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Adjustable gastric banding is a restrictive bariatric procedure during which a fluid-filled silicone band is wrapped around the gastric cardia. The volume of fluid within the band may be adjusted through percutaneous access to a subcutaneous port that is connected to the band by flexible tubing and attached to the anterior abdominal fascia. Increasing band fluid volume results in greater extrinsic compression and more limited flow of luminal contents through the gastric cardia. This chapter describes the indications, technique, and complications associated with this procedure.

The purposes of this study were to mechanically determine the optimal tissue bite size and to evaluate seven suture materials at their largest commercially available size for breaking strength and stiffness using cadaveric adult equine linea alba. Soft tissues were removed from the abdominal fascia of 16 adult horses. Individual test sections were created from the entire linea alba and labeled (1 through 6) starting at the umbilicus and extending craniad. A single biomechanical test was performed on each test section. Tissue bite size (3, 6, 9, 12, 15, 18, and 21 mm) significantly altered breaking strength directly in a logarithmic fashion (P < .0001; R2 = 0.94). Tissue bite size accounted for 44% and linea alba thickness for 24% of the variability in breaking strength of the equine linea alba. The optimal tissue bite size for adult horse was 15 mm from the edge of the linea alba based on lack of significant gain in breaking strength. There were no differences in breaking strength among horses, horses weight, or left and right test sections. Test sections taken from near or at the umbilicus had greater breaking strength (P < .005) and thicker linea alba (P < .001) when compared with more cranial test sections. Linea alba thickness alone accounted for 34% of the variability in breaking strength associated with test section position. There were no differences in linea alba stiffness among tissue bite sizes. All suture loops failed before complete fascial disruption, and 52 of 56 (93%) suture loops failed at the knot.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of abdominal wall defects in the presence of contamination or infection is a significant problem. The loss of tissue warrants enforcement of the abdominal wall, preferably by autologous material. However, autologous repair often requires extensive surgery. This paper presents a review of available literature of placement of an acellular human dermis to repair an abdominal fascia defect, in contaminated as well as in non-contaminated surgical fields. It is illustrated with a case report that describes the successful reconstruction of an infected abdominal wall defect with a human acellular dermis allograft. A systematic literature review was undertaken with searches performed in the Pubmed and Cochrane databases for the period up till March 2009, using the search terms Alloderm [Substance Name], Hernia [Mesh] and the key words acellular dermis, acellular dermal matrix, human acellular dermal allograft and abdominal wall defect. To assess methodological quality, each article was subjected to a modification of the methodological index for non-randomized studies (MINORS) according to Slim et al. Two items from the original index were not included because none of the studies selected had an unbiased assessment of the study end points and in none of the studies was a prospective calculation of the study size performed. Seventeen studies were included in the review. Data were extracted regarding study design, number of patients, surgical technique, followup period, contaminated or non-contaminated area of the fascia defect, mortality and morbidity (hemorrhage, seroma, wound dehiscence, infection) of the operative procedure, the longterm results (removal of the graft, reherniation and bulging) and level of evidencey. A total of 169 short-term complications and 151 longterm complications occurred after 643 surgical procedures reconstructing both contaminated and clean abdominal wall defects by implantation of an HADA. Human acellular dermal allograft seems to be a good alternative for autologous repair of contaminated or infected abdominal wall defects.

Surgical site infections (SSI) are the third most common hospital-acquired infections and account for 14% to 16% of all such infections. In elective colorectal operations, the international SSI rate ranges from 4.7%-25%. In a previous retrospective study in this department, the SSI rate was unacceptably high (25%), and the promising different international evaluations of triclosan-coated suture materials encouraged us to create a multicenter randomized trial to improve our results. The main goal of this study was to compare triclosan-coated and uncoated absorbable suture (PDS Plus(®) with PDS II(®)) in elective colorectal operations.This was an internet-based study involving seven surgical centers. All the elective colorectal operations were performed by experienced surgeons. For abdominal fascia closure, running looped PDS was applied; triclosan-coated or uncoated PDS was chosen by computer randomization. Pre-operative and peri-operative variables such as gender, body mass index, neoadjuvant therapy, type II diabetes mellitus, amount of wound dressing material used, nursing days, and microbiological results were recorded. After the operation, the patient's data and risk factors were collected in a password-protected online database.From 485 patients randomized, SSI was documented in 47 patients (12.5%), 23 (12.2%) in the group having triclosan-coated sutures (n=188) and 24 (12.2%) in the uncoated suture group (n=197), a non-significant difference. Of all SSIs, 13 (27.7%) were diagnosed only after discharge, being recognized in the outpatient setting, with four patients in the triclosan suture group (8.5%) and nine in the uncoated suture group (19.2%) being affected with no significant differences in the demographic data. Microbiological examinations, in addition to the same colon flora in both groups, revealed two gram-positive infections in the uncoated suture group. The hospital stay and costs of dressings were significantly higher in patients having SSIs.Compared with the previous retrospective studies of this department, the implementation of looped PDS decreased the incidence of SSI by one-half, whether the suture was triclosan-coated or not. It seems that patient factors are less important than operative factors in the occurrence of SSI, and there were no differences between elective colon and rectal operations in the development of incisional infections. No beneficial effect of triclosan against gram-positive bacteria, which has been reported in the literature, could be confirmed in our study. We could not show an effect against gram-negative enteric microorganisms. Higher additional costs and longer hospital stay with SSI were confirmed.

Abdominal fascia plication using a simple continuous suture can sometimes cause tears in the fascia. This problem can be circumvented when the continuous horizontal mattress suture is used. No data exist from comparing the two suturing techniques. The aim of this study was to examine which technique can potentially cause greater tissue damage. The time required to perform each type of suture was also recorded. Wound closure pads were plicated using the simple continuous and continuous horizontal mattress techniques performed by a single operator using Ethilon 2-0 nylon sutures. To verify their resilience, plastic bags were inflated beneath the pads to 30, 60, and 120 mmHg and tears were recorded. The time needed to perform the procedures was recorded using a stopwatch. Mean time for the continuous vertical mattress suture was 87 s and for the simple continuous suture 116 s. Tears in the pad that was plicated with the simple continuous pattern were significantly longer than those in the pad plicated with the continuous horizontal mattress pattern (fissure mean length ± SD = 3.958 ± 0.157 vs. 2.736 ± 0.157, respectively, p

