Structural and Functional Anatomy of the Abdominal Wall

Expansion of the Subcutaneous Compartment by Umbilicus Resection for Intrathecal Pump Placement: The "Karagoz-Hacivat Technique"

BACKGROUND AND OBJECTIVES

Intrathecal baclofen (ITB) for severe spasticity can encounter complications such as wound dehiscence and ulcers because of elevated intracompartmental pressure within the abdominal subcutaneous and subfascial pocket housing the pump. We propose an innovative technique to manage ITB wound ulcers.

METHODS

Resecting the umbilicus create a more spacious and less tension-prone pocket for the ITB pump.

RESULTS

Between 2015 and 2023, we implanted ITB pumps in 65 patients. Among them, 5 patients presented with skin ulcer or dehiscence underwent surgery using the novel technique. Postoperative follow-up revealed successful wound healing, with no further wound-related complications.

CONCLUSION

The proposed technique provides effective and practical solution to wound and skin complications related to ITB pump. Moreover, it may serve as a viable preemptive strategy during the initial implantation of the ITB pump in selected patients.

Prevalence of Umbilical Hernias by Computed Tomography

INTRODUCTION

Umbilical hernias (UHs) are commonly underdiagnosed due to their asymptomatic presentation. The aim was to determine the prevalence of UHs by computed tomography (CT) in a trauma center, to assess the magnitude of their underdiagnosis.

METHODS

A cross-sectional study was designed, using CT studies to evaluate the integrity of the abdominal wall. The images were obtained from consecutive cases of adult patients (≥18 y) from the database of the radiology and imaging service during a 4-mo period. The sociodemographic features, type of CT scan, and description of the abdominal wall were obtained and compared with the radiology report. In the case of UH presence, the transversal, cephalocaudal, and anteroposterior lengths, as well as its content, were registered.

RESULTS

A total of 472 CT scans were included with a 67.6% (n = 319) prevalence of UH. These were most common in men (58.9%, n = 188/319), but women were more likely to have UH ≥ 10 mm (55%, n = 72/131). Of those with UH, 63.6% were unreported by radiology. The most common content was peritoneal fat (87.5%). UH had medians (interquartile range) of 9.1 mm (6.8, 12.5), 8.3 mm (6, 11.5), and 12.8 mm (8.6, 18.2) in its transversal, cephalocaudal, and anteroposterior lengths, respectively. Transversal length had a high positive correlation with cephalocaudal length (r = 0.877). This datum relationship can be explained by at least 76% due to this factor. Interobserver reliability analyses resulted in substantial reliability (ICC>0.85 and k > 0.85).

CONCLUSIONS

CT is an effective imaging tool for diagnosing UH. There is a high prevalence among the general adult population, with a high radiologic underreporting.

Intercostal nerve electrodiagnostic testing in rib fractures

INTRODUCTION/AIMS

Intercostal nerve injury can occur after rib fractures, resulting in denervation of the abdominal musculature. Loss of innervation to the rectus abdominis and intercostal muscles can cause pain, atrophy, and eventual eventration, which may be an underrecognized and thus undertreated complication of rib fractures. We investigated the clinical utility of intercostal nerve electrodiagnostic testing following rib fractures to diagnose and localize nerve injury at levels T7 and below.

METHODS

Five patients with displaced bicortical rib fractures involving the 7th-11th ribs and clinical eventration of the ipsilateral abdominal wall underwent intercostal nerve conduction studies (NCS) and needle electromyography (EMG) on the affected side. EMG of the rectus abdominis and intercostal muscles was performed with ultrasound guidance, and ultrasound measurements of rectus abdominis thickness were obtained to assess for atrophy.

RESULTS

Average patient age was 59.4 years and average body mass index (BMI) was 31.5 kg/m2. Intercostal NCS and EMG were able to reliably diagnose and localize intercostal nerve damage after rib fractures. Ultrasound demonstrated an average rectus abdominis transverse cross-sectional thickness of 0.534 cm on the affected side, compared with 1.024 cm on the non-affected side.

DISCUSSION

Intercostal electrodiagnostic studies can diagnose and localize intercostal nerve damage after displaced rib fractures. Musculoskeletal ultrasound can be used to diagnose and quantify rectus abdominis atrophy and to accurately and safely guide needle EMG to the intercostal and rectus abdominis muscles.

