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KEY MESSAGE Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essential for understanding the mechanisms of action of the various CS techniques, the changes observed on computed tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who have undergone CS. Purpose Component separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps most importantly, the anatomic and physiologic changes following CS techniques. Methods A systematic review of the literature was conducted using the PubMed database and other sources to identify articles describing abdominal wall changes after CS Results After excluding non-pertinent articles, 14 articles constituted the basis for this review. Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the muscles' overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3) Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postoperative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and posterior CS are underway.

Background The aims of this study were to present the concept of original technique in the management of major incisional subcostal hernias and to evaluate short- and long-term outcome. Method Between January 2010 and January 2020, 280 patients underwent hernia repair surgery for incisional lateral abdominal hernia at Clinic for Digestive Surgery, Clinical Center of Serbia. Among them, 37 patients underwent the modified sublay technique for major incisional subcostal hernia with minimal hernia defect surface of 100 cm2 or greater or minimal hernia defect width or height of 10 cm or greater. The operative techniques are as follows: retromuscular dissection of rectus muscle from posterior sheath on the both sides of hernia defect, external oblique muscle dissection from internal oblique muscle in a circle around hernia defect at the side of the hernia defect, complete reconstruction of the posterior myofascial layer, large heavyweight polypropylene mesh placement in a sublay position, and complete or partial reconstruction of anterior myofascial layer. Results A median (range) hernia defect surface was 150 (100-500) cm2. A median operative time was 130 (90-330) minutes. The morbidity rate was 18.9%. A median (range) postoperative hospital stay was 7 (2-24) days. After the median follow-up of 50 (1-108) months, 2 patients (5.4%) developed recurrent hernia. Conclusions The modified sublay technique using large heavyweight polypropylene mesh provides good results in the management of major subcostal abdominal wall defects.

Background. Inguinal hernias in children are a common problem. They occur in 520 cases of 1000 newborns, with the prevalence in males of about 10 times. Therefore, they present a very important problem in pediatric surgery. Materials and methods. This prospective study was performed from 2019 to 2020 and included 30 patients with diagnosed inguinal hernias. Video-assisted percutaneous hernia sac ligation was performed in all patients. Results. The mean operating time was 10.3 2.7 min in patients with unilateral inguinal hernias and 14.7 1.6 min in patients with the bilateral variant. No complications or recurrences were observed during the six-month follow-up period. In one case, an additional 3 mm port setting was performed in an eight-month-old child. The main reason for doing this was the fibrous transformation of the parietal peritoneum because of the existence of incarcerations in the anamnesis. Conclusion. This technique garners all the advantages of a minimally invasive surgical treatment of inguinal hernias using the Tuohy needle. However, the conductor application allows us to create the same approach using a Touhy needle. This means that we can perform an isolated hernia sac ligation without getting under the preperitoneal tissue ligature, parts of the internal oblique and transverse muscles, aponeurosis of the external oblique muscle, and subcutaneous fat. This presented video-assisted percutaneous hernia sac ligation method seems like a potential minimally invasive way to treat inguinal hernias in children.

[Purpose] This study aimed to clarify the required number of measurements to calculate trunk muscle thickness at each position. [Participants and Methods] The participants were 30 elderly males aged >65 years. The right lumbar multifidus (L2), lumbar multifidus (L5), erector spinae, transversus abdominis, internal oblique, and external oblique muscle thicknesses were measured on longitudinal images obtained using ultrasonography in the lying, sitting, and standing positions. Two measurement values for each muscle thickness was used to calculate the intraclass correlation coefficient (1.1–1.5). [Results] The intraclass correlation coefficients of the abdominal muscle thickness measurements with “great reliabilities” were as follows: 1.3–1.5 for the external oblique muscle and 1.2–1.5 for the internal oblique and transversus abdominis muscles in the lying position; 1.3–1.5 for the external oblique and transversus abdominis muscles and 1.2–1.5 for the internal oblique muscle in the sitting position; the intraclass correlation coefficient in the standing position was 1.5 for the external oblique muscle 1.1–1.5 for the internal oblique muscle and 1.3–1.5 for the transversus abdominis muscle. In all the positions, the intraclass correlation coefficient of the measurements of the back-muscle thicknesses ranged from 1.1 to 1.5 for the right lumbar multifidus (L2), lumbar multifidus (L5), and erector spinae. [Conclusion] Depending on the posture, the abdominal muscles require multiple measurements, whereas the back muscles only require a single measurement.