This investigation is devoted to the study of the viscoelastic behavior of human abdominal fascia from the umbilical region. Seventeen samples 10 mm wide and up to 70 mm long were cut along the primary fiber direction (group FL) or perpendicular to it (group FT) and subjected to relaxation tests. The viscoelastic response of the tissue at three different strain levels (4%, 5%, and 6%) was investigated. The relaxation curves were fitted using a two-stage decaying exponential form. The following parameters were determined: initial stress σ(0), relaxation times τ(1) and τ(2), stress reduction Δσ, initial relaxation modulus E and equilibrium relaxation modulus E(eq), as well as the ratio E/E(eq). Fiber orientation and strain levels were varied to determine their influence on the viscoelastic properties of fascia. The results highlight the inherent viscoelastic mechanical properties of umbilical fascia. The values of the viscoelastic parameters determined for the longitudinal and transverse directions varied markedly. Significant differences were found between the two groups FL and FT for the initial stress at 5% and 6% strain (p0.038) and for the initial and equilibrium moduli at the 6% strain level (p0.046). The stress reduction in samples from the FL group (45-55%) was less than that in samples from the FT group (37-54%), but this difference was not significant (p0.388). The influence of strain level on the parameter values was not statistically significant (p0.121). The nonlinear response of the tissue was demonstrated over the chosen strain range.

Traditional treatment for fecal peritonitis resulting from perforation of the left-sided colon has been performed using Hartmann’s procedure to reduce the high mortality caused by anastomotic leakage. However, the morbidity rates associated with abdominal incision (due in great part to wound infection, and dehiscence of abdominal fascia) are high. Therefore, we propose using laparoscopic Hartmann’s procedure with abdominal incisions only for the port site to reduce the high morbidity associated with the laparoscopic procedure as compared to open surgery. Between April 2008 and July 2011, we treated 16 consecutive patients (median age, 83 years) with fecal peritonitis resulting from perforations in the left-sided colon due to various causes. The American Society of Anesthesiologists score of each patient was either IV or V. Patients underwent a four-port laparoscopic Hartmann’s procedure. Specimens were extracted through the stoma site. Irrigation of the abdominal cavity with more than 10 L of saline was performed in every case, as was insertion of three 10-mm silicon drains via the port site into the left- and right subphrenic spaces or the pouch of Douglas. The median total surgical time was 166 min (range, 123–250 min). There were no intraoperative complications, and there was no need to convert to open surgery. Fourteen patients survived. There was no wound infection or dehiscence of abdominal fascia. Successful laparoscopic reversals of the laparoscopic Hartmann’s procedure were performed in all 14 survivors. This laparoscopic Hartmann’s procedure is a promising surgical strategy for treating fecal peritonitis arising from perforation of the left-sided colon.

Renal allograft rupture (RAR) is a rare but serious complication of renal transplantation. The most common cause of RAR is acute rejection but other causes have increased in frequency with advances in immunosuppressive therapy. We report a patient with RAR attributed to coughing while asleep. A 53-year-old male received a living-donor renal transplantation for end-stage renal failure due to diabetic nephropathy. The clinical course was satisfactory, and he was discharged on the 12th postoperative day with a serum creatinine level of 1.24 mg/dl. On the 24th morning, he felt sudden swelling and pain over the incision area soon after a big cough. Ultrasound and computed tomography revealed a perinephric hematoma. Emergency surgical exploration showed complete laceration of the abdominal fascia and 4-cm rupture at the anterolateral aspect of the kidney. High intra-abdominal pressure when coughing had torn the fascia, and the graft appeared to have ruptured under the fascial tension. Bleeding was controlled with a polyglactin 910 2/0 mattress parenchymal suture enforced with application of a fibrin tissue-adhesive collagen fleece. Twelve months after the repair, the patient's renal function was stable with a serum creatinine level of 1.3 mg/dl.

A 65-year-old Japanese male, who was treated for Fournier's gangrene, developed an enlarged erythema over the right thigh and right lower quadrant. The area was surgically debrided, and he was given antibiotics. However, he complained of abdominal swelling with a metallic bowel sound, pain, and vomiting and was then treated for paralytic ileus. Although his symptoms initially improved, he complained again of the same symptoms and underwent surgery for mechanical ileus occurring at the site of a surgical scar from an appendectomy 43 years earlier. This is a very rare case of Fournier's gangrene which caused mechanical ileus of the small intestine and adherence to a peritoneal scar after paralytic ileus due to inflammation of the abdominal fascia following scrotal gangrene.

We read with great interest the article by Wicker and colleagues [1] about the ‘‘Frankfurt concept’’ on how to handle needlestick injuries. This occupational injury occurs more often than usually thought and it is unreported in a lot of case. The algorithm for initial diagnosis and treatment developed at the University Hospital Frankfurt seems to be very useful to decrease the risk of bloodborne infections. The most important aspect of the matter is the persuasion of healthcare workers who suffer a needlestick injury to report as soon as possible their exposure to blood. That will allow a prompt evaluation of risks of infection and the need of an immediate antiviral therapy. In Infobox 1, the authors report standard precautions to prevent occupational blood exposure. They suggest the use of double gloving, wherever possible, to reduce intraoperative blood exposure. We would like to remind the reader of another modality to reduce the risk of intraoperative glove perforation, percutaneous injuries, and contact between exposed skin and a patient’s blood. In 1996, we published the results of a randomized study designed to assess the frequency of hand injuries and contamination in emergency midline abdominal procedures and to determine whether the use of a round-tipped blunt needle for abdominal fascia closure could be effective in reducing the frequency of injuries and glove perforation and increasing surgeons’ safety [2]. Abdominal fascia closure after an emergency operation seems, in fact, to be at greater risk for contamination with a needlestick injury rate of 52–76 % [3, 4]: a great effort by the needleholder is required to pass the needle through muscles and fascia, the needle tip is often hidden from the direct vision of the surgeon, especially if excessive adipose tissue is present, and the surgeon may have decreased attention, being often at the end of an exhausting emergency procedure. In our experience, sharp needles were responsible for all needlestick injuries and the risk of glove perforation was sevenfold lower when blunt needles were used. From that time, we routinely use blunt needle for celiotomy closure with excellent results. In conclusions, we believe that blunt needles and double gloving, alone or together, are the most effective modalities to prevent hand needlestick injuries and contamination and that they should always be used, especially in emergency surgical procedures.