Recent Advances in Functional Hydrogel for Repair of Abdominal Wall Defects: A Review

The abdominal wall plays a crucial role in safeguarding the internal organs of the body, serving as an essential protective barrier. Defects in the abdominal wall are common due to surgery, infection, or trauma. Complex defects have limited self-healing capacity and require external intervention. Traditional treatments have drawbacks, and biomaterials have not fully achieved the desired outcomes. Hydrogel has emerged as a promising strategy that is extensively studied and applied in promoting tissue regeneration by filling or repairing damaged tissue due to its unique properties. This review summarizes the five prominent properties and advances in using hydrogels to enhance the healing and repair of abdominal wall defects: (a) good biocompatibility with host tissues that reduces adverse reactions and immune responses while supporting cell adhesion migration proliferation; (b) tunable mechanical properties matching those of the abdominal wall that adapt to normal movement deformations while reducing tissue stress, thereby influencing regulating cell behavior tissue regeneration; (c) drug carriers continuously delivering drugs and bioactive molecules to sites optimizing healing processes enhancing tissue regeneration; (d) promotion of cell interactions by simulating hydrated extracellular matrix environments, providing physical support, space, and cues for cell migration, adhesion, and proliferation; (e) easy manipulation and application in surgical procedures, allowing precise placement and close adhesion to the defective abdominal wall, providing mechanical support. Additionally, the advances of hydrogels for repairing defects in the abdominal wall are also mentioned. Finally, an overview is provided on the current obstacles and constraints faced by hydrogels, along with potential prospects in the repair of abdominal wall defects.

Musculoskeletal disorders in padel: from biomechanics to sonography

Padel is a racket sport, combining high-frequency and low-intensity athletic gestures, that has been gaining growing scientific interest in recent years. Musculoskeletal injuries are very common among padel players with an incidence rate of 3 per 1000 h of training and 8 per 1000 matches. To the best of our knowledge, a comprehensive collection describing the most common sonographic findings in padel players with musculoskeletal injuries is lacking in the pertinent literature. In this sense, starting from the biomechanical features of padel-specific gestures we have reported the ultrasonographic patterns of most frequent injuries involving the upper limb, the trunk, and the lower limb. Indeed, comprehensive knowledge of the biomechanical and clinical features of musculoskeletal injuries in padel is paramount to accurately perform a detailed ultrasound examination of the affected anatomical site. So, the present investigation aims to provide a practical guide, simple and ready-to-use in daily practice, to optimize the sonographic assessment of padel players by combining it with the clinical findings and the biomechanical features of athletic gestures.

Anthropometric parameters as a predictor for abdominal wall thickness in a patient with gastrostomy

BACKGROUND

Enteral feeding tubes play essential roles in clinical management and nutritional support. Knowledge of the abdominal wall is beneficial in surgical practice and safe for gastrostomy. Anthropometric parameters are currently used for clinical assessment in many clinical applications. That might be beneficial if we applied anthropometric measurement for thickness prediction of the abdominal wall to the schedule of patients' gastrostomy care. This study aimed to evaluate the anthropometric parameters of abdominal wall thickness (AWT).

METHODS

We conducted a cross-sectional study with anthropometric parameters and CT-measured anterior AWT were assessed and analyzed.

RESULTS

The data are collected from January 2020 to March 2021. Arm circumference and body mass index were strongly correlated with AWT at left upper quadrant area and anterior AWT at middle area. The data was created in an TAWT (Thammasat AWT) chart to represent body parameters to AWT.

CONCLUSIONS

Arm circumference is related to AWT. A TAWT chart is designed to help medical personnel evaluate the thickness of the abdominal wall and could guide estimating the gastrostomy tube length.

A new mathematical model for evaluating surface changes in the mid-abdominal sagittal plane after two-level pedicle reduction osteotomy in patients with ankylosing spondylitis

BACKGROUND

The purpose of this study was to create a mathematical model to precalculate the acreage change in the abdominal median sagittal plane (ac-AMSP) of patients with ankylosing spondylitis (AS) for whom two-level pedicle subtraction osteotomy (PSO) was planned.

METHODS

A single-centre retrospective review of prospectively collected data was conducted among 11 adults with AS. Acreage of the abdominal median sagittal plane (a-AMSP) was performed. The distances and angles between the osteotomy apexes, anterosuperior edge of T12, xiphoid process, superior edge of the pubis, and anterosuperior corner of the sacrum were measured on preoperative thoracolumbar computed tomography. A mathematical model was created using basic trigonometric functions in accordance with the abdominal parameters. Planned osteotomized vertebra angles (POVAs) were substituted into the mathematical model, and the predictive ac-AMSP (P-AC) was obtained. A paired sample t test was performed to determine the differences between the P-AC and actual ac-AMSP (A-AC) and between the predictive acreage change rate (P-CR) and actual acreage change rate (A-CR).