Although changes in lateral abdominal wall musculature after posterior component separation with transversus abdominis release have been investigated, the effects of endoscopic subcutaneous anterior component separation (ES-ACS) on postoperative muscle anatomy have not been evaluated. The purpose of this study was to evaluate changes in the lateral abdominal muscles after ES-ACS. Computed tomography (CT) images of patients who underwent ES-ACS were retrospectively evaluated. Lateral abdominal wall thickness and external oblique displacement were measured at the level of fixed retroperitoneal structures. Measurements on the ES-ACS side were compared with those on the contralateral undivided side or with preoperative images in patients with bilateral procedures. Fifteen patients met the criteria for study inclusion. Most patients (n = 13, 86.7%) underwent unilateral ES-ACS. The most commonly performed procedure was laparoscopic intraperitoneal onlay mesh-plus hernia repair (n = 12, 80.0%; the remaining patients underwent open repair). The Mean defect width was 8.4 cm (range 6–15 cm). There was no difference in the thickness of the lateral abdominal musculature between ES-ACS and undivided sides. There was a significant lateral displacement of the external oblique muscle from the lateral edge of the rectus abdominis on the ES-ACS side (mean distance 3.7 cm; p = 0.0006). No midline hernia recurrences, iatrogenic linea semilunaris hernias, or lateral eventrations were observed during a mean follow-up period of 2.6 years (range 0.5–7.4 years). ES-ACS resulted in no atrophy of the lateral abdominal muscles in long-term CT follow-up. The procedure is a safe and effective adjunct to complex hernia repair in selected patients.

Introduction At the moment, there is an ongoing debate regarding the controversial issue of the ideal reservoir placement (RP) surgical technique during implantation of a 3-piece inflatable penile prosthesis, but a definitive winner has not yet emerged. Aim In this light, we herein describe our modified technique for RP into the space of Retzius through the external oblique muscle fascia and present its results. Methods In total, 253 inflatable penile prosthesis procedures (110 AMS 700 and 143 Coloplast Titan) via a single transverse penoscrotal incision were retrospectively reviewed. 2 Kocher-Langenbeck retractors were placed over the right side of the penoscrotal incision and were used to retract the incision superior to the pubic bone. Then, the external oblique muscle fascia was incised medially to the spermatic cord which was retracted laterally. Next, a “W”, Vicryl 1, stay suture was placed to the incision, and under direct visualization, external oblique muscle fibers were dissected and fascia transversalis was perforated using a Metzenbaum scissor. A Foerster lung grasping clamp was then used to dissect further into the extraperitoneal space and create the reservoir space. The reservoir was placed into the created space and fascia incision was closed using the prepositioned stay suture. The procedure was then completed in a standard fashion. Outcomes The main outcome measures were intraoperative or postoperative complications of our modified RP technique. Results All 253 patients were available for short-term follow-up (average 9.1 months, range 3–22 months). No intraoperative or postoperative complications were reported. Reservoir-related prolonged pain (1 month) was reported by 1 patient, resolving completely after treatment with non-steroidal analgesics. Conclusion We are, surely, not proposing that our modified RP technique should supplant all other methods; rather, it should be considered another useful option for RP in the implanter’s armamentarium.

