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A urogynecologist's examination typically includes assessment of the abdominal musculature, including the determination of whether a diastasis recti abdominis (DRA) is present. The purposes of the current study were to examine the (1) prevalence of DRA in a urogynecological population, (2) differences in select characteristics of patients with and without DRA, and (3) relationship of DRA to support-related pelvic floor dysfunction diagnoses. A retrospective chart review was conducted by an independent examiner. Fifty-two percent of the patients examined presented with DRA. Patients with DRA were older, reported higher gravity and parity, and had weaker pelvic floor muscles than patients without DRA. Sixty-six percent of all the patients with DRA had at least one support-related pelvic floor dysfunction (SPFD) diagnosis. There was a relationship between the presence of DRA and the SPFD diagnoses of stress urinary incontinence, fecal incontinence, and pelvic organ prolapse.

Intestinal glutamine utilization is integral to mucosal regeneration. We analyzed the systemic and intestinal glutamine status in Crohn's disease (CD) and evaluated the therapeutic effect of glutamine supplementation in an animal model of ileitis. In CD, glutamine concentrations were decreased systemically and in noninflamed and inflamed ileal/colonic mucosa. Mucosal glutaminase activities were depressed in the ileum independent of inflammation but were not different from controls in the colon. In experimental ileitis, oral glutamine feeding prevented macroscopic inflammation, enhanced ileal and colonic glutaminase activities above controls, and normalized the intestinal glutathione redox status. However, glutamine supplementation enhanced myeloperoxidase activity along the gastrointestinal tract and potentiated lipid peroxidation in the colon. In conclusion, glutamine metabolism is impaired in CD. In experimental ileitis, glutamine supplementation prevents inflammatory tissue damage. In the colon, however, which does not use glutamine as its principal energy source, immune enhancement of inflammatory cells by glutamine increases oxidative tissue injury.

Objective: The objective of this study was to describe the imaging findings at sonography and MRI of rectus abdominis muscle strain in tennis players., Conclusion: Asymmetrical hypertrophy of the recti is seen in elite tennis players. The muscle belly hypertrophies on the side opposite the dominant arm and is subject to muscle tears of its deep fibers below the umbilicus. Imaging can be used to show these injuries.

Fibromatosis of the breast is a benign but locally aggressive neoplasm, which has been described under various names including extra-abdominal desmoid tumour and aggressive fibromatosis. It is a rare condition, accounting for approximately 0.2% of all solid tumours of the breast. Clinically and radiologically the lesion mimics breast cancer and the definitive diagnosis is provided by histology. A high risk of local recurrence is a characteristic of this disease. Radical excision of the tumour with clear histological margins decreases the likelihood of recurrence. The possible association between breast implants and mammary fibromatosis has been reported. In this study we report a case of giant fibromatosis of the breast observed in a young patient and its extensive recurrence, involving all quadrants of the breast, the pectoralis major muscle, the rectus abdominis muscle sheath and the costal layer. The main clinical and pathological characteristics of this rare disease are illustrated, emphasizing the difficulties encountered both in the diagnosis of the primary lesion and in the management of its giant recurrence, particularly as regards the possibility of obtaining a radical surgical excision and the option of performing breast reconstruction.

The desmoid tumour (DT) is a quite rare soft tissues neoplasm that lacks metastatic potential. Though it is characterized by a local infiltrating growth that involves frequent relapses after surgical excision. The presented case report refers to a young female in her childbearing age, who underwent the radical excision of a large DT infiltrating the left rectus muscle of the abdomen. The only radical treatment of this tumour is still the surgical resection carried out far from the tumour borders into the healthy tissues. Nevertheless, when these tumours arise in the abdominal wall, their resection causes wide muscle-fascial defects involving the whole thickness wall and determining serious reconstructive problems. These problems are connected to the use of wide prosthesis that are exposed both to the possible development of visceral adhesions and to the abdominal wall rigidity due to the inclusion in the fibrosis of high quantities of totally non-absorbable material. These remarks induced to employ a new composite prosthesis presenting the double advantage of having a non-adherent visceral surface and part of its network made of absorbable material. Its application in filling the wide abdominal muscle-fascial gap gave very satisfying mechanical and esthetical results.

Methods: The authors retrospectively reviewed 500 free TRAM flaps performed between 1992 and 2003. This cohort was subdivided based on smoking history, obesity, preoperative chemotherapy, preoperative radiation therapy, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and hypertension, and compared surgical complication rates. Measured complications included fat necrosis, mastectomy flap necrosis, abdominal flap necrosis, partial TRAM flap loss, wound infection, hematoma, seroma, vessel thrombosis, and abdominal hernia. Chi2 analysis and Fisher exact test were performed to determine differences between groups, and linear regression models were used to predict the risk factors of surgical complications., Results: Smokers were more likely to have a higher incidence of wound infection (P = 0.01), mastectomy flap necrosis (P = 0.015), abdominal flap necrosis (P = 0.033), and fat necrosis (P = 0.01). Obese patients were more likely to have higher rates of mastectomy flap necrosis (P = 0.01) and hematoma (P = 0.01). Patients with peripheral vascular disease were more likely to have a higher incidence of wound infection (P = 0.031), and patients with preoperative radiation therapy were more likely to have a higher incidence of seroma (P = 0.043). Logistic regression showed that smoking was found to be a risk factor for fat necrosis (P = 0.006), wound infection (P = 0.002), mastectomy flap necrosis (P = 0.039), and abdominal flap necrosis (P = 0.042). Obesity was a risk factor for mastectomy flap necrosis (P = 0.002). Peripheral vascular disease was a risk factor for wound infection (P = 0.032)., Conclusion: Awareness of risk factors and associated complications will lead to modification and individualization of surgical techniques in an attempt to limit these complications and continually improve outcomes.

