Adhesive Bowel Research Articles

A comparative study between condensed polytetrafluoroethylene hernia mesh versus other composite meshes in Endo-laparoscopic ventral hernia repair

IntroductionLaparoscopic ventral hernia mesh repair (LVHR) is gaining popularity possibly due to reduced complications, reduced hospital stay, early return to work and better cosmesis. In intra-peritoneal onlay method (IPOM) a dual layer composite mesh with an absorbable barrier on the visceral surface is used for minimising bowel adhesions. Three most popular prosthetic mesh scaffolds are polypropylene (PP), polyester and expanded polytetrafluoroethylene (ePTFE). A new generation of monolayer condensed polytetrafluoroethylene (cPTFE) Omyra® mesh, which theoretically has better tissue integration with parietal tissue and possibly lesser adhesions with visceral organs is now available for use. ObjectiveThe aim of our study is to assess the safety and efficacy of Omyra (cPTFE) mesh versus other mesh types in LVHR. MethodWe retrospectively collected data from 62 patients who underwent LVHR using cPTFE, as well as other mesh types from January 1, 2011 to December 31, 2020. Patient demographics, Hernia Characteristics, perioperative events, postoperative results and complications were documented and analysed. ResultsAmong the 62 patients studied, there were 27 (43.55 %) in the Omyra group and 35 (56.45 %) in the other synthetic meshes group. The mean age of the Omyra group was 53.19 (31–85) and 55.03 (22–81) for the other synthetic meshes group. There were no differences in terms of patient demographics and major comorbidities. At presentation, the indication was more commonly for recurrence (p = 0.043), and patients were more symptomatic (p = 0.0034) in the Omyra group than the other synthetic meshes group. There were no differences in mean operating time, post-operative recovery and complications, as well as early (<30 days) and late (>30 days) complications during follow up. ConclusionThe use of cPTFE (Omyra™) mesh yielded comparable operative characteristic compared to other synthetic meshes for LVHR. The rate of perioperative complications and early recurrence was similar between Omyra and other synthetic meshes group.

Analyzing postoperative complications in colorectal cancer surgery: a systematic review enhanced by artificial intelligence.

Colorectal cancer stands as a predominant cause of cancer-related mortality worldwide. Despite progressive strides in surgical methodologies, the specter of postoperative complications is very large, significantly impacting both morbidity and mortality rates. This review aims to meticulously examine existing scholarly works to gauge the prevalence, severity, and therapeutic approaches to postoperative complications arising from colorectal cancer surgeries. Employing a systematic approach, this study reviewed 135 peer-reviewed publications from the period of 2000-2023. The corpus was organized into categories reflective of the postoperative complications discussed: anastomotic leakage, port-site metastases, small bowel adhesions and obstructions, thrombosis, ileus, postoperative infections, urinary dysfunctions, and cardiovascular dysfunctions. Advanced artificial intelligence tools were leveraged for in-depth literature searches and semantic analyses to pinpoint research lacunae. The analysis revealed that anastomotic leakage and postoperative infections garnered the majority of academic focus, representing 35% and 25% of the studies, respectively. Conversely, port-site metastases and cardiovascular dysfunctions were less frequently examined, accounting for merely 5% and 3% of the literature. The reviewed studies indicate a disparity in the reported prevalence rates of each complication, oscillating between 3% and 20%. Furthermore, the review identified a dearth of evidence-based management protocols, underscored by a pronounced heterogeneity in treatment guidelines. The literature is replete with analyses on anastomotic leakage and postoperative infections; however, there exists a glaring scarcity of exhaustive research on other postoperative complications. This review emphasizes the pressing need for uniform treatment guidelines and spotlights areas in dire need of further research, aiming at the comprehensive enhancement of patient outcomes following colorectal cancer surgery.

Unusual causes of Small bowel obstruction: a review of the literature and revisited cross-sectional imaging checklist.

