Spontaneous abdominal wall blood vessel rupture as a rare complication of severe pre-eclampsia

This study describes a rare case of a prenatal spontaneous abdominal wall hematoma that occurred in a pregnant woman with severe pre‐eclampsia and upper respiratory tract infection.

Latex-Infused Porcine Abdominal Model: A Novel Microsurgery Simulator for Deep Inferior Epigastric Perforator Dissection

BACKGROUND

 Perforator dissection and flap elevation are routinely performed for microsurgical reconstruction; however, there is a steep learning curve to mastering these technical skills. Though live porcine models have been utilized as a microsurgical training model, there are significant drawbacks that limit their use, including cost, limited ability for repetition, and obstacles associated with animal care. Here we describe the creation of a novel perforator dissection model using latex augmented non-living porcine abdominal walls. We provide anatomic measurements that demonstrate valuable similarities and differences to human anatomy to maximize microsurgical trainee practice.

METHODS

 Six latex-infused porcine abdomens were dissected based on the deep cranial epigastric artery (DCEA). Dissection was centered over the abdominal wall mid-segment between the second and fourth nipple line. Dissection steps included exposure of lateral and medial row perforators, incision of anterior rectus sheath with perforator dissection, and dissection of DCEA pedicle. DCEA pedicle and perforator measurements were compared with deep inferior epigastric artery (DIEA) data in the literature.

RESULTS

 An average of seven perforators were consistently identified within each flap. Assembly of the model was performed quickly and allowed for two training sessions per specimen. Porcine abdominal walls demonstrate similar DCEA pedicle (2.6 ± 0.21 mm) and perforator (1.0 ± 0.18 mm) size compared with a human's DIEA (2.7 ± 0.27 mm, 1.1 ± 0.85 mm).

CONCLUSION

 The latex-infused porcine abdominal model is a novel, realistic simulation for perforator dissection practice for microsurgical trainees. Impact on resident comfort and confidence within a microsurgical training course is forthcoming.

Preoperative visualization of midline-crossing subcutaneous arteries in transverse abdominal flaps using photoacoustic tomography

BACKGROUND

Photoacoustic tomography is a noninvasive vascular imaging modality that uses near-infrared pulsed laser light and ultrasound to visualize vessels. We previously demonstrated the utility of photoacoustic tomography for anterolateral thigh flap surgery involving body-attachable vascular mapping sheets. However, it was not possible to obtain clear separate images of arteries and veins. In this study, we tried to visualize subcutaneous arteries that cross the midline of the abdomen, since these arteries are known to be important for obtaining large perfusion areas in transverse abdominal flaps.

METHODS

Four patients scheduled to undergo breast reconstruction with abdominal flaps were examined. Photoacoustic tomography was performed preoperatively. The tentative arteries and veins were traced according to the S-factor, an approximate hemoglobin oxygen saturation parameter calculated using 2 laser excitation wavelengths (756 and 797 nm). Intraoperatively, arterial-phase indocyanine green (ICG) angiography was performed after abdominal flap elevation. Images of vessels speculated to be arteries by preoperative photoacoustic tomography were merged with those of intraoperative ICG angiography and analyzed in an 8 × 4-cm2 area below the umbilical region.

RESULTS

The S-factor was used to visualize the midline-crossing subcutaneous arteries in all 4 patients. A matching analysis compared preoperative tentative arteries according to photoacoustic tomography with ICG angiography results in the 8 × 4-cm2 area below the umbilical region and indicated a 71.3-82.1% match (average: 76.9% match).

CONCLUSIONS

This study demonstrates that the S-factor, a noninvasive, label-free imaging modality, can be used to successfully visualize subcutaneous arteries. This information can aid in selecting perforators for abdominal flap surgery.

A vein-viewing application enabled detecting abdominal wall varices related to the presence of non-treated gastroesophageal varices: a cross-sectional study

BACKGROUND

Gastroesophageal varices (GOV) are a life-threatening complication in chronic liver disease. A method for non-invasively predicting GOV is crucial for management. This study aimed to determine whether a vein-viewing application can detect abdominal wall varices (AWV) and elucidate the relationship between AWV and GOV.

METHODS

One-hundred patients with chronic liver diseases were prospectively enrolled. All the patients underwent esophagogastroduodenoscopy within three months of the enrollment. Unmanipulated images (UI) and vein-weighted images (VWI) were taken for assessing AWV by a vein-viewing application on iPhone. Two doctors independently evaluated both image types. We defined the grading of both UI and AWV as grade 0 (non-detectable), grade 1 (slightly detectable), and grade 2 (distinct).

RESULTS

The causes of liver diseases among the 71 men and 29 women (median age, 70.5 yr) included Hepatitis B (n = 19), Hepatitis C (n = 21), alcoholism (n = 33), primary biliary cholangitis (n = 3), autoimmune hepatitis (n = 4) and others (n = 20). GOV was indicated in 60 patients, and half of them had not been treated previously (non-treated). VWI could significantly visualize AWV than UI (72% vs. 24%, p = 0.0005). The presence of cirrhosis (chronic hepatitis vs. cirrhosis = 64.6% vs. 91.4%, p = 0.004) and GOV (52.3% vs. 74.3%, p = 0.032) were significantly higher in the VWI-AWV grade 2 group. Multivariate analysis demonstrated that VWI-AWV grade 2 was an independent factor related to the presence of non-treated GOV [OR = 3.05 (1.24-7.53), p = 0.016].

