Abdominal Wall Function Research Articles

Morphology and arterial supply of the pyramidalis muscle in an Australian female population using computed tomography angiography

IntroductionThe structure and function of the human anterolateral abdominal wall have been thoroughly described. However, there has been limited anatomical study of the pyramidalis muscle and its arterial supply. The aim of this study was to analyse the patterns of arterial supply to the pyramidalis in a female population.MethodsA retrospective study of 32 computed tomography angiography scans of the abdominal wall of adult women was performed to assess the prevalence (bilateral or unilateral presence, or absence), morphology (medial border height, base width and thickness) of pyramidalis and patterns of arterial supply.ResultsPyramidalis prevalence was bilateral in 75% of computed tomography angiography studies (24/32), unilateral in 6.3% (2/32) and absent in 18.8% (6/32). Of the five patterns of pyramidalis arterial supply observed and described in detail, the most frequent (68%, 34/50 of cases) originated from an exclusive muscular branch of the inferior epigastric artery. Origin from the pubic branch of the inferior epigastric artery was seen in 4% (2/50). There was a single case (2%, 1/50) of artery origin from a variant obturator artery, a common trunk with the pubic branch from the inferior epigastric artery, and from the muscular branch to rectus abdominis. The artery could not be defined in 22% (11/50).ConclusionIn this computed tomography angiography study of women, five patterns of Pyramidalis arterial supply were identified. In the majority of cases, the pyramidalis derived its arterial supply from an exclusive, isolated muscular branch of the inferior epigastric artery.

Quality of life and abdominal wall functionality after abdominal wall reconstruction: A prospective single center follow-up study

BackgroundFascial breakdown with the occurrence of an incisional hernia (IH) is an important and challenging complication of any laparotomy. For a long time, the success of the abdominal wall reconstruction (AWR) was measured only from the surgeon’s perspective by defining outcome measures such as wound morbidity and recurrence. The understanding that complete recovery is difficult to assess without considering patients has shifted the paradigm of optimal outcomes to Patient Reported Outcome Measures (PROMS) and Quality of Life (QoL), which are pivotal to evaluate the success and efficacy of AWR.MethodsWe conducted a prospective follow-up study of 91 patients undergoing mesh-augmented abdominal wall reconstruction for primary or recurrent incisional hernia between January 2021 and December 2023. Demographic data, comorbidities, and hernia characteristics were recorded. All patients were evaluated preoperatively by a native abdomino-pelvic CT scan to assess the characteristics of hernia (length, width, surface, and volume of the incisional hernia sac and of peritoneal cavity), the presence of mesh (if previously inserted), and abdominal wall muscles status. All intervention were performed by the same surgical team according to the techniques described by Rives – Stoppa (RS), Ramirez (ACS), and Novitsky (PCS). Abdominal wall function was assessed using trunk raising (TR) and double leg lowering (DLL) measurements performed preoperatively, 1 month, 6 months, and 1 year postoperatively. At the same time, pre- and post-operative quality of life was analysed using the EQ-5D score.ResultsMean age of 59.42 ± 12.28 years and a male/female ratio of 35/56 were recorded, most of them being obese. There were 36 (42%) patients with defects larger than 10 cm. The distribution of the type of surgical intervention was: RS 35 patients, ACS 13 patients, and PCS 43 patients. The mean value of combined score for the preoperative abdominal wall functionality was 4.41 ± 1.67 (2–8) while the mean value of preoperative EQ-5D index was 0.652 ± 0.026 (-0.32–1.00). QoL was poor and very poor for 48% (44) of the patients who recorded index values less than 0.56 (50% percentile). Preoperative EQ-5D index was highly correlated with Combined AWF score (r = 0.620; p < 0.0001) and the correlation was specific (AUC = 0.799; p < 0.0001; asymptotic 95%CI = 0.711–0.923). At 12 months, the AWF score increased to 8.13 ± 2.58 (1–10) and the QoL total score to 0.979 ± 0.007 (0.71–1). Good and very good total scores for QoL were recorded for 47 patients (84%) compared to 33 (36%) in the preoperative evaluation (χ2 with Yates continuity correction for two degrees of liberty = 46.04; p < 0.00001).ConclusionOur results suggest that patients can expect to see a significant overall improvement in all five components of QoL measured with the help of Eq. 5D questionnaire. This improvement is dependent by hernia size, and some individual patient’s factors (diabetes, cardiovascular diseases, and age over 60 years).