Objective: Ischemia-related complications may occur during postmastectomy transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. The aim of our study was to investigate whether necrosis of susceptible flap regions could be reduced by dichloroacetate (DCA)-induced stimulation of oxidative metabolism in hypoxic tissue., Methods: The study was a randomized control trial using male Sprague-Dawley rats. A pedicled TRAM flap based upon the right inferior epigastric artery was elevated and reapproximated. Animals were randomly assigned to 1 of 5 treatment groups (n = 6). Group I received no DCA; groups II through V were administered 75 mg/kg DCA orally 24 hours preoperative; in addition, groups II through IV received 75 mg/kg/d DCA orally postoperative for 4 days; group III also received 75 mg/kg DCA (IP) intraoperatively; groups IV and V were given 15 mg/kg/d DCA orally for 6 days before the 24-hour preoperative treatment. Four days postsurgery, skin paddles were photographed and assessed for viability. Underlying TRAM muscle was biopsied for histologic analysis. Blood lactate levels were measured at pre- and postoperative time points. The mean percentages of viable skin paddle were as follows: 32.0%+/- 4.0% (group I), 68.1% +/- 6.2% (group II), 84.3% +/- 5.9% (group III), 92.8% +/- 2.0% (group IV), 82.6% +/- 5.8% (group V)., Results: Statistically significant differences were found in all experimental (DCA) groups relative to the controls (P < 0.01). Group IV (6-day DCA preconditioning, plus 24-hour preoperative and 4-day postoperative treatment) displayed the greatest improvement in flap viability, significantly better than other DCA groups (P < 0.01). Group IV also had significantly lower serum lactate levels than controls (P < 0.05). Histologic examination of muscle biopsies revealed reductions in inflammation and necrosis correlating with DCA treatment and skin paddle survival., Conclusions: This study indicates that DCA may provide a useful pharmacologic tool for reducing ischemia-related necrosis in TRAM flaps.

Numerous experimental and clinical studies have shown that skeletal muscle apoptotis may increase in wasting conditions and suggest that apoptosis might contribute to the loss of lean body mass. Data in cancer patients are still lacking. The present study aimed at verifying whether apoptosis was enhanced in the skeletal muscle of 16 patients with gastric cancer with respect to controls. A biopsy specimen was obtained from the rectus abdominis muscle. The occurrence of apoptosis in muscle biopsies was determined morphologically by the fluorescent transferase-mediated dUTP nick end labeling assay and by immunohistochemistry for caspase-3 and caspase-1. Mean weight loss was 6+/-2% in cancer patients and 0.5+/-0.1% in controls (p<0.0001). Serum albumin levels (g/dL) were 3.7+/-0.3 in cancer patients and 4.1+/-0.2 in controls (p<0.05). The percentage of apoptotic myonuclei was similar in cancer patients and in controls (1.5+/-0.3 versus 1.4+/-0.2, respectively; p=ns), in gastric cancer patients with mild (1.6+/-0.4) or moderate-severe weight loss (1.4+/-0.5) (p=ns), and in the different stages of disease (stages I-II: 1.5+/-0.7; stage III: 1.3+/-0.4; stage IV: 1.6+/-0.3; p=ns). By immunohistochemistry, caspase-1 and caspase-3 positive fibers were absent in controls and in neoplastic patients. Poly-ADP-ribosyl polymerase, a typical caspase-3 substrate whose processing is indicative of caspase-3 activation, was not cleaved in muscle biopsies of cancer patients. These data suggest that skeletal muscle apoptosis is not increased in neoplastic patients with mild-moderate weight loss and argue against the hypotheses that caspase-3 activation might be an essential step of myofibrillar proteolysis in cancer-related muscle wasting.

Background: It has been claimed that inguinal hernia is not a local disease; it is a local manifestation of a systemic disorder of collagen metabolism. Previous studies have shown that patients with inguinal hernia have some anomalies in collagen metabolism and changed ratio of collagen types., Aim: To search the changes in collagen and elastic fiber contents of the skin, rectus sheath, transversalis fascia and peritoneum in primary inguinal hernia patients., Methods and Materials: Twenty patients operated on for inguinal hernia (HR) included in the study (11 direct and 9 indirect). Nine patients underwent open cholecystectomy served as the control group (CC). A 0.5 x 1 cm. tissue was sampled from skin, rectus sheath, transversalis fascia and peritoneum in HR group. Skin, rectus sheath and peritoneum samples were taken from the patients in CC group. The sections of those samples were submitted to two different staining methods: "Masson's trichrome" for collagen and "van Gieson" for elastin fibers and graded with light microscopy., Results: The rectus sheath samples of CC had higher staining scores for both collagen and elastin fibers in comparison with HR (p = 0.032 and p = 0.026, respectively). CC had a significantly higher score for collagen in peritoneum samples (p = 0.019). There were no statistically significant differences between the patients with direct and indirect inguinal hernias for collagen or elastin fibers scores in skin, rectus sheath, transversalis fascia and peritoneum samples., Conclusions: These findings, which concur with most of the previous studies, support the theory that inguinal hernia may not be merely a local disease and can be more generalized, at least a regional connective tissue disorder. Regarding the difference between direct and indirect hernias, it could not be possible to report a certain answer, and this issue should be considered together with previous quantitative researches and more sophisticated studies may take place in the future (Tab. 2, Fig. 2, Ref. 23).

