[Transposition of rectus muscles of abdomen and autodermoplasty in the treatment of major and huge recurrent postoperative middle hernias]

Experience of treatment of patients with major and huge recurrent postoperative middle hernias is analyzed. Control group consisted of 131 patients who were operated with Yanov's combined methods of autodermoplasty. Specific complications in early postoperative period were seen at 18 (13.7%) patients, 1 (0.7%) patient died. In long-term period recurrence was diagnosed at 26 (55.3%) of 47 operated patients with major hernias. Original combined methods of hernioplasty for major and huge recurrent postoperative middle hernias have been developed. Sixty-two patients were operated with these methods, specific complications in early postoperative period were seen at 8 (12.9%) patients, 2 (3.2%) patients of them died. Recurrence in long-term period was diagnosed at 1 (1.7%) patient. It is concluded that combination of O. Ramirez surgery with autodermoplasty is high effective.

[Preventive plasty of the abdominal wall with endoprosthesis "Esfil" in operations on organs of the abdominal cavity]

An analysis of clinical and US investigations of the abdominal wall in 210 patients with different surgical diseases of the abdominal cavity allowed division of the patients into three groups: without clinical and ultrasonic alterations, with a mild degree and with a severe degree of the anatomo-functional weakness of the abdominal wall. Indications for preventive endoprosthesis of the abdominal wall were determined using the method of quantitative evaluation of risk factors of postoperative hernias developed by the authors. Preventive endoprosthesis of the abdominal wall with a polypropylene endoprosthesis "Esfil" was fulfilled during operation on organs of the abdominal cavity in 11.9% of the patients by absolute indications. The number of postoperative hernias was reduced to 0.9%.

Descriptive study of peristomal complications

OBJECTIVE

The objective of this study was to assess new ostomy patients for the presence of peristomal complications when they returned for their 2-month postoperative follow-up at a major university hospital.

DESIGN

A prospective descriptive design was used.

SETTING AND SUBJECTS

For 1 year, new ostomy patients were seen at a 540-bed university-based hospital. Subjects included 220 patients with ostomies who underwent a fecal or urinary diversion at a university-based hospital.

INSTRUMENTS AND METHODS

For 12 months, each patient who returned for a 2-month follow-up visit was assessed by 1 of 3 WOC nurses for the presence or absence of peristomal complications using a tool developed by the investigators. The study was conducted from August 2001 to August 2002. Descriptive statistics were used to summarize the data.

RESULTS

A total of 220 new ostomy patients were examined, 35 of whom had peristomal complications for a frequency of 16%. Sixteen of the 35 patients had ileostomies, 10 patients had colostomies, and 9 patients had ileal conduits. Of the 35 patients with peristomal complications, 24 had irritant dermatitis, 7 had mechanical injury, and 3 had Candida infections. The WOC nurses determined the causes of the peristomal complications to be related to flush stomas, peristomal hernias, inappropriate opening in the skin barrier, and mechanical injury from the pouching systems. Nine of 35 patients had flush stomas; 5 patients developed peristomal hernias. For 7 patients, the skin barrier in the pouching system was larger than the stoma, allowing the effluent to contact the peristomal skin, resulting in denuded peristomal skin; and 7 patients had pressure areas on the peristomal skin and were wearing convex pouching systems.

CONCLUSIONS

With more laparoscopic ostomy surgeries resulting in decreased hospital stays, there is less opportunity for the patient to learn pouching techniques and problem solving regarding peristomal complications. Patients require more education regarding peristomal issues and follow-up after discharge to ensure the maintenance of a secure pouching system. Decreased hospital stays and decreased reimbursement for outpatient and home health services will continue to be a challenge for the WOC nurse. There is also a need for universal definitions of complications and the need for continued studies examining the frequency of these complications, as well as the role of stoma site marking in reducing these complications.

Is polypropylene mesh safe and effective for repairing infected incisional hernia in renal transplant recipients?

INTRODUCTION

Infected incisional hernias are common in kidney transplant patients. Treating them in immunosuppressed patients can take months, increasing costs and implying loss of working productivity. Abdominal wall prostheses have not been used in infected immunosuppressed patients because of poor infection control. We evaluated the outcome of the surgical treatment of these patients with polypropylene mesh to shorten the hospitalization time and patient recovery. The records of 462 consecutive kidney transplant patients (March 2000 to February 2004) were reviewed. Of these 462 patients, 13 (2.8%) had infected or contaminated herniations at the transplant incision. They developed between 2 and 60 days (mean 14) after transplantation. The racial distribution was not significant, but herniations were more common in patients from cadaveric donors (4.5% versus 0%, P = 0.005). Predisposing factors were found in 6 patients (46.2%) and included complications from transplant surgery in 2, obesity in 1, leukopenia in 3, sepsis in 1, diabetes mellitus in 1, and wall weakness in 1 patient (3 had more than one risk factor).