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends.

Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field.

Abdominal Wall Function Following Breast Reconstruction with Abdominal Tissue Flaps: A Systematic Review

Abdominal Wall Function Following Breast Reconstruction with Abdominal Tissue Flaps: A Systematic Review

Minimally invasive lipoabdominoplasty (MILA) tactic.

While diastasis recti (DR) was long neglected by general surgeons, plastic surgeons considered conventional abdominoplasty as the only repair option. However, this scenario has changed recently, either due to a better understanding of the correlation between DR and abdominal wall function and greater risk of recurrence in abdominal hernia repairs, or due to the development of new minimally invasive techniques for repairing DR. One of these surgical procedures consists of the concept of an abdominoplasty, that is, supra-aponeurotic dissection and plication of the DR (with or without abdominal hernia) but performed through three small supra-pubic incisions by laparoscopy or robotic approach. More recently, this procedure has gained new stages. Liposuction and skin retraction technology have been associated with MIS plication of DR, which increases the indications for the technique and potentially improves results. For the first time in the literature, we describe these steps and the synergy between them.

EARLY OUTCOMES OF ROBOTIC ENHANCED VIEW TOTALLY EXTRAPERITONEAL VENTRAL HERNIA REPAIR: A SINGLE-CENTER EXPERIENCE.

Incisional hernia (IH) is an abdominal wall defect due to a previous laparotomy, and surgical repair is the only treatment. IH has a negative impact on patients' quality of life. In the last decades, the approach has improved from open to laparoscopic and robotic surgery with the objective of promoting better abdominal wall function after reconstruction. Today, robotic enhanced-view totally extraperitoneal (reTEP) is one of the most advanced techniques for abdominal wall reconstruction. The aim of this study was to analyze the early results of patients with incisional hernia submitted to repair with reTEP. This is a retrospective cohort study, and all patients who underwent reTEP surgery for ventral hernia in the years 2021 and 2022 were included. The only exclusion criteria were patients who underwent another type of herniorrhaphy. Statistical analysis was performed using the Stata software. A total of 32 participants were submitted to reTEP; the majority had an incisional hernia, and according to the European Hernia Society, EUS-M score 3 was the most prevalent. The mean surgical time was 170 min, and the console time was 142 min. Most patients stayed 2 days in the hospital. No intraoperative complications were reported. reTEP is a safe and effective technique and has favorable outcomes in the early postoperative period. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings.

Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction.

Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes (PROs) in breast reconstruction has been poorly characterized. A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction was conducted over 15 years. Patient operative characteristics were recorded and outcomes were analyzed. PROs were assessed using the BREAST-Q abdominal survey. In total, 75 women (108 flaps) with the mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (24%), muscle-sparing (43%), and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in 7%; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p < 0.05). Bulge formation occurred more often in f-TRAM donor sites (p = 0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. The survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with postoperative bulge reported higher abdominal physical well-being scores, regardless of flap type (p < 0.01). Bulge was correlated with lower satisfaction (p < 0.05). The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was primarily a cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.

Clinical and Radiological Evaluation of Onlay Mesh Abdominoplasty in Obese Multiparous Patients with Moderate-to-Severe Rectus Diastasis.

Women with multiple pregnancies often experience abdominal protrusion and/or a lax abdominal wall. Various open surgical techniques have been developed to address rectus diastasis in abdominoplasty, ranging from suture plication to mesh reinforcement. This study aims to compare the clinical and radiological changes between traditional abdominal plication and the addition of non-absorbable mesh for rectus muscle (RM) diastasis repair in terms of function, postoperative outcome, and recurrence. This prospective retrospective study involved 63 women who underwent cosmetic tummy tuck surgery and met certain eligibility criteria. Patients with only mild diastasis recti, midline hernia, contraindications for major surgery, recent smoking history, or refusal of mesh augmentation were excluded. Clinical examination for abdominal protrusion or bulging and CT imaging was performed to check for recurrence of diastasis recti. The study included 33 patients who underwent mesh repair and 30 who underwent traditional abdominal plication. Follow-up was conducted after 1year using CT and a questionnaire to assess various factors compared to preoperative measurements, with overall satisfaction rated on a 10-point Likert scale. There was no significant difference in demographic data between the two groups. Patients who underwent mesh repair had a slightly longer hospital stay and drain duration. The average waist circumference decreased in both groups without any statistically significant difference. Objective CT showed significant reductions in both groups in inter-rectus distance, RM width and circumference, and intra-abdominal circumference compared to preoperative values. All patients expressed satisfaction with scar quality and umbilicus aesthetics, and no recurrence was detected either clinically or radiologically during the follow-up period. Comprehensive preoperative assessment and imaging techniques like ultrasound and CT scans allow surgeons to detect postpartum changes in the abdominal wall. Mesh reinforcement may be indicated for diastasis above 4 cm in obese multiparous females. Thorough preoperative evaluation permits customized surgical plans to optimally restore abdominal wall anatomy and function. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