Intestinal obstruction is a common surgical emergency with high morbidity and mortality. Patients presenting with features of small bowel obstruction need urgent evaluation to avoid complications such as bowel gangrene, perforation, or peritonitis. Imaging is necessary in most cases of suspected bowel obstruction, to take an appropriate decision, for apt patient management. Among the common causes of small bowel obstruction, adhesions, external herniae, malignancies, and Crohn's disease top the chart. Imaging helps in determining the presence of obstruction, the severity of obstruction, transition point, cause of obstruction, and associated complications such as strangulation, bowel gangrene, and peritonitis. This review is based on the cases with unusual causes of bowel obstruction encountered during our routine practice and also on the extensive literature search through the standard textbooks and electronic databases. Through this review we want our readers to have sound knowledge of the imaging characteristics of the uncommon yet important causes of bowel obstruction. We have also revisited and structured a checklist to simplify the approach while reporting a suspected case of small bowel obstruction. Imaging plays a key role in the diagnosis of small bowel obstruction and in determining the cause and associated complications. Apart from the common causes of small bowel obstruction, we should also be aware of the uncommon causes of small bowel obstruction and their imaging characteristics to make an accurate diagnosis and for apt patient management.

Iatrogenic small bowel perforation during elective laparoscopic intraperitoneal onlay meshplasty leading to intraoperative change of plan: a case report with review of literature

Iatrogenic bowel injury during any surgery, be it open or laparoscopic; is associated with significant morbidity. Moreover, if the said injury occurs in a surgery in which a foreign material is planned to be implanted in the patient’s body as a prosthesis e.g., hernia surgery; the surgical team may have to deviate from its original plan of action. Even in the best of hands, iatrogenic bowel trauma can occur inspite of following best recommended practices. This usually occurs in the setting of dense adhesions of bowel to the parietes. Herein, we present one such case of a 72-year-old lady who was planned for laparoscopic incisional mesh hernioplasty, but had to be subjected to an intraoperative change in plan, due to iatrogenic enterotomy.

Establishment of a postoperative bowel adhesion model in Rats

Postoperative adhesive bowel obstruction is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive bowel obstruction can be managed non-operatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive bowel obstruction. Treatment recommendations are still controversial. Intestinal adhesions commonly occur in patients after abdominal surgery, often between intestines, between intestines and the abdominal wall, or within the peritoneum. Adhesions can lead to symptoms such as abdominal pain, constipation, and bloating, and may result in serious complications such as intestinal obstruction, bowel necrosis, acute peritonitis, and sepsis, which can be life-threatening. Therefore, reducing the occurrence of intestinal adhesions is crucial for abdominal surgery. To minimize adhesions, endoscopic techniques can be employed to reduce the abdominal opening area and thus decrease the probability of adhesion formation. However, this approach requires specialized equipment and surgical skills, making it somewhat challenging. Alternatively, anti-adhesion products can be used to lower the risk of adhesion formation. In this study, a murine cecal abrasion adhesion model was established and will be simulated common adhesion scenarios observed in patients after abdominal surgery. The efficacy of anti-adhesion gel materials will be then evaluated to assess their anti-adhesion properties. The record of gross adhesion severity assessment was performed. The adhesion status between the cecum and abdominal wall was observed on postoperative days 3 and 14. The results was shown that three days post-surgery operation, the group exhibited more severe adhesions upon gross examination. By day 14 post-surgery operation (at animal sacrifice), the histopathological analysis revealed that the group exhibited thicker fibrous tissue thickness, increased neovascularization, and higher collagen accumulation in the peritoneum. Therefore, based on the results of this experiment, a postoperative bowel adhesion rat is reliable and can be safely used to test the efficacy of novel anti-adhesive formulations to prevent intra-abdominal adhesions by using this model.

