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Hernia repairs are the most common abdominal wall elective procedures performed by general surgeons. Hernia-related postoperative infective complications occur with 10% frequency. To counteract the risk of infection emergence, the development of effective, biocompatible and antimicrobial mesh adjuvants is required. Therefore, the aim of our in vitro investigation was to evaluate the suitability of bacterial cellulose (BC) polymer coupled with gentamicin (GM) antibiotic as an absorbent layer of surgical mesh. Our research included the assessment of GM-BC-modified meshes' cytotoxicity against fibroblasts ATCC CCL-1 and a 60-day duration cell colonisation measurement. The obtained results showed no cytotoxic effect of modified meshes. The quantified fibroblast cells levels resembled a bimodal distribution depending on the time of culturing and the type of mesh applied. The measured GM minimal inhibitory concentration was 0.47 µg/mL. Results obtained in the modified disc-diffusion method showed that GM-BC-modified meshes inhibited bacterial growth more effectively than non-coated meshes. The results of our study indicate that BC-modified hernia meshes, fortified with appropriate antimicrobial, may be applied as effective implants in hernia surgery, preventing risk of infection occurrence and providing a high level of biocompatibility with regard to fibroblast cells.

Introduction: Introduction: teduglutide (TED) is indicated for the treatment of patients with short-bowel syndrome (SBS) who are dependent on parenteral support. Case report: we report the case of a 60-year-old woman with SBS treated with TED. She had previously undergone multiple surgical resections due to Crohn's disease. Her remnant bowel included only the duodenum and 50-60 centimeters of jejunum. The patient was dependent on intravenous fluids (2,320 mL/48 h) and had a high stoma output (3,000 mL/day). After four months of TED the jejunostomy output had decreased to 2,200 mL/day with a thicker consistency, and intravenous fluid therapy was reduced to 2,010 mL/48 h. TED was withdrawn due to acute pancreatitis and enlargement of two supraumbilical hernias with high strangulation risk. Discussion: pancreatitis has been reported in clinical studies, and determination of amylase and lipase is recommended in all patients receiving TED. In contrast, there are no recommendations for the surveillance of hernia enlargement in patients on TED therapy, but we suggest the need for surveillance based on this case report.

Background: Effective repair of full-thickness abdominal wall defects requires a patch with sufficient mechanical strength and anti-adhesion characteristics to avoid the formation of hernias and intra-abdominal complications such as intestinal obstruction and fistula. However, patches made from polymers or bio-derived materials may not meet these requirements and lack the bionic characteristics of the abdominal wall., Materials and Methods: In this study, we report a consecutive electrospun method for preparing a double-layer structured nanofiber membrane (GO-PCL/CS-PCL) using polycaprolactone (PCL), graphene oxide (GO) and chitosan (CS). To expand the bio-functions (angiogenesis/reducing reactive oxygen species) of the patch (GO-PCL/NAC-CS-PCL), N-acetylcysteine (NAC) was loaded for the repair of full-thickness abdominal wall defects (2×1.5cm) in rat model., Results: The double-layered patch (GO-PCL/NAC-CS-PCL) showed excellent mechanical strength and biocompatibility. After 2 months, rats treated with the patch exhibited the desired repair effect with no hernia formation, less adhesion (adhesion score: 1.50±0.50, P<0.001) and more collagen deposition (percentage of collagen deposition: 34.94%±3.31%, P<0.001)., Conclusion: The double-layered nanomembranes presented in this study have good anti-hernia and anti-adhesion effects, as well as improve the microenvironment in vivo. It, therefore, holds good prospects for the repair of abdominal wall defects and provides a promising key as a postoperative anti-adhesion agent., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Liu et al.)