Background Breast reconstruction with autogenous tissue is a well-established technique, but there are some limitations related to donor-site morbidity. Among available techniques, the superficial inferior epigastric artery (SIEA) flap is the least invasive procedure because it does not require harvesting or incision of the rectus muscle or the abdominal fascia. Besides adequate flap choice, the proper selection of the recipient vessels is an important factor. Thus, the internal mammary perforator branches (IMPBs) have been an attractive option regarding recipient pedicle morbidity. Methods The investigators reported the use of the free SIEA flap with the IMPBs as a recipient site to reconstruct radical mastectomy. Results Five patients with invasive ductal carcinoma underwent modified radical mastectomy and reconstruction. The IMPBs were selected as the recipient site and a free SIEA flap was used. The donor defect was closed directly without synthetic mesh. Satisfactory breast shape was achieved, and no complications were observed. Conclusions For selected patients, the SIEA flap and IMPBs may constitute a new alternative for immediate breast reconstruction, because of the possibility of large tissue transfer with minimal donor and recipient area morbidity. The SIEA pedicle size and the quality of IMPB vessels should be carefully evaluated.

Traditionally, the primary goal of any abdominoplasty has always been to excise the central lower abdominal excess skin or pannus and plicate the abdominal fascia through a suprapubic incision. Unfortunately, this traditional abdominoplasty may often fall short of this goal: a scar that may ride too high; persistent skin and lipodystrophy at the pubis, thighs, flanks, and hips; and unfortunately a consistent incidence of midline skin necrosis or wound dehiscence. High lateral tension abdominoplasty addresses these shortfalls. It may be defined as a more complete treatment of the lower trunk aesthetic unit from the abdomen to the pubis, hips, and thighs, with a greater overall aesthetic result and margin of vascular safety. This article outlines the techniques and tools to accomplish these superior results safely and consistently.

Hernia repair continues to be a problem facing surgeons today, particularly because of the high incidence of reoccurrence. This work presents preliminary data of a pioneering effort to investigate the effect of mesenchymal stromal cells (MSCs) on mechanical property enhancement in full thickness fascial defects. Heparinized MSCs harvested from a rabbit’s tibia/iliac crest were applied to two fascial defects on the rabbit’s abdominal wall, with two other defects acting as controls (no MSCs added). After an 8 week recovery period, the entire abdominal fascia was harvested for mechanical property testing and elastographic strain analysis. Preliminary results from uniaxial tensile testing indicate a significant increase in the modulus of toughness strain energy, with at least a 50% increase in the MSC treated defects as compared with the control defects. Results from the elastographic strain analysis show excellent correlation in the calibration of the elastography to the uniaxial tensile test, with nearly identical moduli of elasticity. In addition, the elastographs clearly show tissue property heterogeneity at all stages of tensile testing. The MSC treated tissue demonstrates promise of enhanced material properties over that of the nontreated tissue; testing and analysis is ongoing. The elastography provides pixel-level description of tissue property variations providing critical information on wound healing effectiveness that would be impossible with other methods. In the ongoing research, optical elastography, in combination with the traditional tensile test and tissue histology, will be used to characterize localized biomechanical properties directly within the defect area and to locate “crack” initiation and propagation sights as the material is strained to rupture.

Objetivo. Evaluar clínicamente la hernioplastia umbilical en terneros con el empleo de fascia abdominal autógena. Material y métodos. Fueron utilizados cinco terneros de raza Brahman (6-12 meses) y peso promedio de 200 kg, los terneros se intervinieron quirúrgicamente por presentar hernia umbilical recidivante. El anillo herniario se reforzó con autoinjerto de fascia abdominal fijado con puntos en “U” horizontales, con sutura de poliamida (50 libras de presión). El tejido conectivo subcutáneo se suturó con polyglactin 910 del calibre 2-0 en patrón de puntos continuos. En el posoperatorio, se evaluó la evolución clínica de la cicatrización cutánea y la presencia o no de recidiva herniaria por un periodo de 60 días. Resultados. En todos los animales se observó edema intenso de los focos quirúrgicos (foco donador en la región inguinal y foco receptor en la región umbilical), sin dehiscencia de la herida cutánea, abscedación, ni recidiva de la hernia. Conclusiones. La técnica quirúrgica utilizada y el autoinjerto de fascia abdominal fueron eficientes en la corrección de hernia umbilical recidivante en terneros, hecho que permite recomendarla en casos semejantes.

To evaluate the optimal technique and material for abdominal fascia closure after midline laparotomy, first by means of a precisely defined study population and follow-up period and second by the surgically driven aspects.Overview of existing systematic reviews and meta-analysis of randomized controlled trials. A systematic literature search (Medline, Embase, and The Cochrane Central Register of Controlled Trials) was performed to identify randomized controlled trials in elective and emergency populations comparing suture techniques (continuous vs. interrupted) and materials (rapidly vs. slowly vs. nonabsorbable). Random effects conventional and cumulative meta-analyses were calculated and presented as odds ratios and the corresponding 95% confidence intervals.Five systematic reviews and 14 trials including 7711 patients (6752 midline incisions) were analyzed. None of the systematic reviews differentiated elective versus emergency laparotomy. The analysis of available primary studies revealed significant lower hernia rates using a continuous (vs. interrupted) technique (OR: 0.59; P=0.001) with slowly absorbable (vs. rapid-absorbable) suture material (OR: 0.65; P=0.009) in the elective setting, which was in contrast to the conflicting results of existing systematic reviews. No statistical heterogeneity was detected in the elective setting (I=0%). Seven studies incorporating elective and emergency procedures revealed inconclusive and heterogeneous results (I=45%-85%). No studies have evaluated closure methods solely in the emergency setting so far.No further trials should be conducted for evaluation of technique and available materials for elective midline abdominal fascial closure, according to the results of our cumulative meta-analysis. Future trials will have to define the optimal closure strategy in the emergency setting and relevance of new suture materials and other strategies such as the use of prophylactic mesh in targeted subpopulations.

Protrusion of the abdominal wall secondary to abdominoplasty may occur in patients with weakness of the aponeurotic structures. The anterior layer of the rectus abdominis muscle consists of fibers that are transverse rather than vertical. Based on this anatomical feature, vertical sutures are suggested for the correction of diastasis recti, since they include a greater amount of fascial fibers and thus would be more resistant to tensile strength than horizontal ones.The anterior layers of the rectus abdominis muscles of 15 fresh cadavers were dissected. Two vertical lines were marked on each side of the linea alba, corresponding to the site where plication is usually performed in abdominoplasties. Three abdominal levels were evaluated: the supraumbilical, umbilical, and infraumbilical levels. A simple suture was placed in the vertical direction in one group and in the horizontal direction in the other group, at each of the three levels previously described. These sutures were connected to a dynamometer, which was pulled medially toward the linea alba until rupture of the aponeurosis occurred.The mean strength required to rupture the aponeurotic structures in which the vertical sutures had been placed was greater than for the horizontal ones (p 0.0001).The vertical suture of the rectus abdominis sheaths was stronger than the horizontal suture because of the more transversal arrangement of its aponeurotic fibers. Thus, routine use of the vertical suture in plications of the aponeurosis of the rectus abdominis muscles is suggested.

