Primary endometriosis of the abdominal wall: an entity to be included in the differential diagnosis of abdominal wall masses

Endometriosis consists of the presence of extrauterine endometrial tissue. It is usually localized in the pelvis, although it can also be found in other sites. Cutaneous localization is unusual and the most frequent form appears on scars from obstetric or gynecological interventions. It can, however, develop spontaneously, especially in umbilical or inguinal areas and can be confused with irreducible hernias or granulomas. We present the cases of three patients with spontaneous endometriotic nodules of the abdominal wall. The lesions were located in the umbilical region in two patients and in the suprapubic area in one. In two patients clinical suspicion led to preoperative diagnosis, although diagnosis is usually established after histopathological analysis of the surgical specimen.     

Abdominal wall closure in laparotomy

The midline laparotomy is among the most common ways of accessing the peritoneal cavity. This approach is not only used for surgery of the digestive tract but is also extensively applied in vascular, gynecology and urological surgery. When this surgical procedure is conducted in an emergency setting, and depending on the type of surgery (clean and /or contaminated), the incidence of complications may be particularly high, especially when acute dehiscence of the wall occurs (evisceration). Furthermore, the rate of herniation related to midline laparotomy is still high at approximately 16% of cases. Despite efforts to evaluate different suture techniques, suture threads (reabsorbable or non-reabsorbable) and general factors that may interfere with the repair process, the incidence of complications associated with this approach has not been reduced. After multiple studies including meta-analyses, the outcome of laparotomy closure has not essentially improved. We should therefore consider the use of new ways of closing the abdomen in selected patients that might somehow reinforce the surgical wound and notably reduce the incidence of short- and medium-term complications. One such method could perhaps be the use of a biomaterial to support and strengthen conventional sutures.     

Abdominal wall injuries occurring after blunt trauma: incidence and grading system

Background

Traumatic abdominal wall injuries (AWIs) are being increasingly recognized after blunt force injury.

Methods

All available abdominal/pelvic computed axial tomography (CAT) scans of blunt trauma patients evaluated at our level I trauma center from January 2005 to August 2006 were reviewed for the presence of AWI. AWI was graded using a severity-based numeric system. AWI grade was then compared with variables from a prospectively maintained trauma registry.

Results

Of 1549 reviewed CAT scans, 9% showed AWI (grade I = 53%, grade II = 28%, grade III = 9%, grade IV = 8%, and grade V = 2%). There was no association between AWI and seatbelt use, Injury Severity Score, weight, or need for abdominal surgery.

Conclusions

AWI occurs in 9% of blunt trauma patients undergoing abdominal/pelvic CAT scans. The incidence of herniation on CAT at presentation after blunt trauma is .2%, and the incidence of patients at risk of future hernia formation is 1.5%. AWI can be effectively cataloged using a straightforward numeric grading system.     

High coincidence of inguinal hernias and abdominal aortic aneurysms

Weakness in the musculotendinous barrier of the abdominal wall leads to inguinal herniation. Fiber degeneration by increased metabolism has been described recently as a causative factor. In previous investigations heightened elastase was detected in abdominal aneurysms. In order to investigate a possible relationship between hernias and abdominal aneurysms, patients scheduled for infrarenal aneurysm repair were examined for history of inguinal hernia. The prevalence of inguinal hernias (n=49; 41%, p<.001) in 119 patients with abdominal aneurysms was significantly elevated, compared to 81 patients with aortic occlusive disease (n=15; 18.5%) and 298 patients with coronary artery disease (n=54; 18.1%). Additionally, the number of patients with recent hernia repair (n=19; 16%) or still awaiting repair (n=11; 9%) was very high in the patient group with abdominal aortic aneurysms. Smoking habits were not different among all groups. We conclude that the prevalence of inguinal hernias in patients with abdominal aortic aneurysms is high compared with those with peripheral arterial occlusive disease or coronary atherosclerosis. These findings indicate a systemic fiber degeneration.     

Biological prostheses: indications and usefulness in the repair of abdominal wall defect

The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response.     

Abdominal wall sinus: an unusual presentation of spilled gallstone

Gallbladder perforation and spillage of bile is common during laparoscopic cholecystectomy. We report a case of an abdominal wall sinus due to a spilled gallstone presenting 10 years after laparoscopic cholecystectomy.     

