Resistance to adhesion formation: A comparative study of treated and untreated mesh products placed in the abdominal cavity

Background: New materials have been devised to prevent postoperative adhesions when placing a prosthesis in contact with abdominal contents. Methods: Eighty rats underwent laparotomy and denudation of the serosa of the cecum and peritoneal covering of the abdominal wall. Five treated mesh products (Parietex Composite, Parietene Composite, Bard Composix E/X, Sepramesh, and Gore-Tex Dual Mesh) and one untreated mesh product (untreated Parietene) were randomly placed between the cecum and abdominal wall. A group without mesh was used as control. The animals were sacrificed at 21 days following surgery and analyzed for the presence of adhesions.Results: The incidence of adhesion formation, mean adhesion area, maximum adhesion length, and strength of adhesion separation were similar between Parietex Composite, Parietene Composite, and Bard Composix E/X, and they were significantly less than with Sepramesh, untreated Parietene, and the control group. Gore-Tex Dual Mesh resulted in less adhesions, adhesion area, mean strength of separation, and work of separation than the untreated Parietene group and the control group. Sepramesh resulted in less strength and work of separation compared to the control group. Conclusions: The incidence of adhesions and work and strength of adhesion separation are reduced when using a treated mesh, compared to the untreated mesh and the control group without mesh. Parietex Composite, Parietene Composite, Bard Composix E/X, and Gore-Tex Dual Mesh were superior to Sepramesh, untreated Parietene, and the control group in the prevention of adhesion formation.Disclosure statement: This study was sponsored by: Sofradim, Trévoux, France     

Tension-free vaginal mesh repair for recurrence of pelvic organ prolapse after vaginal mesh procedures: a case report

A 61-year-old woman presented with the chief complaint of a vaginal bulge for 2 years. She had undergone two operations for pelvic organ prolapse. The initial procedure was the Manchester procedure and posterior colporrhaphy, and the second was a vaginal repair with mesh for recurrent rectocele 3 years after the initial surgery. She noticed the vaginal bulge shortly after the second surgery. A gynecological examination revealed a stage III rectocele associated with a 2 cm, firm mass at the posterior vaginal wall. T2-weighted magnetic resonance imaging showed a 2 × 3 cm high-intensity mass located between the vaginal wall and rectum. The recurrent rectocele might have been caused by incomplete support from the mesh, which was not fixed in the vaginal wall, resulting in formation of a mass. The patient underwent complete mesh removal and tension-free vaginal mesh-posterior surgery for the rectocele. The excised mesh had shrunk from a 7 × 5 cm rectangle mesh preoperatively into a firm 2 × 2 × 3 cm mass. No recurrence has been seen for 18 months postoperatively.     

Endoscopy of the posterior fossa and dissection of acoustic neuroma.

OBJECT: The authors evaluated the importance of endoscopes in eliminating the disadvantages of the posterior fossa approach, such as the lack of adequate visualization of the lateral aspect of the internal acoustic canal (IAC). METHODS: Between 1989 and 1998, 32 patients underwent removal of acoustic neuroma (AN) via a combined retro-sigmoid-retrolabyrinthine approach. Endoscopes were used at different stages of the operation, and their use was evaluated with regard to elimination of the disadvantages of the posterior fossa approach. All patients in whom AN had been diagnosed underwent surgery in which a standard retrosigmoid-retrolabyrinthine approach was used. Standard sinus endoscopes of 0 degree, 30 degrees, and 70 degrees were introduced into the cerebellopontine angle before debulking the tumor, and the IAC was inspected at the end of the operation. Neurovascular integrity as well as the relationship between the AN and surrounding structures were evaluated. The IAC was inspected for residual tumor, and if any was found, endoscopically guided tumor dissection was performed. CONCLUSIONS: Endoscopes have facilitated an understanding of the anatomy between an AN and neighboring neurovascular structures. For surgery in which the posterior fossa approach is used, endoscopes can make operations safer by eliminating the disadvantages of the approach. In addition to allowing inspection of the fundus, it is possible to perform endoscopically guided tumor dissection within the IAC.     

