Pre-expanded epigastric flap cover for ventral hernia following fungal necrotizing fascitis of caesarian section wound: An unusual complication

Introduction

Reconstruction of anterior abdominal wall after necrotizing abdominal wall infections is a challenge.

Material and methods

A 35-year-old lady presented with 20 × 18 cm sized defect of the anterior abdominal wall following fungal necrotizing fascitis. The defect was covered by an overlay prolene mesh and the soft tissue deficit was corrected by pre-expanded epigastric flap based on the superior epigastric artery.

Conclusion

A concerted multi-specialty effort is needed to correct these defects.

     

Polypropylene-based composite mesh versus standard polypropylene mesh in the reconstruction of complicated large abdominal wall hernias: a prospective randomized study

Purpose

To compare polypropylene mesh positioned onlay supported by omentum and/or peritoneum versus inlay implantation of polypropylene-based composite mesh in patients with complicated wide-defect ventral hernias.

Methods

This was a prospective randomized study carried out on 60 patients presenting with complicated large ventral hernia in the period from January 2012 to January 2016 in the department of Gastrointestinal Surgery unit and Surgical Emergency of the Main Alexandria University Hospital, Egypt. Large hernia had an abdominal wall defect that could not be closed. Patients were divided into two groups of 30 patients according to the type of mesh used to deal with the large abdominal wall defect.

Results

The study included 38 women (63.3 %) and 22 men (37.7 %); their mean age was 46.5 years (range, 25–70). Complicated incisional hernia was the commonest presentation (56.7 %).The operative and mesh fixation times were longer in the polypropylene group. Seven wound infections and two recurrences were encountered in the propylene group. Mean follow-up was 28.7 months (2–48 months).

Conclusions

Composite mesh provided, in one session, satisfactory results in patients with complicated large ventral hernia. The procedure is safe and effective in lowering operative time with a trend of low wound complication and recurrence rates.

     

Abdominal wall dysfunction in adult bladder exstrophy: a treatable but under-recognized problem

Purpose

Bladder exstrophy is defined by urogenital and skeletal abnormalities with cosmetic and functional deformity of the lower anterior abdominal wall. The primary management objectives have historically been establishment of urinary continence with renal function preservation, reconstruction of functional and cosmetically acceptable external genitalia, and abdominal wall closure of some variety. The literature has focused on the challenges of neonatal approaches to abdominal wall closure; however, there has been a paucity of long-term followup to identify the presence and severity of abdominal wall defects in adulthood. Our goal was to characterize the adult disease and determine effective therapy.

Methods

A retrospective review of a consecutive series of six patients was performed.

Results

We report and characterize the presence of severe abdominal wall dysfunction in these adult exstrophy patients treated as children. We tailored an abdominal wall and pelvic floor reconstruction with long-term success to highlight a need for awareness of the magnitude of the problem and its solvability.

Conclusions

The natural history of abdominal wall laxity and the long-term consequences of cloacal exstrophy closure have gone unexplored and unreported. Evaluation of our series facilitates understanding in this complex area and may be valuable for patients who are living limited lives thinking that no solution is available.

     

Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation

Background

A minority of patients undergoing posterior component separation (PCS) have abdominal wall defects that preclude complete reconstruction of the visceral sac with native tissue. The use of absorbable mesh bridges (AMB) to span such defects has not been established. We hypothesized that AMB use during posterior sheath closure of PCS is safe and provides favorable outcomes.

Methods

We performed a retrospective review of consecutive patients undergoing PCS with AMB at two hernia centers. Main outcome measures included demographics, comorbidities, and post-operative complications.

Results

36 patients were identified. Post-operative wound complications included five surgical site infections. At a median of 27 months, there were five recurrent hernias (13.9%), 2 of which were parastomal, but no episodes of intestinal obstruction/fistula.

Conclusions

Utilization of AMB for large posterior layer deficits results in acceptable rates of perioperative wound morbidity, effective PCS repairs, and does not increase intestinal morbidity or fistula formation.

     

Mesh migration into the esophageal wall after mesh hiatoplasty: comparison of two alloplastic materials

Background

Hiatal mesh implantation in the operative treatment of gastroesophageal reflux disease has become an increasing therapy option. Besides clinical results little is known about histological changes in the esophageal wall.

Methods

Two different meshes [polypropylene (PP), Prolene^®; polypropylene–polyglecaprone 25 composite (PP–PG), Ultrapro^®] were placed on the diaphragm circular the esophagus of 20 female rabbits. After three months a swallow with iodine water-soluble contrast medium for functional analysis was performed. After the animals were sacrificed, histopathological evaluation of the foreign-body reaction, the localization of the mesh relating to the esophageal wall was analyzed.