TECHNICAL CONSIDERATIONS

A prospective protocol of surgical correction with polypropylene mesh was established. After wound cleansing with normal saline, repair was done by primary fascial approximation and polypropylene mesh reinforcement. Broad-spectrum antibiotics and large-bore drains were used. Follow-up ranged from 1 to 40 months (mean 14.5). All patients did well except for one recurrence, 14 months after correction.

CONCLUSIONS

Surgical repair with polypropylene mesh is safe and effective in treating infected or contaminated herniations in kidney transplant patients, with an acceptable (9.1%) incidence of recurrence.

Prevention and management of access port site hernia associated with the laparoscopic adjustable gastric band

Access port site hernia is a rare complication associated with the laparoscopic adjustable gastric band (LAGB). Specifically, this unique problem occurs when a fascial defect allows herniation adjacent to the Silastic tubing connects the LAGB to the access port. A 48-year-old woman who had previously undergone placement of LAGB presented with a bulge lateral to the access port; physical examination revealed a hernia near the access port. At laparoscopy, a large portion of omentum was herniated lateral to the Silastic tubing at the port site. This was laparoscopically repaired by first reducing the omentum and then placing a surgical mesh underlay to cover the defect; the patient recovered uneventfully. Access port site hernia is a rare complication with only a single case report published in the literature. We present a case of access port site hernia that was laparoscopically repaired. In addition, we have identified several important technical aspects that may contribute to the development of access port site hernias.

Internal hernia after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Internal hernia (IH) is a technical complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP) that can have severe consequences. Little has been written on characterizing this complication. Antecolic Roux limb passage has been suggested to be safe without defect closure.

METHODS

The records of 785 patients who underwent LRYGBP (136 antecolic, 649 retrocolic) between 1998 and 2003 were reviewed. In our early experience (n = 107), we used a retrocolic technique without defect closure.

RESULTS

Twenty patients underwent surgical intervention for IH. The median interval between LRYGBP and symptom onset was 303 days (range, 25 to 1642 days). Abdominal pain was uniformly present, and 63% of patients developed nausea and/or vomiting. Exploratory laparoscopy was attempted in 94% of patients; conversion was necessary in 33%. A total of 21 IHs were identified (13 Petersen's, 5 mesocolic, 2 jejunojejunal, and 1 adhesion-related hernia). No nonviable bowel was identified, and no deaths occurred. A retrocolic technique involving closure of all defects resulted in the lowest rate of hernias (3/542; 0.55%) compared with the antecolic (12/136; 8.81%; P < .0001) and early retrocolic techniques (6/107; 5.6%; P < .0002).

CONCLUSION

IH can occur long after gastric bypass surgery, and a low threshold for reoperation is crucial to avoid gut infarction. A retrocolic technique with defect closure appears to afford the lowest risk of IH. The lower incidence of IH in other series after antecolic technique likely results from a less aggressive detection and management approach, because our nonclosure technique could not differ from that of other authors. All defects must be closed to minimize the risk of hernia, whether antecolic or retrocolic.

The duodenal fossae: anatomic study and clinical correlations

The aim of this study was to present anatomic macroscopic aspects and the relationship between the duodenum and the posterior abdominal wall. The authors describe anatomic types of peritoneal duodenal fossae and stress some points of surgical importance. Twenty-four cadavers, fixed in formalin, were dissected. Ten peritoneal fossae were given prominence and the authors show the anatomical structures topographically, from a superficial plane to a deep viscerae level. There is usually a complete fusion of the duodenal loop with the posterior parietal peritoneum except the duodenojejunal flexure. The study reveals three right retroduodenal fossae, three left retroduodenal fossae, two inferior duodenal fossae, one left paraduodenal fossa and one superior duodenal fossa. These peritoneal recesses mostly result from an incomplete adhesion of the Treitz's fascia. This work provides some explanation of paraduodenal hernias that represent a rare case of intestinal obstruction. Two cases of these internal hernias are illustrated and their pathophysiology and embryologic basis are discussed.