CONCLUSIONS

The vein-viewing application non-invasively detected AWV related to the presence of cirrhosis and GOV, and VWI-AWV grade 2 was an independent factor related to the presence of non-treated GOV.

Diagnostic complexity of rifampicin-induced coagulopathy in a patient with spontaneous muscle bleeding: A case report

INTRODUCTION

Rifampicin is currently used to treat various bacterial infections, with the most significant application in the treatment of tuberculosis. Dose-independent side effects of the drug can lead to the development of various coagulation disorders, among which disseminated intravascular coagulation is the most dangerous. The mechanism of coagulopathy itself is multifactorial, but it is thought to be mediated by an immune response (formation of antigen-antibody complexes) and consequent damage to platelets and the vascular endothelium.

PATIENT CONCERNS

A 66-year-old woman, with numerous comorbidities including chronic renal failure, condition after implantation of a permanent pacemaker, and a positive blood culture for Staphylococcus aureus, presented with spontaneous bleeding in the muscle wall, and in the clinical picture of hemorrhagic shock.

DIAGNOSIS

Knowing the multifactorial mechanism of rifampicin-induced coagulopathy, possible factors were considered, such as infections, comorbidities, drug use and drug-drug interactions, pathological laboratory parameters, and coagulograms. Clinical presentation of abdominal pain and intra-abdominal mass, with laboratory verification of prolonged activated partial thromboplastin time and computed tomography-proven hematoma suspected of acute bleeding, redirects clinical suspicion of drug-induced coagulopathy.

INTERVENTIONS

By discontinuing rifapicin and administering vitamin K and fresh frozen plasma, normalization of laboratory coagulation parameters was achieved. Bleeding from the muscle wall required correction of acute anemia with red cell concentrates, surgical intervention, and additional antibiotic therapy for secondary infection of the operative wound.

OUTCOMES

At the end of 6 weeks of antibiotic (antistaphylococcal) therapy (due to the basic suspicion of possible infectious endocarditis), the normalization of inflammatory parameters occurred with a sterile control blood culture and a normal coagulogram.

CONCLUSION

Clinicians should be aware of the possible side effects of the administered drugs, especially taking into account the overall clinical picture of a patient, including comorbidities and possible drug interactions.

The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations

PURPOSE

Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap.

METHODS

We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients' characteristics, such as abdominal surgery history.

RESULTS

CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm).

CONCLUSIONS

Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.

Factor XI-deficient mice exhibit increased bleeding after injury to the saphenous vein

Essentials Factor XI (FXI) deficient mice have normal hemostasis in a tail transection model. The hemostatic capacity of FXI-/- mice was assessed in three different bleeding models. FXI-/- mice have increased saphenous vein bleeding. FXI-/- mice may be a useful experimental model to study bleeding associated with FXI deficiency.

SUMMARY

Background Factor XI (FXI) is a key component of the intrinsic pathway of coagulation. It can be activated by either FXIIa or thrombin and amplifies thrombin generation during clot formation. Congenital FXI deficiency in humans (known as hemophilia C) is associated with bleeding after hemostatic challenge. However, to date there are no reports of excess bleeding in FXI-deficient mice. Objectives To determine if the absence of FXI in mice prolongs bleeding in different models. Methods We assessed the hemostatic capacity of FXI-/- mice in three different bleeding models: tail bleeding, surgical bleeding and saphenous vein bleeding. Results We found that tail bleeding and surgical bleeding of FXI-/- mice were similar to wild-type mice. However, FXI-/- mice had an impaired hemostatic capacity in the saphenous vein bleeding model compared with wild-type controls. Conclusions Our results indicate that FXI-/- mice have a mild hemostatic defect after injury to the saphenous vein but not after transection of the tail or vessels in the abdominal wall.

[Thinning of the deep inferior epigastric artery perforator flap based on the vascular structure of the arterial perforator]

OBJECTIVE

To explore flap thinning based on the study of the arterial structure and blood perfusion of the deep inferior epigastric artery perforator (DIEP) flap using computed tomography (CT) angiography.

METHODS

Clinical imaging study: Preoperative CT angiography was performed in 15 patients with DIEP flap reconstruction to investigate the vascular structure of arterial perforator. Cadaveric imaging study:10 abdominal specimens harvested from fresh cadavers were cannulated with trocar and injected with contrast medium in the deep inferior epigastric artery perforator. During the perfusion of the contrast medium in the flap,the flap was scanned by three-dimensional CT. The CT data was then sent to CT workstation and the images were processed and reformatted to study the vascular structure of arterial perforators and the blood perfusion.

RESULTS

75 artery perforators in clinical study and 40 artery perforators in cadaveric study were chosen and analyzed. The major deep inferior epigastric artery perforators run directly across the deep layer of adipose tissue without bifurcating beneath the Scarpa's fascia. Above the Scarpa's fascia, the artery perforators bifurcate and ultimately terminate in the subdermal vascular plexus. Blood perfusion mode: The subdermal vascular plexus served as the only pathway for blood perfusion between perforasomes. There are two different pathways for blood perfusion in the perforasome: the subdermal plexus and the existing vascular structure of perforator.

CONCLUSIONS

Based on the vascular structure of arterial perforator and blood perfusion of the DIEP flap, thinning of the DIEP flap under the Scarpa's fascia is safe while thinning above the Scarpa's fascia should performed according to the blood supply zone of the DIEP flap.

