period of CSE in the case of a Pfannenstiel incision was significantly shorter than that in the case of a vertical midline incision (24.0 vs 33.0 months, P = 0.006). A total of 187 (94.4%) patients had a single endometrioma, 11 (5.6%) patients had multiple endometriomas, and the 11 multiple-endometrioma patients had all undergone a Pfannenstiel incision. Lesions of endometrioma were common in corner sites, after either incision: 142/171 (83.0%) in Pfannenstiel incision scars and 32/38 (84.2%) in vertical incision scars., Conclusions: The findings of this study indicate that the Pfannenstiel incision carries a higher risk of CSE than the vertical midline incision. Thorough cleaning at the conclusion of CS, particularly of both corner sites of the adipose layer and the fascia layer, is strongly recommended for CSE prevention. Further studies might provide additional recommendations.

The exstrophy-epispadias complex represents a spectrum of genitourinary malformations ranging from simple glanular epispadias to an overwhelming multisystem defect, cloacal exstrophy. Neonatal total reconstruction of bladder exstrophy-epispadias complex is the treatment of choice. An adult patient presenting with untreated exstrophy is very rare. Malignant transformation, commonly adenocarcinoma, in such cases is a known complication due to mucosal metaplasia of urothelium. Management in such cases necessitates a radical surgical procedure that often results in a massive defect in the anterior abdominal wall. Providing a cover for such defects is a challenging task for the reconstructive surgeon. Local skin flaps and wide mobilisation of the rectus muscle are the usually employed techniques for closure of such defects. However, these may be inadequate in extremely large defects such as those encountered in our patients. We, hereby, describe our technique of closure of the abdominal wall defect using a pedicled anterolateral thigh flap., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To define the indication for preventive mesh implantation in patients scheduled for laparotomy., Material and Methods: There were 108 patients divided into the control (52 patients without anterior abdominal wall hernia) and the main (56 patients with ventral hernia) groups., Results: Predominance of collagen type III over type I was observed in patients older 60 years in the main group. The maximum ratio of collagen types I and III was 1.4 in the main group. The minimum number of inter-fiber spaces (n=5) was noted in patients aged 30-40 years. The maximum density of connective tissue was 250 pixels per inch., Conclusion: Analysis of connective tissue structures revealed some important age-related features and markers of connective tissue dysplasia in the main group. An indication for preventive mesh implantation in patients scheduled for laparotomy was determined.

Objective: To design a novel system of scoring prune belly syndrome (PBS) phenotypic severity at any presenting age and apply it to a large pilot cohort., Patients and Methods: From 2000 to 2017, patients with PBS were recruited to our prospective PBS study and medical records were cross-sectionally analysed, generating individualised RUBACE scores. We designed the pragmatic RUBACE-scoring system based on six sub-scores (R: renal, U: ureter, B: bladder/outlet, A: abdominal wall, C: cryptorchidism, E: extra-genitourinary, generating the acronym RUBACE), yielding a potential summed score of 0-31. The 'E' score was used to segregate syndromic PBS and PBS-plus variants. The cohort was scored per classic Woodard criteria and RUBACE scores compared to Woodard category., Results: In all, 48 males and two females had a mean (range) RUBACE score of 13.8 (8-25) at a mean age of 7.3 years. Segregated by phenotypic categories, there were 39 isolated PBS (76%), six syndromic PBS (12%) and five PBS-plus (10%) cases. The mean RUBACE scores for Woodard categories 1, 2, and 3 were 20.5 (eight patients), 13.8 (25), and 10.6 (17), respectively (P < 0.001)., Conclusions: RUBACE is a practical, organ/system level, phenotyping tool designed to grade PBS severity and categorise patients into isolated PBS, syndromic PBS, and PBS-plus groups. This standardised system will facilitate genotype-phenotype correlations and future prospective multicentre studies assessing medical and surgical treatment outcomes., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

An extensive 35 × 20 cm sized full-thickness abdominal wall defect was created after resection of aggressive abdominal fibromatosis in a 19-year-old male patient. Immediate reconstruction was not possible due to prolonged operation time and resulting severe bowel edema. A silicone sheet with NPWT was applied over the exposed viscera. After 1 week, silicone sheet was substituted with a composite mesh. Then, abdominal wall reconstruction with bilateral free anterolateral thigh (ALT) flaps (30 × 12 cm and 25 × 12 cm sized) was performed. Since there was only a single reliable recipient vessel available, we linked 2 ALT free flaps sequentially in a flow-through fashion to the left inferior epigastric artery and vein. Two donor sites were closed primarily. The flap fully survived and the defect was covered successfully without any complication for 11 months of follow up. Multiple flaps may be needed for large full-thickness abdominal wall defect coverage. Linked fasciocutaneous free flaps could be a solution with a less donor site morbidity even in the case of limited available recipient vessels. The purpose of this study is to introduce our experience of extensive full-thickness abdominal wall reconstruction using only ipsilateral deep inferior epigastric vessels., (© 2017 Wiley Periodicals, Inc.)

Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head, neck and esophageal tumors. Tumor cell implantation is a rare complication in patients with aerodigestive cancers, who have undergone PEG tube placement. The objective of this review is to determine the incidence and contributing risk factors leading to the implantation of metastases into the abdominal wall following PEG placement. A comprehensive review of the literature in PUBMED (2008-2018) was performed.  The literature search revealed reports of more than 50 cases of abdominal wall metastases after PEG placement. As most of these studies were case reports, the exact rate of metastasis remains unknown. Generally pharyngoesophageal location of primary cancer (100%), squamous cell histology (98%), poorly differentiated tumor cells (92%), advanced pathological stage (97%), and large primary cancer size were identified as strong risk factors for the development of stomal metastasis. Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy.