Surgical treatment of large contaminated abdominal wall defects

BACKGROUND

Repair of a large, severely contaminated abdominal wall defect is a challenging problem. Most patients are currently treated with a multistaged procedure, which is time consuming, carries a high complication rate, and is often not finalized.

STUDY DESIGN

In this study, our experience with a one-stage repair of contaminated abdominal wall defects using the Components Separation Method was evaluated with respect to morbidity and recurrence. Medical records of patients with contaminated abdominal wall defects, treated with the Components Separation Method from 1996 to 2000, were studied. Patients were invited to visit the outpatient clinic for a physical examination.

RESULTS

Twenty-six patients with a median age of 49 years and a mean defect size of 267 cm2 were treated. Intraoperative contamination, graded according to the National Research Council (NRC), showed 22 National Research Council III patients and 4 National Research Council IV patients. Postoperatively, five superficial wound infections, three cases of pneumonia, three instances of recurrent enterocutaneous fistulation, and two cases of sepsis were observed. One of the patients with sepsis died after anastomotic disruption led to peritonitis and multiple organ failure. Two asymptomatic recurrences were diagnosed (8%) after a median followup of 27 months.

CONCLUSIONS

Large contaminated abdominal wall hernias can be closed by the Components Separation Method, with a low recurrence rate but considerable morbidity.

Narbenhernien

With a long-term incidence of 10-20%, incisional hernias remain one of the most common surgical complications. Beside technical causes, wound-healing problems are increasingly being discussed. Conventional suture repair shows disappointing results and should be used only in selected cases. By the implantation of mesh prostheses, notable improvement could be achieved, with recurrence rates of <10%. Its main principle is retromuscular mesh reinforcement of the entire scar. Particularly in the neighbourhood of osseous structures, only retromuscular placement allows sufficient subduction of the mesh by healthy tissue of at least 5 cm in all directions. Preparation must take into account the special anatomic features of the abdominal wall, especially in the area of the Linea alba and Linea semilunaris.

A laparoscopic method for optimal peritoneal dialysis access

Both medical benefits to the patient and financial incentives to the health care system exist to increase the use of peritoneal dialysis as renal replacement therapy. Providing long-term peritoneal access free of mechanical dysfunction continues to represent a major challenge to the success of this modality. Variable outcomes result from the lack of standard implantation methodology and failure to address persistent problems associated with current implantation techniques. This prospective case study compared noninfectious procedural complications of three approaches to establish peritoneal dialysis access. The groups consisted of 63 catheters implanted by traditional open dissection, 78 catheters implanted by basic laparoscopy without associated interventions, and 200 catheters implanted by advanced laparoscopic methods including rectus sheath tunneling, selective prophylactic omentopexy, and selective adhesiolysis. Mechanical flow obstruction, the major outcome indicator, followed only 1 of 200 (0.5%) implantation procedures in the advanced group and was significantly better (P < 0.0001) than the open dissection (17.5%) and basic laparoscopic (12.5%) groups. A low rate of pericannular leaks (1.3-2%) was not different for the three groups. One pericannular hernia occurred in the open group. Catheter mechanical dysfunction attributable to the surgical technique can nearly be eliminated through adjunctive procedures made possible only by a laparoscopic approach.

Strangulated small bowel evisceration after intraperitoneal drainage

We report an exceptional case of strangulated small bowel evisceration through an intraperitoneal drainage after open cholecystectomy. It is a recognized but rare complication of surgical procedures. The drainage must be sited carefully and when necessary. If possible, drains of less than 10 mm external diameter should generally be used.

Port complications following laparoscopic adjustable gastric banding for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has gained widespread acceptance. However, the technique has problems intrinsic to the material wear and tear around the port and connecting tubing that can lead to failure. Port complications are considered to be minor; however, few studies have analyzed them, and the optimal technique of port implantation and management has not been elucidated.

METHODS

All patients who suffered from complications involving the tubing or access-port were included in this study. Their complaints, imaging studies, operative reports and hospitalization files were retrospectively reviewed.

RESULTS

1,272 of the patients were available for a mean follow-up period of 37 months. During this time, 91 patients (7.1%) experienced port complications that required 103 revisional operations. Of these patients, 62 had system leaks, 19 infectious problems, and 10 miscellaneous problems requiring operative correction. Overall port problems led to band removal in 6 patients, and replacement in 1 patient.