The aim of the study is to characterise mechanical properties of human abdominal fascia according to its direction of loading and localization. The one-dimensional tensile behaviour of human abdominal fascia and its orthotropy has been studied experimentally using human umbilical (UF) and transversalis fascia (FT). The specimens have been cut and stretched parallel and orthogonal to the main fibre bundles. 90 specimens 10mm wide and up to 70mm long have been tested. The following mechanical parameters, characterising tensile properties of human abdominal fascia, have been calculated from the obtained stress–stretch ratio curves: maximal stress T L max , stretch ratio at maximal stress λ T max , maximal stretch ratio at failure λ max , and a secant modulus E ( i ). The tissue strips obtained from defined areas reveal break stress between 0.63 and 1.99MPa for FT and 0.93–1.61MPa for UF. The parameter estimation has shown that in the physiological strain range specimens from both type of fascia can be considered orthotropic material according to their secant module, maximum stress T L max and stretch at maximum stress. Anisotropy factor AF (ratio of the stress in longitudinal and transverse directions) has been used to establish the level of the orthotropy of material and its variations with the stretch ratio. The maximum AF is 4.3 for FT at 20% deformation and 3.3 for UF at 5% deformation. The differences between the mechanical properties of FT and UF according to localization are not statistically significant thus the mechanical properties of human abdominal fascia are not affected by the localization.

An attractive umbilicus is an essential component of the abdominal wall. It defines the midline abdominal sulcus and adds to a shapely abdominal curvature. Certain procedures place the umbilicus at risk thus providing a need for a neoumbilicus. Three-hundred and twenty cases of abdominoplasties, panniculetomies, and TRAM flaps for breast reconstruction were reviewed. Five patients underwent an umbilical reconstruction after loss of the native umbilicus. A crescent-shaped incision was used to create an inferiorly based skin flap. The flap was inset to the abdominal fascia. A small full-thickness skin graft was used to form the superior hood. All patients attained an esthetically pleasing umbilicus with minimal scarring. No contracture, flap necrosis, or graft loss were noted. We present a novel, simple, and reliable technique of umbilical restoration. It circumvents the need for external scars and allows for achieving a naturally appearing umbilicus.

Abdominal hernias are not rare in women, but incisional bladder hernias are rare. The incisional hernia is a condition caused by protrusion of the abdominal viscera through the abdominal fascia. The presenting symptoms in the cases reported included suprapubic discomfort, irritative voiding symptoms, and urinary incontinence. We present a case of bladder herniation with temporary bowel incarceration through a lower midline incision, which followed operative intervention. The temporary bowel herniation was managed conservatively because the impairment of the blood supply was not severe.

A method for proper choice of hernia meshes, based on a criterion which specifies the type of the hernia mesh with mechanical properties closest to those of the human abdominal fascia has been proposed. Sensitivity analysis of the method was performed. Based on the results of three type of meshes it was established that the best mechanically compatible mesh was Surgimesh with filament diameter 0.14 mm.

Background This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This ‘‘open abdomen’’ must then be temporarily closed. However, the FC rate varies between techniques. Methods The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) ‘‘open abdomen,’’ ‘‘fascial closure,’’ ‘‘vacuum,’’ ‘‘reapproximation,’’ and ‘‘ventral hernia.’’ Open abdomen was defined as ‘‘the inability to close the abdominal fascia after laparotomy.’’ Two reviewers independently extracted data from original articles by using a predefined checklist. Results The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%). Conclusions These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rates.

Background The vascular territory of the superficial inferior epigastric artery (SIEA) remains to be clarified. The SIEA flap has traditionally been classified as a hemiabdominal flap, but recent evidence points to the fact that a sizable superficial artery is capable of supplying the entire abdominal ellipse. Methods Twenty-five patients who met the anatomical criteria for undergoing SIEA flap surgery were studied. The abdominal flap was raised on a superficial inferior epigastric pedicle; the dominant musculocutaneous perforators were preserved and clamped above the abdominal fascia on either side. The vascular territory of the superficial epigastric artery and the contribution of the deep epigastric system were visualized using laser-induced fluorescence of indocyanine green. The surgical technique was modified (SIEA, deep inferior epigastric perforator, or bipedicle) based on perfusion measurements and the indication for surgery. Results The SIEA vascular territory did not cross the midline in 16 patients (64 percent), and ranged from 0 percent (two patients) to the entire abdominal ellipse (five cases). Fourteen patients (56 percent) were operated on with a unipedicle SIEA flap, five patients (20 percent) were operated on with a bipedicle flap, and in six (24 percent), a conventional deep inferior epigastric perforator flap was used. As a SIEA flap was originally intended in all patients, intraoperative perfusion measurements changed the surgical plan in 11 patients (44 percent). Conclusions The SIEA angiosome is variable and ranges from 0 to 100 percent of the lower abdominal flap. Intraoperative perfusion measurements are indispensable for evaluating the sufficiency of this pedicle for tissue transfer, especially if the contralateral flap zones are needed for reconstruction.

BACKGROUND We evaluated in which anatomic layer (above the fascia [AF] or below the fascia [BF]) wound infusion of bupivacaine has the best effect on postoperative pain after abdominal hysterectomy. METHODS Sixty-two ASA physical status I and II patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy were enrolled into this prospective randomized, double-blind study. A standard general anesthetic was administered. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above (group AF, n = 29) or below (group BF, n = 31) the superficial abdominal fascia and 0.25% bupivacaine was administered via a patient-controlled analgesia device, programmed to deliver 9.0 mL with a 60-min lockout interval for 24 h. During the first 6 h after surgery, rescue i.v. fentanyl (25 microg) was administered to achieve a visual analog scale score of

Introduction A new technique of gastroschisis closure in which the defect is covered with sterile dressings and allowed to granulate without suture repair was first described in 2004. Little is known about the outcomes of this technique. This study evaluated short-term outcomes from the largest series of sutureless gastroschisis closures. Methods and Patients A retrospective case control study of 26 patients undergoing sutureless closure between 2006 and 2008 was compared to a historical control group of 20 patients with suture closure of the abdominal fascia between 2004 and 2006. Four major outcomes were assessed: (1) time spent on ventilator, (2) time to initiating enteral feeds, (3) time to discharge from the neonatal intensive care unit, and (4) rate of complications. Results In multivariate analysis, sutureless closure of gastroschisis defects independently reduced the time to extubation as compared to traditional closure (5.0 vs 12.1 days, P = .025). There was no difference in time to full enteral feeds (16.8 vs 21.4 days, P = .15) or time to discharge (34.8 vs 49.7 days, P = .22) with sutureless closure. The need for silo reduction independently increased the time to extubation (odds ratio, 4.2; P = .002) and time to enteral feeds (odds ratio, 5.2; P Conclusion Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces length of intubation and does not significantly alter the time required to reach full enteral feeds or hospital discharge.