Bulboprostatic anastomotic urethroplasty with preservation of potency: anatomical study, operative approach and clinical results

OBJECTIVE. To identify the precise anatomy of the membranous and bulbous urethrae and their relation to the neurovascular bundles (cavernous nerves and vessels). Based on the findings, a modified surgical technique was developed to preserve potency by avoiding injury to the neurovascular bundles during surgery on the posterior urethra. MATERIAL AND METHODS: The material for this study consisted of 10 male cadavers. We injected eight cadavers with a mixture of red latex and lead oxide. By means of meticulous dissection we removed the bladder, prostate, urethra, penis, surrounding vessels and nerves. We also identified the anatomical relations between various urogenital structures and the vessels and nerves. We examined the specimens radiologically. In the other two cadavers, we removed the membranous urethrae and subjected them to histological examination. We used haematoxylin-eosin and Verhoeff von Gieson stains to study the elastic tissues. RESULTS: The membranous urethra measured 2.5-3 cm in length. It originated from the lower third of the anterior surface of the prostate (and not from the apex) as a continuation of the prostatic urethra. The wall of the membranous urethra contained abundant elastic fibres. The neurovascular bundles were located posterolateral to the mid-portion of the prostate and prostatic apex. Near the apex the neurovascular bundle divided into two parts: a larger anterior part and a smaller posterior part. The anterior part crossed the membranous urethra, then the bulb of the penis at the 1 and 11 o'clock positions and finally entered the corpus cavernosum. The posterior part crossed the membranous urethra more posteriorly to enter the bulb of the penis. Between 1992 and 2003 we managed 22 patients (age range 16-50 years) with posterior urethral obstruction secondary to pelvic fracture by means of bulboprostatic anastomosis. We managed 17 patients via the perineal route and five via a combined perineoabdominal-transpubic route. All of these patients were potent before the operation, which proved the integrity of the neurovascular bundles. We could spare the anterior divisions of the neurovascular bundles (greater cavernous nerves and vessels) during their crossing of the bulb of the penis by cutting and dissecting within the bulb (not outside it) before dismembering it from the urogenital diaphragm. We also refrained from any dissection of the apex and the posterolateral surfaces of the prostate to avoid injury to the neurovascular bundles. At 6-year follow-up (range 1-10 years) 21/22 patients preserved their potency, giving a success rate of 95.45%. Of the 22 patients, two became temporarily impotent after the operation but regained potency within a period of 4-6 months. CONCLUSION: Our technique of neurovascular bundle preservation during bulboprostatic anastomotic urethroplasty may solve the problem of postoperative impotence.     

Resorbable pericardial replacement--an experimental study]

The resorbable pericardial substitute: In modern heart surgery every patient undergoing cardiac surgery will eventually require a second operation including resternotomy. To reduce the risk of damage to the heart it has been recommended to close the pericardial sac primarily. Unfortunately there is no ideal pericardial substitute yet available. This experimental study summarizes our experience with the use of Gore-Tex Surgical Membrane and Vicryl-Collagen mesh as pericardial substitutes which have been implanted orthotopically in 12 rats. After a mean follow-up of 86 days we evaluated macroscopically the pericardial adhesions, the closure of the pericardial defect and histologically the inflammatory reaction. At explanation we found that both pericardial substitutes produce little adhesion. But in rats with Vicryl-Collagen mesh as a pericardial substitute there were only a very few inflammatory cells and total closure of the pericardial defect was in 4 out of 6 rats present. These findings suggest that Vicryl-Collagen mesh seems to be a superior pericardial substitute and also allows formation of a neopericardium.     

Potency following radical prostatectomy with wide unilateral excision of the neurovascular bundle

Delineation of the neurovascular bundles has made it possible to identify the branches of the pelvic plexus to the corpora cavernosa intraoperatively and to decide whether the bundles can be preserved or resected widely with the specimen. In the course of performing 312 radical retropubic prostatectomies the neurovascular bundle was widely excised unilaterally in 49 men with advanced clinical disease in whom, based on preoperative or intraoperative assessment, the bundle appeared to be involved by tumor. Because of this selection criterion these patients had higher clinical stage (52 per cent had clinical stage B2) and pathological stage (35 per cent had microscopic involvement of pelvic lymph nodes) disease than our previously reported series. In 38 patients the margins of resection were negative for tumor. In 11 patients despite attempts at wide excision of the lesion the surgical margins of resection were positive. In all 11 men with positive surgical margins there was extensive periprostatic extension of tumor and 8 had involvement of the pelvic lymph nodes. However, in none of the 11 patients with positive surgical margins were the margins positive only at the site where the bundle was spared, which shows that unilateral sparing of the neurovascular bundle did not compromise removal of tumor. Of the 29 men who were potent preoperatively and who have been followed for 1 year or longer postoperatively 20 (69 per cent) are potent. The return of sexual function correlated with age: 5 of 5 men (100 per cent) 40 to 49 years old were potent postoperatively compared to 8 of 10 (80 per cent) 50 to 59 years old and 7 of 14 (50 per cent) 60 to 69 years old. Histological evaluation of the resected specimens revealed that some of the men who were potent postoperatively had soft tissue and nerves resected in the region of the contralateral spared neurovascular bundle. By measuring nerves in the spared region of the neurovascular bundle we found that the role of the neurovascular bundles in potency is not owing to large nerves but to many nerves of varying size. In conclusion, potency can be maintained after radical prostatectomy in most patients in whom it is necessary to excise 1 neurovascular bundle widely without compromising the removal of tumor.     

