Reconstructing abdominal wall defects with a free composite tissue flap: A case report

BACKGROUNDReconstructive repair of huge full-thickness abdominal wall defects following debridement for abdominal electric burns remains a clinically challenging task. An ideal abdominal wall repair means a re-closure of the defected abdominal wall with pedicled neurovascular myofascial flaps, restoration of the abdominal wall integrity, and maintenance of the abdominal wall muscle tension to prevent the occurrence of abdominal wall hernia. When treating huge full-thickness defects, composite autologous tissue flaps are a good option for the repair. CASE SUMMARYThis study reported the case of a 43-year-old male patient suffering from full-thickness abdominal wall defects complicated with necrosis of multiple bowel segments and duodenal leak following high-voltage burns involving the left upper limb and abdomen. After debridement for abdominal electric burns and end-to-end anastomosis for the necrotic bowels, reconstruction with acellular dermal matrix grafting and vacuum sealing drainage were performed for temporary abdominal closure. The remaining 18 cm × 15 cm full-thickness abdominal wall defect was repaired using a combined anterolateral thigh and tensor fascia lata free flap. The proposed method achieved the functional reconstruction of the abdominal wall.CONCLUSIONThis approach restored the abdominal wall integrity, maintained certain muscle tension, avoided abdominal hernia, reached satisfactory aesthetic effect, and resulted in no complications in the grafting regions.     

Preservation of Denonvilliers' fascia for nerve‐sparing laparoscopic total mesorectal excision: A neuro‐histological study

Urogenital complications due to pelvic autonomic nerve damage frequently occur following rectal surgery. We investigated whether total mesorectal excision (TME) with preservation of the Denonvilliers' fascia (DVF) can effectively prevent the removal of pelvic autonomic nerves through microscopy. Twenty consecutive male patients with mid‐low rectal cancer who received TME with preservation or resection of the Denonvilliers' fascia (P and R groups, respectively) were included. Serial transverse sections from surgical specimens were studied histologically. Nerve fibers at the surfaces of the mesorectum were counted. Clinical correlation between the amount of nerve fibers removed and post‐operative sexual function was analyzed. Nerve fibers closely localized to the DVF in the R group displaying rich erectile activity (positive anti‐nNOS immunostaining). At the anterior surface of the mesorectum, the mean numbers of nNOS‐positive nerve fibers per specimen in the P group were significantly lower than the R group (3.0 ± 1.8 vs. 5.0 ± 2.3, P < 0.05). Compared to the R group, patients in the P group had higher IIEF scores and better erectile function at 3 and 6 months post‐operatively. The DVF is a key risk zone for pelvic denervation during laparoscopic TME. Preservation of the DVF can prevent the removal of autonomic nerves and protect post‐operative erectile function. Clin. Anat. 32:439–445, 2019. © 2019 Wiley Periodicals, Inc.     

盆筋膜解剖及其与直肠固有筋膜关系研究

目的 探讨盆筋膜的结构、范围及其与直肠固有筋膜的层次关系。方法 2020年12月至2021年3月对由广东药科大学生命与生物制药学院人体解剖与胚胎学系及中山大学中山医学院人体解剖学教研室提供的12具（男性5具、女性7具）骨盆标本进行大体观察，并对Denonvilliers筋膜进行组织学观察。结合2019年12月至2021年3月中山大学附属第三医院胃肠外科收治的20例直肠癌病人（男性10例、女性10例）的盆腔磁共振图像和手术视频进行解剖学印证。结果 12具骨盆大体标本显示，盆筋膜与Gerota筋膜相延续，部分纤维于S4水平构成直肠骶骨筋膜，向下与直肠固有筋膜融合终止于联合纵肌；部分纤维与后方骶前筋膜融合构成肛提肌上筋膜及肌间纤维。Denonvilliers筋膜在盆腔前外侧约2点、10点处与盆筋膜相延续构成完整筒状结构，包绕内层由直肠固有筋膜封套的直肠系膜；除“侧韧带”处有盆腔自主神经直肠支、淋巴管、直肠中动脉相连外，两层筋膜形成完整的双筒状结构，横断面呈同心圆状。除直肠支进入直肠固有筋膜外，盆腔自主神经主要分支均位于盆筋膜内层及Denonvilliers筋膜以外，沿直肠固有筋膜轮廓游离能够避免损伤盆腔自主神经。在7具女性骨盆标本中均能见到菲薄的Denonvilliers筋膜结构。直肠癌病人的横断面磁共振图像能够看到直肠固有筋膜与外侧盆筋膜、Denonvilliers筋膜的轮廓和间隙，手术视频资料也可见到完整盆壁筋膜和Denonvilliers筋膜的轮廓。结论 直肠癌手术中，在盆筋膜、Denonvilliers筋膜与直肠固有筋膜两层结构的间隙进行分离，并保持两层筋膜的完整性，对于保证肿瘤根治性和保护排尿及性功能至关重要。     

The Efficacy and Safety of Regional Nerve Blocks in Total Hip Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundRegional nerve blocks may be used as a component of a multimodal analgesic protocol to manage postoperative pain after primary total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after THA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published prior to March 24, 2020 on fascia iliaca, lumbar plexus, and quadratus lumborum blocks in primary THA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks.ResultsAn initial critical appraisal of 3,382 publications yielded 11 publications representing the best available evidence for an analysis. Fascia iliaca, lumbar plexus, and quadratus lumborum blocks demonstrate the ability to reduce postoperative pain and opioid consumption. Among the available comparisons, no difference was noted between a regional nerve block or local periarticular anesthetic infiltration regarding postoperative pain and opioid consumption.ConclusionLocal periarticular anesthetic infiltration should be considered prior to a regional nerve block due to concerns over the safety and cost of regional nerve blocks. If a regional nerve block is used in primary THA, a fascia iliaca block is preferred over other blocks due to the differences in technical demands and risks associated with the alternative regional nerve blocks.     