Predicting disease recurrence in patients with endometriosis: an observational study

BackgroundDespite surgical and pharmacological interventions, endometriosis can recur. Reliable information regarding risk of recurrence following a first diagnosis is scant. The aim of this study was to examine clinical and survey data in the setting of disease recurrence to identify predictors of risk of endometriosis recurrence.MethodsThis observational study reviewed data from 794 patients having surgery for pelvic pain or endometriosis. Patients were stratified into two analytic groups based on self-reported or surgically confirmed recurrent endometriosis. Statistical analyses included univariate, followed by multivariate logistic regression to identify risk factors of recurrence, with least absolute shrinkage and selection operator (Lasso) regularisation. Risk-calibrated Supersparse Linear Integer Models (RiskSLIM) and survival analyses (with Lasso) were undertaken to identify predictive features of recurrence.ResultsSeveral significant features were repeatedly identified in association with recurrence, including adhesions, high rASRM score, deep disease, bowel lesions, adenomyosis, emergency room attendance for pelvic pain, younger age at menarche, higher gravidity, high blood pressure and older age. In the surgically confirmed group, with a score of 5, the RiskSLIM method was able to predict the risk of recurrence (compared to a single diagnosis) at 95.3% and included adenomyosis and adhesions in the model. Survival analysis further highlighted bowel lesions, adhesions and adenomyosis.ConclusionsFollowing an initial diagnosis of endometriosis, clinical decision-making regarding disease management should take into consideration the presence of bowel lesions, adhesions and adenomyosis, which increase the risk of endometriosis recurrence.

DIAGNOSIS AND SURGICAL TREATMENT OF ADHESIVE OBSTRUCTION OF THE SMALL INTESTINE USING MODERN METHODS (LITERATURE REVIEW)

Small bowel adhesions are quite common after abdominal surgery, which makes this problem significant for medical practice. The obstruction can lead to serious complications such as intestinal necrosis, peritonitis and others, which requires surgical intervention. In recent years, there has been an active introduction of innovative treatment methods such as laparoscopy, endoscopic approaches and the use of drugs to prevent adhesions. Thus, the topic of diagnosis and treatment of adhesive small intestinal obstruction remains relevant and requires constant attention from the medical community to improve treatment results and reduce complications in patients.

Acute Small-bowel Obstruction: An Appraisal of Common Etiology and Management at the Federal Medical Centre, Keffi, North-central Nigeria.

Acute small intestinal obstruction is a common surgical emergency in the sub-Saharan region. Over the decades, complicated inguinal hernias have been identified as a leading cause. However, we observed from our clinical practice that complicated inguinal hernias were not the most common etiology. This study aimed to evaluate the common etiology of acute small bowel obstruction in the study center and compare our findings with that from other centers and existing literature. This was a retrospective, cross sectional study carried out over a period of five years (January 2017 to December 2021). This study looked at the patients presenting with acute, mechanical, small bowel obstruction that did not respond to conservative treatment in our hospital facility. Relevant information were extracted from patients' clinical details and entered into the proforma prepared for this study. A total of 147 patients were recruited into this study out of which 85(57.8%) were males and 62 (42.2%) were females (M:F=1.44:1). Majority (80.3%) of the patients that presented with post-operative bowel adhesion had previous appendectomy. Simple bowel obstruction was seen in 93 (63.3%) patients while strangulated obstruction and gangrenous bowel were seen in 26 (17.7%) patients and 22 (15.0%) patients respectively. Majority (47.6%) of the patients had adhesiolysis done while others had bowel resection. The common cause of acute small bowel obstruction as observed in this study is post-operative adhesions arising from previous appendectomy and laparotomies.