Although was published many cases of ectopic osteogenesis of traumatic, neurogenic cause or hereditable form, the etiology of ectopic osteogenesis remaining unknown. We present ectopic osteogenesis in the rectus abdominal sheath. The study material was represented from fragments of ectopic bones discovered in rectus sheath of four patients suffering iterative surgical abdominal interventions. The pieces of ectopic bone were decalcified and then were made to the standard techniques (paraffin inclusion, general techniques dyeing). The process of ectopic osteogenesis was analyzed through microscopically study to seriated sections of discovered piece, finding the presence of the hematopoesis foci. We conclude that is important identifying and characterizing the osteoinductor agents because these allowed the study of osteogenesis to the cellular level and make an estimation of the abnormally bone developing mechanisms. A possible osteoinductor factor has been considerate the non-absorbable wound closure material.

We herein report a rare case of myositis ossificans originating from the abdominal rectus muscle, found in a 38-year-old woman who presented with a left upper abdominal mass. The mass was initially suspected to be a malignant neoplasm because no history of either operation or trauma existed for this patient. Moreover, the location of the mass was unusual and the enhancement patterns of the dynamic magnetic resonance images were similar to that of a malignant tumor. Based on the radiologic findings, a surgical exploration was performed. A well-circumscribed mass, which measured 3.2 x 2 cm, was found in the rectus muscle. Microscopic findings showed a typical zonal pattern with a fibroblastic central zone and a zone of ossification at the periphery. Although abdominal myositis ossificans is extremely rare, it is one of the causes of abdominal mass lesions and can be mistaken for a malignant tumor. Therefore, a thorough knowledge of the evolution of myositis ossificans is necessary and in cases with malignant suggestion on magnetic resonance imaging, like that seen in our case, we suggest that a surgical excision may be necessary for both the diagnosis and treatment.

One of the postoperative complications of retroperitoneal incision is a flank bulge that is suggested to be caused by 11th intercostal nerve injury leading to denervation of the ipsilateral muscles. To avoid this complication, we have tried to minimize retroperitoneal incision for abdominal aortic aneurysm (AAA) repair. The feasibility of the less incisional retroperitoneal approach for the repair of AAA to prevent postoperative flank bulge was investigated. Twenty-seven patients undergoing elective repair for infrarenal AAA through the left retroperitoneal approach were divided into group-L (less incision: 11.9+/-1.8 cm, n = 7) and group-C (conventional incision: 17.8+/-1.9 cm, n = 20). All operations were performed by a traditional hand-sewn anastomosis without laparoscopic support. Five bifurcated grafts were used in group-L and 15 in group-C. The postoperative course of all patients was uneventful except that one patient in group-C required reoperation for bleeding. Intraoperative parameters of both groups were almost comparable. All patients in group-L were extubated in the operating theater, whereas it was possible only for 11 patients in group-C. Resumption of alimentation was significantly earlier in group-L (P = 0.0117). There was no significant difference in postoperative hospital stay between groups. No late flank bulge was experienced. Significant late atrophy of the left rectus muscle (left/right thickness-ratio = 0.59+/-0.24) was seen in group-C (P = 0.0042 vs preoperative value), which was not observed in group-L (P = 0.0008 between groups). The less incisional retroperitoneal AAA repair seems feasible and safety technique that might prevent postoperative flank bulge and reduce surgical stress.

Occasionally, during liver transplantation, vascular reconstructions have to be performed. Donor vessels can be harvested for this purpose. However, when these are lacking, alternatives should be available. A possible alternative can be the use of autologous rectus fascia sheath, folded as a tube with the mesothelium on the inside. Earlier experimental studies from our centre showed the successful use of the rectus fascia sheath graft in vascular defects in animal experiments. This report describes the first use of this autologous tubular graft for replacement of the inferior caval vein interponate during liver transplantation in men.

Predictable bone induction in clinical contexts requires information on the expression and cross regulation of gene products of the transforming growth factor-beta (TGF-beta) superfamily elicited by single applications of each recombinant human bone morphogenetic/osteogenic proteins (BMPs/OPs). Using the calvarium and the rectus abdominis muscle of adult baboons Papio ursinus as a model for tissue induction and morphogenesis, this study investigated the induction of bone morphogenesis by gamma-irradiated hOP-1 delivered by gamma-irradiated bovine insoluble collagenous bone matrix, the hOP-1 osteogenic device, for bone induction in heterotopic and orthotopic sites of the primate Papio ursinus and the expression patterns of OP-1, collagen type IV, BMP-3 and TGFbeta1mRNAs elicited by increasing single applications of doses of the hOP-1 osteogenic devices (0.1, 0.5 and 2.5 mg hOP-1/g of matrix) applied heterotopically in the rectus abdominis muscle and orthotopically in 48 calvarial defects of 12 adult baboons. Histology and histomorphometry on serial undecalcified sections prepared from the specimens harvested on day 15, 30 and 90 showed that all the doses of the hOP-1 osteogenic device induced bone formation culminating in complete calvarial regeneration by day 90. Type IV collagen mRNA expression, a marker of angiogenesis, was strongly expressed in both heterotopic and orthotopic tissues. High levels of expression of OP-1 mRNA demonstrated autoinduction of OP-1 mRNAs. Expression levels of BMP-3 mRNA varied from tissues induced in heterotopic vs. orthotopic sites with high expression in rapidly forming heterotopic ossicles together with high expression of type IV collagen mRNA. The temporal and spatial expressions of TGF-beta1 mRNAindicate a specific temporal transcriptional window during which expression of TGF-beta1 is mandatory for successful and optimal osteogenesis. The induction of bone by hOP-1 in Papio ursinus develops as a mosaic structure with distinct spatial and temporal patterns of gene expression of members of the TGF-beta superfamily that singly, synergistically and synchronously initiate and maintain tissue induction and morphogenesis.