Polypropylene (PP) meshes are the most widely used as hernioplasty prostheses. As far as hernia repair is concerned, bacterial contamination and tissue adhesion would be the clinical issues. Moreover, an optimal mesh should assist the healing process of hernia defect and avoid undesired prosthesis displacements. In this present study, the commercial hernia mesh was modified to solve the mentioned problems. Accordingly, a new bi-functional PP mesh with anti-adhesion and antibacterial properties on the front and adhesion properties (reduce undesired displacements) on the backside was prepared. The backside of PP mesh was coated with polycaprolactone (PCL) nanofibers modified by mussel-inspired L-3,4-dihydroxyphenylalanine (L-DOPA) bioadhesive. The front side was composed of two different nanofibrous mats, including hybrid and two-layered mats with different antibacterial properties, drug release, and biodegradation behavior, which were based on PCL nanofibers and biomacromolecule carboxyethyl-chitosan (CECS)/polyvinyl alcohol (PVA) nanofibers containing different ofloxacin amounts. The anti-adhesion, antibacterial, and biocompatibility studies were done through in-vitro experiments. The results revealed that DOPA coated PCL/PP/hybrid meshes containing ofloxacin below 20 wt% possessed proper cell viability, AdMSCs adhesion prevention, and excellent antibacterial efficiency. Moreover, DOPA modifications not only enhanced the surface properties of the PP mesh but also improved cell adhesion, spreading, and proliferation., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Mesh-related infection is a critical outcome for patients with hernia defect stabilized with synthetic or biological meshes. Even though bioactive meshes loaded with antibiotics or antiseptics are slowly emerging in the market, the available solutions still lack versatility. Here, we proposed a polymer solution, i.e., hyaluronic acid-poly(N-isopropylacrylamide) (HApN), which forms a hydrogel to be used as coating for meshes only when it reaches body temperature., Methods: We assessed how the gelation of HApN was influenced by the incorporation of different antibiotic and antiseptic formulations, and how this gel can be used to coat several mesh types. The impact of the coating on the elastic behavior of a macroporous mesh was tested under cyclic elongation condition. Finally, we selected two different coating formulations, one based on antibiotics (gentamicin + rifampicin) and one based on antiseptic (chlorhexidine) and tested in vitro their antimicrobial efficacies., Results: HApN can be used as carrier for different antimicrobial agents, without having a strong influence on its gelation behavior. Porous or dense meshes can be coated with this polymer, even though the stability was not optimal on macroporous meshes such as Optilene when pores are too large. HApN loaded with drugs inhibited in vitro the growth of several Gram-positive and Gram-negative bacteria., Conclusion: Compared to the available technologies developed to endow meshes with antibacterial activity, the proposed HApN offers further versatility with potential to prevent mesh-related infection in hernioplasty.

Competing Interests: Competing interests: None declared.

The aim of this study was to investigate whether enoxaparin (ENX) administration would increase seroma risk and worsen mesh tissue recovery in an experimental rat hernia repair model. Fifty-six adult male Wistar-Albino rats were included in the study. Rats were equally and randomly separated into seven groups: Group 1, Control, only subcutaneous dissection was performed; group 2, Sham, Hernia defect was primary sutured; Group 3, Prolene mesh; Group 4, Dual mesh; Group 5, ENX + Sham; Group 6, ENX + Prolene mesh; Group 7, ENX + Dual mesh. ENX was subcutaneously injected at a dose of 180 U/kg per day for 7 days. Rats were killed after the amount of subcutaneous seroma was determined by ultrasound on day 7 following the surgical procedure. Mesh-tissue healing was evaluated using histopathological and immunohistochemical (CD31) staining methods. The mean seroma amount significantly increased in Groups 5-7 compared to Groups 2-4. CD31 immunostaining showed a reduction in neovascularization in Groups 6 and 7, compared to Groups 3 and 4. Neovascularization decreased and hemorrhage, necrosis and oedema findings remarkably increased in Groups 6 and 7, when compared to Groups 3 and 4. Fibroblastic activity and inflammation were more prominent in Groups 3 and 4. It should be kept in mind that ENX interferes with inflammation, which is desired in the early period of healing and leads to an increase in overall seroma amount with anti-coagulant effects, which in turn may disrupt wound healing and mesh-tissue adhesions, as was indicated in our study., (© 2016 John Wiley & Sons Australia, Ltd.)