Incarcerated anterior abdominal wall hernias in a community hospital

Summary Abdominal wall hernias are among the most common problems encontered by surgeons. It is generally agreed that a hernia should be electively repaired to avoid the complication of incarceration and its attendant risk of strangulation. Nevertheless, many patients remain undiagnosed or are reluctant to have surgical correction of hernias, and as a result many emergency procedures are performed for complications of neglected hernias. We performed a retrospective analysis of incarcerated anterior abdominal wall hernias, and we used multivariate analysis to identify variables that were predictive of gangrenous bowel. There were a total of 1680 anterior abdominal wall hernias during the study period. Surgery was performed emergently for acute incarceration in 132 patients (7.9%), 25% of these were strangulated, and 57.6% of the strangulated cases progressed to gangrene. Femoral hernias had the highest incidence of incarceration and strangulation. Independent predictors of gangrenous bowel were a pulse rate > 100, ASA class four or greater, radiographic evidence of obstruction and the presence of a femoral hernia. The overall mortality rate was 4.5% for the patients with incarceration, and 15.8% for the patients with gangrenous sac contents. The mortality from incarcerated anterior wall hernias has decreased over time, but mortality is still appreciable. Hernias should be repaired electively to avoid the complication of incarceration. The presence of gangrenous bowel can be predicted by a pulse rate > 100, ASA class four or greater, radiographic evidence of obstruction and the presence of a femoral hernia.     

ROBotic Utility for Surgical Treatment of hernias (ROBUST hernia project)

We describe the evolution in hernia repair approaches in our practice during the first 3 years of adopting robotic assisted laparoscopic surgery. For inguinal hernia repair, we began using the robotic platform for complex hernias, and the use of open repair decreased from 17% to 6%. For primary ventral hernias, open procedures decreased from 59% to 10% and for incisional ventral hernias, from 48% to 11%. Moreover, a large shift in mesh position for ventral hernias was seen, with an increase of the retromuscular position from 20% to 82% and a decrease of intraperitoneal mesh position from 48% to 10%.The robotic platform seems to hold a significant potential for complex inguinal hernias, in addition to ventral and incisional hernias which require component separation. A shorter hospital stay and less postoperative complications might make the adoption of the robotic platform for abdominal wall surgery a valuable proposition.     

Primary and unusual abdominal wall hernias

Primary ventral hernias can be congenital or acquired, but are not associated with a fascial scar or related to a trauma. Some ventral hernias such as Spigelian, lumbar, or obturator hernias represent a diagnostic challenge, given their relative rarity and their unusual anatomic locations. The article presents the etiology, clinical presentation, and diagnosis of these hernias, and briefly describes the various surgical approaches, including open and laparoscopic.     

腹壁切口疝29例治疗体会

目的 分析腹壁切口疝的易发因素、补片修补方法、修补术后预防感染措施.方法 回顾性分析2005年1月至2009年6月间收治的腹壁切口疝29例,从疝的大小、修补方法、伴发病以及术后感染等方面对切口疝的修补进行分析讨论.结果 29例术后恢复顺利,无严重并发症,切口感染2例(7%),未出现补片排异反应.随访6个月～4年无复发,...     

Controversies in the current management of traumatic abdominal wall hernias

The management of traumatic abdominal wall hernias is controversial. We performed a MEDLINE search and report a personal series of 10 patients. Cases were classified according to the cause of injury. Fifty-six percent were caused by car accidents and 14% by bicycle accidents. Diagnosis was clinical in 22% and surgical in 13% and intra-abdominal lesions were found in 67%. Treatment was delayed in 12%. In our series, 55% were lumbar hernias due to traffic accidents and all were associated with pelvic fracture. Treatment was delayed in 50%, including laparoscopic surgery with good results. In conclusion, traumatic hernias due to road traffic accidents are frequently associated with intra-abdominal lesions. The diagnostic technique of choice is computed tomography and delayed surgery (laparoscopy) is an effective option.     