The triangles of Grynfeltt and Petit and the lumbar tunnel: an anatomo-radiologic study

PURPOSE

Lumbar hernias are protrusions of intra-abdominal contents classically through the superior (Grynfeltt) and inferior (Petit) lumbar triangles. The anatomy of the triangles is variable and quantitative data are few. No radiological data on the anatomy of the triangles are available.

METHODS

Fifty computed tomography angiography of the upper abdomen (M25, F25, mean age 72.5-year-old) were analyzed. The dimensions and the contents of the lumbar triangles were analyzed. The characteristics of the space between the two triangles were also documented.

RESULTS

The superior lumbar triangle showed a mean surface area of 5.10 ± 2.6 cm². In the area of the triangle, the 12th intercostal pedicle and the 1st lumbar branches of the iliolumbar vessels were found in 42 and 46 %, respectively. The inferior lumbar triangle had a mean surface of area 18.7 ± 8.4 cm². In this area, the 2nd, 3rd, and 4th lumbar branches were found in 9, 67, and 8 %, respectively. On oblique coronal images, a direct tunnel between the superior and the inferior lumbar triangles was found, showing an oblique course, with a postero-anterior direction (mean length 36.5 ± 5.8 mm, mean caliber 7.4 ± 3.1 mm).

CONCLUSIONS

Among the anatomical factors of weakening of the abdominal wall, the course of branches of the lumbar vessels was documented not only in the superior but also in the inferior lumbar triangle. A real musculoaponeurotic tunnel between the superior and the inferior lumbar triangles located in the oblique coronal plane was found, that could play a role in the development of incarceration or strangulation of lumbar hernias.

Observation of a Flowing Duct in the Abdominal Wall by Using Nanoparticles

The primo vascular system (PVS) is being established as a circulatory system that corresponds to acupuncture meridians. There have been two critical questions in making the PVS accepted as a novel liquid flowing system. The first one was directly to show the flow of liquid in PVS and the second one was to explain why it was not observed in the conventional histological study of animal tissues. Flow in the PVS in the abdominal cavity was previously verified by injecting Alcian blue into a primo node. However, the tracing of the dye to other subsystems of the PVS has not been done. In the current work we injected fluorescent nanoparticles (FNPs) into a primo node and traced them along a primo vessel which was inside a fat tissue in the abdominal wall. Linea alba is a white middle line in the abdominal skin of a mammal and a band of fat tissue is located in parallel to the linea alba in the parietal side of the abdominal wall of a rat. In this fat band a primo vessel runs parallel to the prominent blood vessels in the fat band and is located just inside the parietal peritoneum. About the second question on the reason why the PVS was not in conventional histological study the current work provided the answer. Histological analysis with hematoxyline and eosine, Masson’s trichrome, and Toluidine blue could not discriminate the primo vessel even when we knew the location of the PVS by the trace of the FNPs. This clearly explains why the PVS is hard to observe in conventional histology: it is not a matter of resolution but the contrast. The PVS has very similar structure to the connective tissues that surround the PVS. In the current work we propose a method to find the PVS: Observation of mast cell distribution with toluidine blue staining and the PN has a high density of mast cells, while the lymph node has low density.

[DELAYED AND PRIMARY RECONSTRUCTION OF MAMMARY GLAND IN PATIENTS WITH THE BREAST CANCER]

Immediate and late follow—up results of oncoplastic operations, performed in 75 patients, suffering mammary gland cancer (MGC), including in 22—a delayed, and in 53—primary reconstruction of the breast, were analyzed. In 66 patients musculo— cutaneous flaps on nutrient pedicle, taken up from the back and abdominal wall tissues, with underlying mammary gland endoprosthesis,were applied as a transplant. Ductal invasive MGC was diagnosed in 70 patients, invasive lobular one — in 5. After delayed reconstruction of the breast 81.8% patients have survived five years, and after primary reconstruction — 73.6%. Performance of oncoplastic operations in patients, suffering MGC, have permitted to achieve satisfactory immediate and late follow—up results of treatment, it constitutes essential element in complex of rehabilitation measures after performance of radical mastectomy.

[Application of abdominal venous angio-architecture in flap thinning of deep inferior epigastric artery perforator flap]

OBJECTIVE

To explore the venous angio-architecture of deep inferior epigastric artery perforator ( DIEP) flap with computed tomography angiography( CTA) and the application of venous angio-architecture in flap thinning of DIEP flap.

METHODS

From February 2012 to August 2014, preoperative CTA examination of venous system of DIEP flap was performed in 11 patients to study the course, the branch and the anastomosis of the deep inferior epigastric veins, the superficial inferior epigastric veins and the perforator veins. The flap thinning of DIEP flap was based on the finding of the abdominal venous system.

RESULTS

The CTA images were obtained including 22 deep inferior epigastric veins, 22 superficial inferior epigastric veins and 22 perforator veins. The distance between the superficial inferior epigastric vein and abdominal midline was 3.30 cm to 5.77 cm in the zone 3 cm above umbilicus and in the zone 15 cm below umbilicus. The superficial inferior epigastric vein was 0.29 to 0.39 in depth ratio. The superficial inferior epigastric veins were the main drainage vessels of superficial abdominal wall according to the CTA images. They were anastomosed with the deep inferior epigastric veins through perforator veins. The 11 DIEP flaps were thinned based on the structure of the superficial inferior epigastric veins and all flaps had no drainage disturbance.

