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.

     

Robot-assisted extravesical vesicovaginal fistula repair utilizing laparoscopically mobilized omental flap interposition

Introduction and hypothesis

High vesicovaginal fistulas (VVF) in the setting of good apical support are best repaired via a transabdominal approach. Laparoscopic VVF repair was first reported in 1998. Several series of robot-assisted VVF repairs have since been published. The robot-assisted approach allows repair of high apical vaginal fistulas while avoiding the morbidity of laparotomy, shortening convalescence, and facilitating the use of omental interposition flaps. This video presents the technique for robot-assisted extravesical VVF repair utilizing a laparoscopically mobilized omental flap.

Methods

A 43-year-old woman developed a VVF after a total abdominal hysterectomy for fibroids. Pre-operative CT urogram and office cystoscopy confirmed the diagnosis and ruled out ureteral involvement. She underwent a robot-assisted extravesical VVF repair utilizing a laparoscopically mobilized omental flap.

Results

The surgery was uncomplicated, and the patient was discharged on post-operative day 1. A cystogram 2 weeks post-operatively revealed no evidence of a fistula. At 3 months follow-up, the patient denied any urinary incontinence.

Conclusions

Robot-assisted extravesical VVF repair avoids the morbidity of a laparotomy, provides excellent exposure, and avoids a large cystotomy. It maintains vaginal length and allows for significantly better visualization compared with the transvaginal approach. This repair offers improved outcomes for certain patients depending on their history, anatomy, and the surgeon’s experience.

     

Anteriorly based pudendal thigh flap for scrotal reconstruction based on the deep external pudendal artery (DEPA) flap

Background

Major scrotal skin loss represents a significant challenge for reconstructive surgeons. Although many therapeutic methods have been established for the treatment of such defects, each technique has its own advantages and disadvantages. A posteriorly based pudendal thigh fasciocutaneous flap at the perianal region has been described for reconstruction of genital organs, but an anteriorly based pudendal thigh fasciocutaneous flap has not been described for scrotal reconstruction.

Aim

The aim of this study was to introduce and evaluate the use of an anteriorly based pudendal thigh flap for scrotal reconstruction.

Methods

Twenty flaps in 15 patients with major scrotal defects were subjected to reconstruction using this flap. The etiology of scrotal loss was Fournier gangrene in all cases. Five patients each underwent bilateral and ten patient unilateral reconstructions, by the anteriorly based pudendal thigh flap, based on the deep external pudendal artery (DEPA).

Results

All 20 flaps survived completely. Additionally, the donor site was closed directly, and the scar was hidden in the perineal crease. The donor site healed uneventfully, as one patient required a secondary procedure for healing.

Conclusion

An anteriorly based pudendal thigh flap is highly reliable for coverage of major scrotal defects. This flap allows adequate coverage with excellent aesthetic appearance of the scrotum.Level of Evidence: Level II, therapeutic study.

     

Versatility of lateral arm flap for hand reconstruction—a clinical experience

Background

The lateral arm free flap (LAFF) has several advantages in hand reconstruction due to multiple factors. We aimed to show the versatility of LAFF in treating hand defects.

Methods

A retrospective analysis of all LAAF for hand reconstruction carried out at our institutions between August 2006 and August 2012 was undertaken. Clinical records were reviewed with respect to patients’ age and gender, size and location of defect, type and size of flaps, and complications.

Results

Twenty-four hand defects were reconstructed using LAFF. These included 15 cutaneous flaps, 8 fascial flaps, and 1 osteocutaneous flap. All flaps survived well except for one case that developed arterial insufficiency and required anastomotic revision. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure.

Conclusions

The free lateral arm flap is a versatile and reliable option for defect coverage at the hand for small- and medium-size defects. It can be raised as a cutaneous, fascial, or osteocutaneous flap. Several advantages favor the use of lateral arm flap in hand reconstruction. These include preservation of major arm blood vessels, its constant vascular anatomy, long pedicle, and low donor site morbidity.Level of Evidence: Level IV, therapeutic study.

     

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.

     

Non-lethal Right Liver Atrophy After TIPS Occlusion in A Cirrhotic Patient: Introducing The Hepatic Biembolization

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is the standard procedure in the treatment of refractory ascites and variceal bleeding in the setting of portal hypertension. Secondary obstruction of the shunt is a classic but potentially lethal complication.

Methods

We present here the case of a cirrhotic patient that underwent a TIPS for refractory ascites, with early complete thrombosis without lethal complication.

Results

Obstruction of the TIPS led to thrombosis of both the right hepatic and the right portal veins with progressive total atrophy of the right liver and marked hypertrophy of the left liver. Despite initial poor liver function, biological hepatic markers improved slowly until complete recovery.