Objectives: To determine if asymmetry of trunk muscles and deficits of motor control exist among elite cricketers with and without low back pain (LBP). Design: Single-blinded observational quasi-experimental design study Setting: Assessments were conducted in a hospital setting. Participants: Among a total eligible sample of 26 male elite cricketers (mean age 21.2 (SD 2.0) years), selected to attend a national training camp, 21 participated in the study. Risk factors: The independent variables were ‘group’ (LBP or asymptomatic) and ‘cricket position’ (fast bowler versus the rest of the squad). Main outcome measurements: The dependent variables were the cross-sectional areas (CSA) of the quadratus lumborum (QL), lumbar erector spinae plus multifidus (LES + M) and psoas muscles, the thickness of the internal oblique (IO) and transversus abdominis (TrA) muscles, and the amount of lateral slide of the anterior abdominal fascia. Results: The QL and LES + M muscles were larger ipsilateral to the dominant arm. In the subgroup of fast bowlers with LBP, the asymmetry in the QL muscle was the greatest. The IO muscle was larger on the side contralateral to the dominant arm. No difference between sides was found for the psoas and TrA muscles. Cricketers with LBP showed a reduced ability to draw in the abdominal wall and contract the TrA muscle independently of the other abdominal muscles. Conclusions: This study provides new insights into trunk muscle size and function in elite cricketers, and evidence of impaired motor control in elite cricketers with LBP. Rehabilitation using a motor control approach has been shown to be effective for subjects with LBP, and this may also benefit elite cricketers.

In reconstructive surgery, fascial flaps provide thin, pliable tissue for mucosal closure or serve as a highly vascularized support for skin grafts. Their angiogenic potential is used for experimental neovascularization of avascular tissue grafts. However, most fascial flaps in animal surgery have random pattern design with short reach. As a pilot study for a femur revascularization project in rabbits, a new axial fascial flap is described based on the superficial inferior epigastric (SIE) vessels. They were used in this species previously only as ligated bundles or in fasciocutaneous flaps. The topographical anatomy of the SIE-vessels, lower abdominal fascia, and panniculus carnosus are outlined. The angiogenic capabilities are demonstrated microangiographically by abundant vessel formation in a femur allograft. Used in a pedicled fashion, this flap is an alternative to femoral and saphenous vessels for prefabrication or revascularization procedures in the lower abdomen, genital area, and thigh. Distant recipient sites seem possible with microsurgical transfer. © 2007 Wiley-Liss, Inc. Microsurgery, 2007.

Aim: To examine the time-dependent biomechanical properties of four different implanted synthetic materials. Materials and Methods: 18 New Zealand rabbits were randomly categorized into three groups: group 1 to be evaluated at the 2nd week, group 2 at the 8th week, and group 3 at the 12th week. Before the implantation, baseline values were obtained. Each of the 2 × 5 cm sized materials of mersilene, prolene, ultrapro and vypro mesh were placed in the anterior abdominal fascia. The mesh materials were removed, tensile strength (N/mm2) and ultimate strain (%) were measured by tensinometry and surface area losses (cm2) were calculated. Results: Tensile strength values (mean ± SD) were 9.2 ± 1.5, 8.5 ± 1.2 for mersilene, 25.2 ± 7.3, 14.0 ± 2.9 for prolene, 2.2 ± 0.6, 12.5 ± 1.4 for ultrapro and 8.1 ± 1.6, 7.0 ± 1.8 for vypro at baseline and the 12th week. Ultimate strain values (mean ± SD) were 131.2 ± 46.1, 110.4 ± 98.6 for mersilene, 181.0 ± 26.4, 78.5 ± 14.4 for prolene, 91.5 ± 8.2, 89.6 ± 20.5 for ultrapro and 84.3 ± 8.9, 55.0 ± 13.2 for vypro at baseline and the 12th week. Surface areas (mean ± SD) were 8.87 ± 0.14, 9.38 ± 0.17, 8.4 ± 0.32 and 8.76 ± 0.16 for mersilene, prolene, ultrapro and vypro at the 12th week respectively. Conclusions: Although prolene mesh demonstrated a decrease in its tensile strength it still remains the highest at the 12th week. Considering the significant time-dependent increase in its tensile strength, ultrapro mesh should be studied in humans. A final decision on the preference of ultrapro mesh in sling surgery could be reached after such studies.

Background: The aesthetic and natural appearance of the transposed umbilicus after abdominoplasty is a key factor to the overall result and satisfaction of patient and surgeon alike. In this article, the authors present a technique in umbilical transposition that creates a natural-appearing umbilicus. Methods: The skin in the neoumbilical position is deepithelialized and incised in the midline, thus creating two dermal flaps that are sutured down to the abdominal fascia, thereby creating a natural periumbilical concavity, inconspicuous scars, and a tension-free closure, resulting in a decreased chance for cicatricial umbilical scarring. Twenty patients underwent umbilical transposition during abdominoplasty with this technique between 2003 and 2005. Results: Both patient and surgeon satisfaction were very high, with three senior surgeons changing their surgical technique after being introduced to that described in this article. One complication culminated in partial skin dehiscence early in our experience when deep dermal sutures were not used for skin closure. Conclusion: The technique described is simple, safe, and easily learned, and results in a very satisfying aesthetic and natural-appearing umbilicus in patients after abdominoplasty.

Objective: Plasma hemopexin activity, associated with increased vascular permeability, was evaluated in healthy pregnant and non-pregnant women and in pre-eclamptic women. Methods: Hemopexin activity and the hemopexin inhibitor, extracellular ATP, were assayed in plasma from pregnant (n=10), preeclamptic (n=9), and non-pregnant women (n=10) using standard methods. Abdominal fascia tissue fragments from preeclamptic and pregnant women were immunohistochemically stained for vascular ectoapyrase or ecto-5'nucleotidase. Results: The data show significantly enhanced Hx activity exclusively in plasma from pregnant women and significantly enhanced plasma ATP in pre-eclamptic women compared with the other groups. Dephosphorylation of preeclamptic plasma resulted in reactivation of Hx activity. Fascia tissue-samples from preeclamptic women showed reduced ecto-apyrase activity and enhanced ecto-5'nucleotidase activity compared to pregnant women. Conclusion: Enhanced hemopexin activity may be associated with normal pregnancy, but not with preeclampsia. Decreased hemopexin in pre-eclamptic patients may be due to enhanced plasma ATP, which is possibly promoted by diminished activity of vascular ecto-apyrase.