RESULTS

The mean age and GK were 44.4 ± 8.99 years and 102.9° ± 19.17°, respectively. No significant difference exists between A-CR and P-CR via mathematical modeling (p > 0.05). No statistically significant difference existed between POVA and actual osteotomized vertebra angles (AOVA) (p > 0.05). A statistically significant difference was observed between preoperative and postoperative measurements of LL, SVA, and GK variables (p < 0.001).

CONCLUSIONS

The novel mathematical model was reliable in predicting the ac-AMSP in AS patients undergoing two-level PSO.

Effects of composition and pH on the degradation of hyaluronate and carboxymethyl cellulose gels and release of nanocrystalline silver

Adhesions are fibrous tissue connections which are a common complication of surgical procedures and may be prevented by protecting tissue surfaces and reducing inflammation. The combination of biodegradable polymers and nanocrystalline silver can be used to create an anti-inflammatory gel to be applied during surgery. In this study, sodium hyaluronate and sodium carboxymethyl cellulose were added in concentrations from 0.25% to 1% w/v to aqueous nanocrystalline silver solutions to create viscous gels. Gels were loaded into dialysis cassettes and placed in PBS for 3 days. pH was adjusted using potassium phosphate monobasic and sodium hydroxide. Release of silver into the PBS was measured at several time points. Polymer degradation was compared by measuring the viscosity of the gels before and after the experiment. Gels lost up to 84% of initial viscosity over 3 days and released between 24% and 41% of the added silver. Gels with higher initial viscosity did not have a greater degree of degradation, as measured by percent viscosity reduction, but still resulted in a higher final viscosity. Silver release was not significantly impacted by pH or composition, but still varied between experimental groups.

Female Abdominal Landmarks and Their Improvements Using Polydioxanone Thread Placement for Umbilicus Elevation

Background

Different landmarks on the abdomen have been used to evaluate abdominal aesthetics. However, because researchers use different methods for landmark measurements, there is no consensus as to which landmarks to use for either assessing abdominal aesthetics or guiding surgical planning.

Methods

Female model photographs were analyzed for abdominal aesthetics with the umbilicus as the key dividing point. Because of the limitation on the number of landmarks that could be shown with model photographs, abdominal landmarks on actual female patients were studied. The variations of landmark metrics due to positional changes and before/after our polydioxanone (PDO)-assisted high-definition liposuctions were recorded.

Results

For model photographs, the abdominal apex to mid-umbilicus distance (AU) versus midumbilicus to lower abdominal skin crease (UC) ratio was 1.626. Almost all bony landmarks demonstrated significant caudal shift when switched from standing to supine positions. Meanwhile, other landmarks also underwent substantial changes. This provides evidence that metrics taken in different positions cannot be compared with one another. As expected, after umbilici were elevated with our special technique, the relevant metrics improved postoperatively, with results close to being ideal. However, marked deviations from the mean measured values do exist.

Conclusions

Abdominal landmarks change with positional adjustment. In standing position, many landmarks can be used for assessment of abdominal aesthetics. Ideally, efforts should be made such that the final AU/UC is close to 1.618, and XU/UP and UIC close to ideal, for satisfactory surgical results. Nevertheless, in actual practice, umbilicus positions can be varied to accomplish desired goals.

Internal and External Oblique Muscle Asymmetry in Sprint Hurdlers and Sprinters: A Cross-Sectional Study

The abdominal muscles are vital in providing core stability for functional movements during most activities. There is a correlation between side asymmetry of these muscles and dysfunction. Thus, the purpose of this study was to evaluate and compare trunk muscle morphology and trunk rotational strength between sprint hurdlers, an asymmetrical sport, and sprinters, a symmetrical sport. Twenty-one trained collegiate sprint hurdlers and sprinters were recruited for the study (Hurdlers: 4M, 7F; Sprinters: 8M, 2F), average age (years) hurdlers: 20 ± 1.2; sprinters: 20.4 ± 1.9, height (cm) hurdlers: 172.6 ± 10.2; sprinters: 181.7 ± 4.5, and weight (kg) hurdlers: 67.6 ± 12.0; sprinters: 73.9 ± 5.6. Using real-time ultrasound, panoramic images of the internal oblique (IO) and external oblique (EO) were obtained at rest and contracted (flexion and rotation) in a seated position for both right and left sides of the trunk. While wearing a specially crafted shoulder harness, participants performed three maximal voluntary trunk rotational contractions (MVC). The three attempts were then averaged to obtain an overall MVC score for trunk rotation strength. Average MVC trunk rotational strength to the right was greater among all participants, p < 0.001. The IO showed greater and significant thickness changes from resting to contracted state than the EO, this was observed in all participants. The IO side asymmetry was significantly different between groups p < 0.01. Hurdlers, involved in a unilaterally demanding sport, exhibited the expected asymmetry in muscle morphology and in trunk rotational strength. Interestingly, sprinters, although involved in a seemingly symmetrical sport, also exhibited asymmetrical trunk morphology and trunk rotational strength.