Background: A rectus sheath haematoma is a difficult condition to diagnose and is usually treated by conservative measures. However, significant sized haematomas can result in severe haemodynamic repercussions, especially in those patients with co-morbidities and anticoagulation., Case Report: The case reported here is of a 68 year old anticoagulated patient with severe medical co-morbidity who presented with abdominal pain and hypotension. An abdominal CT scan demonstrated a large rectus sheath haematoma and small bowel infarction. The relationship between these two separate causes of an acute abdomen is discussed and imaging findings are illustrated., Conclusions: A careful history and a high index of suspicion are necessary to diagnose a rectus sheath haematoma. Further imaging such as CT may be required and if diagnosed early enough, it should be treated aggressively based on the clinical findings.

Objective: To discuss the diagnosis and management of rectus sheath hematomas after transvaginal follicle aspiration., Design: Case report., Setting: A single healthy patient in an academic IVF center., Patient(s): A healthy patient undergoing routine transvaginal follicle aspiration for IVF., Intervention(s): CT scan, serial phlebotomy, IV fluid, in-patient observation., Main Outcome Measure(s): Condition at discharge., Result(s): Patient was successfully managed with conservative measures. After the initial decline, serial hematocrits were stable over 24 hours without any operative interventions., Conclusion(s): Rectus sheath hematomas are rare complications of IVF and can be managed conservatively.

Background: Correction of rectus diastasis is a procedure performed by most surgeons during abdominoplasty. The purpose of this study was to demonstrate the long-term efficacy of the correction of rectus diastasis when plication of the anterior rectus sheath is performed with a nonabsorbable suture., Methods: Twelve female patients who underwent abdominoplasty were studied. Rectus diastasis was measured preoperatively with two computed tomographic scan slices: one above and one below the umbilicus. The bony levels where the slices were obtained served as a reference for the postoperative computed tomographic scans. During the operation, rectus diastasis was measured at the same levels as the preoperative scan slices. At the same time, the necessary force to bring the medial edge of the rectus muscle to the midline was measured with a dynamometer. Postoperative scans were obtained at 3 weeks and 6 months after the operation. A long-term follow-up scan was obtained from 76 to 84 months postoperatively for every patient., Results: The 3-week postoperative scan proved that the correction of rectus diastasis had been achieved by the procedure. Despite the fact that there were different levels of abdominal wall resistance and that the average weight gain in this period was 6.5 kg, the long-term computed tomographic scans showed that there was no recurrence of rectus diastasis in any patient of this series, both in the superior and inferior abdomen., Conclusions: Plication of the anterior rectus sheath with nonabsorbable suture appears to be a long-lasting procedure for correcting rectus diastasis.

The aim of this study was to evaluate whether the dissection of the vascular pedicle of the deep inferior epigastric perforator (DIEP) flap could induce secondary muscle atrophy. Evaluation of the rectus abdominis muscle was performed using ultrasonography, and the muscle thickness was measured as an expression of muscle substance. This was performed at 4 levels: below the xiphoid process, at the umbilicus level, above the symphysis, and between the 2 last mentioned (central zone). The results were expressed as the ratio of the muscle thickness on the operated side where dissection of the vascular pedicle was performed to the thickness of the contralateral not operated muscle. Thirteen patients were included with a mean follow up of 20 months (range, 7-42 months). The combined measurements showed that the thickness of the muscle as a whole was significantly reduced on the operated side compared with the opposite side. Broken down to the specific levels, the greatest reduction in thickness, approximately 10%, was found at the xiphoid process and above the symphysis. We conclude that performing the dissection of the vascular pedicle of the DIEP flap gives a small but significant degree of muscular atrophy.

Background: Percutaneous endoscopic gastrostomy (PEG) tube placement is a safe and widely accepted alternate route for enteral alimentation in the head and neck cancer patient population. Cancer metastatic to a PEG tube exit site is a rare but serious complication of this procedure. We sought to determine the route of spread responsible for PEG site metastases such that we may prevent further occurrences of this highly morbid condition. We also report a case of PEG site metastasis at our institution., Methods: We performed a MEDLINE search for the years 1962 to 2002 and conducted a review of the literature. In the case at our institution, a 63-year-old man was referred to our institution with recurrent squamous cell carcinoma of the right base of tongue; he also had a 1.5-cm left apical lung nodule. He underwent PEG tube placement at the time of staging panendoscopy. Six months after the original tube placement, he had an ulcerated mass develop at the PEG site; biopsy of the mass revealed squamous cell carcinoma histologically identical to the base of tongue tumor. He also had recurrent lung cancer and four hepatic lesions develop., Results: In our MEDLINE search, of the five patients diagnosed with PEG site disease >10 months after PEG placement, all five (100%) had synchronous distant metastatic disease. In the group of patients diagnosed with PEG site metastases < or =10 months after PEG placement, only four (24%) of 17 had synchronous distant metastatic disease. All patients underwent PEG placement by means of the "pull" technique. Direct implantation with a variable-sized initial tumor burden can explain all cases of PEG site metastasis. The presence of distant metastases is representative of the natural history of advanced head and neck malignancies. Smaller initial tumor implants present later than would larger initial tumor burdens, when the patient is more likely to have distant metastatic disease. In the case at our institution, the patient did not respond to treatment for his hepatic and PEG site metastases and his lung cancer, and he died 4 months after detection of the PEG site metastasis., Conclusions: PEG site metastases are iatrogenic complications of PEG tube placement in patients with squamous cell carcinoma of the upper aerodigestive tract. The use of laparoscopic, open, or the "push" technique of PEG tube placement in patients with head and neck cancer may prevent direct implantation of malignant cells into an enteral access site.