CONCLUSION

Access-port complications after the Lap-Band procedure are among the most common and annoying ones, and can render the device susceptible to failure. Careful surgical technique and routine use of radiologic guidance for band adjustments are the keys to avoiding complications.

Pregnancy after gastric bypass surgery and internal hernia formation

BACKGROUND

Gastric bypass is a surgical procedure that is increasingly performed in the United States to treat morbid obesity. Because of the changes associated with pregnancy, women with a history of gastric bypass surgery may be at an increased risk of gastrointestinal complications during the antepartum period, as demonstrated by these cases.

CASES

The first patient presented at 12 weeks of gestation with abdominal pain. Computed tomography scan revealed rotation of the small bowel mesentery. In the operating room, a Petersen's internal hernia was observed. The second patient presented at 34 weeks of gestation with epigastric pain, nausea, and vomiting. An abdominal computed tomography scan suggested distention of the biliopancreatic limb, duodenum, and bypassed stomach. She underwent exploratory laparotomy with repair of an internal (mesenteric loop) hernia.

CONCLUSION

As obstetricians, we should be aware of the potential for internal hernias in pregnant patients who have undergone bariatric surgery.

Bicycle-handlebar hernia: a rare traumatic abdominal wall hernia

Handlebar hernia is a rare, traumatic, abdominal wall hernia caused by high-velocity direct trauma. It involves disruption of the abdominal wall muscles, with bowel loop herniated through the defect in the abdominal wall, and may have major or even lethal complications. We report a case of bicycle-handlebar hernia in a 9-year-old boy who had all layers of his abdominal wall disrupted by a fall when bicycling; however, his skin and intra-abdominal organs were completely intact. Computed tomography demonstrated subcutaneous intestinal loops protruding through the rent. Primary repair was performed, and his postoperative course was uneventful.

Radiological Diagnosis of Internal Hernia after Roux-en-Y Gastric Bypass

BACKGROUND

Internal hernia is a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Preoperative diagnosis may be difficult on the basis of history and physical examination. CT scanning is often performed as a diagnostic tool for patients with symptoms after LRYGBP but is often read by the radiologist as non-specific or normal. Preoperative review of the study by the bariatric surgeon who is familiar with the neo-anatomy can identify the internal hernia and its location.

METHODS

We retrospectively reviewed our first 185 patients undergoing LRYGBP to identify all patients who developed an internal hernia. The patient's symptoms, physical findings and CT scans were reviewed. Time to presentation with the internal hernia was noted. Radiological interpretation of the scans was recorded, as well as the bariatric surgeon's preoperative impression after review of the scans.

RESULTS

In our initial experience of 185 patients undergoing LRYGBP, 5 patients presented at various times in their postoperative course with an internal hernia, for an incidence of 2.7%. All patients underwent preoperative CT scanning. Radiologist interpretation of the scans identified one internal hernia of the 5 preoperatively and was suggestive in another. Preoperative review of the scans by the bariatric surgeon was not only highly suggestive of the diagnosis, but of the location as well, in all 5 cases.

CONCLUSION

Preoperative diagnosis of an internal hernia in patients after LRYGBP is often difficult. CT scanning has been found to be a very helpful diagnostic tool, especially when reviewed preoperatively by the bariatric surgeon.

Body wall dysplasia: a rare case of abdominal hernia

Malformations of the fetal abdominal wall include a broad spectrum of anomalies, and prenatal sonography provides the possibility of detecting most of them. Omphalocele and gastroschisis are the most common conditions, but there are other rare forms. We describe here a rare case of body wall dysplasia that we called abdominal hernia that appeared upon prenatal sonography as an omphalocele-like defect.

Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus: Presentation of 12 patients

BACKGROUND

Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus is an unusual and complex form of closed-loop obstruction that may result in a fatal outcome unless treated timely and properly. The aim of this article was to review our experience with this condition, with emphasis on the etiopathogenesis, clinicopathologic features, and treatment options.

METHODS

We conducted a retrospective analysis of medical records of 12 patients treated at 2 university hospitals over a period of 30 years between 1970 and 2000.