Intra-abdominal pressure correlates with abdominal wall tension during clinical evaluation tests

BACKGROUND

The abdominal muscles play an important respiratory and stabilization role, and in coordination with other muscles regulate the intra-abdominal pressure stabilizing the spine. The evaluation of postural trunk muscle function is critical in clinical assessments of patients with musculoskeletal pain and dysfunction. This study evaluates the relationship between intra-abdominal pressure measured as anorectal pressure with objective abdominal wall tension recorded by mechanical-pneumatic-electronic sensors.

METHODS

In a cross-sectional observational study, thirty-one asymptomatic participants (mean age = 26.77 ± 3.01 years) underwent testing to measure intra-abdominal pressure via anorectal manometry, along with abdominal wall tension measured by sensors attached to a trunk brace (DNS Brace). They were evaluated in five different standing postural-respiratory situations: resting breathing, Valsalva maneuver, Müller's maneuver, instructed breathing, loaded breathing when holding a dumbbell.

FINDINGS

Strong correlations were demonstrated between anorectal manometry and DNS Brace measurements in all scenarios; and DNS Brace values significantly predicted intra-abdominal pressure values for all scenarios: resting breathing (r = 0.735, r² = 0.541, p < 0.001), Valsalva maneuver (r = 0.836, r² = 0.699, p < 0.001), Müller's maneuver (r = 0.651, r² = 0.423, p < 0.001), instructed breathing (r = 0.708, r² = 0.501, p < 0.001), and loaded breathing (r = 0.921, r² = 0.848, p < 0.001).

INTERPRETATION

Intra-abdominal pressure is strongly correlated with, and predicted by abdominal wall tension monitored above the inguinal ligament and in the area of superior trigonum lumbale. This study demonstrates that intra-abdominal pressure can be evaluated indirectly by monitoring the abdominal wall tension.

Sonographic demonstration of a spontaneous rectus sheath hematoma following a sneeze: a case report and review of the literature

Spontaneous rectus sheath hematoma (SRSH) is an uncommon cause of acute abdominal pain characterized by bleeding within the rectus sheath; it is a benign condition and, in most cases, it is treated conservatively. Bleeding of the abdominal wall is an unusual condition that is quite challenging to identify promptly and can be easily overlooked during a routine physical examination. In daily practice, anticoagulant therapy is one of the main risk factors for hemorrhagic events. In this respect, we report a rare case of spontaneous hematoma of the abdominal wall (diagnosed and monitored through an ultrasound examination) that arose after sneezing in a patient receiving anticoagulant treatment.

Effect of photobiomodulation therapy on trunk flexor performance after incisional hernia repair: a randomized controlled trial

To investigate the effect of two photobiomodulation approaches on trunk flexor performance after incisional hernia repair and to compare the effects of both wavelengths. Forty-five patients were randomly distributed after isokinetic trunk flexor assessments into infrared laser, red laser, and placebo groups. Each patient received laser treatment followed by a traditional physical therapy program. In laser treatment, 24 points in both recti were irradiated by infrared or red laser light with the following parameters; 0.6 J per point, 214.28 J/cm² as energy density, and 17.85 W/cm² as intensity, while the control group received a placebo approach. All groups received clinical treatments at a rate of 3 sessions per week for 4 weeks; in addition, the physical therapy program was continued on other days for all groups. Isokinetic trunk flexor strength was measured before treatment and 4 weeks after treatment as in each measurement, fatigue protocol was designed, and the trunk flexor strength was measured before fatigue test while the trunk flexor resistance to fatigue was measured after fatigue test. After 4 weeks, pre-and post-fatigue trunk flexor strengths in both laser groups were significantly increased compared to pre-and post-fatigue trunk flexor strength in the placebo group, respectively, and there was no significant difference between the two laser groups. Photobiomodulation approaches enhance trunk flexor response to exercise after incisional hernia repair. This enhancement leads to greater strength and more fatigue resistance for the trunk flexors in photobiomodulation groups compared to the placebo group and no difference between the two photobiomodulation effects.

Extended field-of-view ultrasound imaging is reliable for measuring Transversus Abdominis muscle size at rest and during contraction

Background

The strength and size of core muscles, including the abdominal muscles, are crucial to proper function in most activities. Therefore, it is important to reliably assess these characteristics. Our primary objective was to determine if the length, thickness and cross-sectional area of the transversus abdominis (TrA) can be visualized independently from the internal and external abdominal oblique muscles using extended field of view ultrasound imaging at rest and with contraction and to establish its intra- and inter-tester reliability.