We present a case of rectus sheath hematoma compounded by anterior abdominal wall haemorrhage. Its clinical and anatomical relationship is discussed., (Copyright 2005 Wiley-Liss, Inc.)

Endometriosis is characterized by the presence of histological normal endometrial tissue outside the uterine cavity. Most frequently endometriosis occurs within the pelvis. Extrapelvic endometriosis is less common, but can involve nearly every organ. We present two patients in whom endometriosis was found in the rectus abdominis muscle and discuss the imaging findings and pathological correlation.

A case of primary hydatid disease, a rare location, is presented. The patient was a 20 year old female who presented with complaining of painful mass in the right hypochondrium 2 months before presantation. This cyst was strongly adherent to the two layers of m.rectus abdominis fascias. It was completely removed. No other site of hydatid disease was found and the patient remained well postoperatively.

Reconstruction after mastectomy for breast carcinoma with implants or myocutaneous flaps is a widely used surgical technique. Recurrence of breast carcinoma after these procedures is uncommon. Most recurrences occur in the skin or scar site of the mastectomy and are readily detectable by physical examination. There are rare reported cases of recurrent carcinoma occurring within the flaps that are usually diagnosed with the aid of imaging and subsequent pathologic examination. In most cases, these recurrences represent invasive or in situ ductal carcinoma. We report an additional 2 cases of breast carcinoma recurring within the myocutaneous flap, both of which exhibited uncommon histologic features not previously reported.

Objective: To evaluate gadolinium-enhanced MR imaging in athletes with chronic groin pain and correlate with the clinical features., Design and Patients: MR examinations performed in 52 athletes (51 male, 1 female; median age 26 years) with chronic groin pain and 6 asymptomatic control athletes (6 male; median age 29 years) were independently reviewed by two radiologists masked to the clinical details. Symptom duration (median 6 months) and clinical side of severity were recorded. Anatomical areas in the pelvis were scored for abnormality (as normal, mildly abnormal or abnormal) and an overall assessment for side distribution of abnormality was recorded, initially without post-gadolinium sequences and then, 3 weeks later (median 29 days), the post-gadolinium sequences only. Correlation between radiological and clinical abnormality was calculated by Spearman's correlation., Results: Abnormal anterior pubis and enthesis enhancement significantly correlated with clinical side for both radiologists (both P=0.008). Abnormal anterior pubis and adductor longus enthesis oedema was significant for one radiologist ( P=0.009). All other features showed no significant correlation ( P>0.05). In the control cases there was no soft tissue abnormality but symphyseal irregularity was present ( n=2). For both radiologists assessment of imaging side severity significantly correlated with clinical side for post-gadolinium ( P=0.048 and P=0.023) but not non-gadolinium sequences ( P>0.05)., Conclusion: The extent and side of anterior pubis and adductor longus enthesis abnormality on MR imaging significantly and reproducibly correlates with the athletes' current symptoms in chronic adductor-related groin pain.

Significant structural and functional changes in smooth muscle cells (SMCs) of microvessels (diameter 30 to 300 microm) occur in hypertension. However, in microvessels of hypertensive patients, the differentiation pattern of SMCs underlying such changes remains undefined. To analyze the differentiation pattern of SMCs (adult, postnatal, or fetal), 49 muscle biopsies (rectus abdominis) were analyzed: 16 from children (aged 11 months to 11 years), 15 from normotensive adults (aged 55 to 74 years), 18 from hypertensive adults (aged 55 to 74 years). Transverse cryosections of specimens were studied by immunocytochemistry using monoclonal antibodies SM-E7 and NM-F6, which recognize smooth muscle myosin heavy chain (MyHC) and A(pla1)-like nonmuscle MyHC, respectively. The total number of microvessels was assessed via SM-E7 staining. The number of NM-F6 positive (fetal-type SMC) or negative (adult-type SMC) microvessels was assessed. The number of microvessels per area unit was considerably lower (P<0.0005) in normotensive adults (0.22+/-0.17) than in children (0.98+/-0.61). Even more significant reduction was found in hypertensive adults compared with control adults (P=0.013) and children (P<0.0005). The qualitative immunocytochemistry analysis by NM-F6 revealed 2 differentiation patterns of the media layer of microvessels: positive or negative. In hypertensive subjects, the percentage of microvessels positive to NM-F6 was 49.8+/-35.6%, close to that found in children (50.6+/-12.6%), whereas in normotensive subjects it was significantly lower (24.4+/-21.1%). The following conclusions were drawn. (1) The medial layer of microvessels is heterogeneous in terms of SMC differentiation. (2) In hypertension, a prevalence of fetal-type SMCs takes place in microvessels, resembling that of children. Compared with children, a rarefaction of microvessels is present in normotensive adults that is even more remarkable in hypertensive adults.