CONCLUSIONS

Preoperative CTA images can display the venous angio-architecture of deep inferior epigastric artery perforator flap. The superficial inferior epigastric vein can be utilized as reference architecture to guide flap thinning of DIEP flap.

Intraoperative indocyanine green fluorescence angiography to predict wound complications in complex ventral hernia repair

INTRODUCTION

Complex ventral hernia repair (VHR) is associated with a greater than 30% wound complication rate. Perfusion mapping using indocyanine green fluorescence angiography (ICG-FA) has been demonstrated to predict skin and soft tissue necrosis in many reconstructive procedures; however, it has yet to be evaluated in VHR.

METHODS

Patients undergoing complex VHR involving component separation and/or extensive subcutaneous advancement flaps were included in a prospective, blinded study. Patients with active infection were excluded. ICG-FA was performed prior to incision and prior to closure, but the surgeon was not allowed to view it. An additional blinded surgeon documented wound complications and evaluated postoperative photographs. The operative ICG-FA was reviewed blinded, and investigators were then unblinded to determine its ability to predict wound complications.

RESULTS

Fifteen consecutive patients were enrolled with mean age of 56.1 years and average BMI of 34.9, of which 60% were female. Most (73.3%) had prior hernia repairs (average of 1.8 prior repairs). Mean defect area was 210.4 cm2, mean OR time was 206 min, 66.6% of patients underwent concomitant panniculectomy, and 40% had component separation. Mean follow-up was 7 months. Two patients developed wound breakdown requiring reoperation, while 1 had significant fat necrosis and another a wound infection, requiring operative intervention. ICG-FA was objectively reviewed and predicted all 4 wound complications. Of the 12 patients without complications, 1 had an area of low perfusion on ICG-FA. This study found a sensitivity of 100% and specificity of 90.9% for predicting wound complications using ICG-FA.

CONCLUSION

In complex VHR patients, subcutaneous perfusion mapping with ICG-FA is very sensitive and has the potential to reduce cost and improve patient quality of life by reducing wound complications and reoperation.

[PLASTY, USING THIN CUTANEO-ADIPOSAL FLAPS OF ANTERIOR ABDOMINAL WALL, FOR INJURIES OF THE WRIST AND THUMBS]

Experience of a late plasty, using a thin cutaneo-adiposal flaps of abdominal wall of a full-layered wounds of soft tissues of the thumbs and a wrist in 6 injured persons, was presented. Critical postoperative complications and the flaps loss were not observed. Parts of the edge necrosis of the flaps in 3 patients were excised, the wound suturing was done or autodermoplasty, in 1 of them osteosequesterectomy was performed. The reconstruction purpose--restoration of the cover tissues and revascularization of the thumbs and wrists defects--was achieved in all the patients.

Safely combining abdominoplasty with aggressive abdominal liposuction based on perforator vessels: technique and a review of 300 consecutive cases

BACKGROUND

There continues to be controversy about performing abdominoplasty concurrently with abdominal liposuction. The concern is that liposuction on the already vascularly compromised abdominal flap will lead to increased complications and flap necrosis. The central abdomen is supplied by the epigastric system. If perforator vessels from this system are spared, the blood supply to the abdomen can be spared and liposuction should be able to be safely performed on the elevated abdominal flap. The purpose of this study was to evaluate the safety of abdominoplasty with concurrent abdominal liposuction when a perforator vessel is spared.

METHODS

A standard abdominoplasty was performed, sparing one or two perforator vessels from the deep superior epigastric artery system. A retrospective chart review of 300 consecutive patients who underwent abdominoplasty surgery combined with concurrent abdominal liposuction was performed. Complications, total volume of abdominal liposuction, and results were reviewed.

RESULTS

The overall complication rate was 17.3 percent (52 patients). Sixteen percent (48 patients) suffered minor complications and 1.3 percent (four patients) suffered major complications.

CONCLUSIONS

Abdominoplasty can be combined safely with concurrent abdominal liposuction when a perforator vessel is spared. The combination of concurrent liposuction with abdominoplasty showed no increase in complication rates when a perforator vessel was spared. The perforator vessels are located consistently in a 2-cm radius located 4 cm from the midline and 6 cm from the subcostal margin. The potential advantages of abdominoplasty with concurrent liposuction include a better postoperative cosmetic result.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

[Investigation of simple and complex prelamination of vascularized flaps in experiment]

Prelamination, permitting improvement not esthetics only, but also function of the damaged region, to create necessary, by contents and configuration, vascularized complexes of tissues, is applied for effective treatment of complex defects in tissues. In experiment on laboratory animals for prelamination of vascularized flaps were applied separate and combined placement of mucosal and cartilaginous autotransplants. Results of the investigation witness possibility and efficacy of creation of content--component complexes of tissues, owing necessary characteristics for their further application in the clinic during performance of reconstructive interventions.