Results

Sixteen rabbits survived the complete observation period of three months. After three months distinctive mesh shrinkage was observed in all animals and meshes had lost up to 50% of their original size before implantation. We found a delayed passage of the fluid into the stomach in all operated animals. There was a significant increased diameter of the outer ring of granulomas in the PP group (76.5 ± 8.0) compared to the PP–PG group (64 ± 8.5; p = 0.002). However, we found a mesh migration into the esophageal wall in six out of seven animals (PP) and five out of nine animals (PP-PG), respectively.

Conclusion

Experimental data suggest that more knowledge is necessary to assess the optimal size, structure, and position of prosthetic materials for mesh hiatoplasty. The indication for mesh implantation in the hiatal region should be carried out very carefully.

     

Submucosal Hematoma of the Sigmoid Colon as a Complication of Anticoagulation Treatment

Background

Anticoagulation therapy after coronary stent implantation is necessary and crucial for patients with severe coronary heart disease. Submucosal bleeding of the colon is an infrequent complication of anticoagulants.

Methods

TWe present the case of a 70-year-old woman with spontaneous submucosal hematoma and active bleeding of her sigmoid colon due to anticoagulants after intracoronary stenting.

Results

This patient underwent a timely surgical operation. Treated by our experienced multidisciplinary team, her recovery was smooth without any other major complications.

Conclusions

Surgical intervention is an appropriate therapy for patients with intractable bleeding.

     

Umbilical paracentesis for incarcerated umbilical hernia in patients with end-stage liver disease

Purpose

Patients with cirrhosis and ascites are prone to abdominal wall complications largely predominate by umbilical hernia. Elective surgery is indicated in select patients but a high morbidity and mortality rate occurs if it is performed in emergency conditions.

Methods

We present a clinical case of a patient with advanced alcoholic liver disease who came to the emergency room for an acutely incarcerated umbilical hernia. Due to the high surgical risk, we had to discuss other treatment options.

Results

The use of umbilical paracentesis for incarcerated hernia reduction in cirrhotic patients with tense ascites is a safe and reproducible technique.

Conclusions

Umbilical paracentesis could be considered as an alternative to emergency surgery in these high-risk patients.

     

High-Frequency of Computer Tomography and Surgery for Abdominal Pain After Roux-en-Y Gastric Bypass

Introduction

Acute, intermittent, and chronic abdominal pain is a common complaint after Roux-en-Y gastric bypass (RYGB).

Objectives

The aim of the study was to evaluate the use of medical imaging and the need for surgery treating abdominal pain after RYGB in a cohort with long-term follow-up.

Methods

Data from 569 patients who underwent RYGB as the primary bariatric procedure at a public hospital in Norway between April 2004 and June 2011 were prospectively registered in a local quality registry for bariatric surgery. All abdominal imaging and abdominal surgical procedures were registered until August 2017.

Results

Mean follow-up was 100 months (61–159). During the observation period, 22% had one CT, 9% had two CTs, 4% had three CTs, and 5% had four or more CTs for abdominal pain. Twenty-two percent underwent abdominal surgery, as 16% had one and 6% had two or more operations and gynecological procedures excluded. The purpose of operation was postoperative complications (1.4%), suspected internal herniation (9.3%), cholecystectomy (9.3%), appendectomy (2.3%), hernias (3.2%), and perforated ulcer in the gastrojejunal anastomosis (0.7%). Mean time interval was 42?±?27 months from RYGB to cholecystectomy and 51?±?26 months for suspected IH.

Conclusion

With a mean follow-up period of more than 8 years after RYGB, 40% of the patients suffered from abdominal pain, needing one or more CT scans. The need for surgery treating suspected internal hernia and cholecystectomy was equal, at 9.3% for both procedures, but the mean time from RYGB to operation was shorter for cholecystectomies.

     

Triclosan-coated sutures reduce wound infections after hepatobiliary surgery—a prospective non-randomized clinical pathway driven study

Objectives

Wound infections after abdominal surgery are still frequent types of nosocomial infections. Suture materials might serve as a vehicle for mechanical transport of bacteria into the surgical wound. To reduce bacterial adherence to surgical sutures, triclosan-coated polyglactin 910 suture materials with antiseptic activity (Vicryl plus®) were developed. The aim of this prospective non-randomized clinical pathway driven study was to ascertain if the use of Vicryl plus® reduced the number of wound infections after transverse laparotomy.

Patients and methods

Between October 2003 and October 2007, 839 operations were performed using a transverse abdominal incision. In the first time period, a PDSII® loop suture was used for abdominal wall closure. In the second time period, we used Vicryl plus®. Risk factors were collected prospectively to compare the two groups.

Results

Using a PDSII® loop suture for abdominal wall closure in the first time period, 9.2% of the patients developed wound infections. In the second time period, using Vicryl plus®, the number of wound infections decreased to 4.3% (p?