This study was undertaken to assess the changes in the local morphology of the rectus abdominis muscle following intramuscular dissection of the deep inferior epigastric artery perforators after harvesting of the deep inferior epigastric perforator (DIEP) flap. While the DIEP provides the well-known advantage of use of the lower abdominal tissue with preservation of the integrity of the abdominal wall musculature, postoperative problems such as abdominal asymmetry, bulges and reduced flexion capacity have been found. These changes may be due to rectus abdominis muscle damage from ischemia or denervation. We used ultrasonography to assess the changes in rectus abdominis muscle thickness and contractility, preoperatively, 1-month and 1-year postoperatively. The study group consisted of 17 rectus abdominis muscles in 14 patients subjected to intramuscular dissection of perforators. The control group consisted of 11 intact rectus abdominis muscles in 11 patients who had undergone unilateral DIEP flap elevation, the dissected muscles being part of the study group. We found that the resting muscle thickness in the study group was, significantly increased at 1-month postoperatively, resolving by 1-year follow-up. As these changes were not seen in the control group, the increased muscle thickness is attributed to postoperative oedema that resolves with time. All muscles in the study and control groups retained contractility showing no evidence of muscle denervation. Our date demonstrates that intramuscular dissection of perforator vessels in the DIEP flap leads to minimal changes in the local morphology and contractility of the rectus abdominis muscle.

Background: Recurrent rectus diastasis is a troublesome complication because its correction requires an extensive procedure., Case Reports: Two patients with recurrent rectus diastasis secondary to abdominoplasty corrected by plication of the anterior rectus sheath are presented. These patients had lateral insertion of the rectus muscles. They were treated by the advancement of the rectus muscles after undermining of the posterior rectus sheath and a two-layer closure to correct the rectus diastasis. Good cosmetic results and postoperative pain control were achieved in both cases., Discussion: The causes, prevention, and treatment for this type of rectus diastasis are described. The main reason for recurrence of this deformity in these patients was lateral insertion of the rectus muscles on the costal margins. On the basis principle, an efficient technique to correct this deformity is described. A postoperative compute tomography scan with slices made at the same bony level as the preoperative control examination demonstrated total correction of rectus diastasis over a long-term follow-up evaluation., Conclusion: Advancement of the recti muscles seems to be a reliable method for correcting recurrent rectus diastasis in patients with lateral insertion of the recti muscles.

We have experienced a case which developed mesenteric ischemia followed by necrosis of the rectus abdominal muscle after off pump coronary artery bypass grafting (OPCAB). A 62-year-old man with a history of long-term hemodialysis was diagnosed with left main trunk disease. He underwent triple OPCAB uneventfully. No inotropic agents were needed perioperatively. He underwent normal hemodialysis on the first postoperative day, and then complained of severe abdominal pain with progressive metabolic acidosis. A 170 cm length of the ileocecal segment fell into necrosis and was excised and an ileostomy was constructed in an emergency setting. He developed another abdominal pain 6 days after the second operation. An additional surgery confirmed necrosis of the right rectus abdominal muscle complicated with a significant infection. He developed mediastinitis and died of multi-system organ failure 37 days after OPCAB. The mechanism of this serious complication is discussed.

Hypothesis: Tissue flaps are commonly used for surgical reconstruction, especially to cover difficult wounds and in breast reconstruction following mastectomy. Complications due to inadequate flap perfusion are a source of morbidity and, in the lower extremity, can result in amputation., Setting: Laboratory., Interventions: We evaluated the ability of platelet-derived growth factor (PDGF) B and fibroblast growth factor 2 plasmid DNA, formulated in a type I collagen matrix, to promote tissue survival in a rat transverse rectus abdominis muscle flap model based on the inferior deep epigastric vascular supply. In the absence of any therapeutic agent, only about 24% of flap tissue survives in this model. The DNA/matrix formulations were delivered subcutaneously into the skin paddles 7 days before flap elevation, and tissues were harvested 7 days later., Results: Our studies reveal dramatic increases in overall vascularity after treatment with PDGF-B and fibroblast growth factor 2 plasmid DNA; however, only PDGF-B increased flap survival (130% increase at 228 micro g/cm(2) of plasmid DNA vs controls; P<.01). Transdermal spectral imaging demonstrated an increase in patent vessels supporting blood flow in flaps treated with PDGF-B plasmid DNA vs the fibroblast growth factor 2 transgene., Conclusion: Matrix-enabled gene therapy may provide an effective nonsurgical approach for promoting flap survival and is well suited for surgical applications in which transient therapeutic transgene expression is desired.

Background: Despite several clinical and experimental studies, the mechanisms behind the development of port site metastases in laparoscopic surgery have remained largely unknown. The current study was designed to investigate the effect of pneumoperitoneum on blood flow in the abdominal wall and its possible effects on tumor growth at this site., Methods: A total of 40 Wistar Fu rats had a laser Doppler probe placed on their left rectus muscle and a suspension of 50,000 adenocarcinoma cells was injected into their right rectus muscle. The experimental group (n = 20) was insufflated with air at 10 mmHg for 45 min while abdominal blood flow was registered before and during insufflation and after exsufflation. The control group (n = 20) was not insufflated but the blood flow was recorded in the same manner. After 9 days, all animals were killed and the occurrence of tumor was observed. The tumors were analyzed with respect to weight and volume., Results: The insufflation caused an 82% reduction in blood flow in the experimental group (p < 0.001). No reduction in blood flow was registered in the control group. Tumor nodules developed significantly more often in the insufflated group (20/20) compared to the controls (14/20) (p = 0.016). Tumor weight (p = 0.003) and volume (p < 0.001) were significantly increased in the insufflated group., Conclusions: Pneumoperitoneum seems to enhance tumor growth. It also causes a significant reduction in blood flow in the abdominal wall, which may contribute to the increased susceptibility of tumor take.