Abdominal wall hernia repair: from prosthetic meshes to smart materials.

Hernia reconstruction is one of the most frequently practiced surgical procedures worldwide. Plastic surgery plays a pivotal role in reestablishing desired abdominal wall structure and function without the drawbacks traditionally associated with general surgery as excessive tension, postoperative pain, poor repair outcomes, and frequent recurrence. Surgical meshes have been the preferential choice for abdominal wall hernia repair to achieve the physical integrity and equivalent components of musculofascial layers. Despite the relevant progress in recent years, there are still unsolved challenges in surgical mesh design and complication settlement. This review provides a systemic summary of the hernia surgical mesh development deeply related to abdominal wall hernia pathology and classification. Commercial meshes, the first-generation prosthetic materials, and the most commonly used repair materials in the clinic are described in detail, addressing constrain side effects and rational strategies to establish characteristics of ideal hernia repair meshes. The engineered prosthetics are defined as a transit to the biomimetic smart hernia repair scaffolds with specific advantages and disadvantages, including hydrogel scaffolds, electrospinning membranes, and three-dimensional patches. Lastly, this review critically outlines the future research direction for successful hernia repair solutions by combing state-of-the-art techniques and materials.

Another Tool in the Quest for the Perfect Living Liver Donor Operation.

Living donor surgeons must balance donor safety with regard to bleeding, vascular injury, and biliary complications while minimizing short-term pain and long-term abdominal wall function. At the same time, living donor patients are usually deeply concerned about the recipient’s outcomes. Reduced donor morbidity at the cost of increased recipient complications is not acceptable. In this issue, Park et al report their experience with 448 consecutive donors who underwent living donor right hepatectomy by a single surgeon over the course of 5 y.1 One hundred eighty-seven of these donors underwent a mini-incision compared with the conventional J-shaped incision. The team functions within a center that performed more than 1600 donor right hepatectomies over the 5-y period. Right hepatectomy is a physiologically significant operation with risks related to loss of hepatic parenchyma. Many donor surgeons have argued that due to the risks of the surgery including hepatic failure, vascular injury, and biliary complications, the open approach should remain the primary approach.2 However, minimally invasive approaches have been introduced starting with Cherqui et al in 20023 and for right hepatectomies in 2013.4 Although a few centers have embraced the full laparoscopic approach for near donors, adoption broadly in the community of donor surgeons has been slow. Ten years after the initial right hepatectomy reports, fully laparoscopic donor hepatectomy surgery remains isolated to a few centers.5,6 As the authors mention, mini-incision, laparoscopy-assisted and hand-assisted approaches, have been introduced to minimize abdominal wall injury while reducing the learning curve associated with fully laparoscopic approach. Park et al show that excellent outcomes can be achieved for the donors and the recipients using an 8.5- to 13-cm right subcostal incision. They demonstrated low rates of biliary and vascular complications for both donors and recipients. Authors note that when they started mini-incision living donor right hepatectomy, they avoided larger liver and higher body mass index patients or patients with large inferior right hepatic veins. Later in their experience, they develop increased comfort with higher body mass index patients. Interestingly, at the authors’ institution, only 5% of the right hepatectomies are performed laparoscopically, and 3 of the 5 performing donor hepatectomies only perform mini-incision on selected patients. This rigorous selection of patients highlights challenges for broader application of smaller incisions even at the most experienced centers in the world. Making a minimally invasive donor operation safer, more easily reproducible, and with a shortened learning curve is the ideal all donor surgeons should be striving toward. Park et al have shown that mini-incision right donor hepatectomy can be part of that toolbox but likely the perfect operation is still out there waiting to be developed.