Conclusion

Antiseptic-coated loop Vicryl suture for abdominal wall closure can be superior to PDSII sutures in respect to the development of wound infections after a two-layered closure of transverse laparotomy.

     

The dome procedure: a new technique for the reconstruction of the umbilicus

Purpose

The absence of the umbilicus is, in essence, an aesthetic deformity of the abdominal wall. The goal of reconstructing the umbilicus is to obtain a natural, three-dimensional appearance. In this study, we present a new technique called the “dome procedure” for the reconstruction of the umbilicus.

Methods

This procedure can be applied under local anaesthesia on an outpatient basis and the drawing of the design is simple. The technique was applied to six patients who presented with an absence of the umbilicus following repair of a large incisional and umbilical hernia.

Results

No major or minor complications were encountered. Patient satisfaction was high after surgical intervention.

Conclusions

The dome procedure, which enables the umbilicus to have a natural appearance with sufficient depression and normal-appearing wrinkles, is simple, easy to perform, and safe.

     

Colonic diverticulosis is associated with abdominal wall hernia

Purpose

Colonic diverticulosis and abdominal wall hernia are common pathologies. Studies have suggested that connective tissue alterations play a role in the formation of both diverticulosis and abdominal wall hernia. The aim of this cohort study was to evaluate the association between diverticulosis and abdominal wall hernia in a large cohort of patients undergoing colonoscopy.

Methods

All consecutive patients who underwent colonoscopy between 2001 and 2013 at Bispebjerg Hospital were eligible for inclusion. The endoscopists prospectively registered the findings of diverticulosis in a database. Data were merged with the Danish Hernia Database identifying patients who underwent groin and ventral hernia repair. Calculated odds ratios (ORs) were used to describe the extent of association and multivariable logistic regression models were utilized to adjust for age and gender.

Results

A total of 13,855 patients were included, 3685 (26.6%) of whom were diagnosed with diverticulosis. Diverticulosis was independently associated with direct inguinal, OR 1.33, 95% CI 1.00–1.76, P = 0.049, and umbilical/epigastric hernia repair, OR 1.74, 95% CI 1.16–2.63, P = 0.008.

Conclusions

Colonic diverticulosis was associated with direct inguinal and umbilical/epigastric hernia repair suggesting that connective tissue alterations, herniosis, could be a common etiologic factor of colonic diverticulosis and these abdominal wall hernias.

     

Endovaskuläre Therapie genetisch bedingter Aortenerkrankungen

Background

The most important structural proteins of the vascular wall are collagen and elastin. Genetically linked connective tissue diseases lead to degeneration and aneurysm formation, spontaneous dissection or rupture of arteries. The most well-known are Marfan syndrome, vascular Ehlers-Danlos syndrome type IV, Loeys-Dietz syndrome and familial aortic aneurysms and dissections.

Objective

This review article adresses the current status of endovascular treatment options for important connective tissue diseases.

Material and methods

Evaluation of currently available randomized studies and register data.

Results

The therapy of choice for patients who are mostly affected at a young age is primarily conservative or open repair. There is only limited evidence for endovascular aortic repair (EVAR) of abdominal aneurysms or thoracic endovascular aortic repair (TEVAR).

Conclusion

The progression of the disease with dilatation leads to secondary endoleakage and high reintervention rates with uncertain long-term results. For this reason there is currently consensus that EVAR and TEVAR should be limited to justified exceptional cases and emergency situations in patients with genetically linked aortic diseases.

     

Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction

Purpose

Open abdominal wall reconstruction is often a complex endeavor, usually performed on patients with multiple risk factors and co-morbidities.

Methods

In this article, we review soft tissue management techniques that can optimize the skin and subcutaneous tissue, with the goal of reducing surgical-site occurrences.

Results

Regardless of the hernia repair technique used, outcomes can be highly dependent on the appropriate management of the skin and subcutaneous tissue. Indeed, dehiscence and surgical-site infection can jeopardize the entire reconstruction, especially in cases where synthetic mesh might become exposed and/or infected, setting up a “vicious cycle” (Holihan et al. in J Am Coll Surg 221:478–485, 2015).

Conclusion

Multidisciplinary cooperation between the general and plastic surgeon is useful in cases of tenuous blood supply to the abdominal skin, in cases of redundant, marginal or excessive skin, and in cases of deficient skin.

     

Repair of a vesicouterine fistula following cesarean section

Introduction and hypothesis

Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta.

Methods

A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video.

Results

No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage.

Conclusions

Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.

     

Transmigration of fibrino-purulent inflammation and malignant cells into an artificial dura substitute (Neuro-Patch®): report of two cases

Purpose

The objective of this work was to present possible, though rare, complications of Neuro-Patch® implantation after brain surgery.

Methods

Two patients, aged 62 and 63 years, who had a partial dural substitution with an artificial polyurethane graft after neurosurgical resection of a gross tumour, are presented.