Conclusion

Hence, we suggest the concept of combined right portal and hepatic vein embolization as a new procedure to induce partial liver hypertrophy before major liver resection, even in cirrhotic patients.

     

Anatomische Rekonstruktion nach weiblicher Genitalbeschneidung

Background

Female genital mutilation/cutting (FGM/C) is a worldwide problem affecting millions and millions of women and is especially common in Africa and Arabic countries. Affected women suffer from severe physical and psychological problems. Anatomic reconstruction is therefore an important and life-changing option for many affected women.

Objective

This article gives an overview of specialized techniques developed by the author for functional and aesthetic vulvar reconstruction following FGM/C, in addition to some basic background problems of FGM/C.

Material and methods

The anterior obturator artery perforator flap (aOAP flap), the omega domed flap (OD flap), and a microsurgical procedure called neurotizing and molding of the clitoral stump (NMCS procedure) are described.

Results

The aOAP flap for vulvar reconstruction, the OD flap for clitoral prepuce reconstruction and the NMCS procedure for reconstruction of the glans of the clitoris showed natural, reliable and long-lasting results, all of which normalize the anatomy of the mutilated external female genitalia.

Conclusion

The reconstruction options presented contribute to re-establish normal anatomy and therefore support women’s health and likewise relieve the burden enforced upon them by FGM/C.

     

Rectovaginal fistula repair using a gracilis muscle flap

Introduction and hypothesis

This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula.

Methods

We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient’s prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula.

Conclusion

Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.

     

Presentation and management of rectovaginal fistulas after delivery

Introduction

Obstetric trauma leading to rectovaginal fistula (RVF) formation results from perineal laceration and/or from prolonged ischemia and necrosis following obstructed labor. Due to modern obstetric care fistulas are rare in industrialized countries.

Methods

Patients undergoing surgery for a RVF between January 2005 and December 2014 at the Department of Obstetrics and Gynecology, Tuebingen, Germany, were identified and their records were reviewed retrospectively.

Results

Of 48 patients, 13 developed RVF of obstetric etiology. Parity ranged from 2 to 4. RVF repair was performed in all patients using a transvaginal approach: fistula excision and multilayer closure (7 of 13) with Martius flap interposition (1 of 7) and sphincteroplasty (5 of 13). One RVF closed spontaneously. Due to significant destruction of the anal canal, large RVF and RVF recurrence, 4 of the 13 patients needed a temporary protective ileostomy. Fistula closure was achieved in 12 of 13 patients.

Conclusion

The choice of RVF repair should be tailored to the underlying pathology and type of repair done previously and the patient’s wishes

     

Simple and effective: transvaginal vesico-vaginal fistula repair with a modified Latzko technique

Introduction and hypothesis

The incidence of vesico-vaginal fistulas after hysterectomies for benign indications in developed countries is less than one percent. The objective of this video is to demonstrate an easy-to-follow, step-by-step approach to repairing a small, uncomplicated vesico-vaginal fistula transvaginally using a modified Latzko technique.

Methods

In this video, we present a case of a 46-year-old woman who developed a simple, uncomplicated vesico-vaginal fistula after a total abdominal hysterectomy. To correct her fistula, we used a modified Latzko technique, which is a transvaginal approach to vesico-vaginal fistula repair that involves mobilizing the vaginal mucosa around the fistula and then closing the pubo-vesical fascia and vaginal mucosa in layers.

Results

The patient had successful surgical correction of her vesico-vaginal fistula without recurrence of the fistula.

Conclusions

For small, uncomplicated vesico-vaginal fistulas, a transvaginal approach has an equivalent success rate to that of other approaches with less invasiveness and faster recovery times. Therefore, it is reasonable to use a modified Latzko technique to help restore the quality of life to women affected by small, uncomplicated vesico-vaginal fistulas.

     

Mesenteric Lymphatic Vessel Density Is Associated with Disease Behavior and Postoperative Recurrence in Crohn’s Disease

Purpose

The aims of the present study were to examine the density of lymphatic vessels in the mesentery and to assess the predictive value of the mesenteric lymphatic vessel density for postoperative clinical recurrence.

Methods

Ileocolonic resection specimens were obtained from 53 patients with Crohn’s disease and 10 non-inflammatory bowel disease control subjects. Mesentery adipose tissues adjacent to the bowel wall were used for the histological quantification of lymphatic vessels using immunohistochemistry with the D2-40 antibody. The relationships between lymphatic vessel density and disease behavior, the presence of granulomas, the presence of creeping fat, and postoperative clinical recurrence were assessed.