P-038 BOTULINUM TOXIN IN THE TREATMENT OF COMPLEX ABDOMINAL HERNIAS: A REVIEW OF CLINICAL OUTCOMES

Abstract Aim Adjuvant use of botulinum toxin (BTX), which causes temporary paralysis of the lateral abdominal wall muscles, may have a roll in achieving a functional abdominal wall reconstruction when treating complex hernias, without the need of component separation techniques (CST). Methods Retrospective analysis of all patients with complex hernia between April 2021 and October 2022 in which BTX was used. Patients that would have to go through CST regardless and patients with other adjuvant treatments were excluded. Results 22 patients had BTX, with a total of 13 patients included in this study. The median age was 64 and BMI 30,7kg/m2. The average CT imaging measurement of the transverse defect was 13,7cm. The median of Cedar's calculation was 27%. 7 patients (54%) only needed a Rives Stoppa Wantz (RSW) for midline closure, but 6 patients still needed a CST. The median time of the surgery for the RSW was 233 min and for the CST 330 min. Of the patients submitted to RSW, 1 complicated with a deep incisional infection and 2 CST patients had surgical complications. No recurrences in the RSW group and one hernia persistence after a major complication on the CST group. Conclusion The BTX can have an important role as an adjuvant in the treatment of large incisional hernias and in some patients may allow its repair with a less invasive surgical technique, with less operative time and less complications. More studies are needed in this area.

P-047 REDUCING THE RISK OF MESH EROSION IN A MODIFIED RETROMUSCULAR SUGARBAKER TECHNIQUE FOR PARASTOMAL HERNIA REPAIR

Abstract Aim Modified retromuscular Sugarbaker procedure (SP) is a promising approach for parastomal hernia repair. However, its potential complications, including the risk of mesh erosion, encourages us to develop other techniques of mesh placement. We propose an addition to this parastomal retromuscular mesh reinforcement. Materials and Methods We present the case of a 53 year old-woman, with a history of proctocolectomy with end ileostomy due to anal adenocarcinoma, undergoing emergency surgery due to parastomal hernia incarceration. Sugarbaker repair was performed placing inlay composite mesh fixed with reabsorbable tackers. Subsequently, the patient was admitted for recurrent parastomal hernia and midline ventral hernia surgery. Results We performed a modified retromuscular SP as described by Pauli in 2016. After midline laparotomy, hernia content was reduced and extensive retromuscular dissection with transversus abdominis release (TAR) performed, placing a wide retromuscular polypropylene mesh prior to closing parastomal fascial defect. Stoma was parietalized from lateral to medial in an S-shaped configuration. We placed a segment of bioabsorbable mesh covering the parietalized stoma to avoid direct contact with the polypropylene mesh. No recurrence was detected 3 months after surgery, pending reassessment at 6 months. Conclusions This repair provides the benefits of an open posterior component separation with TAR, maintaining the biomechanics of a functional abdominal wall, whilst offering the advantages of mesh reinforcement in a modified Sugarbaker configuration. Our experience with this novel technique seems promising. Rate of mesh erosion is yet to be defined and requires long-term studies before widespread adoption, with special concern on mesh placement.

The Scarless Neo-Umbilicus in DIEP-Flap Breast Reconstruction

While the DIEP (deep inferior epigastric perforator) flap has become the gold standard in autologous breast reconstruction due to its favourable tissue characteristics and preserved abdominal wall function, a constant attempt is done to improve the outcome of the donor site. Even if just a small detail, the umbilicus has a big impact on the overall aesthetic outcome of the donor site. As an already established technique in abdominoplasties, we introduced the neo-umbilicus as the standard procedure for DIEP donor site closure. The aim of this study was to assess the aesthetic outcome of this neo-umbilicoplasty technique in DIEP-flaps. This is a single-center cohort study. A total of 30 consecutive breast cancer patients were treated during a period of 9 months with a mastectomy and an immediate reconstruction with a DIEP-flap. In all patients, the reconstruction of the umbilicus was done by an immediate neo-umbilicoplasty technique, consisting of a cylindrical fat resection at the new loco typico and fixation of the dermis directly to the rectus fascia. All patients were photographed in a standardised setting. Subjective patient satisfaction was assessed with a survey consisting of three questions and aesthetic outcome was evaluated by an independent professional panel consisting of three plastic surgeons. The results were compared to a previous cohort of conventional umbilicoplasties in DIEP-flap patients. Twenty-six patients participated in the follow-up study. There were no wound complications associated with the neo-umbilicus. Questionnaire results demonstrated high but not statistically significant different patient satisfaction. The panel scores were statistically significant (p < 0.05) better for the neo-umbilicus reconstructions. The aesthetic outcome was rated higher in patients with a higher BMI compared to those in patients with a low BMI. The creation of a neo-umbilicus at the donor site after DIEP-flap breast reconstruction is a quick and safe technique and leads to a superior aesthetic donor site result.