[Prophylaxis and treatment of postoperative complications of abdominoplasty]

Results of abdominoplasty conduction in 206 patients were analyzed. Early postoperative complications are studied and methods of their prophylaxis are elaborated. Minimization of the local complications rate was achieved due to estimation of the anterior abdominal wall state, its angioarchitectonics, the apparatus control of PO2 in cutaneous-subcutaneous flap, rational combination of dermolipectomy and liposuction, prophylaxis of microcirculation disorders. In detailed analysis of remote, first of all, esthetic results of the anterior abdominal wall plasty we have concluded about necessity of the state estimation of surrounding anatomic structures. While planning and conduction of the anterior abdominal wall plasty it is mandatory to take into account the pubis subcutaneous layer width, as well as lateral regions of abdominal wall, pelvis and costal arcs, the form and localization of costal arcs, especially of XII rib and a vertebral column form. Such approach have secured the operation esthetic level raising, reduction of local complications rate, permitted more trustworthy to prognosticate the outcome.

[Morphological characteristic of tissues, surrounding prosthesis in patients, suffering cutaneo-prosthetic fistulas and paraprosthetic hernias]

While application of the net prostheses in surgery of anterior abdominal wall hernias (AAWH) the complications are noted, such as the prosthesis cyst development, the net wrinkling, migration and separation with the hernia recurrence. Morphological investigation of tissues were conducted in regions of cutaneo-prosthetic fistulas and hernial gates, formatted by the prosthesis edge, in 22 patients, operated for AAWH, in 6 of them cutaneo-prosthetic fistulas were observed. Morphological changes in region of prosthesis, taking part in the hernial defect development, as well as in the wrinkled part of the prosthesis, were characterized by pronounced inflammation, development of rude cicatrices and infiltration of tissues. While durable existence of cutaneo-prosthetic fistulas the prosthesis degradation and destruction occurs as well as the breaks and cracks; on sites of the tissue, surrounding the prosthesis, the microorganisms and fungi vegetations may evolve, trusting its secondary infectioning.

Celiacomesenteric trunk: a rare anatomical variation with potential clinical and surgical implications

The arterial supply of the abdominal viscera is derived via three single arteries: the celiac axis, the superior mesenteric artery, and the inferior mesenteric artery. These arteries usually originate separately from the ventral aspect of the abdominal aorta. In some cases, two or more of these arteries may originate from a common trunk. The celiacomesenteric trunk is a rare condition that can generate clinical and surgical complications. Preoperative knowledge of vascular anomalies is critical when planning a surgical approach. We report a patient who underwent Multi-detector Computed Tomography (MDCT) before a vascular procedure, and a common trunk for celiac axis and superior mesenteric artery (celiac mesenteric trunk) was incidentally found.

Abdominal wall ischemic fasciitis associated with a torso brace in a young girl

We describe a rare case of ischemic fasciitis of the abdominal wall in a child with scoliosis. The fasciitis was apparently caused by the constant pressure exerted by her torso brace. Clinicians should be alert to the possibility of mechanical factors in the etiology of ischemic fasciitis.

[Peculiarities of the blood microcirculation in the anterior abdominal wall in patients with excessive body mass]

Investigation was conducted, using laser Doppler flowmetry (LDF) with the help of LAKK-02 analizator, with the objective to improve the results of surgical treatment and prophylaxis of complications in the postoperative wound healing in patients, suffering concomitant obesity. Characteristic disorders of microcirculation in soft tissues of the anterior abdominal wall in the operative intervention region were analyzed. There were examined 31 patients, suffering obesity stages I-III, their body mass index was (39.11 +/- 0.79) kg/m2 at average. Microcirculation disorders in soft tissues of the anterior abdominal wall have caused worsening of the postoperative period course in the patients. LDF is a highly informative noninvasive method, which have to be used trustworthy for estimation of a microcirculation bed state in the patients, suffering obesity.

Evaluation of intra-operative abdominal wall perfusion in post-bariatric abdominal dermolipectomy

OBJECTIVE

Abdominal dermolipectomy after massive weight loss has become a standard procedure. However the complication rates such as wound necrosis or secondary healing complications are still high. In this context ischaemia or inadequate micro-perfusion are known as triggers of wound healing complications. Little is known about the regional perfusion patterns before and after post-bariatric abdominal dermolipectomy. This study focuses on assessment of intraoperative micro-perfusion patterns of the abdominal tissue.

METHODS

The perfusion of the abdominal wall flap was monitored intra-operatively in 17 patients with an average BMI of 29.2 ± 3.7 kg/m² after bariatric surgery. All patients underwent abdominal post-bariatric dermolipectomy after massive weight loss while applying the non-invasive O2C laser-spectrophotometer. The micro-perfusion parameters oxygen saturation (SO₂), relative haemoglobin content (rHB) and relative blood flow (BF) were intra-operatively measured.

RESULTS

The results of this study show that the part of the abdominal fat typically resected during dermolipectomy has the lowest SO₂ before surgery. Furthermore, the results demonstrate that previously well oxygenated parts in the median line of the abdominal fat undergo a significant decrease in oxygen saturation upon mobilisation and subsequent suturing, while the caudal wound edges show an increase of micro-perfusion parameters.

CONCLUSION

Data show that micro-perfusion is worst in the median line of the cranial wound edge and is significantly altered after mobilisation. In addition an intra-operative increase of micro-perfusion in the caudal part of the wound edge, especially in the mons pubis area, can be measured.

[Experience with hernioplasty after Lichtenstein in inguinal hernias]

The presented method of hernioplasty was used in 1242 patients with different types of inguinal hernias. In 428 patients plasty of the inguinal canal was performed by the classical method of Lichtenstein, in 814 patients the method was modified. The method modified by the authors is described in detail. Improved results of treatment are associated by the authors with reduced ischemization of the sutured tissues with reticulate endoprosthesis. Recurrent hernias were noted in 0.2% in the main group, and 1.8% in the control group.