Cross-sectional study.To investigate the function of the transversus abdominis (TrA) and internal oblique (10) muscles bilaterally during a simulated weight-bearing task using ultrasound imaging.An important aspect of neuromuscular control at the lumbopelvic region is stabilization. Biomechanical models have predicted that activation of transversely oriented muscles, such as the TrA and 10 muscles, can stiffen the sacroiliac joints and actively stabilize the pelvis for weight bearing.Nineteen healthy subjects were positioned in supine lying with their right heel against a footplate linked to a force transducer. Each subject performed a static simulated weight-bearing task of the right lower extremity. Ultrasound imaging was used to assess resultant changes in thickness of the 10 and TrA muscles, as well as the lateral slide of the anterior abdominal fascia on each side of the abdomen alternately. Muscle thickness and slide of the fascia were assessed at standardized force levels (0% and 25% of body weight).Substantial increases (P.0001) in mean (+/- SD) thickness of the 10 (18.5% +/- 9.7%) and TrA (24.7% +/- 175%) muscles during the weight-bearing task were measured. Lateral movement (slide) of the anterior abdominal fascia of the TrA muscle also occurred (mean +/- SD, 1.3 +/- 2.0 mm; P = .014) with weight bearing. Changes in muscle thickness and amount of slide were similar for the left and right side of the abdomen (Por = .11).The findings are consistent with biomechanical models that predicted symmetrical activation of the deep transversely oriented lumbopelvic muscles in healthy subjects in response to a unilateral functional weight-bearing task. Ultrasound imaging as a measurement tool represents a noninvasive method for measuring abdominal muscle function in functional axial loading.

Omphalopagus conjoined twins were born by cesarean section after their 24-year-old gravida 2, para 1 mother went into labor at 35 weeks' gestation. Initial studies included roentenograms, an upper gastrointestinal study, small bowel follow-through, and computerized tomography with intravenous contrast from neck through pelvis. Results of these studies showed that the twins had very little shared vasculature, but did share a pericardium and liver parenchyma. The infants were allowed to gain weight and grow. After 3 weeks, tissue expanders were placed subcutaneously and were rapidly expanded in 2 weeks. The infants were then separated. An Argon Beam Coagulator was used to aid the separation of the liver. The abdominal fascia was closed primarily on each infant, and the skin easily closed without tension. During the first 36 hours of the postoperative course, both infants required significant ventilatory support including inhaled nitric oxide. After this period, the ventilatory support decreased dramatically and rapidly. The infants were discharged 9 days after their surgical separation. Conjoined omphalopagus twins, the use of tissue expanders and the Argon Beam Coagulator, and the postoperative course are discussed.

A description of the use of polypropylene mesh insertion in the abdominal fascia in patients with open surgical wounds

The lower abdominal skin and fat have become a standard for breast reconstruction because the abdominal tissue can mimic the breast to a high degree. With today's increasing focus on safety and routine of microsurgical interventions, more attention must be paid to donor-site morbidity. The superficial inferior epigastric artery (SIEA) free flap is the least invasive microsurgical procedure for breast reconstruction because this operative technique does not require harvesting of the rectus muscle or the abdominal fascia. A total of 11 breast reconstructions were performed with this technique and had an average follow-up of 23 months. The anatomy, operative technique, and various indications for the SIEA flaps are demonstrated.

Increased trimming and consequent carcass downgrade was experienced in a broiler flock. Condemned birds had gray to black pigmentation of the subcutaneous tissue and fat of the abdomen, and bluish pigmentation of the shanks. Histopathology revealed accumulation of melanin in these tissues. No significant bacteria were isolated. Accumulation of melanin in the skin and fascia is because of the cumulative and interactive effects of several genes. Additionally, pigmentation of abdominal fat has a high correlation with accumulation of melanin in the skin of the shanks. Although melanization of the skin and abdominal fascia is not harmful to people, it may cause severe economic losses to the producer.

Non-bladed trocars, radially-dilating systems, and conical blunt devices are considered less traumatic to the abdominal wall because they do not incise the fascia itself. Consequently, several authors have suggested that closure of the abdominal fascia may be unnecessary if such non-bladed laparoscopic trocars are used. We report of a case in whom a port-site hernia was diagnosed at the site of a 12-mm non-bladed trocar 11 days after laparoscopic nephrectomy.

Non-bladed trocars and radially dilating systems are considered less traumatic to the abdominal wall because they do not incise the fascia itself. Since the fascia is not cut, it has believed that the fascia closes by itself. Consequently, several authors have suggested that closure of the abdominal fascia may be unnecessary when such non-bladed laparoscopic trocars are used. We report of a case in which a port site hernia was diagnosed at the site of a 12 mm non-bladed trocar 11 days after laparoscopic nephrectomy. Although it may be true that in many cases port site closure is unnecessary and does not result in bowel herniation, this case along with a prior report serve as important reminders that port site hernias are possible even in the use of non-bladed or radial dilating systems, and that there exists a number of potential variables that may predispose to herniation and consequently the ability to predict such events in individual patients remains uncertain. As such, we recommend closing 10 mm or larger port sites irrespective of trocar design.

An operator blinded dual modality trial of measurement of the abdominal muscles during "drawing-in" of the abdominal wall.1) To investigate, using magnetic resonance imaging (MRI), the function of the transversus abdominis muscle bilaterally during a drawing-in of the abdominal wall. 2) To validate the use of real-time ultrasound imaging as a measure of the deep abdominal muscle during a drawing-in of the abdominal wall.Previous research has implicated the deep abdominal muscle, transversus abdominis, in the support and protection of the spine and provided evidence that training this muscle is important in the rehabilitation of low back pain. One of the most important actions of the transversus abdominis is to "draw-in" the abdominal wall, and this action has been shown to stiffen the sacroiliac joints. It is hypothesized that in response to a draw in, the transversus abdominis muscle forms a deep musculofascial "corset" and that MRI could be used to view this corset and verify its mechanism of action on the lumbopelvic region.Thirteen healthy asymptomatic male elite cricket players aged 21.3 +/- 2.1 years were imaged using MRI and ultrasound imaging as they drew in their abdominal walls. Measurements of the thickness of the transversus abdominis and internal oblique muscles and the slide of the anterior abdominal fascia were measured using both MRI and ultrasound. Measurement of the whole abdominal cross-sectional area (CSA) was conducted using MRI.Results of the MRI demonstrated that, as a result of draw-in, there was a significant increase in thickness of the transversus abdominis (P0.001) and the internal oblique muscles (P0.001). There was a significant decrease in the CSA of the trunk (P0.001). The mean slide (+/-SD) of the anterior abdominal fascia was 1.54 +/- 0.38 cm for the left side and 1.48 +/- 0.35 cm for the right side. Ultrasound measurements of muscle thickness of both transversus abdominis and the internal oblique, as well as fascial slide, correlated with measures obtained using MRI (interclass correlations from 0.78 to 0.95).The MRI results demonstrated that during a drawing-in action, the transversus abdominis contracts bilaterally to form a musculofascial band that appears to tighten (like a corset) and most likely improves the stabilization of the lumbopelvic region. Real-time ultrasound imaging can also be used to measure changes in the transversus abdominis during the draw-in maneuver.