Application of Ultrasonic Bone Curette in Endoscopic Endonasal Skull Base Surgery: Technical Note

Background Endoscopic endonasal surgery (EES) of the skull base often requires extensive bone work in proximity to critical neurovascular structures. Objective To demonstrate the application of an ultrasonic bone curette during EES. Methods Ten patients with skull base lesions underwent EES from September 2011 to April 2012 at the University of Pittsburgh Medical Center. Most of the bone work was done with high-speed drill and rongeurs. The ultrasonic curette was used to remove specific structures. Results All the patients were submitted to fully endoscopic endonasal procedures and had critical bony structures removed with the ultrasonic bone curette. Two patients with degenerative spine diseases underwent odontoid process removal. Five patients with clival and petroclival tumors underwent posterior clinoid removal. Two patients with anterior fossa tumors underwent crista galli removal. One patient underwent unilateral optic nerve decompression. No mechanical or heat injury resulted from the ultrasonic curette. The surrounding neurovascular structures and soft tissue were preserved in all cases. Conclusion In selected EES, the ultrasonic bone curette was successfully used to remove loose pieces of bone in narrow corridors, adjacent to neurovascular structures, and it has advantages to high-speed drills in these specific situations.     

Review of synthetic mesh-related complications in pelvic floor reconstructive surgery

There is significant risk of re-operation after pelvic reconstructive surgery. In an attempt to improve outcome, synthetic materials are increasingly being used to augment pelvic organ prolapse repair despite lack of strong evidence to support their routine use. The use of synthetic mesh to correct apical, anterior and posterior vaginal wall prolapse is not without complications. This review aims to evaluate the long-term complications of synthetic mesh in pelvic reconstructive surgery.     

��ǻ����λֱ�������б�����Լ���Ѫ������Ҫ��

??Preservation of pelvic plexus and neurovascular bundles in the laparoscopic sphincter-preserving surgery for low rectal cancer CHI Pan?? CHEN Zhi-fen. Department of Colorectal Surgery??Union Hospital??Fujian Medical University??Fuzhou 350001??China
Corresponding author??CHI Pan??E-mail??cp3169@163.com
Abstract Recently??more and more laparoscopic surgery is applied to treat the rectal cancer. The preservation of pelvic plexus and neurovascular bundles is the key and difficult part of the laparoscopic sphincter-preserving surgery for low rectal cancer??and it is the important factor of postoperative urinary and sexual function. Because of the different appearance of laparoscopic anatomy compared to the open surgery??recognizing the structures and finding the correct surgical plane during laparoscopic rectal surgery will help preserve related nerve structures.     

Microsurgical Removal of Olfactory Groove Meningiomas via the Pterional Approach

Commonly used frontobasal approaches for microsurgical removal of olfactory groove meningiomas have certain disadvantages, such as late exposure of the neurovascular complex located dorsal to the tumor, namely, the internal carotid artery, middle cerebral artery, anterior cerebral artery, and the optic nerves. In addition, the frontal sinuses are frequently opened and there can be compression of the frontal lobes from significant spatula pressure. We report our experience with the pterional approach for these tumors in 28 patients. All patients presented with hyposmia/anosmia; 20 had personality changes and 8 had visual deficits. At surgery, after dissection of the sylvian fissure, the internal carotid artery, middle cerebral artery, anterior cerebral artery, and the homolateral optic nerve were exposed before removal of the posterior tumor parts. Reduction of focal pressure was achieved by removal of the contralateral tumor following partial resection of the falx and crista galli. Total tumor removal was obtained in all but 1 patient. One patient died of pulmonary embolism. The psychoorganic syndrome resolved in all but 1 patient; visual deficits improved in 6 patients. There were no postoperative infections. We consider the pterional approach to be superior to others for these lesions because it provides early exposure of the neurovascular complex, preservation of the frontal venous drainage, and avoidance of postoperative cerebrospinal fluid fistulae.     

Pelvic fasciae in urology

INTRODUCTION

Despite the vast literature on pelvic fascia, there is confusion over the periprostatic structures and their nomenclature, including their orientation, the neurovascular bundles and the existence of the prostatic ‘capsule’. In this review, we seek to clarify some of these issues.