Using autologous common femoral artery and external oblique muscle fascia is a simple and reliable option for repairing infected aortic pseudoaneurysms. Reoperation of infected pseudoaneurysms is challenging and requires secure aortic repair with complete infection eradication. Here, we report two cases of infected pseudoaneurysms in the ascending aorta cannulation site after cardiac surgeries. Common femoral arteries and fascia were harvested in the same lesion as repair materials. The aortic pseudoaneurysms were repaired under deep hypothermic circulatory arrest. Femoral arterial patches were reinforced with circumferential aponeurosis strips. There was no infection recurrence or repair site dilatation in the long-term follow up of both patients.

BACKGROUND AND AIMS: The eventration involves a highly variable surgical entity with a wide range of possible surgical techniques for its repair, without having found a “Gold Standard” technique. With these animal study, we propose a possible and useful surgical procedure for hernia repair. MATERIALS AND METHODS: We present a modified technique of the anterior component separation (ACS) based on a release of the external oblique muscle from a posterior anatomical approach, accessing the space from the retrofascial space of the anterior sheath of the rectus abdominis muscle. The technique was performed in an experimental animal model with pigs of the “Large White” breed of 20-25 kg since the pig is a good representative model of human anatomy and its abdominal wall. RESULTS: The technique was performed in an experimental animal model with pigs of the “Large White” breed. The procedure through the anterior retrofascial space of the rectus abdominal muscle was easily done, allowing the access to the inter-oblique space and facilitating the release of the external oblique muscle. CONCLUSION: Waiting for its clinical application, the ACS by its external retrofascial space approach could be an interesting surgical resource for incisional hernia repair.

A progressive, generalized loss of skeletal muscle mass and associated deterioration in muscle strength and performance increases with age. Aging affect the respiratory muscle performance on respiratory system due to anatomical and physiological changes in muscle strength as well as thickness of the respiratory muscles. During resting breathing the limitation of movement is more evident in expiration than inspiration were the FEV1/FVC% falls in older people. There are lot of study on peripheral muscle thickness and muscle torque among elderly population, but not much study on respiratory muscle training. This made us to conduct a study on pulmonary function and muscle thickness in elderly population by training the expiratory muscles. To determine the effects of external oblique muscle training on pulmonary function and muscle thickness in elderly population. 60 geriatric voluntary subjects were assigned to experimental and control group as (n=30) each. Experimental group subjected to 16 weeks of external oblique strengthening along with incentive spirometer training. Control group subjected to incentive spirometer alone. Pre and post training muscle thickness and pulmonary parameters were assessed. The paired t test found there is significant difference (P

Amaç:Analjeziklerin yetersiz veya yüksek doz kullanımı giderek önem kazanmaktadır;bu yüzden analjezi yöntemleri her gün geçtikçe gelişmektedir. Transversusabdominis plan (TAP) bloğu ultrasoneşliğinde batın cerrahilerinde ağrı kontrolü için yapılan bir yöntemdir.Çalışmamızda Ultrason eşliğinde farklı bölgelerden ölçümler alarak TAP bloğununhangi bölgeden uygulanması gerektiğini araştırmayı amaçladık.Materyal ve Metot:Çalışmaya 18-65 yaş arası 30 hasta çalışmaya alındı. Ön karın bölgesindenultrason’nun lineer probu subkostal bölgeden ve krista iliyakanın üstündenanterior aksiler bölge ve mediyal aksiler hatta denk gelecek bölgeden internaloblık kas, eksternal oblik kas, ve transversus abdominal plan kılıf genişliğikaydedildi. Yine bu bölgelerin görüntü netliği (kötü, iyi ve çok iyi olarak )değerlendirilip kaydedildi.Bulgular: Kristailiyaka üzerinden anterior aksiler hattın (A1) median aksiler hat (A2) ilekarşılaştırılmasında alınan ölçümlerde internal oblik kas, eksternal oblik kas,transversus abdominus kası genişlikleri ve transversus abdominus fasiya dahadüşük çıkmış ve istatistiksel olarakolarak anlamlı bulunmuştur (P, Background:Inadequate or overdose use of analgesics is becoming increasingly important;therefore, analgesia methods are developing day by day. Transversus abdominisplan (TAP) block is a method for pain control in abdominal surgeries underultrasound guidance. In our study, we aimed to investigate the area where TAPblock should be applied by taking measurements from different regions underultrasound guidance.Methods: Thirty patientsaged between 18-65 years were included in the study. Linear oblique muscle,external oblique muscle, and transverse abdominal plan sheath width from theanterior axillary region and medial axillary line from the anterior abdominalregion, from the subcostal region of the ultrasound to the anterior abdomen,and from the upper iliac crest were recorded. The image sharpness of theseregions (poor, good and very good) was evaluated and recorded.Results: Internal obliquemuscle, external oblique muscle, transversus abdominus muscle widths andtransversus abdominus fascia were found to be lower and statisticallysignificant (P