Contains fulltext : 47695.pdf (Publisher’s version ) (Closed access) Glove perforation frequently occurs during the course of surgical procedures, introducing risks for both surgeons and patients. The aim of this study was to compare the use of blunt tapered and "sharp" needles during abdominal wall closure with respect to the incidence of glove perforation and the convenience of needle handling. A series of 200 patients undergoing laparotomy in a 6-month period for general surgical disorders were randomized to two groups; in one, the abdominal fascia was closed with a blunt tapered needle; in the other, a sharp needle was used. The main outcome measures were glove perforation and convenience of handling the needle. Univariate and multivariate analyses were performed. In all, 56 glove perforations occurred during 40 (20%) surgical procedures. Perforation rates differed significantly: 12% for the blunt (n = 100) tapered needle and 28% (n = 100) for the sharp needle (p = 0.003). Only in 12 cases (21%) was the glove perforation detected at surgery. The type of needle (odds ratio 0.35, p = 0.006) and time taken to close the fascia (odds ratio 1.001, p = 0.05) significantly affected the risk of glove perforation. At multivariate logistic regression analysis the type of needle (odds ratio 0.23, p = 0.004) and the visual analog linear scale (VAS) for ease of needle handling (odds ratio 1.18, p = 0.019) were important predictive factors for glove perforation. With the blunt tapered needle, the VAS was significantly (p = 0.0003) higher at primary laparotomy than at relaparotomy. Use of the blunt tapered needle reduces the incidence of glove perforation. Laborious closure predicts glove perforation. Blunt tapered needles are less convenient in closing a scarred abdominal fascia.

The incidence of incisional abdominal hernias, an unreported complication after a Bernese periacetabular osteotomy, was evaluated. Two cases of an incisional hernia above the iliac crest were detected in a series of 950 cases since 1984. Although the incidence has been small, risk factors may be obesity, weak abdominal muscle strength, or increased abdominal pressure attributable to chronic coughing or obstipation. The surgeon should recognize the importance of restoring continuity of the abdominal fascia in patients with such factors.

We report a 65-year-old man with complications of aortoesophageal fistula after esophagectomy. A combined middle-lower esophagectomy with remnant gastrectomy was performed for esophageal cancer. The alimentary tract was restored by intrathoracic esophagojejunal anastomosis using a surgical stapler. Twenty-four days later the patient suddenly had hypovolemic shock develop due to aortoesophageal fistula. We performed emergency surgery, and the aortic fistula was directly closed with a 3-0 monofilament using abdominal fascia as a pledget. Thirty-eight days later, alimentary reconstruction was performed using a free jejunal graft. Aortic pseudoaneurysm due to direct closure was predictably detected, and transluminal endovascular stent grafting was indicated.

Background: The introduction of any surgical procedure brings with it new technical challenges. The use of laparoscopy offers patients a reduction in pain and better cosmesis. However, over time, new technical challenges associated with laparoscopic surgery are becoming more evident. In particular, the closure of the small trocar site fascial incisions is often awkward and time consuming. The aim of this article is to introduce a closing procedure that facilitates the safe approximation of the abdominal fascia in these wounds. Method: One hemostat is used to visualize the fascia of one side of the wound and separate the fascia from the underlying abdominal viscera. Another hemostat retracts the opposite side of the wound. The suture needle is passed through the fascia and between the open tips of the hemostat. The tips of the second hemostat grasp the driven needle and carry it out of the wound. Conclusion: The use of two hemostats to close these wounds not only facilitates the closure but is also probably safer than the standard technique.

Dialysis access remains the “Achilles heel” of maintenance hemodialysis. When candidate vessels have been exhausted in pursuit of fashioning native vascular access, alternative vessels are used. With recurrent catheter deployment, venous stenoses develop and render candidate veins unsuitable for catheter reception. We present a neat and novel solution for clinical practice in dealing with unexpected cases. A 68-year-old female, with end-stage renal disease secondary to diabetic nephropathy had been receiving hemodialysis for 4 years. Her past medical history comprised: peripheral arterial disease with resultant bilateral above the knee amputation and iliac artery endovascular stenting; essential hypertension; lifelong tobacco consumption. She had no candidate vessels for venous catheter placement, other than small caliber femoral veins. A decision was made to insert two smaller, more flexible 10 French catheters into bilateral femoral veins to allow better venous reception and more secure tunneling. This takes into account our experience with the use of larger, less supple catheters and the acute angles involved with typically tunneling upwards through the lower abdominal fascia. The patient was keen to continue dialysis and accepted the enhanced risk (two tunnels) of bilateral lower limb venous thrombosis and bacteremia. We present this interesting image Figure 1 (abdominal X-ray), demonstrating bilateral cuffed tunneled femoral dialysis access; concurrent vascular ectopic calcification and the presence of a left iliac stent. We understand this to be, the first medical image in the world literature of bilateral cuffed femoral dialysis catheters in situ – an unlikely clinical situation. Figure 1 Abdominal X-ray.

OBJECTIVE After the resection of cranial base tumors, there may not be enough free dural margin left for reconstruction after involved bone and dura have been removed. In such a situation, dural reconstruction becomes a problem. We propose a new technique of dural closure in such cases. METHODS A fascial graft is prepared from either fascia lata, abdominal fascia, pericranium, or temporal fascia and is trimmed to a size slightly larger than that of the dural defect. The fascial graft is placed over the dural defect and affixed to the underlying bone with a piece of titanium mesh, titanium screws, or both. The graft is then reinforced with fibrin glue. RESULTS This method of dural reconstruction has been used in five patients with basal meningiomas. Three were in the petromastoid area, and two were in the planum-ethmoid area. None of these patients experienced postoperative cerebrospinal fluid leak, and none experienced any complications related to the reconstruction. CONCLUSION This technique of dural reconstruction can be used in selected cases of basal tumors without enough free dural margin to sew into a fascial graft.