Methods

Twenty-six individuals were recruited to participate in the study (20 F, 6 M), average age 24.0 years (SD 9.4), height 170.7 cm (SD 8.6) and weight 63.9 kg (SD 9.0). From this total number of participants, two groups of 16 randomly selected participants were assessed to determine intra- and inter-tester reliability respectively. Extended field of view ultrasound images were obtained at three vertebral levels during rest and contraction in the side lying position for both the right and left sides of the trunk.

Results

Excellent intra-tester and inter-tester reliability was seen (ICC range of 0.972 to 0.984). The overall average percent standard error of the measurement for all measurements and locations was approximately 4%. The overall average minimal difference for the thickness measurement for the resting and contraction conditions combined were as follows: intratester 0.056 (0.014) cm and intertester 0.054 (0.017) cm, for area intratester 0.287 (0.086) cm² and intertester 0.289 (0.101) cm² and for length intratester 0.519 (0.097) cm and intertester 0.507 (0.085) cm.

Conclusions

Extended field of view ultrasound imaging is an effective method of reliably capturing clear images of the TrA during rest and contraction. It provides an efficient mechanism for the analysis of muscle morphology by being able to measure the cross-sectional area, thickness, and length on one image. This methodology is recommended for studies investigating TrA function and training.

Totally endoscopic sublay (TES) repair for lateral abdominal wall hernias: technique and first results

BACKGROUND

The optimal surgical treatment for lateral hernias of the abdominal wall remains unclear. The presented prospective study assesses for the first time in detail the clinical value of a totally endoscopic sublay (TES) technique for the repair of these hernias.

METHODS

Twenty-four consecutive patients with a lateral abdominal wall hernia underwent TES repair. This technique is naturally combined with a transversus abdominis release maneuver to create a sufficient retromuscular/preperitoneal space that can accommodate, if necessary, a giant prosthetic mesh.

RESULTS

The operations were successful in all but one patient who required open conversion because of dense intestinal adhesion. The mean defect width was 6.7 ± 3.9 cm. The mean defect area was 78.0 ± 102.4 cm² (range 4-500 cm²). The mean mesh size used was 330.2 ± 165.4 cm² (range 108-900 cm²). The mean operative time was 170.2 ± 73.8 min (range, 60-360 min). The mean visual analog scale score for pain at rest on the first day was 2.5 (range 1-4). The average postoperative stay was 3.4 days (range 2-7 days). No serious complications (Dindo-Clavien Grade 2-4) were seen within a mean follow-up period of 13.3 months.

CONCLUSIONS

A totally endoscopic technique (TES) for the treatment of lateral hernias is described. The technique revealed to be reliable, safe and cost-effective. The first results are promising, but larger studies with longer follow-up periods are recommended to determine the real clinical value.

Optimized electrical bioimpedance measurements of abdominal wall on a porcine model for the continuous non-invasive assessment of intra-abdominal pressure

This work describes the optimization of electrical bioimpedance measurements for indirect intra-abdominal pressure (IAP) assessment. The experimental run was performed on a female Sus scrofa domesticus (domestic pig). Different values of IAP were induced by inflation of the abdominal cavity, using a trocar placed near the umbilicus over the linea alba. The whole experiment was run within 1 h of the subject being sacrificed. The abdominal wall thickness was measured at an IAP of 5 mmHg. An exponential trend linking between the bioimpedance values at 99.8 kHz and the IAP was found. Non-optimized electrode placement presented a strongly reduced sensitivity to IAP changes above 7 mmHg. Upon optimization and placing the electrodes with a separation of about 3.6 times the measured abdominal wall thickness, the sensitivity for high IAP drastically increased, allowing continuous non-invasive monitoring of IAP, confirming the optimization method proposed in this work.

Non-invasive indirect monitoring of intra-abdominal pressure using microwave reflectometry: system design and proof-of-concept clinical trial

Monitoring intra-abdominal pressure (IAP) has become a standard in intensive care units. Correlation between the abdominal wall’s thickness (AWTh) and IAP has been reported previously. The abdominal wall can be modeled as a compound of parallel dielectric slabs; changes in their width have a direct effect on the reflection coefficient of the abdominal wall at microwave frequencies. This work describes the design of a reflectometry system and its proof-of-concept trial on five patients during laparoscopic surgery. The system complies with IEEE Std. C95.1-2005 concerning exposure of humans to microwave electromagnetic fields in controlled environments. The results putatively show an inverse correlation between IAP and the reflection coefficient, and a strong dependence on the body mass index. A better understanding of the dynamics in the changes of the AWTh (during intra-abdominal hypertension) will allow further development of a microwave-based technique for the continuous non-invasive indirect monitoring of IAP in critical patients.