MATERIALS AND METHODS

Review of published medical literature relating to the anatomy of the pelvic fascia including a Pubmed search using the terms – pelvic fascia, Denonvilliers'' fascia, prostate capsule, neurovascular bundle of Walsh, pubo-prostatic ligament and the detrusor apron.

CONCLUSIONS

The findings of the study were as follows:

1. The ‘capsule’ of the prostate does not exist. Rather, the fibromuscular band surrounding the prostate forms an integral part of the gland.
2. The prostate is surrounded by fascial structures – anteriorly/anterolaterally by the prostatic fascia and posteriorly by the Denonvilliers'' fascia. Laterally, the prostatic fascia merges with the endopelvic fascia.
3. The posterior longitudinal fascia of the detrusor comprises a ‘posterior layer’ of the detrusor apron, extending from the bladder neck to the prostate base.
4. The neurovascular structures tend to be located posterolaterally, but may not always form a bundle. A significant proportion of fibres may lie away from the main nerve structures, along the lateral/posterior aspects of the prostate.

     

Vertebral synovial chondromatosis. Report of two cases and review of the literature

Synovial chondromatosis is an uncommon disorder characterized by the formation of multiple cartilaginous nodules within the synovium, most commonly affecting large joints. Its involvement with the spine is rare; only six cases have been reported. The authors describe two patients with synovial chondromatosis involving the cervical spine. In the first case, synovial chondromatosis arose from the left C1-2 facet joint. This patient underwent a two-stage procedure including a posterior approach for tumor resection and occipitocervical fusion as well as a transmandibular circumglossal approach to the anterior craniocervical junction to complete the tumor removal. Interestingly, on histopathological examination, scattered foci of low-grade chondrosarcoma were intermixed within the synovial chondromatosis. To the authors' knowledge, this is the first report of secondary low-grade chondrosarcoma arising in vertebral synovial chondromatosis. In the second case, synovial chondromatosis involved the left C4-5 facet joint. Tumor resection and cervical fusion were performed via a posterior approach. In this report, the authors describe the clinical presentation, radiographic findings, operative details, histopathological features, and clinicoradiological follow-up data obtained in these two patients and review the literature pertaining to this rare entity.     

Laparoscopic ventral hernia repair using expanded polytetrafluoroethylene–polyester mesh compound

Background Many biomaterials and composites have been used in clinical and experimental laparoscopic ventral hernia repair. The ideal prosthesis should allow firm binding to the abdominal wall without adhesion to the bowel. Methods A compound prosthesis was made by circumferentially suturing a Gore-Tex mesh as visceral interface to a smaller polyester mesh as parietal interface, and it was used in 46 laparoscopic ventral hernia repairs between January 2000 and December 2004. Results Average operative time was 65 min, with no intraoperative complications. Mean hospital stay was 2.2 days. Postoperative complications were five seromas, two hematomas, and one recurrence after a mean follow-up of 32.2 months. Conclusion The prosthesis used was made of two biomaterials that have been tested and tried over the years. The polyester layer is known to induce sufficient tissue ingrowth, whereas Gore-Tex minimizes adhesion formation. The memory of the compound was high enough to allow easy laparoscopic unrolling and handling.     

骨盆骨折后尿道损伤和阳萎

目的：探讨骨盆骨折后尿道并发阳萎的机制及如何避免阳萎的发生。方法：随访骨盆的后尿道损伤１８例与狭窄２５例的治疗效果。结果：后尿道损伤１８例,采用会师牵引复位术治疗,２例发生阳萎（１１．１％）;陈旧性后尿道狭窄２５例,经各种手术修复尿道后,５例发生阳萎（２０．０％）。结论：阳萎主要由骨盆骨折损伤勃起神经与血管及阴茎海绵体引起,伤后的手术操作及多次尿道复位或成形术,亦增加阳萎的发生率。     

Rectal erosion of synthetic mesh used in posterior colporrhaphy requiring surgical removal

Treatment of pelvic organ prolapse with transvaginally placed synthetic mesh has recently increased. Several reports of complications have surfaced raising the overall question of safety regarding its use for vaginal prolapse repair. This case report describes a rectal erosion and dyspareunia that resulted from mesh placed into the posterior vaginal wall. A 47-year-old woman underwent a laparoscopic supracervical hysterectomy and a posterior repair with polypropylene mesh resulting in a rectal erosion. Despite removal of all of the mesh that could be excised rectally resulting in a healed rectal mucosa, the patient had persistent dyspareunia and pain requiring complete removal of the mesh using a vaginal approach. After surgery, the patient had resolution of all her symptoms. Further studies of transvaginally placed synthetic mesh need to be performed to determine its safety and efficacy.     