The protrusion of articular soft-tissue from the temporomandibular joint (TMJ) into the external ear in the absence of trauma, neoplasm or inflammation is rare. We present below a Nigerian adult male with retrodiscal herniation of soft-tissues of the TMJ into the external auditory meatus through a persistent foramen of Huschke. We are not aware of any reports of this developmental defect or its prevalence in the Nigerian medical literature. Therefore, this case is presented to heighten the index of suspicion of physicians when managing patients with otorrhea and otalgia; which is often primarily diagnosed or misdiagnosed as otitis externa. This will help avoid complications associated with the anomaly, some of which could be very serious.

Background: To evaluate the use of hyperosmolar therapy in the management of elevated intracranial pressure (ICP) and transtentorial herniation (TTH) in patients with renal failure and supratentorial lesions., Methods: Patients with renal failure undergoing renal replacement therapy treated with 23.4% saline (30-60 mL) and/or mannitol for high ICP or clinical evidence of TTH were analyzed in a retrospective cohort., Results: The primary outcome measure was reversal of TTH or ICP crisis. Secondary outcome measures were modified Rankin scale on hospital discharge, survival to hospital discharge, and adverse effects. Of 254 subjects over 7 years, 6 patients with end-stage renal disease had 11 events. All patients received a 23.4% saline bolus, along with mannitol (91%), hypertonic saline (HS) maintenance fluids (82%), and surgical interventions (n = 2). Reversal occurred in 6/11 events (55%); 2 of 6 patients survived to discharge. ICP recording of 6 TTH events showed a reduction from ICP of 41 ± 3.8 mmHg (mean ± SEM) with TTH to 20.8 ± 3.9 mmHg (p = 0.05) 1 h after the 23.4% saline bolus. Serum sodium increased from 141.4 to 151.1 mmol/L 24 h after 23.4% saline bolus (p = 0.001). No patients were undergoing hemodialysis at the time of the event. There were no cases of pulmonary edema, clinical volume overload, or arrhythmia after HS., Conclusions: Treatment with hyperosmolar therapy, primarily 23.4% saline solution, was associated with clinical reversal of TTH and reduction in ICP and had few adverse effects in this cohort. Hyperosmolar therapy may be safe and effective in patients with renal failure and these initial findings should be validated in a prospective study.

Background: An ethnomedicinal study was conducted to document medicinal plants used in the treatment of ailments in villages surrounding Kimboza forest reserve, a low land catchment forest with high number of endemic plant species., Methods: Ethnobotanical interviews on medicinal plants used to treat common illnesses were conducted with the traditional medical practitioners using open-ended semi -structured questionnaires. Diseases treated, methods of preparation, use and habitat of medicinal plants were recorded., Results: A total of 82 medicinal plant species belonging to 29 families were recorded during the study. The most commonly used plant families recorded were Fabaceae (29%), Euphorbiaceae (20%), Asteraceae and Moraceae (17% each) and Rubiaceae (15%) in that order. The most frequently utilized medicinal plant parts were leaves (41.3%), followed by roots (29.0%), bark (21.7%), seeds (5.31%), and fruits (2.6%). The study revealed that stomach ache was the condition treated with the highest percentage of medicinal plant species (15%), followed by hernia (13%), diarrhea (12), fever and wound (11% each), and coughs (10%). Majority of medicinal plant species (65.9%) were collected from the wild compared to only 26.7% from cultivated land., Conclusions: A rich diversity of medicinal plant species are used for treating different diseases in villages around Kimboza forest reserve, with the wild habitat being the most important reservoir for the majority of the plants. Awareness programmes on sustainable utilization and active involvement of community in conservation programmes are needed.

Uncal herniation due to a large cerebral infarct is well-described in adults, with high rates of morbidity and mortality. This phenomenon, however, has not been previously reported in neonates. We present a newborn male delivered via cesarean section with difficult extraction who presented with frequent seizures. He was found to have an acute left MCA territory infarct secondary to an M1 occlusion detected on MRI/MRA. He became lethargic and developed a left uncal herniation on CT at 72h of life. He was treated medically with osmolar agents and hemodynamic support, and had resolution of the herniation on CT at 120h of life. At 19 months he had residual moderate right hemiparesis with only mild gait disturbance and mild speech delay. As seen in this case, uncal herniation, though rare, may occur in neonates. Also, the outcome for this neonate was much better than for typical adults with a similar disease course.