Abdominal wall sonography: a pictorial review

The anterior abdominal wall, which is composed of three layers (skin and adipose tissues; the myofascial layer; and the deep layer, consisting of the transversalis fascia, preperitoneal fat, and the parietal peritoneum), has many functions: containment, support and protection for the intraperitoneal contents, and involvement in movement and breathing. While hernias are often encountered and well reviewed in the literature, the other abdominal wall pathologies are less commonly described. In this pictorial review, we briefly discuss the normal anatomy of the anterior abdominal wall, describe the normal ultrasonographic anatomy, and present a wide range of pathologic abnormalities beyond hernias. Sonography emerges as the diagnostic imaging of first choice for assessing abdominal wall disorders, thus representing a valuable tool for ensuring appropriate management and limiting functional impairment.

[Surgical anatomy of the abdominal wall]

Knowledge of the anterolateral abdominal wall anatomy is crucial for a surgical approach to the abdominal cavity and for reconstructive surgery of abdominal wall defects. Furthermore it can help the surgeon ensure optimal surgical results by avoiding anatomical complications. This overview presents the surgical relevant anatomy and emphasizes surgical principles and pitfalls in abdominal wall surgery.

Successful treatment of a chronic abdominal wall seroma with the polysaccharide 4DryField® PH - A case report

INTRODUCTION

Seroma formation is one of the most prevalent complications after liposuction, abdominoplasty, mastectomy or hernia repair. They can disappear without treatment, but also may persist and require complex therapy. This report describes how 4DryField^® PH polysaccharide powder successfully was applied for chronic seroma therapy.

PRESENTATION OF THE CASE

An 80year old male patient presented with a persistent seroma (1000cm³ volume) resulting from liposuction about 15 years ago. In a first approach he was treated using en bloc excision without opening the capsule. Three month later the patient presented with a recurrent seroma of the same size. This time 1100cm³ bloody discolored fluid was aspirated. The skin was lifted using a redon tubing drawn through the whole length of the wound cavity. This allowed even distribution of 4DryField^® PH powder (10g) within the former seroma cavity. Computed Tomography (CT) imaging after 4.5 month and sonographic examination after an additional year confirmed treatment success.

DISCUSSION

Besides conventional methods for hemos-/lymphostasis several adjunct measures like fibrin sealants, medication with corticoids and diurectics have been proposed for seroma prevention/therapy, unfortunately, with conflicting evidence. In an experimental study seroma prevention with a polysaccharide was demonstrated; however, clinical proof is missing. This case provides first clinical evidence that 4DryField^® PH polysaccharide powder evenly distributed in the former seroma cavity can prevent its recurrence.

CONCLUSION

4DryField^® PH powder treatment of seroma is a promising new approach for prevention and treatment of chronic seroma.

Bioprosthetic mesh of bacterial cellulose for treatment of abdominal muscle aponeurotic defect in rat model

The use of meshes for treatment of hernias continues to draw attention of surgeons and the industry in the search of an ideal prosthesis. The purpose of this work is to use meshes manufactured from bacterial cellulose, evaluate their organic tissue interaction and compare with an expanded polytetrafluorethylene (ePTFE's) prosthesis used to repair acute defect of muscle aponeurotic induced in rats. Forty-five male Wistar rats were classified using the following criteria: (1) surgical repair of acute muscle aponeurotic defect with perforated bacterial cellulose film (PBC; n = 18); (2) compact bacterial cellulose film (CBC; n = 12) and (3) ePTFE; (n = 15). After postoperative period, rectangles (2 × 3 cm) including prosthesis, muscles and peritoneum were collected for biomechanical, histological and stereological analysis. In all cases, the maximum acceptable error probability for rejecting the null hypothesis was 5 %. Between PBC and CBC samples, the variables of strain (P = 0.011) and elasticity (P = 0.035) were statistically different. The same was found between CBC and ePTFE (elasticity, P = 0.000; strain, P = 0.009). PBC differed from CBC for giant cells (P = 0.001) and new blood vessels (P = 0.000). In conclusion, there was biological integration and biomechanical elasticity of PBC; therefore, we think this option should be considered as a new alternative biomaterial for use as a bio prosthesis.