Optimizing Rapid Recovery After Anterior Hip Arthroplasty Surgery: A Comparative Study of Fascia Iliaca Compartment Block and Local Infiltration Analgesia

BackgroundMultimodal pain therapy combining analgesics, local infiltration analgesia (LIA) and peripheral nerve blocks, such as fascia iliaca compartment block (FICB), can improve postoperative pain, nausea and vomiting (PONV) and ambulation in patients undergoing total hip arthroplasty (THA). We hypothesized that addition of FICB would decrease opioid requirements and length of stay (LOS) but could create a motor block.MethodsThis is a single center, prospective, blinded randomized controlled study of 152 patients undergoing elective THA via direct anterior approach from October 2019 till August 2021. Three patient groups were defined: patients receiving only spinal anesthesia (control group, n = 53); spinal anesthesia with LIA perioperatively (n = 50); and spinal anesthesia with FICB on the recovery unit (n = 49). Outcome measures consisted of postoperative pain scores, PONV, length of hospital stay, opioid requirements and mobility.ResultsOverall pain scores were low for all patient groups, with a lower pain score for LIA in comparison to the control group until 4 hours postoperatively (P < .05). Length of hospital stay, postoperative pain, nausea and vomiting (PONV) scores and quadriceps muscle strength did not differ significantly between groups. The control group showed higher scores at 12 hours postoperatively in comparison to FICB regarding rehabilitation potential, use of walking aids and activities of daily living (P < .05), but all groups reached the same endpoint 48 hours postoperatively. The LIA and FICB groups required less opioids until 24 hours postoperatively.ConclusionLIA is a beneficial adjuvant therapy to spinal anesthesia in THA patients as it may decrease pain scores and the need for opioid consumption. Adjuvant FICB only provided lower opioid requirements.     

经腹腹腔镜下右肾周筋膜解剖研究及其在腹腔镜右肾切除中应用价值

目的通过研究经腹途径腹腔镜下右肾肾周筋膜的分层结构,为腹腔镜筋膜入路右肾切除手术的可行性及安全性提供解剖学依据。方法在国内外学者对肾周筋膜研究的基础上结合CT肾周筋膜的呈现,对经腹途径腹腔镜下肾周筋膜分层结构进行研究,并以此为基础设计好手术的筋膜入路及分离途径并应用于指导经腹腹腔镜下右肾切除术,记录2015年1月至2019年6月来自阳江市中医医院和人民医院的45例患者的术中肾周筋膜观察结果及手术时间、出血及术中术后并发症等。结果经腹途径腹腔镜下肾周间隙周围存在一个潜在连续的由疏松纤维条索填充的无血管层面,这个无血管层面存在于相邻的两层肾周筋膜之间,45例患者均按术前设计的手术路径顺利完成手术,其中42例患者可以很好或较好的保持筋膜完整性的情况下完成分离,2例脓肾患者及1例无功能肾患者由于粘连明显未能保持分离面筋膜完整性,平均手术时间73 min,平均出血50 ml,术后引流管时间2.7 d,术中无肠管及下腔静脉损伤病例,术后无肠漏及严重的继发出血病例,无围手术期死亡病例。结论肾周筋膜的分层结构及肾周间隙周围存在的连续的潜在无血管层面为经腹途径腹腔镜筋膜入路右肾切除有效的解剖依据,经腹腹腔镜下筋膜入路右肾切除是安全可行的,可以让手术更加安全及出血更少。     

Anatomical structures at risk using different approaches for sacrospinous ligament fixation

For 50 years now, sacrospinous ligament fixation (SSLF) has been used to treat pelvic organ prolapse consequent on altered integrity of the pelvic myofascial structures. It is usually performed vaginally, but it has recently been performed laparoscopically through either an anterior or a posterior approach, with the broad ligament as a landmark to differentiate the two. In the present study, these two laparoscopic approaches were assessed using Thiel-embalmed cadavers. The anterior and posterior approaches were compared in terms of the closest distance to anatomical structures at risk, including pelvic viscera, the obturator nerve, and vascular structures. The posterior approach was more often closer to the investigated vessels and the rectum. The obturator nerve and the ureter were close to both the anterior and posterior approaches. The urinary bladder was closer using the anterior approach. From an anatomical standpoint, therefore, the anterior laparoscopic approach for SSLF is more likely to cause injury to the urinary bladder, whereas the posterior approach is more prone to causing rectal and vessel injuries. This study illustrates, from a basic science perspective, the importance of combining fascia research, novel endoscopic or minimally invasive surgical exposures informed by anatomy, and contemporary trends in gynecology in order to improve patient outcomes. Clin. Anat. 33:522–529, 2020. © 2019 Wiley Periodicals, Inc.