Mondor's disease of the breast. A retrospective review

BACKGROUND

Mondor's disease is a rare benign clinical entity characterized by thrombophlebitis of the superficial veins of the anterolateral thoraco-abdominal wall. Although several predisposing factors have been reported, the exact pathogenesis remains unclear.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of all patients older than 14 years who were diagnosed with Mondor's disease of the breast at the Breast Cancer Surgery Unit of Army General Hospital over a 3-year period.

RESULTS

Five cases of Mondor's disease were identified among 5717 breast examinations performed during the study period. In 4 patients the disease was considered to be idiopathic. Ultrasonography established the diagnosis in all patients but mammography was inconclusive in two cases due to the presence of dense breast tissue. Four patients received symptomatic treatment. All patients had complete clinical resolution within 2-8 weeks of presentation, and they are well without any evidence of recurrence for 3 to 32 months later. No cases were associated with breast cancer.

CONCLUSIONS

Mondor's disease of the breast is a rare benign self-limiting clinical entity. Ultrasonography is the diagnostic modality of choice but mammography may be inconclusive in the presence of dense breast tissue. Awareness of this rare entity is mandatory to prevent an unnecessary biopsy whereas the patients should be reassured of the benign nature of this disorder. Thorough evaluation is however necessary to rule out an underlying breast cancer or another systemic disease.

Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery

OBJECTIVE

We sought to describe relationships of clinically relevant nerves and vessels of the anterior abdominal wall.

STUDY DESIGN

The ilioinguinal and iliohypogastric nerves and inferior epigastric vessels were dissected in 11 unembalmed female cadavers. Distances from surface landmarks and common incision sites were recorded. Additional surface measurements were taken in 7 other specimens with and without insufflation.

RESULTS

The ilioinguinal nerve emerged through the internal oblique: mean (range), 2.5 (1.1-5.1) cm medial and 2.4 (0-5.3) cm inferior to the anterior superior iliac spine (ASIS). The iliohypogastric emerged 2.5 (0-4.6) cm medial and 2.0 (0-4.6) cm inferior. Inferior epigastric vessels were 3.7 (2.6-5.5) cm from midline at the level of the ASIS and always lateral to the rectus muscles at a level 2 cm superior to the pubic symphysis.

CONCLUSION

Risk of anterior abdominal wall nerve and vessel injury is minimized when lateral trocars are placed superior to the ASISs and >6 cm from midline and low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscles.

Foreign-body response to sterile catheters is variable over 20 weeks

We hypothesized that placement of sterile catheter material into the peritoneal cavity results in a foreign-body response that varies with exposure duration. Sterile medical Silastic catheter material was aseptically implanted into the abdomens of 42 anesthetized Sprague-Dawley rats. Controls (n = 18) underwent sham operations without catheter implantation. After 4, 8, or 20 weeks, the animals were anesthetized, the abdomen was opened, and the catheter material was recovered and processed to separate the cells adhering to the catheters. The cells, abdomen, and catheter material were all cultured to demonstrate sterility, and transport experiments were carried out. After euthanasia of the animals, abdominal wall tissue was examined for submesothelial thickness and vascular density, and immunohistochemistry (IHC) for cytokines was performed. Cells from the catheter material were processed for immunocytochemistry (ICC). The catheter, adherent cells, and abdomen were free of bacteria. Inflammatory changes in peritoneal thickness and angiogenesis were highest at 4 weeks and declined thereafter to 20 weeks. Transport of mannitol was higher at 4 weeks in treated animals than in controls, and albumin transport was higher at 8 weeks in treated animals than in controls. The IHC for cytokines demonstrated changes paralleling the structural alterations (p < 10(-5)). The ICC of the catheter cell layer demonstrated mesothelial cells, macrophages, fibroblasts, and T cells. Over 20 weeks, the foreign-body response to polymer catheters placed intraperitoneally in rats without injection of solution depends on exposure time, with an initial immune response evident at 4 weeks and decreasing thereafter.

[Application of four-dimensional computed tomography angiography in the study of vascular structure of the deep inferior epigastric artery perforator]

OBJECTIVE

To explore the vascular structure of the deep inferior epigastric artery perforator with the four-dimensional computed tomography (CT) angiography.

METHODS

10 abdominal specimens harvested from fresh cadavers were cannulated with trocar and injected with contrast medium in the deep inferior epigastric artery at different levels, including the deep inferior epigastric artery, its bifurcations, the lateral or medial large perforators. During the perfusion of the contrast medium in the flap, the flap was scanned by three-dimensional CT (four-dimensional defined as three dimensional CT plus time). The CT data were sent to CT workstation and the images were processed and reformatted.

RESULTS

The deep inferior epigastric artery perforator terminates in the subdermal vascular plexus, with bifurcating superior to the Scarpa fascia and under the skin. The anastomosis in the abdominal midline occurs in the subdermal vascular plexus. The blood flow distributes in two ways, one is the subdermal vascular plexus, the other is the existed vascular structure. The zone overlying the rectus muscle in the pedicle side has the best blood supply, the other adjacent zone on the ipsilateral side of the abdomen, the zone overlying the contralateral rectus muscle and the zone lateral to the contralateral rectus muscle has declining perfusion.