Imaging Findings of Liposuction with an Emphasis on Postsurgical Complications

Liposuction is one of the most frequently performed cosmetic surgeries worldwide for reshaping the body contour. Although liposuction is minimally invasive and relatively safe, it is a surgical procedure, and it carries the risk of major and minor complications. These complications vary from postoperative nausea to life-threatening events. Common complications include infection, abdominal wall injury, bowel herniation, bleeding, haematoma, seroma, and lymphoedema. Life-threatening complications such as necrotizing fasciitis, deep vein thrombosis, and pulmonary embolism have also been reported. In this paper, we provide a brief introduction to liposuction with the related anatomy and present computed tomography and ultrasonography findings of a wide spectrum of postoperative complications associated with liposuction.

Embryogenesis and types of subcostal hernia--a rare entity

BACKGROUND/PURPOSE

Four infants with congenital subcostal hernia are reported, as it is a rare entity with only two cases previously reported. Further, there are no reports concerning the complex multisystem subtype. Embryogenesis of the associated anomalies and subcostal hernia and their management are discussed.

MATERIALS/METHODS

Clinical features, history, investigations, associated anomalies, and management data of four patients with subcostal hernia were collected and analyzed.

RESULTS

The following associated anomalies were detected: renal agenesis (2), musculoskeletal abnormality (3), congenital heart disease (2), müllerian-renal-cervicothoracic somite abnormalities and vertebral-anorectal-cardiac-tracheoesophageal-renal-radial-limb anomalies (1). The subcostal hernias were treated by laparoscopic assisted (3) or laparoscopic herniorrhaphy (1).

CONCLUSIONS

Subcostal hernia is a rare entity with varied clinical presentations and presents either as an isolated defect or as a complex multisystem defect. The exact etiology is still unknown. Phenotypic manifestation of the complex defect is probably due to developmental gene defect affecting the coordinated growth of mesoderm around 4th to 10th weeks of fetal life.

Autologous dermal grafts for rectus sheath reconstruction and application in closure of ventral myofascial defects

Ventral abdominal hernias pose a reconstructive challenge, with recurrence rates after primary closure exceeding 50 % and synthetic options at high risk for infection. We describe our experience with using autologous dermis, sourced from the redundant overlying abdominal skin, for reconstruction of ventral abdominal wall defects. We describe the surgical technique, applied anatomy and an analysis of short- and long-term outcomes. Twelve consecutive patients undergoing repair of medium-large size, reducible abdominal wall defects were recruited. The dermal graft technique was used in each case, utilizing an autologous running strip of abdominal skin for reconstruction. Both short- and long-term outcomes were assessed prospectively. Scores were given on a scale of 1-10, with 1 = least/worst and 10 = most/best. The described technique was successfully undertaken in all patients. Long-term follow-up demonstrated a 100 % resumption of normal activities, with an improvement in quality of life and physical activity scores postoperatively, and no recurrences. Short-term complications were notable, with five patients requiring postoperative intensive care unit admission, and seven patients requiring respiratory support. In conclusion, the use of autologous rectus sheath reinforcement may achieve good surgical outcomes and high patient satisfaction. While early respiratory complications should be noted, the potential utility of this technique is worthy of future investigation.

The search for ideal hernia repair; mesh materials and types

Hernia surgery continues to draw the attention of surgeons, patients, and the industry. This strong interest has driven the establishment of professional medical societies with the sole purpose of furthering the understanding of hernias and hernia repair. In the more than 100 years of development, industry has played a major role in advancing the technology to perfect the performance of hernia repair with the hope of establishing the "best" technique and its associated technology. However, with the development of newer prosthetics and approaches to hernia repair, many surgeons do not fully understand the properties of the available prosthetics. The goal of this review is to highlight the different types of meshes in an effort to clarify to surgeons what types of materials are available to them and how to select an appropriate one for a given case.

Case report: incisional hernia as a complication of extreme lateral interbody fusion

BACKGROUND CONTEXT

Minimal access surgery is becoming more popular for spinal fusion because of a lower theoretical risk of complications and shorter postoperative recovery period, compared with the traditional open approach. The lateral approach uses retroperitoneal transpsoas access to the vertebra, obviating the need for an approach surgeon and minimizing muscular disruption, thus allowing a quicker recovery. Initial reports of the lateral transpsoas procedure described few complications. However, a number of complications have subsequently been documented. To our knowledge, there has not been a description of an incisional hernia after this approach.

PURPOSE

To report the rare complication of an incisional hernia after a minimal access lateral transpsoas approach for lumbar interbody fusion.

STUDY DESIGN

Case report.

METHODS

We reviewed the hospital charts, radiographs, and intraoperative photographs of a patient who underwent a minimally invasive lateral approach lumbar spine fusion with a subsequent incisional hernia that necessitated laparoscopic repair.