Ventral hernia repair in conjunction with LIPO-ABDOMINOPLASTY in overweight patients: A comprehensive approach.

Repair of large midline ventral hernias still represents a challenge for general surgeons. As obesity is a key factor of this type of hernias, usually the patients are presented with abdominal wall laxity, excess skin and subcutaneous fat. Combined procedures has evolved over the last six decades to repair the hernias and to improve the shape of the abdomen, but was associated with high rate of wound complications. The components separation technique for ventral hernia repair was introduced in 1990 by Ramirez et al to avoid mesh repair was associated with a high rate of success. Until recently, the convenience of simultaneously performing ventral hernia repair and abdominal contouring surgery remains controversial. The aim of this study is to present our experience in the integration of the anterior component separation technique for repair of midline wide ventral defects, with the lipoabdominoplasty in selected patients with high body mass index, to achieve a functional abdominal wall repair and to provide a better aesthetic outcome. In this prospective case-control study, 15 adult female multiparous women, all were overweight and obese, presented with midline ventral hernias and abdominal deformity was operated upon where a comprehensive technique in the form of herniorapphy, anterior component separation technique and lipoabdominoplasty were performed. The patients were followed up for 3-6 months period to monitor incidence of complications, hernia recurrence and to assess the aesthetic outcome. All the 15 patients were overweight and obese with BMI ranged between 26.5 and 39.6 kg/m2 . The mean operative time was 184 ± 28.8 minutes (range 150-240 minutes). The mean postoperative length of hospital stay was 3 days ranging from 1 to 5 days. In addition to the hernia, all the patients suffered from diastasis of recti ranged from 9 to 15 cm in the transverse dimension. No mortality or major complications encountered, no hernia recurrence, only minor complications occurred in four patients (26.8%). Two patients developed seroma which resolved by aspiration, one patient suffered wound infection with partial loss of the umbilicus and one developed superficial skin necrosis at the central area of the flaps which healed uneventfully by secondary intention. All the patients were satisfied with the cosmetic outcome. In conclusion, this comprehensive approach is effective technique for reconstruction of large midline ventral defects and provide a good aesthetic appearance of the anterior and lateral abdomen in appropriately selected obese patients.

Anatomical types and anastomosis methods of concomitant veins of deep inferior epigastric artery

To summarize the anatomical types of the concomitant veins of deep inferior epigastric artery and the corresponding choice of anastomosis methods, and to evaluate the indications and safety of various methods. Between October 2015 and June 2021, 296 female patients received breast reconstruction with autologous free lower abdominal flap, including 154 cases of immediate breast reconstruction and 142 cases of delayed breast reconstruction. The average age of the patients was 36.5 years, ranged from 26 to 62 years. Unilateral free deep inferior epigastric artery perforator flap transplantation was performed in 172 cases, and unilateral free muscle-sparing rectus abdominis myocutaneous flap transplantation was performed in 124 cases. The internal thoracic vessels were selected as the recipient vessels in all cases. The length of vascular pedicle ranged from 9.5 to 13.0 cm, with an average of 11.2 cm. The concomitant veins of deep inferior epigastric artery included three anatomical types: one-branch type in 26 cases (8.8%), two-branch type in 180 cases (60.8%), and Y-shaped structure in 90 cases (30.4%). Anastomosis of inferior epigastric artery was performed with the proximal end of internal thoracic artery, while that of vein should be adjusted according to the diameter, length, wall thickness, and branches of the vein. The specific classification of venous anastomosis included: ① The sole concomitant vein of deep inferior epigastric artery was anastomosed with the internal mammary vein (26 cases); ② The two concomitant veins of deep inferior epigastric artery were anastomosed with the internal mammary vein respectively (151 cases); ③ The larger one of two concomitant veins of deep inferior epigastric artery was anastomosed with the internal mammary vein, and the other one was ligated and discarded (29 cases); ④ The two concomitant veins of deep inferior epigastric artery were Y-shaped, and the common trunk segment was directly anastomosed with the internal mammary vein (31 cases); ⑤ The smaller branch of the concomitant veins of Y-shaped structure was ligated, and the thicker branch was anastomosed with the internal mammary vein (17 cases); ⑥ The concomitant veins of Y-shaped structure were anastomosed with the internal mammary veins respectively (42 cases). Among the patients who underwent venous anastomosis according to scheme ④, 3 cases had venous crisis of flap after operation, of which 1 case was successfully rescued by emergency exploration; the other 2 cases had flap necrosis, of which 1 case survived after being repaired by pedicled latissimus dorsi flap, and 1 case closed the wound directly. Flaps with other venous anastomosis protocols survived completely. All 296 patients were followed up 12-70 months, with an average of 37.5 months. The reconstructed breast has good shape, good elasticity, and no skin flap contracture. The donor site of the flap only left linear scar, and the abdominal wall function was not affected. The method of direct anastomosis of concomitant veins of deep inferior epigastric artery with Y-shaped structure is relatively risky, and the vessels are prone to be twisted and compressed, leading to the occurrence of venous crisis. It can improve the safety of surgery if only one large vein is anastomosed or two veins are separated to anastomose respectively.