腹腔镜直肠癌手术中神经血管束显露保护及其损伤防治

全直肠系膜切除的提出推动了结直肠外科进入膜解剖时代,极大降低了直肠癌的局部复发率及改善了泌尿及性功能的保护。但由于盆丛及神经血管束与直肠系膜间存在多处微血管及神经的支配关系,导致直肠系膜在侧前方及侧后方与盆壁均存在致密粘连,神经血管束被分为多层的Denonvilliers筋膜包裹及分割,Denonvilliers筋膜后叶向后与盆筋膜壁层的前叶相延续,盆筋膜壁层分层包绕腹下神经、盆丛及神经血管束,保护Denonvilliers筋膜后叶及盆筋膜壁层的完整性是保护神经血管束的重要原则,神经纤维周围有微血管并行,来自髂内血管系统走向直肠系膜的滋养血管具有不同于盆筋膜壁层表面微血管的走行特征,可作为辅助筋膜辨识的重要标志。适当的牵拉暴露、分离手法,优化的手术流程,熟悉筋膜解剖以及微血管对筋膜辨认的作用是避免神经血管束损伤的关键措施。     

Management of complications arising from transvaginal mesh kit procedures: a tertiary referral center’s experience

This case series’ purpose is to review a referral center’s experience with complications from mesh kits. A chart review of 12 patients who presented with complications associated with transvaginal mesh kit procedures was performed. All patients underwent complete surgical removal of the mesh to treat mesh exposure, pain, or vaginal bleeding/discharge followed by an anterior or posterior repair. The mean follow-up time after surgery was 3.4 months. Eight of 12 patients had mesh that had formed a fibrotic band. Six of 12 patients had complete resolution of pain. Of the nine patients with mesh exposure, all required significant resection of the vaginal wall. No further mesh exposure occurred. The use of transvaginal mesh kits may cause previously undescribed complications such as pelvic/vaginal pain or large extrusions requiring complete removal. Removal of all mesh except the arms may cure or significantly improve these problems.     

Repair of giant abdominal hernias: does the type of prosthesis matter?

Closure of the abdominal wall after trauma or major surgery may be difficult due to visceral edema or fascial weakness; thus, the risk of developing a ventral hernia (VH) is high. Commonly, these hernias are repaired using a prosthetic mesh. Complications following mesh repair can develop. We hypothesize that the type of prosthetic material affects outcome. This is a retrospective chart review of patients admitted from 1996 to 2002 undergoing VH (> or = 20 x 10 cm) repair with prosthetic mesh. Data collected included age, sex, and race. Patients were stratified by prosthetic material as follows: Gore-Tex (GR), Marlex + Gore-Tex (MG), Marlex (MR), and Marlex + Vicryl (MV). For the purpose of clinical analysis, the groups were collapsed into subgroups: Gore-Tex exposure (GT) or non-Gore-Tex exposure (NG). Outcome measures were hernia recurrence (HR), wound infection (WI), and fistula formation (FF). Statistical analysis utilized chi2 test and Fisher's exact test. There were 55 VH repairs in 37 patients. The mean age was 43.9 (+/- 16.3), males out-numbered females 22 (59.5%) to 15 (40.5%). The majority of the patients were Caucasian (29; 78.4%). There were 30 trauma patients (81.1%), and 7 general surgery patients (18.9%). The HR for the study (n = 55) was 20 (36.4%), the WI was 17 (30.9%), and the FF was 3 (5.5%). GR group (6; 66.7%) had a significant higher wound IF rate than MR group (8; 26.7%) (Chi P = 0.02, Fisher P = 0.047). All other group comparisons (HR, WI, and FF) were N.S. The Gore-Tex versus non-Gore-Tex subgroup comparison results were as follows: GT (n = 18) had a WI 8 (44.4%), HR 6 (33.3%), and FF 0 (0%). NG (n = 37) had a WI 9 (24.3%), HR 14 (37.8%), and a FF 3 (8.1%). There was a trend toward a higher wound infection in the GT versus NG, but it did not reach statistical significance. We conclude that 1) the wound infection rate was higher in the Gore-Tex versus the Marlex group (Chi P = 0.02, Fisher P = 0.047). Wound infection in the presence of Gore-Tex usually mandates the removal of the mesh resulting in a hernia recurrence. 2) There was a trend toward a higher wound infection in the GT (44.4%) versus NG (24.3%), but it did not reach statistical significance.