Objective: To evaluate the role of 23.4% saline in the management of transtentorial herniation (TTH) in patients with supratentorial lesions., Methods: Consecutive patients with clinically defined TTH treated with 23.4% saline (30 to 60 mL) were included in a retrospective cohort. Factors associated with successful reversal of TTH were determined., Results: Seventy-six TTH events occurred in 68 patients admitted with intracerebral hemorrhage (n = 29), subarachnoid hemorrhage (n = 16), stroke (n = 8), brain tumor (n = 8), subdural hematoma (n = 5), epidural hematoma (n = 1), and meningitis (n = 1). In addition to 23.4% saline, TTH management included hyperventilation (70% of events), mannitol (57%), propofol (62%), pentobarbital (15%), ventriculostomy drainage (27%), and decompressive hemicraniectomy (18%). Reversal of TTH occurred in 57/76 events (75%). Intracranial pressure decreased from 23 +/- 16 mm Hg at the time of TTH to 14 +/- 10 mm Hg at 1 hour (p = 0.002), and 11 +/- 12 mm Hg at 24 hours (p = 0.001) among 22 patients with intracranial pressure monitors. Reversal of TTH was predicted by a >/=5 mmol/L rise in serum sodium concentration (p = 0.001) or an absolute serum sodium of >/=145 mmol/L (p = 0.007) 1 hour after 23.4% saline. Adverse effects included transient hypotension in 13 events (17%); no evidence of central pontine myelinolysis was detected on post-herniation MRI (n = 18). Twenty-two patients (32%) survived to discharge, with severe disability in 17 and mild to moderate disability in 5., Conclusion: Treatment with 23.4% saline was associated with rapid reversal of transtentorial herniation (TTH) and reduced intracranial pressure, and had few adverse effects. Outcomes of TTH were poor, but medical reversal may extend the window for adjunctive treatments.

Objective: To determine complications and neurologic outcomes associated with dexamethasone administration to dogs with surgically treated thoracolumbar intervertebral disk herniation, compared with dogs not receiving dexamethasone., Design: Retrospective case series., Animals: 161 dogs with surgically confirmed thoracolumbar disk herniation., Procedures: Medical records from 2 hospitals were used to identify dogs that had received dexamethasone < 48 hours prior to admission (dexamethasone group dogs), dogs that received glucocorticoids other than dexamethasone < 48 hours prior to admission (other-glucocorticoid group dogs), and dogs that received no glucocorticoids (nontreatment group dogs). Signalment, neurologic injury grade, laboratory data, and complications were extracted from medical records., Results: Dexamethasone group dogs were 3.4 times as likely to have a complication, compared with other-glucocorticoid or nontreatment group dogs. Dexamethasone group dogs were 11.4 times as likely to have a urinary tract infection and 3.5 times as likely to have diarrhea, compared with other-glucocorticoid or nontreatment group dogs. No differences in neurologic function at discharge or recheck evaluation were detected among groups., Conclusions and Clinical Relevance: Results indicated that treatment with dexamethasone before surgery is associated with more adverse effects, compared with treatment with glucocorticoids other than dexamethasone or no treatment with glucocorticoids, in dogs with thoracolumbar intervertebral disk herniation. In this study population, no difference in outcome was found among groups. These findings suggest that the value of dexamethasone administration before surgery in dogs with thoracolumbar disk herniation should be reconsidered.