Objective To determine the value of shear wave elastography (SWE) in assessing abdominal wall muscles, including rectus abdominis (RA), external oblique muscle (EO), internal oblique muscle, and transversus abdominis (TrA) in patients with diastasis recti abdominis (DRA) and healthy controls. Methods From October 2018 to December 2019, 36 postpartum DRA patients and 24 nulliparous healthy women were identified. Inter-rectus distance (IRD) measurements were taken by B-mode ultrasound. Shear wave speed (SWS) values were acquired by one operator at ten specific locations. Clinical and ultrasound variables, including demographics, IRD, muscle thickness, and muscle SWS, were compared between the two groups using Student’s t test or Fisher's exact test. Pearson correlation analyses were conducted for the variables of IRD, muscle thickness, and SWS in the 36 DRA patients. Results The maximum diameter of recti abdominus separation was located at the umbilicus in DRA patients (4.59 ± 1.14 cm). The SWS value was significantly lower in the RA (p = 0.003) and higher in the TrA muscle (p p p = 0.001). Conclusions The application of SWE to abdominal wall muscles in DRA patients is feasible. The correlation between SWS value and IRD in RA should be interpreted with caution.

Background The management of large abdominal wall defects, such as omphalocele or gastroschisis, remains a challenge for pediatric surgeons. Though several techniques have been described to repair those conditions, there is no procedure considered to be the standard worldwide. We report an infant girl with a giant ventral hernia after staged surgery for omphalocele in whom delayed closure of a large abdominal wall defect was performed successfully using “endoscopic component separation technique (ECST)” without serious complications. Case presentation A baby girl was admitted to our hospital because of a giant omphalocele, which had been prenatally diagnosed. The omphalocele was supraumbilical and included the entire liver. After staged surgery, a large abdominal wall defect was closed by skin, creating a giant ventral hernia. We performed endoscopic separation component technique (ECST) for the closure of her abdominal wall defect when she was 11 months of age. ECST was initiated with placement of a 5.0-mm port just above the inguinal ligament and under the external oblique muscle. The space between the external and internal oblique muscles was created by the insufflation pressure, and a second 5.0-mm port was placed at 1.0 cm below the inferior edge of the rib into the space. As the further dissection was carried, the aponeurosis of the external oblique muscle was identified as a white line, running vertically from the epigastrium to inguinal ligament. It was transected longitudinally using electrocautery over its full length. The same procedure was performed on the contralateral side and the abdominal wall was successfully closed. Postoperative course was uneventful. Conclusions The technique of ECST, described here, is simple and safe for infants, and the cosmetic result is satisfactory.

This chapter illustrates a technique of free muscle flap harvesting and its subsequent transfer with revascularization. The second part of the chapter demonstrates an experiment with neovascularization of the abdomen’s external oblique muscle wrapped around the superficial lower epigastric vessels. Latissimus dorsi and neovascularized flap rectus abdominis are excellent training and experimental interventions, especially for experienced microsurgeon.