RESULTS

A 75-year-old woman with a history of low back and left lower extremity pain with radiographic evidence of foraminal stenosis and degenerative spondylolisthesis underwent a successful L4-L5 discectomy with an extreme lateral interbody fusion via a retroperitoneal transpsoas approach. This was supplemented with a posterior minimally invasive surgery instrumented fusion from L4 to L5. The patient reported significant improvement in symptoms on initial follow-up, however, complained of a prominence over her incision 4 weeks later. An incisional hernia was diagnosed and subsequently repaired laparoscopically, from which the patient recovered uneventfully.

CONCLUSIONS

Postoperative incisional hernia after extreme lateral interbody fusion is a complication that has not been previously described in the literature but is one that spine surgeons must recognize. This case may prompt surgeons to use a more posterior approach to avoid this complication. Additionally, direct repair of the transversalis fascia is critical to avoiding this complication.

Musculature tissue engineering to repair abdominal wall hernia

Hernia repair is one of the most frequently performed operations in surgical clinics. Tissue engineering provides insights for the treatment of abdominal wall hernias and other disorders involving deficiencies in the musculature. The present review summarizes the mechanisms of muscle development and regeneration and provides an overview of tissue engineering strategies for the construction of muscles.

Endometrial stromal cells and immune cell populations within lymph nodes in a nonhuman primate model of endometriosis

Mounting evidence suggests that immunological responses may be altered in endometriosis. The baboon (Papio anubis) is generally considered the best model of endometriosis pathogenesis. The objective of the current study was to investigate for the first time immunological changes within uterine and peritoneal draining lymph nodes in a nonhuman primate baboon model of endometriosis. Paraffin-embedded femoral lymph nodes were obtained from 22 normally cycling female baboons (induced endometriosis n = 11; control n = 11). Immunohistochemical staining was performed with antibodies for endometrial stromal cells, T cells, immature and mature dendritic cells, and B cells. Lymph nodes were evaluated using an automated cellular imaging system. Endometrial stromal cells were significantly increased in lymph nodes from animals with induced endometriosis, compared to control animals (P = .033). In animals with induced endometriosis, some lymph node immune cell populations including T cells, dendritic cells and B cells were increased, suggesting an efficient early response or peritoneal drainage.

Long-term histologic and mechanical results of a Permacol™ abdominal wall explant

PURPOSE

We hypothesize that Permacol™ may allow controlled integration over time while providing long-term mechanical stability and native tissue remodeling. The purpose of this report is to investigate these properties in an explanted piece of Permacol™ after 2 years in vivo.

METHODS

A 62-year-old female presented with a complex abdominal wall history having undergone a transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction 10 years ago, followed by an abdominal wall repair with Marlex™ mesh for weakness 3 years later. Two years ago, she developed an abdominal bulge repaired with a Permacol™ overlay. Twenty-three months postoperatively, she presented with abdominal distension. Computed tomography (CT) scanning demonstrated a fluid collection behind the Permacol™. She underwent incision and drainage of the hematoma/bursa and quilting repair of the abdominal wall. A 1 × 6-cm Permacol™ section was resected as part of closure. Histology, immunohistochemistry, and mechanical testing of the Permacol™ explant were performed.

RESULTS

Histology showed fibroblast and blood vessel ingrowth with no cellular infiltrates reflective of inflammation. Immunohistochemistry for human-specific collagen types I and III and elastin detected staining throughout. Sections stained with non-specific control antibody exhibited no discernable staining. Elastin highlighted blood vessels. Native Permacol™ had a breaking strength of ~20 N, while for explanted Permacol™, it was ~33 N.

CONCLUSIONS

Permacol™ maintained durability while allowing vascular ingrowth without residual inflammation. Explant demonstrated integration with human collagen and elastin remodeling throughout. Increase in mechanical strength may reflect newly synthesized collagen and elastin. These histologic findings and clinical result support the use of Permacol™ in complex abdominal wall reconstruction.

A case report of a congenital left subcostal hernia in a neonate

We present an unusual case of a congenital left subcostal hernia in a female born at 39 weeks by caesarean delivery to a 39 year-old gravida(2)para(1-2)abortus(0) mother. The pregnancy was complicated by gestational diabetes, although she had normal prenatal imaging. After an uneventful caesarean delivery, the patient's initial physical examination was normal although subsequently was found to have a left subcostal hernia. During surgical evaluation, a reducible hernia was found along with left renal agenesis and no underlying masses. At 4 weeks of age, the patient's hernia was successfully repaired with no sequela. We present the first reported case of a congenital subcostal hernia, evaluation, and treatment.