CONCLUSIONS

The four-dimensional CT is a useful method to study the vascular structure of the deep inferior epigastric artery perforator in the superficial fascia.

Successful treatment of mesenteric varices after living donor liver transplantation with retrograde transvenous obliteration via an abdominal wall vein

Balloon-occluded retrograde transvenous obliteration is an established treatment for gastric varices; it has been used more rarely to treat mesenteric varices. We report a 12-year-old girl who had received a living donor liver transplant and suffered melena due to ruptured mesenteric varices. We addressed treatment of the mesenteric varices by retrograde transvenous obliteration of an abdominal wall collateral vein detected by superior mesenteric arteriography.

[Hematoma of the abdominal wall. A case report: pitfall of Seldinger method via femoral artery]

We reported a case of an abdominal wall hematoma which caused by Seldinger method via the femoral artery. A 48-year-old female, suffered from direct carotid cavernous fistula, was treated by transfemoral transvenous embolization (TVE). The whole procedure was completed without difficulty except minor resistance of guide wire manipulation during left femoral artery catheterization. Four hours later, the patient became hypotensive and showed the sign of impending shock without definitive causes. Nine hours after the embolization a huge hematoma of the abdominal wall was found. It required the total 1200 m/ of blood transfusion before her blood pressure returned to normal. She recovered fully from this event and discharged uneventfully. There is a speculation that a deep circumflex iliac artery (DCIA) was injured with an angle-shaped guide wire and bled into the abdominal wall. And subsequent systemic heparinization prevented the coagulation process, resulting a large hematoma. Anatomically, an angle-shaped guide wire is easily able to migrate into DCIA. To prevent a vascular injury, it is very important to manipulate a guide wire under fluoroscopic control and to select a J-shaped guide wire instead of an angle-shaped one.

[A man with a swelling of his navel]

A patient with liver cirrhosis and portal hypertension demonstrated the rerouting of blood through the veins of the abdominal wall.

Large gaps of midline abdominal incisions and their management

The operative management of midline full-thickness abdominal wall gaps is difficult, often requires several surgical procedures and is associated with significant short- and long-term complications. A rectus abdominis-posterior sheath (RAPS) flap with skin grafting provides a tension-free one-step repair which was used in three patients successfully with midline abdominal wall (including the skin) gaps who had multiple previous operations related to intra-abdominal malignancy. No complications occurred in these patients in relation to this procedure.

The femoral artery and its branches in the baboon Papio anubis

The aim of the research was to examine the anatomy of the arterial system in the inguinal region, hip and thigh of Papio anubis. No description of this was found in the available scientific literature, although, at the same time, the baboon is considered to be a good animal model in biomedical research. Macroscopic anatomical research was carried out on 20 hind limbs (10 cadavers: 9 male and 1 female) of adult Papio anubis and the results were then compared with the anatomy of the arterial hind limb systems of other apes as described in the literature. The circulatory system of the whole body was filled with coloured latex via the common carotid artery and internal jugular vein, and traditional methods were then used to prepare the vessels. The arterial system in the hind extremity of Papio anubis was recorded. The anatomical names of human arteries were used as well as the names of those of apes as applied in the literature. The femoral artery was the only artery supplying the hind limb of Papio anubis. It started under the inguinal ligament as a continuation of the external iliac artery. It went down and divided into the popliteal artery, which coursed in the popliteal fossa, and the saphenous artery, which passed on the medial side of the thigh and leg. The number of smaller branches and the way in which they issued from the larger arteries were documented. The external diameter and length of the hind limb arteries were measured. It was observed that the cutaneous branches of the femoral artery supplied the inguinal and genital regions and the abdominal wall, while the deep artery of the thigh was the main vessel of the hip and thigh.

[A method for quantifying vessel anastomosis in skin flap]

OBJECTIVE

To present a method for quantifying the anastomosis between two vessels based on angiograpy and provide a theoretical basis for vascular study in skin flap.

METHODS

Ten bilateral skin flaps of 20 cm x 20 cm based on deep iliac circumflex vessels were elevated from the abdominal wall including musculus rectus abdominis and deep superior epigastric vessels in 5 minipigs which were 100-115 cm in length and 25-35 kg in weight. One side was inserted an expander under the panniculus carnosus and was expanded regularly with 30-40 ml isotonic Na chloride injection (expanded group) and the other was unexpanded group which were without any treatment. A X-ray image of the flap vessles was obtained after a gelatin-lead oxide mixture was carotid arterially injected and 24 hours of cryopreservation of the body. Three parallel lines with equal interval perpendicular to long axis of the two vessels were designed at the communication area. Vessel anastomosis quantifying was determined by counting the number of marks derived from the intersections of the lines and the vessels and statistical analysis was carried out.

RESULTS

The mark of intersection in expanded group (81.20+/-10.33) was more than that in unexpanded group (22.40+/-5.41), showing significant difference (P<0.01).

CONCLUSION

The method for quantifying vessel anastomosis in skin flap is simple, reliable, and easy-to-perform. The principles of this procedure may also be applied to other experimental and clinical studies.