The strength of porcine small intestinal submucosa in abdominal wall repair after transverse rectus abdominis myocutaneous flap harvesting was examined in a rat model. Changes in the levels of selected molecular markers of inflammation after small intestinal submucosa implantation were also studied. Eighty-three rats were divided into three groups. In experimental group I, an abdominal wall defect created by removal of the rectus abdominis muscle was repaired with placement of a 1.5 x 5-cm2 patch of small intestinal submucosa. In experimental group II, the muscle defect was repaired with a combination of small intestinal submucosa patch placement and fascial closure. In the control group, the defect was repaired with direct fascial closure. At postoperative times of 3 days, 2 weeks, 1 month, and 2 months, the muscle tissues adjacent to the abdominal wall repair site were subjected to biopsies for assessment of inflammation markers. Full-thickness sections of the abdominal wall from the repair site in each animal were removed for tensile strength testing and histological examinations. The results demonstrated that interleukin-6 and interferon-gamma levels were increased in the two experimental, small intestinal submucosa-treated groups at 3 days and 2 weeks postoperatively. The results of mechanical testing demonstrated that the average tensile strength of the repaired abdominal wall in the repair model with combined small intestinal submucosa placement and fascial repair was significantly greater than the values for repairs with fascial closure or small intestinal submucosa placement alone. The use of small intestinal submucosa placement in combination with fascial repair can significantly improve the strength of the repaired abdominal wall after transverse rectus abdominis myocutaneous flap harvesting.

We present a modified histochemical method to examine, simultaneously, nuclei and fibre type in human skeletal muscle. The new procedure (Haem-ATPase) is based on two previously used histochemical protocols. Biopsies were obtained from the rectus abdominis muscle of patients undergoing elective abdominal surgery. Fibre type composition, cross-sectional area (CSA) and nuclei to fibre ratio (N:F) were determined from frozen sections of each biopsy. To test the validity of the new method, serial sections of each biopsy were stained separately using the standard and modified methods. No differences were found in fibre type distribution, mean-weighted CSA and N:F when comparing the modified method with the standard methods. The Haem-ATPase method was found to shrink fibre size by at least 3% ( P>0.05) compared with the established myosin acid labile method. We propose that this modified technique is suitable for initial examination of both the nuclei and fibre type in the same frozen sections of human skeletal muscle.

Spigelian hernia, or ventro-lateral hernia is a rare clinical condition, it represents about 1.5% of hernial formation cases of the abdominal wall. It is localised laterally to the rectus muscle and emerges from the semilunar arch. The line, which joins the IX rib to the pubic tubercle, defines the limit between muscular and aponeurotic portion of trasversus abdominis muscle. Diagnosis often results misunderstood. As a matter of fact, this hernia has typically an intraparietal localization and the clinical picture seldom presents characteristic signs. The hernial sac and its content can be appreciated subcutaneously in only 2% of cases. It is estimated that about 50% of patients affected by this condition have a certain diagnosis before surgery. The early clinical signs are generally aspecific and deceitful, represented by oppressive grief and rarely by an abdominal wall tumor; it occurs that it starts with a complication: intestinal occlusion (23%), subocclusion (8%), strangulation (20%, but some authors report percentage up to 50%). We report 5 cases who came to our observation during the last 7 years; all patients underwent elective surgery, and specifically 3 patients in day surgery. Starting from the discussion of these cases, we review anatomy, etiology, clinical nature, instrumental investigation and surgical technique of this rare kind of hernia, comparing our experience to literature reported case histories.

The anterior rectus sheath, efficacious in reconstructive surgery, is used in oromandibular reconstruction with the free rectus abdominis musculocutaneous flap. This study describes reconstruction with this sheath in 20 patients: to preserve only the swallowing function in 10 patients (formation of the bulge of the reconstructed oral floor and prevention of its sinking); to preserve both swallowing and articulation in 5 patients (formation of the bulge of the reconstructed tongue and prevention of its sinking, concurrent with a money-pouch-like reconstruction of the tongue, laryngeal suspension, and neuroanastomosis); and to prevent exposure of the reconstruction plate, replacing the resected mandibular continuity in 5 patients. The purpose of reconstruction was achieved in all patients. The vascularized free rectus abdominis musculocutaneous flap with a firm anterior rectus sheath may be the first choice for these types of reconstruction., (Copyright 2003 Wiley-Liss, Inc.)

Hepatitis C virus-related mixed cryoglobulinemia is a vasculitis, associated with a number of systemic manifestations and diseases. The Authors present a patient with mixed cryoglobulinemia, who developed acute abdominal pain and severe anemia, caused by spontaneous haematoma of rectus abdominis sheath. Prompt diagnosis of this unusual complication of cryoglobulinemia vasculitis may allow conservative treatment and avoid surgery, which is more expensive and invasive. To the best of Author's knowledge, spontaneous rectus sheath haematoma in a patient with cryoglobulinemia has not been previously reported.