There have been no studies in which the change in lateral abdominal muscle thickness was compared with shear modulus and electromyography during isometric contraction. Thus, the aim of this study was to compare the change in external oblique muscle (EO) thickness in relation to shear modulus and electromyography during isometric contraction. The case report was conducted on a healthy man, 46 years of age, without any low back pain symptoms within two years prior to the study. An Aixplorer ultrasound was used in SSI mode to measure muscle thickness and shear modulus in the EO on the right side of the body. The eMotion EMG system was used to control EO muscle activity. The expected force (0 kg, 4 kg, 6 kg, 7 kg) was controlled by a force gauge coupled with an external S-Type load cell. Relative to EO rest thickness during an isometric contraction, EO muscle thickness decreased for each force used. Compared to the rest stage (0 N), the EO shear modulus during an isometric contraction systematically increased, which suggested diminished elasticity during the generation of more force. Similarly, EO activity for Chanel 1 and 2 increased during isometric contraction. Changes in the thickness of the lateral abdominal muscles using ultrasound imaging should not be equated with a change in their function or force generation ability.

The components separation technique (CS) is used for the reconstruction of complex abdominal wall defects. Release and undermining of the rectus abdominis muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline, reducing recurrence of ventral hernia, but causes major changes in the physiology of abdominal wall. The purpose of the study was to determine which muscle release and undermining produces the lowest tension on the midline.Twenty fresh cadavers were dissected and the anterior and posterior layers of the rectus sheath were isolated in the midline. The forces necessary to advance the layers of the rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after release and undermining of the right RAM and left EOM; and after release and undermining of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for the different muscles involved, layers of the rectus sheath, measurement points, and stages of separation.Tension on the abdominal midline after the release and undermining of both the RAM and EOM was reduced by 56% (p0.05), 42% after the release and undermining of the EOM alone (p0.05), and 35% after release and undermining of the RAM alone (p0.05).Release and undermining of the EOM by CS led to lower tension on the abdominal midline compared to that associated with the release of the RAM alone.

Background Over the last few years, various concepts of applying core stabilization mechanisms in the formation of human motor function have come to existence. The objective of the research was to assess the influence of two types of core stability training on deep abdominal muscle thickness and on global trunk mobility. Methods The study involved 108 individuals divided into 3 groups: LT (local training), performing the stability training based on locally isolated work of the transversus abdominis muscle; GT (global training), performing the training based on global movement patterns; and CG (control group), who did not undergo the training. The workout programs comprised 4 weeks of the exercise, 4 times a week. The measurement of the observed muscle thickness was carried out by means of ultrasound imaging. Trunk mobility was evaluated based on the toe-touch test, as well as the measurement of lateral flexion ranges. All the measurements were performed before the workout programs, right after finishing and 2 weeks after the end of the training cycle. Results Both training concepts have an impact on deep abdominal muscle thickness; however, in the LT group, significant improvement was noted with regard to the transversus abdominis, whereas in the GT group the improvement concerned the external oblique muscle. Both training methods also improved trunk mobility in the sagittal and frontal plane. Conclusions The results we have obtained imply that both concepts of core stability training affect the human body at a structural as well as functional level. The application of the described training methods may not only provide measurable benefits in the field of clinical physiotherapy, for instance in the treatment of spine-related back pain, but also in motor training designed to improve athletes' performance and to minimize the risk of injury.