Allogreffes de langue, de trachée, de paroi abdominale, d'utérus, de pénis. Précisions sur d'autres applications de l'allotransplantation de tissus composites vascularisés chez l'homme

The first hand and face allografts opened a new era in medicine history: a time when allotransplantation and reconstructive surgery coupled their principles. Their success and their development made composite tissue allotransplantation (CTA) a clinical reality for our speciality. Although still recent and limited, experience from this new surgical practice will widen with feedback from the first clinical cases and with experience gained from more clinical cases, more anatomical areas, more type of allografts, more surgical techniques, more immunosuppressive regimens. Tongue, trachea, abdominal wall, uterus, penis allotransplantations have been performed, contemporarily. Whatever the future and the benefits for the selected patients might have been, reports from these - un- and misknown - cases contribute to a better knowledge of CTA, its therapeutic potential, its limits, its challenges.

Blood sample collection in lizards

Blood sample collection in lizards is an important technique. This column describes techniques for sample collection from the ventral coccygeal vein and the ventral abdominal vein.

Successful Treatment of Mesenteric Varices with Balloon-occluded Retrograde Transvenous Obliteration via an Abdominal Wall Vein

Balloon-occluded retrograde transvenous obliteration (BRTO) is an established therapy for gastric varices, but it has been used less frequently for mesenteric varices. This report describes the successful management of mesenteric varices with BRTO performed via an abdominal wall collateral vein detected on contrast medium-enhanced computed tomography.

The versatility of the SIEA flap: a clinical assessment of the vascular territory of the superficial epigastric inferior artery

Following the TRAM and the DIEP the SIEA flap is the next logical step to reduce the donor site morbidity in autologous breast reconstruction. The vascular axis of the SIEA flap, however, is completely different from the deep epigastric pedicle, on which previous lower abdominal flaps were based. Therefore, a mapping of the vascular territory, which can be reliably harvested on this pedicle, seems mandatory before this new technique can become established.

AIM

To chart the angiosome of the superficial inferior epigastric artery with regard to breast reconstruction and to evaluate the random extension of the vascular territory, which can be reliably raised on this pedicle.

STUDY DESIGN

Clinical, prospective study in a university-affiliated department of plastic surgery.

PATIENTS

Ten patients undergoing autologous breast reconstruction with the superficial inferior epigastric perforator flap and five patients undergoing aesthetic abdominoplasty with isolation of the abdominal flap on the superficial epigastric vessels.

MATERIAL AND METHODS

After isolation of the abdominal panniculus on a single superficial inferior epigastric artery pedicle, the flap was divided in the four conventional zones according to Hartrampf. Perfusion in each of the four zones was measured on the table using the technique of dynamic laser-fluorescence videoangiography.

RESULTS

Perfusion of Hartrampf Zone III occurred first (25s post-injection) and the perfusion index amounted median 89% of reference. Perfusion of Zone I occurred median 5s later and the relative perfusion was 80%. Perfusion of the contralateral zones II and IV was dramatically reduced to 8% and zero, respectively, and this reduction was statistically significant (p<0.0001).

CONCLUSION

The true angiosome of the superficial epigastric artery is located laterally on the ipsilateral hemiabdomen. Its random extension is unreliable and ranges most frequently only to the midline. Based on the results of this study, survival of the skin and subcutaneous fat taken laterally to the border of the contralateral rectus sheath seems questionable. Therefore, the versatility of the SIEA flap for autologous breast reconstruction seems limited when compared with the conventional methods based on the deep inferior epigastric system.

The Cutaneous Arteries of the Anterior Abdominal Wall: A Three-Dimensional Study

BACKGROUND

Abdominal perforator flaps represent a natural progression in the quest to minimize abdominal wall morbidity. Their one disadvantage is the significant rate of vascular complications to which they are subject in some series. The authors examined the vascular anatomy of the abdominal integument, to determine why such complications occur and how they may be prevented.

METHODS

In 10 fresh cadavers, major arteries supplying the abdominal wall were injected with a lead-based contrast medium. The abdominal integument of each cadaver was imaged using a 16-slice spiral computed tomography scanner, to produce three-dimensional reconstructions of the arterial anatomy. Reconstructions were observed for orientation, course, and morphology of the major perforators within the abdominal integument.

RESULTS

Perforators of the deep inferior epigastric artery (DIEA) varied markedly in their orientation, course, and morphology among specimens. By contrast, perforators of the superior epigastric artery (SEA) were relatively consistent in their morphology and orientation. In eight of 10 specimens, SEA perforators with extensive anatomical "territories" orientated toward the umbilicus were present. These SEA perforators pierced the rectus sheath within 4 cm of the costal margin and were present bilaterally in seven of eight specimens.

CONCLUSIONS

The unpredictable orientation and course of DIEA perforators indicate that the blood supply of abdominal perforator flaps, raised without clear knowledge of their unique vascular anatomy, may often be more random than axial. This may account for much of the ischemia-related morbidity observed with DIEA-based perforator flaps. Preservation of SEA perforators adjacent to the costal margin during abdominoplasty will likely improve abdominal wall perfusion and reduce donor-site morbidity.

Erosion of the Inferior Epigastric Artery: A Rare Complication of Intrathecal Drug Delivery Systems

Intrathecal baclofen is an invaluable therapeutic modality in the management of severe spasticity, especially in patients with cerebral palsy, multiple sclerosis, and spinal cord and brain injuries. This case report presents a rare complication of long-term intrathecal infusion with the development of a huge anterior abdominal wall hematoma with extension to the retroperitoneal space as a result of a repeated blunt trauma to the site of the intrathecal pump with erosion of the inferior epigastric artery. This inferior epigastric artery erosion could be avoided by implanting the intrathecal pump laterally away from the rectus abdominus muscle sheath.