Results

Median lymphatic vessel density in the mesentery adjacent to inflamed or non-inflamed intestine was lower in control subjects than in Crohn’s disease patients (2.13‰; interquartile range [IQR], 1.83–2.61; 8.34‰; IQR, 6.39–10.22; 4.43‰; IQR, 3.32–5.78; P ? 0.001). Increased mesenteric lymphatic vessel density was significantly associated with stricturing behavior, the presence of intestinal granulomas, the presence of creeping fat, and bowel thickness. Interestingly, patients with disease recurrence had an increased mesenteric lymphatic vessel density of the proximal mesenteric margin at the time of resection compared with those who did not have disease recurrence (6.23‰; IQR, 5.43–6.75 vs. 3.28‰; IQR, 2.93–4.29; P ? 0.001).

Conclusions

In addition to its correlation with disease behavior, bowel thickness, and the presence of intestinal granulomas and creeping fat, increased mesenteric lymphatic vessel density in the proximal margin is predictive of early clinical recurrence after surgery in patients with Crohn’s disease.

     

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

Introduction and hypothesis

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

Methods

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

Results

The patient’s postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

Conclusions

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

     

Lymph nodes around the posterior gastric artery: their existence,frequency, and clinical implications

Purpose

The lymphatic flow along the posterior gastric artery (PGA) is considered of possible clinical importance in terms of lymphatic metastasis; however, little is known about the lymph nodes (LNs) around this artery. The purpose of this study was to establish if LNs exist around the PGA and to evaluate their clinical implications.

Methods

We examined the tissues surrounding the PGA from 21 cadavers to search for LNs. We also investigated the patterns of lymphatic metastases in patients who underwent surgery for gastric neoplasms at our institute to detect their presence along the PGA.

Results

The PGA was identified in 11 cadavers, and LNs around the PGA were detected microscopically in 2 of these. Lymphatic metastasis directly to the LNs at the splenic artery without any metastases was regarded as skip metastasis along the PGA. Skip metastasis was found in two of ten patients who underwent surgery for remnant gastric cancer.

Conclusions

The existence of LNs around the PGA was confirmed, and based on our findings, lymphatic metastasis through the PGA is possible in patients with remnant gastric cancer.

     

The Pfannenstiel scar and its implications in DIEP flap harvest: a clinical anatomic study

Background

Despite the utility of the deep inferior epigastric artery perforator (DIEP) flap, the presence of abdominal wall scars can limit flap perfusion. Pfannnstiel scars are among the most common abdominal scars, during which undermining at either a subfascial or suprafascial level can damage perforators. There is an anecdotal belief that raising a DIEP flap in the presence of a Pfannenstiel scar may be less reliable due to vascular disruption.

Methods

A clinical prospective analysis of retrospectively recorded imaging from 150 patients (300 hemi-abdominal walls) was undertaken. Preoperative imaging, with two computer software programmes used to reconstruct three dimensional (3-D) volume-rendered images and analyse vasculature, was used to accurately identify and measure perforators.

Results

A total of 959 perforators were identified, with 319 perforators identified in the ‘Pfannenstiel scar’ group and 640 perforators in the ‘no abdominal scar’ group. All patients, except for one patient with a Pfannenstiel scar, had one or more perforators that were larger than 1.0 mm in diameter. There were no differences in the number of DIEA perforators (6.81 vs 6.22, p?=?0.2819); however, perforators of the ‘Pfannenstiel scar’ group were of larger mean diameter than the ‘no abdominal scar’ group (0.96 vs 0.85 mm (p?=?0.0027).

Conclusions

The presence of a Pfannenstiel scar is associated with larger perforator size than controls and no diminution in overall perforator number. As such, a Pfannenstiel scar may in fact aid DIEP flap harvest, a finding consistent with anecdotal outcomes.Level of Evidence: Level III, risk / prognostic study.

     

Inferiorly based nasolabial flap for reconstruction of the moderate to large defects of lips following cancer resection

Background

Reconstruction of the lip defects following wide excision of the squamous cell cancer is challenging for the surgeon. Our aim was to define the role of the inferiorly based nasolabial flap for lip reconstruction in such cases with moderate to large size defects.

Methods

Lip defects were reconstructed with a unilateral or bilateral subcutaneous nasolabial flaps depending on the size of the defect following wide resection of their lip cancers.

Results

All the defects were reconstructed in a single stage. We achieved good lip seal and at least good function in eating and speaking. There was no entropion of the lip, and all the reconstructed lips preserved their height.