Staged reduction of abdominal contents using a silastic sheet has become standard management in gastroschisis where primary closure is not possible. With the introduction of a pre-made Silastic silo coupled to a spring-loaded ring (Ben Tec, Sacramento, CA), the procedure can be done at the bedside. We present a simple technique utilizing a disposable umbilical-cord clamp that makes reduction a fast, one-physician procedure and present a preoperative step that facilitates tension-free closure of the abdominal fascia.

THE PATIENT was an 82-year-old woman with Munchausen syndrome who had undergone multiple abdominal operations, including appendectomy, cholecystectomy, hysterectomy, bilateral salpingooophorectomy, splenectomy, adhesiolysis, and right hemicolectomy. She also had undergone three operations to repair a recurrent ventral incisional hernia. The last repair, in which Marlex mesh was used, had been performed 14 years before. In that procedure a subfascial technique was used, with the mesh being secured to the edges of the fascial defect. Tissue interposition between small-bowel loops and mesh was not possible because of a lack of omentum as a result of the prior operations. The patient had been in relatively good health for the last 14 years until she experienced spontaneous drainage of enteric contents from the midabdominal wall. She had no signs of sepsis, although she was malnourished. A fistulogram confirmed communication with the midjejunum. No mucosal irregularities were seen on the small-bowel series. A CT scan of the abdomen did not reveal any intraperitoneal collections. An 8-week trial of bowel rest, total parenteral nutrition, and somatostatin failed to spontaneously close the fistula. After the patient was nutritionally repleted, an exploratory laparotomy to resect the enterocutaneous fistula was performed. At the time of surgery, multiple adhesions were present between bowel loops . A loop of jejunum was densely adherent to the mesh, which had eroded into the bowel wall in one area (Figure). We resected this segment of jejunum, as well as all of the involved mesh, and performed a primary stapled anastomosis. The patient’s abdominal fascia was severely attenuated and, after excision of the remaining mesh, a 4 × 6-cm defect was present. The wound was closed with retention sutures, and the area of the fascial defect was allowed to heal by secondary intention. The postoperative course was complicated only by delayed return of bowel function, and the patient was discharged on postoperative day 13, tolerating a regular diet.

Visco-elastic mechanical properties of human abdominal fascia O 79 80 81 82 83 O Miglena Kirilova *, Stoyan Stoytchev , Dessislava Pashkouleva , Vesselina Tsenova , Radka Hristoskova b R 84 85 86 87 88 89 90 P a Institute of Mechanics, Bulgarian Academy of Sciences, Acad. G. Bonchev Str., Bl. 4, Sofia 1113, Bulgaria b Department of Clinical Pathology, Tsaritsa Joanna University Hospital, 1527 Sofia, Bulgaria

Objective Full exposure of an aneurysm and surrounding structures with minimal brain retraction is important to eliminate the aneurysm safely and accurately. We describe an extended transsphenoidal approach for clipping an anterior communicating artery (ACoA) aneurysm. Clinical presentation A 58-year-old woman had a surgical history significant for subtotal removal of a macroadenoma via the posterior portion of the planum sphenoidale using an extended transsphenoidal approach. Intervention During the tumor removal, a small unruptured ACoA aneurysm was incidentally found. The aneurysm was eliminated through the same operative route under a direct and wide view. The dural window was patched with abdominal fascia and sutured with 5-0 nylon in a watertight fashion. Conclusion The extended transsphenoidal approach could expose an ACoA complex and aneurysm without substantial brain retraction. If the major limitations of this approach (e.g., postoperative cerebrospinal fluid leakage and meningitis) can be overcome using technical advances, this technique will offer a minimally invasive approach to the ACoA complex.

The fundamental objective of staged laparotomy is to accomplish definitive operative management in a calculated, stepwise fashion based on the patient’s physiologic tolerance. This important concept has emerged from collective experience with massive acute abdominal injuries but clearly extends to elective operative procedures and surgical challenges in other torso compartments. Whereas the inability to achieve hemostasis is due most frequently to a recalcitrant coagulopathy following trauma, other scenarios include inaccessible venous injuries, coexisting extraperitoneal life-threatening injuries, uncertain viability of abdominal contents, and the inability to reapproximate abdominal fascia due to reperfusion-induced visceral edema. There are five critical decision-making phases of staged laparotomy: I, patient selection; II, intraoperative reassessment; III, physiologic restoration in the surgical intensive care unit; IV, return to the operating room for definitive procedures; and V, abdominal wall reconstruction. The abdominal compartment syndrome (ACS) is a common, often insidious complication of staged laparotomy. In fact, during phases II and III there is often a delicate balance between effective pressure tamponade of capillary bleeding and the untoward effects of the ACS. During phases IV and V a frequent dilemma is how to enclose the abdominal contents to reduce protein loss and facilitate patient mobilization.

Objectives. To report on the safety of radical retropubic prostatectomy (RRP) in patients with a penile prosthesis presenting with clinically localized prostate cancer. Methods. From January 1990 to December 1997, 8 consecutive men with a penile prosthesis underwent RRP for clinically localized prostate cancer. Retrospective data regarding patient population, operating time, estimated blood loss, length of hospital stay, and clinical outcome were evaluated. Results. Mean patient age was 65.4 years (range 57 to 70) at the time of RRP, with a mean preoperative serum prostate-specific antigen level of 11.5 ng/mL. Mean duration of RRP surgery was 183.9 minutes, and the mean estimated blood loss was 1281.8 mL. No complication requiring penile prosthesis removal occurred. In 1 case, the reservoir tubing was punctured during closure of the abdominal fascia wall. This was immediately recognized and fixed. All patients had a functioning penile prosthesis after RRP. Conclusions. RRP can be safely and expeditiously performed in patients with a pre-existing penile prosthesis. The risk of prosthesis malfunction after RRP is very low. Patients with a penile prosthesis and prostate cancer should not be denied the option of undergoing RRP.

A 14-year-old girl with congenital heart disease underwent ventricular assist device placement before cardiac transplantation. The inability to close her abdominal fascia necessitated the placement of Prolene mesh, which subsequently became exposed and contaminated when her incision dehisced. Stable closure was obtained with Vicryl mesh and a rectus abdominis turnover flap. Her posttransplant course was notable for compression of the donor heart, necessitating prolonged open sternotomy. She failed an attempt at delayed sternal closure due to compression of the right ventricle by the sternum. In addition to standard pectoralis advancement flaps, a pedicled osseous sternal flap based on her left internal mammary artery was developed to avoid ventricular compression yet still provide some protection to the mediastinum. Alternative uses of this vascularized bone flap to assist with chest wall reconstruction are discussed.