Background: Few data are presently available on the effective control of cavernous sinus (CS) invasion of invasive prolactinomas. The aim of this retrospective study, through a mean period of 5 years follow up, is to observe the tumor shrinkage of CS invasive prolactinomas, as well as PRL normalization with bromocriptine therapy., Methods: 68 patients met the criteria of invasive prolactinomas (Grade III or IV in the classification scheme of Knosp and colleagues; serum PRL level greater than 200 ng/ml). 33 patients underwent bromocriptine therapy as the initial treatment, and 14 of these 33 had combined treatment with microsurgery and/or radiotherapy. The other 35 patients received microsurgery as the primary treatment, after which two patients had normal PRL without taking bromocriptine and other 33 patients received bromocriptine treatment after microsurgery., Results: Tumor volume on magnetic resonance images had completely disappeared in 50 patients (74%), while all the other 18 patients had residual tumor in the parasellar areas, invading the CS, and 14 patients had a secondary empty sella due to tumor shrinkage. Of those 14 patients, seven still had elevated PRL levels; five had optic chiasmal herniation by different degrees (P < 0.05). There were 49 patients with normal PRL levels (72%); five patients with PRL levels more than 200 ng/ml. After the treatment, 14 patients with tumor volume disappearance on MR images and PRL normalization therefore withdrew from bromocriptine therapy. During a subsequent one-and-a-half-year follow-up, tumor recurrence and PRL increase were not found in those 14 patients. Twenty-seven patients maintained normal PRL levels with low-dose bromocriptine, of which 20 patients had their tumor disappear while seven patients had CS residual tumor., Conclusions: About three-fourths of prolactinomas with CS invasion can be effectively controlled not only with regard to tumor volume disappearance but also in serum PRL normalization. Residual tumor in the CS areas with PRL normalization and no pressure symptoms can be treated with low-dose of bromocriptine so as to achieve long-term tumor volume control and endocrine control. Great attention should be paid to CS residual tumors accompanying the empty sella, especially in cases with optic chiasmal herniation.

Objective: To determine the success of medical management of presumptive cervical disk herniation in dogs and variables associated with treatment outcome., Design: Retrospective case series., Animals: Dogs (n=88) with presumptive cervical disk herniation., Methods: Dogs with presumptive cervical and thoracolumbar disk herniation were identified from medical records at 2 clinics and clients were mailed a questionnaire related to the success of therapy, clinical recurrence of signs, and quality of life (QOL) as interpreted by the owner. Signalment, duration and degree of neurologic dysfunction, and medication administration were determined from medical records., Results: Ninety-seven percent of dogs (84/87) with complete information were described as ambulatory at initial evaluation. Successful treatment was reported for 48.9% of dogs with 33% having recurrence of clinical signs and 18.1% having therapeutic failure. Bivariable logistic regression showed that non-steroidal anti-inflammatory drug (NSAID) administration was associated with success (P=.035; odds ratio [OR]=2.52). Duration of cage rest and glucocorticoid administration were not significantly associated with success or QOL. Dogs with less-severe neurologic dysfunction were more likely to have a successful outcome (OR=2.56), but this association was not significant (P=.051)., Conclusions: Medical management can lead to an acceptable outcome in many dogs with presumptive cervical disk herniation. Based on these data, NSAIDs should be considered as part of the therapeutic regimen. Cage rest duration and glucocorticoid administration do not appear to benefit these dogs, but this should be interpreted cautiously because of the retrospective data collection and use of client self-administered questionnaire follow-up., Clinical Relevance: These results provide insight into the success of medical management for presumptive cervical disk herniation in dogs and may allow for refinement of treatment protocols.

Two aged dogs with chronic obstructive airway disease were evaluated because of intermittent swelling of the ventral cervical region. Radiographs made at expiration and caudal positioning of the forelimbs allowed identification of intermittent cervical lung herniation of the left and right cranial lung lobe in both dogs. Pulmonary hyperinflation, increased expiratory effort, and chronic coughing were considered responsible for the lung herniation. Cervical lung hernia should be included in the differential diagnoses of intermittent cervical swelling in dogs with chronic respiratory disorders associated with increased expiratory effort and chronic coughing.

The results of treatment were analyzed in 70 patients with dystrophic diseases of the lumbosacral spine complicated by the displacement of intervertebral disks. All the examinees had a long history and a protracted exacerbation resistant to conservative therapy. Long-term local epidural pharmacotherapy (LTLEP) was used for their treatment. The essence of the method was to employ selective catheterization under X-ray guidance of the epidural space, to bring a catheter directly to a pathological area. Further it was irrigated with drugs many times. The results of treatment were analyzed from changes in the pain syndrome in the early and periods and from the data of repeated studies (magnetic resonance imaging (MRI) and computed tomography (CT)). LTLEP was highly effective, i.e. 84.3% of positive results. Follow-up MRI or CT findings show that the pathological substrate disappears or significantly decreases in sizes in 83.4% of cases. LTLEP is safe: in the study group, there were no complications due to the manipulation itself and after treatment the patients' health status did not deteriorate owing to a therapeutic process. If conservative therapy is inefficient, it may be used as an alternative to conventional and low-invasive neurosurgical operations.