Aims: To evaluate the acute and chronic urodynamic effects of electrically stimulated detrusor myoplasty in dogs., Methods: Eight female mongrel dogs were studied acutely and six dogs chronically (0 to 12 weeks postoperatively). Bladders were wrapped with the rectus abdominis muscle, keeping an intact blood supply and at least two intercostal nerves of the flap preserved. Bladders were electrically stimulated with bipolar electrodes inserted into the muscle. Urodynamics and post void residual were measured post operatively in the acute studies and every 2 weeks for 3 months in chronic studies., Results: Acutely, the increase in intravesical pressure was 45+/-7 cm H(2)O, which resulted in a postvoid residual of 26+/-3%. In the chronic study, increases of intravesical pressure sufficient to empty the bladder during myoplasty electrical stimulation were not sustained, although detrusor compliance and flap viability were preserved., Conclusions: The electrically stimulated detrusor myoplasty worked well acutely to increase vesical pressure sufficient to empty the bladder, but the chronically stimulated myoplasty did not maintain efficient bladder emptying primarily due to electrode problems. Further studies with improved electrode material and placement are required before clinical application of the electrically stimulated detrusor myoplasty can be assessed., (Neurourol. Urodynam. 21:516-521, 2002. Copyright Wiley-Liss, Inc.)

Although spontaneous hemorrhage into the sheath of the rectus abdominis muscle is uncommon in pregnancy, rectus sheath hematomas (RSHs) should be considered in patients who present with an acute onset of abdominal pain in the latter half of pregnancy or the immediate postpartum period. Both sonography and CT are useful in diagnosing RSHs. We report a case of pregnancy-associated RSH initially suspected of being a degenerating leiomyoma or torsed ovary. Sonography showed a large mass of mixed echogenicity with no internal vascularity. CT confirmed that the lesion was suprafacial., (Copyright 2001 John Wiley & Sons, Inc.)

Background: Previous works have suggested that a defect in collagen fiber structure may play a role in inguinal hernia formation. These studies focused mainly on the rectus sheath or the skin, while only few reports dealt with the transversalis fascia. According to these findings and to our previous biomechanical and histological studies suggesting that a connective tissue pathology could play a role in the genesis of groin hernias, we performed a biochemical investigation of the collagen in the transversalis fascia and rectus sheath., Materials and Methods: The samples were collected from 40 adult patients with uni- or bilateral hernias and from 20 control subjects without hernia (autopsies and organ donors). A constant area of tissue was taken by using a calibrator. The wet and dry weights per 100 mm(2) were determined and the total collagen concentration as well as its sequential extractibility in NaCl, acetic acid, and pepsin was measured. The ratios of alpha(1)/alpha(2) chains (I) and of type I/III collagen were assessed by polyacrylamide gel electrophoresis., Results: Samples collected in the control and patient sheaths showed an increased wet weight per 100 mm(2) in the patients. The wet and dry weights per unit area were increased in the patient fascias. The collagen concentration was increased in the indirect hernias. The fascias from the direct hernias (DH) presented a significantly increased collagen extractibility after pepsin digestion (5.6%), when compared to the control fascias (2.6%). The extractibility was 3.4% in the nonherniated (NH) sides. The qualitative study (ratios alpha(1)/alpha(2) (I) and I/III collagen) showed no difference between the fascia groups., Conclusions: The significant increase of collagen extractibility with pepsin in the DH fascias and at a lesser degree in the NH fascias suggests that molecular alterations of collagen could be involved in the genesis of groin hernias. This connective tissue pathology would express preferentially its effects in the inguinal region, since we have observed no major difference between the rectus sheaths of controls and those of patients., (Copyright 2001 Academic Press.)

The paper presents a case of 28-year-old woman operated at the Department of General Surgery University School of Medicine in Poznań because of desmoid tumor of rectus muscle of abdomen. The patient was incorrectly diagnosed a year earlier. The authors emphasize diagnostic problems leading to a delayed diagnosis.

Skeletal muscle failure is a frequent manifestation of sepsis that affects prognosis and rehabilitation by impairing respiration and ambulation. Animal studies have shown that the inducible NO synthase (NOS2) is expressed in skeletal muscles during sepsis, likely affecting muscular function, by promoting the formation of the strong oxidant peroxynitrite. In contrast, whether human skeletal muscle expresses a functional NOS2 in similar conditions is unknown. We studied NOS2 expression (mRNA and protein) and activity and its role in contractile function in samples from rectus abdominis muscle obtained during surgical procedure in 16 septic patients and in 21 controls. Peroxynitrite formation was detected by immunohistochemical detection of nitrotyrosine residues. The main results of this study are as follows: (1) A significant increase in NOS2 mRNA, protein, and activity was found in muscles from septic patients, the expression of NOS2 protein positively correlating with sepsis severity. (2) Contractile force was significantly lower in septic than in control muscles. This phenomenon was not reverted by muscle incubation ex vivo with the NOS inhibitor L-NMMA, indicating that NO was not involved in force reduction at the time of biopsy. (3) NOS2 expression in skeletal myocytes was strongly co-localized with nitrotyrosine, revealing muscular peroxynitrite generation during the septic process, before the muscle was biopsied. Exposure of control muscles to an amount of peroxynitrite similar to that generated in septic muscles during the septic process resulted in a nonreversible reduction in force generation. These results suggest that NOS2 could be involved in the decreased muscular force of septic patients via the local generation of peroxynitrite.