Highlights • We present three cases of incisional hernia repair using onlay self-gripping mesh. • The mesh was placed following the anterior component separation technique. • Self-gripping mesh enhances tissue adhesion and requires minimal suture fixation. • The advantages are more sufficient reinforcement and technical simplicity. • The disadvantages are risk of decreased blood flow, infection, fistula, and pain., Introduction Incisional hernia (IH) is a common postoperative complication that affects 10% of the patients who undergo abdominal surgery. The component separation (CS) technique is suitable for large and/or complex hernias; however, CS alone may not eliminate recurrence and is associated with an increased incidence of wound complications. Self-gripping mesh enhances tissue adhesion and contributes to a reduced risk of migration, chronic pain, and other complications. Here, we present three cases of IH that were successfully repaired by anterior CS (ACS) using onlay self-gripping meshes. Case presentation All three patients underwent surgery using the following technique: Briefly, a skin flap was created with release of the external oblique muscle and preservation of the perforating vessels. The linea alba was closed with absorbable interrupted sutures. A self-gripping mesh was trimmed and placed with a 4–5 cm overlap bilaterally from the closed linea alba using an onlay technique. For all patients, the postoperative courses were uneventful and there were no complications at the 3-month follow-up. Discussion The advantages of our technique include more sufficient abdominal reinforcement, technical simplicity, and minimal time required for mesh placement. The disadvantages are the potential risk of decreased blood flow of the skin flaps, wound infection, intestinal fistula, persisting or chronic pain, and difficulty with subsequent abdominal surgery. Conclusion The use of self-gripping mesh with ACS can be performed without increasing the operative time or causing short-term surgical complications. This technique may be recommended for large IH because of its simplicity and secure abdominal reinforcement provided.

Purpose: The purpose of this study was to evaluate the effect of task-oriented exercise and abdominal muscle contraction using functional electrical stimulation (FES) on abdominal muscle thickness and balance of stroke patients. Methods: Ten stroke patients who met the selection criteria were assigned randomly into two groups of five. One group received FES therapy before task-oriented training (experimental group), while the other group received a FES placebo before task-oriented training (control group). The Mann-Whitney U test was used to compare the groups, and the Wilcoxon Signed-ranks test was used to compare differences between the groups before and after intervention. The Mann-Whitney U test was used to compare the rate changes of each item before and after intervention, between the two groups. Results: In the rectus abdominalis and external oblique muscle thickness tests that used ultrasound, there was a statistically significant difference in the experimental group (p .05). There was also a significant difference between the groups (p .05). Conclusions: FES therapy before task-oriented training increases the thickness of abdominal muscles and improves balance abilities.

Introduction Development of indirect inguinal hernias through the inguinal canal is usually prevented by the shutter and the sphincteric mechanisms, which are known to be destroyed by almost all anterior herniorrhaphies. Objective A new preperitoneal repair, which uses a bipedicled external oblique oponeurotic flap, has been recently introduced and was suggested to change the mechanics of this area. In this hernia repaires, the biomechanics of the inguinal region were assessed in healthy individuals and in patients with hernia after new repair and after other conventional anterior hernial repairs. Methods The study included 20 patients with inguinal hernias and 5 non-hernia control cases (group A). Ten of the hernia cases were repaired by the new preperitoneal repair (group B) wheareas the other 10 were repaired by convemtional anterior repair (modified Bassini) (group C). The 5 control cases were selected from patients without hernia, who were scheduled for inguinal surgery for excision of symptomatic varicoceles. During surgery in all cases, two ligaclips were inserted into the ileopubic tract. After sound healing, all cases were radiographed to detect any change in the position of the ligaclips, on contraction of the external oblique muscle. Any displacement of the inserted ligaclips was considered in this study as a sort of mobility at the floor of the inguinal canal, induced by the contracted muscle. Results The study showed that contraction of the external oblique muscle induced, in all cases, a degree of an upward displacement of the floor of the inguinal canal, which could be called a reversed shutter movement. The magnitude of this reversed shutter mobility was nearly identical in normal controls and in cases that underwent conventional anterior hernial repairs. Conclusion The new preperitoneal repair, with the bipedicled external oblique oponeurotic flap, was found to augment this reversed shutter movement significantly. The possible explanation and the forces that possibly induced this reversed shutter mechanism are herein presented and discussed.