For more than 3 decades, piezogenic pedal papules have been described in the literature. While many individuals with these papules are asymptomatic, patients with trauma or connective tissue diseases can experience pain. In our case study, we describe a unique, nonsurgical approach that abates the pain of painful piezogenic pedal papule (PPPP). Three injections of a solution of equal parts betamethasone (Celestone) and bupivacaine (Marcaine) were curative in a male patient with Ehlers-Danlos syndrome type III with PPPP. In addition, combination steroid/anesthetic injection provides another method of treatment in the management of PPPP.

Background: Injectable phosphatidylcholine, a lecithin-derived phospholipid, has been previously demonstrated to improve the appearance of infraorbital fat pad herniation. Current use internationally has led to a significant interest in this novel substance., Objective: To evaluate the efficacy and safety of injectable phosphatidylcholine, we conducted an open-label study for the treatment of infraorbital fat pad herniation., Methods: Patients received 0.4-mL phosphatidylcholine (50 mg/mL) injections within infraorbital fat pads every 2 weeks. Patient and physician grading of fat herniation, side effects, digital photographs, and a follow-up questionnaire was recorded., Results: Ten of the 13 enrolled patients had three to five treatments. Improvements in fat herniation were reported in 80% and 70% of patients as graded by the physician and patients, respectively. Sixty percent of patients assessed their improvement as equal or greater than 5 points (on a 10-point fat herniation scale); however, the physician judged 40% of patients improving to this degree. Little or no response was seen in three patients. Side effects included burning, erythema, and swelling at the injection site. At follow-up averaging 9 months, 50% of patients reported persistence of benefit, 20% experienced some fading, and 30% were the nonresponders., Conclusions: Injectable phosphatidylcholine is a novel treatment for infraorbital fat herniation that may benefit some patients who are considering blepharoplasty. Larger studies evaluating long-term safety and efficacy of phosphatidylcholine for cosmetic purposes are warranted.

A 53-year-old patient developed an impairing muscle hernia when a fascia lata graft was harvested as a substitute for a cruciate ligament of the knee and closure of the defect was not possible. The fascial defect enlarged with time, extending along the whole upper leg. The large muscle protrusion and incarceration in the distal fascial slit was extremely painful during walking and getting up from a chair. Since autologous grafts were disregarded because of the high tissue pressure and alloplastic substitutes seemed problematic, the large hernia was successfully reduced by local muscle denervation with injections of botulinum-A toxin into the protruding vastus lateralis muscle. This procedure achieved relief of pain and enabled the patient to walk without complaints. Side effects were not observed.

A retrospective review of 1,200 nucleolyses performed over a three year period from January 1995 to December 1997 showed 116 discal treatments for foraminal and extra-foraminal localizations. The anatomic localization through the foramen and the intense clinical signs typify these anatomoclinical forms of lumbar hernia. In contrast with complex and disruptive surgical cure, percutaneous nucleolysis offers a precise and rapid method which can be performed in a very short time in outpatients with a success rate of 80%. Most localizations concern L3-L4 and L4-L5 hernias which give the best clinical outcomes.

An unusual foreign body reaction to silica (quartz), resembling fibrous histiocytoma, is described in 7 patients (age range 22 to 71 years). These lesions occurred in the inguinal region (4 cases) or the abdominal wall (3 cases), and in 5 instances were associated with a history of injection at the same site 10 to 41 years previously. Most commonly the injection consisted of the administration of a sclerosing agent for the repair of a hernia. Microscopically these lesions contained broad sheets of histiocytes separated by bands or concentrically lamellated nodules of collagen. Intra- and extra-cellular birefringent crystals, identified by x-ray diffraction as silica (quartz), were present in all cases and served to distinguish this process from a true neoplasm. Although the injection therapy for hernia is now obsolete, it was formerly practiced in the United States with a variety of sclerosing agents including silica (quartz). Since these lesions are often confused with a benign or malignant fibrous histiocytoma it is recommended that fibro-histiocytic lesions associated with a previous hernia or injection at the same site be examined for the presence of silica.