P-091 IMPROVEMENT OF RESPIRATORY PHYSIOLOGY AFTER POSTERIOR COMPONENT SEPARATION TAR: A PILOT STUDY

Abstract Aim Patients with incisional hernia with a width greater than 9 centimeters, submitted to Posterior Component Separation Trasversus Abdominis Release, by Department of Emergency and Transplantation Surgery in Varese Hospital, were analyzed to define the modifications in respiratory physiology after surgery. Material and Methods Patients that underwent Posterior Component Separation were prospectively analyzed by evaluating: volume of laparocele, volume of abdominal cavity and their ratio. Furthermore Pulmonary Peak pressures and Pulmonary Plateau pressures were measured in three different times: at the induction of the anaesthesia, when the mesh was placed and at the closure of the anterior muscular layer. All patients were submitted to a pre-operative simple spirometry, and re-examinated three months after the surgical procedure with the same procedure to check if modifications in their respiratory function were present. Results Primary results of the study will be shown to define how this surgical procedure impacts on the respiratory function of the patients. The expectation is that an improvement of the respiratory physiology happens independently from a pulmonary pressure elevation which is determinated by the re-allocation of the herniated viscera in the abdomen when the anterior muscular fascia is closed. Conclusions the aim of this study is to show how, the reconstitution of a functional abdominal wall with an efficient respiratory accessory musculature guaranteed by the laparocele correction with Posterior Component Separation, ensures an improvement of respiratory physiology visible with spirometry, independently from the development of a superior intrathoracic pressure.

Application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect

To investigate the application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect. Between October 2018 and March 2021, bilateral free lower abdominal flaps were used to repair large-area complex defects after chest wall tumor surgery in 23 patients. The patients were all female; the age ranged from 23 to 71 years, with an average age of 48.5 years. There were 11 cases of locally advanced breast cancer, 4 cases of phyllodes cell sarcoma, 3 cases of soft tissue sarcoma, 3 cases of recurrence of breast cancer, and 2 case of osteoradionecrosis. The size of secondary chest wall defect after tumor resection and wound debridement ranged from 20 cm×10 cm to 38 cm×14 cm, the size of flap ranged from 25 cm×12 cm to 38 cm×15 cm, the length of vascular pedicle was 9-12 cm (mean, 11.4 cm). Fourteen cases of simple soft tissue defects were repaired by flap transplantation; 5 cases of rib defects (<3 ribs) and soft tissue defects were repaired by simple mesh combined with flap transplantation; and 4 cases of full-thickness chest wall defect with large-scale rib defect (>3 ribs) were repaired by "mesh plus bone cement" rigid internal fixation combined with flap transplantation. The anterior serratus branch of thoracodorsal vessel was selected as the recipient vessel in all cases, the revascularization methods include 3 types: the proximal end of the anterior serratus branch plus other recipient vessels (13 cases), proximal and distal ends of anterior serratus branch (6 cases), and proximal ends of two anterior serratus branches (4 cases). The main trunk of thoracodorsal vessels was preserved completely in 23 patients. All patients were followed up 10-18 months, with an average of 13.9 months. After operation, the flap survived completely, the shape of reconstructed chest wall was good, the texture was satisfactory, and there was no flap contracture deformation. There was only a linear scar left in the flap donor site, and the abdominal wall function was not significantly affected. There was no tumor recurrence during follow-up. The anterior serratus branch of thoracodorsal vessel has a constant anatomy and causes little damage to the recipient site, so it can provide reliable blood supply for free flap transplantation.