The biology of hernias and the abdominal wall

The fundamental mechanism for hernia formation is loss of the mechanical integrity of abdominal wall structural tissue that results in the inability to offset and contain intra-abdominal forces during valsalva and loading of the torso. There is evidence that genetic or systemic extracellular matrix disorders may predispose patients to hernia formation. There is also evidence that acute laparotomy wound failure leads to hernia formation and increases the risk of recurrent hernia disease. It may be that hernia formation is a heterogeneous disease, not unlike cancer, where one population of patients express an extracellular matrix defect leading to primary hernia disease, while other subsets of patients acquire a defective, chronic wound phenotype following failed laparotomy and hernia repairs. It is evident that an improved understanding of structural tissue matrix biology will lead to improved results following abdominal wall reconstructions.     

The use of ultrasound in the diagnosis of abdominal wall hernias

Background The diagnosis of abdominal wall hernias is not always straightforward and may require additional investigative modalities. Real-time ultrasound is accurate, non-invasive, relatively inexpensive, and readily available. The value of ultrasound as an adjunctive tool in the diagnosis of abdominal wall hernias in both pre-operative and post-operative patients was studied. Study design Retrospective analysis of 200 patients treated at the Hernia Institute of Florida was carried out. In these cases, ultrasound had been used to assist with case management. Patients without previous hernia surgery and those with early and late post-herniorrhaphy complaints were studied. Patients with obvious hernias were excluded. Indications for ultrasound examination included patients with abdominal pain without a palpable hernia, a palpable mass of questionable etiology, and patients with inordinate pain or excessive swelling during the early post-operative period. Patients were treated with surgery or conservative therapy depending on the results of the physical examination and ultrasound studies. Cases in which the ultrasound findings influenced the decision-making process by confirming clinical findings or altering the diagnosis and changing the treatment plan are discussed. Results Of the 200 patients, 144 complained of pain alone and on physical exam no hernia or mass was palpable. Of these 144 patients with pain alone, 21 had a hernia identified on the US examination and were referred for surgery. The 108 that had a negative ultrasound were treated conservatively with rest, heat, and anti-inflammatory drugs, most often with excellent results. Of the 56 remaining patients who had a mass, with or without pain, 22 had hernias identified by means of ultrasound examination. In the other 34, the etiology of the mass was not a hernia. Conclusions Abdominal wall ultrasound is a valuable tool in the scheme of management of patients in whom the diagnosis of abdominal wall hernia is unclear. Therapeutic decisions can be influenced by the ultrasound findings that can provide more efficient and economical treatment by expediting their clinical management.     

Factors affecting morbidity and mortality in incarcerated abdominal wall hernias

Background Incarcerated abdominal wall hernia cases may necessitate emergency interventions, but under such circumstances morbidity and mortality rates may increase. The aim of this study was to investigate the factors that affect morbidity and mortality in patients with incarcerated abdominal wall hernias who underwent emergency surgery. Methods Urgent surgical interventions due to incarcerated abdominal wall hernias were performed in 182 patients in our clinics between January 1998 and January 2006. Factors that affect morbidity and mortality in incarcerated abdominal wall hernias were investigated retrospectively by browsing the archives. Logistic regression analysis was used to evaluate parameters that affect morbidity and mortality. Results Morbidity and mortality occurred in 43 (23.6%) and 9 (4.9%) patients, respectively. A symptomatic period of longer than 8 h, presence of accompanying disease, high American Society of Anesthesiology (ASA) score, general anesthesia, presence of strangulation, and necrosis were found to affect morbidity significantly by univariate analysis. Necrosis was the sole factor affecting morbidity significantly by multivariate analysis. Advanced age, presence of accompanying disease, high ASA score, presence of strangulation, necrosis, and hernia repair with graft were found to affect mortality significantly by univariate analysis; however, necrosis was the sole factor affecting mortality significantly by multivariate analysis. Conclusions Intestinal necrosis, which was followed by bowel resection, was the sole factor affecting morbidity and mortality using multivariate logistic regression analysis. Emergency surgery is required for incarcerated abdominal wall hernias before intestinal necrosis develops.     