A 38-year-old female, intact yellow-naped Amazon parrot ( Amazona auropalliata ) presented with an acute swelling along the ventrocaudal body wall, hematochezia, and tenesmus. Physical examination identified a defect in the ventral body wall. Bimodal pain management was initiated at presentation and hematochezia and tenesmus resolved. Radiographic imaging and contrast fluoroscopy identified a partial cloacal strangulation. An exploratory celiotomy was performed. Adhesions to the body wall were identified and broken down, the cloacal position was corrected, and the abdominal musculature repaired. Contrast fluoroscopy performed 72 hours after surgery confirmed normal positioning of the cloaca. Follow-up examinations documented proper postoperative healing of the hernia repair and maintenance of visibly normal passage of droppings. Although various abdominal hernias have been described in birds, this case demonstrates an unreported variation involving partial cloacal strangulation in a parrot., (© 2018 by the Association of Avian Veterinarians.)

Lateral body wall herniation with involvement of the oviduct was diagnosed in a female nanday conure ( Aratinga nenday ) and a female eclectus parrot ( Eclectus roratus ). A history of chronic egg laying and chronic reproductive activity was reported in both cases. A subcutaneous mass in the area of the caudal left lateral body wall was present in both birds. Diagnostic imaging (ultrasonography, computed tomography) and cytologic examination lead to the diagnosis of left lateral body wall herniation with involvement of the oviduct. In the conure, a developing egg was contained within the herniated oviduct. Both cases were successfully treated by salpingohysterectomy and surgical correction of the hernal ring. Lateral body wall herniation with oviductal involvement in birds has not previously been reported and should be considered as a differential for birds presenting with masses originating from the lateral body wall., (© 2018 by the Association of Avian Veterinarians.)

Introduction: Laparoscopic port site metastases are a rare but clinically important cause of biochemically recurrent prostate adenocarcinoma. C-11 choline, among other prostate-specific positron emission tomography (PET) radiotracers, has improved radiologist confidence in these otherwise difficult-to-detect sites of recurrence., Patient Concerns: A 62-year-old male presented with biochemically recurrent prostate adenocarcinoma after undergoing robotic-assisted radical prostatectomy 5 years earlier., Diagnosis: C-11 choline positron emission tomography/computed tomography (PET/CT) demonstrated a choline-avid soft tissue nodule associated with a laparoscopic port site in the right rectus abdominis muscle, with correlative findings on prior magnetic resonance imaging, and biopsy confirming a prostate adenocarcinoma metastasis., Interventions: The patient was initiated on chemohormonal therapy., Outcomes: His prostate-specific antigen (PSA) became undetectable following chemohormonal therapy. A follow-up C-11 choline PET/CT demonstrated complete resolution of prior abnormal radiotracer activity in the right rectus abdominis muscle., Lessons: Port site metastases in prostate adenocarcinoma are rare; however, those who treat prostate cancer patients should be aware of this phenomenon as the number of minimally invasive oncologic procedures increase. C-11 choline PET, among other prostate-specific PET probes, has become an important tool in evaluating patients with biochemically recurrent prostate adenocarcinoma, identifying site-specific metastases in a majority of patients.

Purpose: Fibrin clot is essential for post-operative abdominal adhesion formation. Fucoidans, sulfated polysaccharides, inhibit fibrin clot formation. In addition, they inhibit inflammation and fibrosis, which also play important roles in adhesion formation. The purpose of this study was to evaluate fucoidans' potential for inhibiting post-operative abdominal adhesions and measure their effects on systemic coagulation parameters when administered intraperitoneally (IP)., Methods and Materials: Female Sprague Dawley rats were studied. A 2.5x2.5cm full thickness segment of abdominal wall was excised. The skin edges were approximated. This model induces extensive adhesions and allows objective quantitation. Three fucoidans were evaluated- Sigma Fucoidan Crude (SFC), Fucus vesiculosis 95% (Sigma) and, Peridan. One protocol involved continuous infusion into the abdomen from a subcutaneous osmotic pump. Alternatively, boluses of the solutions were injected IP at the end of the operation. Rats were sacrificed a week later. Adhesion extent was scored. Systemic coagulation effects of fucoidans were also evaluated. INR and aPTT were measured following IP injection of the fucoidan solutions and after 7 days of continuous infusion., Results: Animals given a continuous infusion of either SFC or Peridan yielded adhesion reduction of 80 to 90% from control. Bolus Peridan had no discernable influence on adhesion formation, but a single bolus of SFC caused significant adhesion reductions. Peridan resulted in prompt aPTT elevations which fell to nearly normal by 5 hours. The maximum peak value after SFC injection was seen in 15 hours. The maximal INR elevations were around 2. Measurement of INR and aPTT after a week of continuous infusion of either Peridan or SFC, were always in the normal control range. The third agent, Sigma, frequently yielded intraperitoneal infection found at autopsy., Conclusions: These findings indicate that selected fucoidans infused intraperitoneally for a week after abdominal operations reduce adhesion extent by up to 90%., Competing Interests: Competing interest statement: This work was supported by private investment of G.D.N. Holdings and Anhese, LLC. Author J.P.D. was a board member of Anhese, LLC at the time of these experiments. However, no authors received direct payment from either company. Dr. Delaney did participate in manuscript preparation, experimental design, and the decision to publish. Anhese, LLC applied for and held a provisional patent for the use of fucoidans for adhesion prevention, but the provisional patent has since lapsed. Anhese, LLC has since dissolved. G.D.N. Holdings did not have any role in experimental design, data collection, or preparation of this manuscript. There is currently no financial stake in the outcome of this manuscript or the use of fucoidans for adhesion prevention for the authors of this manuscript or the companies that funded the work. This does not alter our adherence to PLOS ONE policies on sharing data and materials.