Conclusion

Simplicity of dissection, robust blood supply, best color match, short procedure time, and minimal donor site morbidity reinforce this flap as a useful adjunct in lip reconstruction.Level of Evidence: IV, therapeutic study.

     

Reconstruction using a divided latissimus dorsi muscle flap after conventional posterolateral thoracotomy and the effectiveness of indocyanine green-fluorescence angiography to assess intraoperative blood flow

Purpose

In most general thoracic operations performed via standard posterolateral thoracotomy, such as for descending aortic aneurysms and lung cancer, the latissimus dorsi (LD) muscle is divided. However, division of the LD can hamper reconstructive surgery because the initial operation creates unstable blood flow to the divided LD. We conducted this study to assess blood flow in a divided distal LD muscle flap using intraoperative indocyanine green-fluorescence angiography (ICG-FA) with the Hyper Eye Medical System^® (Mizuho Medical Co., Ltd., Tokyo, Japan).

Methods

The subjects were 11 patients who underwent posterolateral thoracotomy with reconstructive surgery using a divided distal LD and other peripheral muscle flaps. Intraoperative ICG-FA was conducted to assess blood flow to the LD.

Results

Intraoperative ICG-FA revealed that at least two intercostal perforators from the sixth to the tenth intercostal spaces were preserved as feeding vessels to the divided distal LD. There were no major complications associated with inadequate blood flow to the muscle flaps.

Conclusion

Intraoperative ICG-FA proved extremely useful for assessing altered blood flow of the divided LD and for selecting preserved intercostal perforators.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

A New Oval Advancement Flap Design for Reconstruction of Pilonidal Sinus Defect

Backgrounds

Pilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been described for treating pilonidal sinus disease, controversy still exists as to the best surgical technique. The aim of this study is to present a new modified advancement flap technique named “omega flap” for the treatment of pilonidal sinus disease.

Materials and methods

This study included 18 patients with pilonidal sinus who were treated between March 2012 and August 2014. All cases underwent oval excision and omega advancement flap reconstruction. Defect size, postoperative complications, postoperative pain, painless sitting time, patient satisfaction and recurrence were evaluated retrospectively.

Results

All patients were discharged on the first postoperative day. There was no flap necrosis. No recurrence and no major complication were observed during follow-up period. The outcomes were also satisfactory regarding functionally and aesthetically, and the patients were satisfied with the results.

Conclusions

Presented method has a different geometry than classical advancement flap methods. Our technique provides two-layered repair with minimal tension and off-midline closure for the reconstruction of pilonidal sinus defect. It is easily performed, reliable, associated with no recurrens and good aesthetic results.

     

Aesthetic rhinoplasty as the final step of nasal reconstruction with a forehead flap

Background

The reconstruction of nasal defects represents a difficult challenge for a plastic surgeon as it can be actually difficult to obtain good aesthetic and functional results. Reconstruction needs the use of several complex flaps, including the forehead flap. However, the use of the forehead flap does not give always the optimal aesthetic result. In our opinion, rhinoplasty can optimize the aesthetic outcome and can be used as the last step in nasal reconstruction.

Methods

From the patients admitted to our department, resulting in full thickness nasal defects and reconstructed using the forehead flap, ten were selected to perform rhinoplasty after passing the inclusion criteria.

Results

In the patients where rhinoplasty was performed we obtained aesthetic and functional improvement. The patients referred better acceptance of the residual surgical stigmata and improvement of social acceptance.

Conclusions

Optimizing the aesthetic appearance of the nose, making it look better than before surgery, is fundamental to improve patient’s life quality and better acceptance of the demolition or trauma.Level of Evidence: Level V, therapeutic study.

     

Robotic vesico-vaginal fistula repair with no omental flap interposition

Introduction and hypothesis

A vesico-vaginal fistula (VVF) is a fistulous tract that connects bladder and vagina, causing urine leakage via the vagina. In the developed world, iatrogenic postoperative VVF is the most common case. Classically, when treating a VVF via the abdominal route, an abdominal flap is mobilized and interposed between the bladder and the vagina.

Methods

In our video, we describe a robotic VVF repair technique with no omental flap interpositioning for a vaginal vault-located fistula.

Results

Duration of surgery was 95 min, estimated blood loss was <50 ml. The postoperative course was uneventful. At the 6-month follow-up, which included clinical and cystographic examinations, the patient had not experienced any recurrence.

Conclusion

In our opinion, a two-layered suturing technique using two semi-continuous sutures for vaginal closure and perpendicular interrupted stitches for bladder closure does not require omental flap mobilization, reducing operating time and possible complications related to accidental peritoneal injuries.