射频辅助腰腹部吸脂联合下腹壁整形术的临床效果

目的 探究射频辅助腰腹部吸脂联合下腹壁整形术的临床效果。方法 选取2021年3月-2023年3月 于我院行吸脂手术的80例患者为研究对象,采用随机数字表法分为常规组和研究组,每组40例。常规组采 用传统吸脂术,研究组采用射频辅助腰腹部吸脂联合下腹壁整形术,比较两组手术抽吸量、手术时间、腰 围周径减少量、消肿时间及满意度。结果 研究组手术抽吸量、腰围周径减少量均大于常规组,消肿时间短 于常规组（P＜0.05）;两组手术时间比较,差异无统计学意义（P＞0.05）;研究组满意率及满意度评分 均高于常规组（P＜0.05）。结论 射频辅助腰腹部吸脂联合下腹壁整形术的整体效果较好,可提高手术抽 吸量,缩小腰围周径,且术后消肿时间较短,恢复较快,患者满意度较高。     

Non-traumatic lateral abdominal wall hernia

A rare lateral abdominal wall hernia is described in an adult patient. This was diagnosed in a patient with a prominent right lateral abdominal wall deformity. The patient had been experiencing pain that increased progressively in severity over time. A computerized tomography (CT) scan of the abdomen revealed the location of the lateral abdominal wall defect. The hernia defect was through the transversus abdominis and the internal oblique, with the inferior aspect of the 11th rib forming part of the superior border of the defect. A 4-cm bony spur from the inferior aspect of the rib formed part of the lateral margin of the defect. The hernia sac was contained within a space underneath the external oblique muscle. The association of the hernia defect with a bony spur was highly suggestive of a congenital etiology. The hernia was successfully repaired laparoscopically with Parietex mesh (Sofradim^®, Lyons, France), and the patient had resolution of the symptoms on discharge and follow-up visits.     

Incidence and risk factors for incisional hernia after open abdominal aortic aneurysm repair

IntroductionIncisional hernia (IH) is common after open abdominal aortic aneurysm (AAA) repair. Recent studies reported incidence rates higher than previously stated. The aim of this study was to quantify the IH incidence after open AAA surgery. The secondary outcome was to identify the risk factors associated with the development of an IH.MethodsRetrospective observational study of all consecutive patients who underwent an open repair of AAA, from January 2010 to June 2018, at our institution. Patients were free of abdominal wall hernias at the moment of inclusion in the study. Data were extracted from electronic records: baseline characteristics, surgical factors, and postoperative events. Computed tomography (CT) scans performed during follow-up were analyzed.ResultsA total of 157 patients were analysed. The IH incidence after open repair of AAA was 46.5% (73 patients). The median time for IH development was 24.43 months (IQR: 10.40–45.27), while the median follow-up time was 37.20 months (IQR: 20.53–64.12). The risk factors linked to IH were: active (HR: 4.535; 95% CI: 1.369–15.022) or previous smoking habit (HR: 4.652; 95% CI: 1.430–15.131), chronic kidney disease (HR: 2.007; 95% CI: 1.162–3.467) and previous abdominal surgery (HR: 1.653; 95% CI: 1.014–2.695).ConclusionThe incisional hernia after open abdominal aortic aneurysm repair affected a high proportion of the intervened patients. Previous abdominal surgery, chronic kidney disease, and smoking habit were independent factors for the development of an incisional hernia.     

Anterior tension-free repair under local anesthesia of abdominal wall hernias in continuous ambulatory peritoneal dialysis patients

Background A 10-year experience of abdominal wall hernia repair performed with anterior tension-free mesh or plug technique under local anesthesia in end-stage renal failure patients submitted to continuous ambulatory peritoneal dialysis (CAPD) is described in order to assess the safety and effectiveness of this approach.Methods Between January 1993 and December 2002, 18 hernia repairs were performed under local anesthesia in 16 patients (14 males and two females) with a mean age of 70 years (48–78). One umbilical and three unilateral inguinal hernias were observed and repaired before starting peritoneal dialysis (PD), while two umbilical, eight unilateral, and two bilateral groin hernias developed and were then treated during PD. Repairs were performed electively in all but one case, which was an emergency operation for strangulation. An ipsilateral scrotal swelling was also present in two indirect unilateral inguinal hernias. In these cases, the hernia sac was ligated before entering, while in the others it was simply dissected and inverted.Results Patients were discharged the same day or the day after surgery. No local or general immediate or late complications occurred. CAPD in subjects operated on during PD treatment was resumed the same day of surgery. In no instance was hernia recurrence or leak of dialysis solution observed at follow-up examinations.Conclusions The absence of surgical and general complications and the nearly immediate resumption of PD indicate the anterior tension-free repair under local anesthesia as a safe and effective technique for CAPD patients even in an ambulatory or day-surgery setting.