Results

In the two patients, the avital tissue was infiltrated by either inflammatory or neoplastic tissue respectively.

Conclusions

This report demonstrates a new pathological point of view in using synthetic materials for the reconstruction of dural defects.

     

Cam morphology and inguinal pathologies: is there a possible connection?

Background

To analyse the prevalences of the cam and pincer morphologies in a cohort of patients with groin pain syndrome caused by inguinal pathologies.

Materials and methods

Forty-four patients (40 men and 4 women) who suffered from groin pain syndrome were enrolled in the study. All the patients were radiographically and clinically evaluated following a standardised protocol established by the First Groin Pain Syndrome Italian Consensus Conference on Terminology, Clinical Evaluation and Imaging Assessment in Groin Pain in Athlete. Subsequently, all of the subjects underwent a laparoscopic repair of the posterior inguinal wall.

Results

The study demonstrated an association between the cam morphology and inguinal pathologies in 88.6% of the cases (39 subjects). This relationship may be explained by noting that the cam morphology leads to biomechanical stress at the posterior inguinal wall level.

Conclusions

Athletic subjects who present the cam morphology may be considered a population at risk of developing inguinal pathologies.

Level of evidence

Level IV, Observational cross-sectional study.

     

The Use of Autologous Peritoneum for Complete Caval Replacement Following Resection of Major Intra-abdominal Malignancies

Objective

Assessment of a simple layer peritoneal tube used as an autogenous inferior vena cava replacement.

Background

Extensive en-bloc multivisceral resection including major vessels is effective in selected abdominal malignancies, but the need for vascular reconstruction represents a surgical challenge. We describe the use of autologous peritoneum for caval replacement.

Methods

Autogenous parietal peritoneum without fascial backing was harvested and tubularized to replace the inferior vena cava (IVC) in four patients with complex abdominal tumors. Surgical morbidity was evaluated using the Clavien–Dindo classification, and graft patency was systematically evaluated with ultrasound.

Results

All four patients had multiorgan resections for malignancies involving the retro-hepatic IVC, and they all required the replacement of infrarenal and suprarenal IVC segments. Additionally, all four required a right nephrectomy, two had a combined major hepatectomy, and one patient needed a veno-venous bypass. All had an R0 resection. A clinical follow-up took place between 5 and 11 months after surgery for each patient. Four-month graft patency was confirmed by ultra-sound and TDM with no sign of disease recurrence.

Conclusions

Autologous peritoneum without fascial backing is a good and safe option for circumferential replacement of IVC after extensive en-bloc tumor resection with IVC involvement.

     

Reconstruction of anterior chest wall: a clinical analysis

Objective

To investigate the methods and clinical efficacy of reconstruction of chest defects with titanium sternal fixation system after the surgical resection of sternal tumors.

Methods

A total of 6 patients with sternal tumor who were diagnosed and underwent resection and repair of the chest wall defects by titanium plates system, from 2017.3 to 2017.11 in our hospital were reviewed. Their pathological types, surgical reconstruction methods, follow-up results were analyzed.

Results

Six cases of sternal tumor were completely resected and the sternums were reconstructed with titanium sternal fixation system. There was no operative death, postoperative chest wall deformity, abnormal breathing or complications of respiratory circulation. After 3 to 10?months of follow-up, there was no loose screw or plate exposure. Not only the thoracic appearances were good, but patients’ satisfaction was high.

Conclusions

Surgical resection is the best treatment for sternal tumors, no matter it is benign or malignant. Titanium sternal fixation system combine with other soft materials can reconstruct the chest wall well after resection, and this technique is efficient as well as easy to learn.

     

A technique for pediatric chest wall reconstruction using custom-designed titanium implants: description of technique and report of two cases

Purpose

We present a surgical technique for chest wall reconstruction using custom-designed titanium implants developed for two female patients to provide both chest wall symmetry and adequate stability for staged breast reconstruction.

Methods

A retrospective review was performed for two adolescent female patients with large chest wall defects who underwent the described technique. The etiology of the chest wall deficiency was secondary to Poland’s syndrome in one patient, and secondary to surgical resection of osteosarcoma in the other patient. For each patient, a fine-cut computed tomography scan was obtained to assist with implant design. After fabrication of the prosthesis, reconstruction was performed though a curvilinear thoracotomy approach with attachment of the implant to the adjacent ribs and sternum. Wound closure was obtained with use of synthetic graft material, local soft tissue procedures, and flap procedures as necessary.

Results

The two patients were followed post-operatively for 35 and 38 months, respectively. No intra-operative or post-operative complications were identified. Mild scoliosis that had developed in the patient following chest wall resection for osteosarcoma did not demonstrate any further progression following reconstruction.

Conclusions

We conclude that this technique was successful at providing a stable chest wall reconstruction with satisfactory cosmetic results in our patients.