A Simplified Abdominal Wall Model to Teach Complex Abdominal Wall Reconstruction.

Summary:A simplified and functional abdominal wall model is necessary for surgical education. The utility of such a model encompasses medical student, resident, and fellow education. This is especially relevant in the fields of general surgery and plastic surgery. An abdominal wall model helps with a more complete understanding of abdomen access, hernia repair, and complex abdominal wall reconstruction. Although several models have been proposed, they are expensive and limitations exist due to access, costly repairs, maintenance, and part replacements. There is currently no consensus or widely adopted model used in surgical training programs. We present a simplified abdominal wall model that is inexpensive and easily reproducible.

Robotic versus hybrid assisted ventral hernia repair: a prospective one-year comparative study of clinical outcomes

Background Laparoscopic ventral hernia repair (LVHR) may be associated with chronic pain, seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence and poor quality of life (QoL). Our study evaluates whether robotic-assisted ventral hernia repair (rVHR) diminishes these complications compared to LVHR with primary closure of the defect (hybrid). Methods Thirty-eight consecutive patients undergoing incisional ventral hernia operation with fascial defect size from 3 to 6 cm were recruited between November 2019 and October 2020. Nineteen patients underwent rVHR and nineteen underwent hybrid operation. The main outcome measure was postoperative pain, evaluated with a visual analogue scale (VAS: 0–10) at 1-month and at 1-year. Hernia recurrence was evaluated with ultrasound examination and QoL using the generic SF-36 short form questionnaire. Results At the 1-month control visit, VAS scores were significantly lower in the rVHR group; 2.5 in the hybrid group and 0.3 in the rVHR group (p < 0.001). At the 1-year control, the difference in VAS scores was still significant, 2.8 vs 0.1 (p = 0.023). There was one hernia recurrence in the hybrid group (p = 0.331). QoL did not differ significantly between the study groups when compared to preoperative physical status at 1-year follow-up (p = 0.121). However, emotional status (p = 0.049) and social functioning (p = 0.039) improved significantly in the rVHR group. Conclusions Robotic-assisted ventral hernia repair (rVHR) was less painful compared to hybrid repair at 1-month and at 1-year follow-up. In addition, improvement in social functioning status was reported with rVHR. Trial Registration ID 5200658.

31. THE PEDICLED VPAP FLAP ALLOWS FOR PRESERVATION OF THE ABDOMINAL WALL IN THE RECONSTRUCTION OF APR DEFECTS

PURPOSE: Abdominoperineal resections (APR) often leave large cavitary defects that have historically been reconstructed with vertical rectus abdominus muscle (VRAM) flaps. We present a case series and surgical technique for a novel approach to reconstructing complex defects with a fasciocutaneous flap, the pedicled vertical profunda artery perforator (VPAP) flap, which was first performed for reconstruction of robotic and minimally invasive APR defects in order to preserve the functional abdominal wall. METHODS: A total of 13 patients underwent immediate or delayed reconstruction of APR defects using a pedicled VPAP. Seven patients underwent a minimally invasive APR, with six robotic-assisted and one laparoscopic-assisted procedure, leaving the abdomen completely intact. One patient had a previously failed VRAM, thus the abdomen was unavailable for reconstruction. One patient had bilateral ostomies. Five reconstructions were performed secondarily due to post-operative infection and dehiscence. RESULTS: Of the 13 cases, 2 patients required take back to the operating room for venous congestion. The major complication rate (15.4%) in this series was similar to historically reported rates described for VRAM reconstruction of APR defects. There were no total flap losses or donor site complications. All patients ultimately had successful wound closure. CONCLUSION: The pedicled VPAP presents a viable solution for reconstruction of APR defects while simultaneously preserving the functional abdominal wall in patients who have undergone minimally invasive ablative procedures. Additionally, this technique offers a reconstructive solution in patients that experience post-operative infection and dehiscence, or in whom the abdominal donor site is not available due to bilateral ostomies.