RESULTS

In this series, the internal herniation resulted in ileosigmoid knotting in 8 cases, whereas it was concomitant with sigmoid volvulus in 4 cases. The types of internal herniation were identified as transmesenteric through the Treves field in 8 patients and as transomental, intersigmoidal, pericecal, and around omphalomesenteric fibrous cord in 1 patient each. The rate of gangrenous bowel was 100%. En bloc resection for combined gangrene of small bowel and large bowel was the treatment of choice in 7 patients, of whom 5 underwent the Hartmann's procedure and 2 underwent primary sigmoidectomy-anastomosis in addition to primary enterectomy-anastomosis. Primary sigmoidectomy-anastomosis and Mikulicz's procedure were performed in 2 patients for gangrenous sigmoid colon only. Three patients underwent primary enterectomy-anastomosis for gangrenous small bowel only. The morbidity rates and the mortality rate were both 33.3%. The mean length of hospital stay following emergency operations was 11.2 days.

CONCLUSIONS

In particular, surgeons who are from developing countries that form the world's "volvulus belt" should be aware of this entity's features and be ready to perform an appropriately selected surgical option for a given patient to accomplish the optimal clinical outcome.

Incisional hernia: a possible complication after the orthotopic urinary diversion?

AIM

One of the complications of abdominal surgical procedures is incisional hernia. This complication is encountered in different rates due to the surgical technique, type of urinary diversion preferred, and whether the patient has additional risk factors or not.

PATIENTS AND METHODS

In this study, 145 patients who had undergone urinary diversions in our clinic were evaluated between the years 1989 and 2002. Of those, 17 were treated by Mainz pouch type II urinary diversion, 47 by Indiana type urinary diversion and 81 patients were treated by orthotopic urinary diversions.

RESULTS

Incisional hernia did not occur in any of the patients who had undergone Mainz pouch type II and Indiana type urinary diversions. Eleven of 145 patients (7.5%) who had undergone urinary diversions developed incisional hernia. All of these incisional hernia occurred in patients who had undergone orthotopic type urinary diversion. These incisional hernias occurred within the first postoperative year (2-8 months).

CONCLUSIONS

We believe that increased intraabdominal pressure for micturition is the predisposing factor for the development of incisional hernias. Furthermore, the patients must avoid from sudden increase of intraabdominal pressure such as suddenly, strong valsalva maneuver during voiding. And we believe usefully press doing from the outside to abdomen during voiding (crede maneuver).

Internal hernias after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Laparoscopic gastric bypass (Lap-RYGB) is an increasingly common procedure performed for severe obesity. Internal hernias are a potential problem associated with Lap-RYGB, and little is known about the clinical presentation and the diagnostic accuracy of this potentially serious complication.

METHODS

A retrospective review of 1,000 retrocolic Lap-RYGB was performed to identify those who developed postoperative internal hernias. Clinical symptoms, radiologic characteristics, and operative outcomes were analyzed to determine clinical and radiologic diagnostic accuracy (including computed tomography [CT] scan and upper gastrointestinal imaging). Subsequent independent review was performed to match operative intervention with radiologic imaging and interpretation. Operative outcomes, including the hernia closure technique, hospital length of stay, and mortality were obtained.

RESULTS

Of 1,000 Lap-RYGB procedures, 45 internal hernias were identified (4.5%) in 43 patients. Hernia location included transverse colon mesentery (n = 43, 95%) or Petersen's defect (n = 2, 5%). The most common clinical symptoms included intermittent, postprandial abdominal pain, and/or nausea vomiting (86%), although 20% had no abdominal tenderness. Initial radiologic imaging studies were diagnostic in 64%, although subsequent review of all imaging studies showed diagnostic abnormalities in 97%. CT findings suggestive of internal hernia include small bowel loops in the left upper quadrant and evidence of small bowel mesentery traversing the transverse colon mesentery. All patients with internal hernias underwent operative repair (98% performed laparoscopic). One patient had a negative laparoscopy, although the preoperative CT suggested an internal hernia was present. The mean time to intervention for an internal hernia repair was 225 days (range 2 to 490), whereas hospital length of stay was 1.2 days (range 1 to 4). No deaths were noted.

CONCLUSIONS

Internal hernias after retrocolic lap-RYGB are associated with vague abdominal complaints and limited radiologic imaging results. A high index of clinical suspicion should be used in this patient population, and surgeon review of radiology imaging studies should be performed. Prompt surgical intervention is successful and can commonly be performed laparoscopically.

Occlusion colique sur hernie lombaire secondaire à un prélèvement de lambeau du muscle grand dorsal

The authors report the case of a 46-year-old woman with large bowel obstruction secondary to lumbar hernia following latissimus dorsi flap. Diagnosis was made by CT. This paper describes the CT features of this rare pathology. A brief review of the literature is also presented.