Evaluation of 4DryField® as an Adhesion Prophylaxis in Pediatric Patients: A Propensity-Score Matched Study

Abstract Introduction Abdominal adhesions following surgery can lead to complications like intestinal obstruction and pelvic pain. While no molecular therapies currently target the underlying adhesion formation process, various barrier agents exist. 4DryField® has shown promise in reducing bleeding and adhesions in adults. This study aimed to assess its effectiveness in children. Methods The study examined all pediatric patients who underwent laparotomy between January 2018 and February 2022. It compared outcomes between those treated with 4DryField® and a control group. Key endpoints included surgical revision, adhesion recurrence, infections, insufficiencies, fever, C-reactive protein (CRP) levels, and time to gastrointestinal passage. Results In total, 233 children had surgery for bowel adhesions. After propensity score matching, 82 patients were included in the analysis: 39 in the control and 43 in the 4DryField® group. 4DryField® did not affect the readhesion rate. Children in the treatment group had significantly more complications (47 vs. 15%, p = 0.002), more often fever, and higher CRP levels. Conclusions 4DryField® did not show potential in reducing adhesion formation, but it was associated with significantly more complications in pediatric patients. Thus, future prospective studies are needed to evaluate the safety and effectiveness of 4DryField® in children.

Effect of feeding time on womens satisfaction after caesarean section a randomized control study.

Trail design A quazi randomizedd controlled trial Methods Particpaints A total of 226 parous women with singleton vaginal delivery at term pregnancy 37 to 42 weeks of gestation with cephalic presentation. Study participants who had undergone the use of tocolytics drugs for delivery, or caesarian section performed under general anaesthesia were excluded from the study. Moreover, participants with intra-operative complications bowel injury, bowel adhesions, post-partum haemorrhage and anaesthetic complications and postoperative complications postpartum haemorrhage, shock, fever, eclampsia, and use of MgSo4 were excluded from the study. The participants with pre-existing medical conditions like hypertension, diabetes and gastrointestinal diseases were screened off and removed from the study. Additionally, obstructed labour and the use of butrophanone as labour analgesia or postoperative analgesia were excluded. Intervention The study participants were divided into two groups based on the intervention considered. After the participants were selected as per inclusion criteria, an informed consent was taken from all the respondents. The early feeding group was allowed for intake of food after 6 hours of delivery starting with liquid diet followed by solid diet. Similarly delayed feeding group was allowed for intake of food after complete reversal of anaesthesia i.e. 12 hours of delivery starting with liquid diet followed by solid diet.

Polypropylene mesh coated with hyaluronic acid/polyvinyl alcohol composite hydrogel for preventing bowel adhesion

Polypropylene (PP) mesh is the most widely used prosthetic material in hernia repair. However, the efficacy of implanted PP mesh is often compromised by adhesion between viscera and PP mesh. Thus, there is a recognized need for developing an anti-adhesive PP mesh. Here, a composite hydrogel coated PP mesh with the prevention of adhesion after hernia repair was designed. The composite hydrogel coating was prepared from polyvinyl alcohol (PVA) and hyaluronic acid (HA) by using the freezing-thawing (FT) method. To overcome the shortcoming of the long time of the traditional freezing-thawing method, a small molecule 3,4-dihydroxyphenylacetic acid (DHPA) was introduced to promote the formation of composite hydrogel. The as-prepared composite hydrogel coating displayed modulus more closely resembling that of native abdominal wall tissue. In vitro studies illustrated that the resulting meshes showed excellent coating stability, hemocompatibility, and non-cytotoxicity. In vivo experiments using a rat abdominal wall defect model demonstrated that the composite hydrogel coated PP mesh could prevent the formation of adhesion, alleviate the inflammatory response, and reduce the deposition of collagen around the damaged tissue. These disclosed results manifested that the PP mesh coated with HA/PVA composite hydrogel might be a promising application in preventing adhesion for hernia repair.

Risk factors for major complications following colorectal resections for endometriosis in the USA

PurposeWe aimed to describe the incidence and identify risk factors for the occurrence of short-term major posto-perative complications following colorectal resection for endometriosis.MethodsA cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012–2020. We included patients with a primary diagnosis of endometriosis who underwent colon or rectal resections for endometriosis.ResultsOf 755 women who underwent colorectal resection, 495 (65.6%) had laparoscopic surgery and 260 (34.4%) had open surgery. The major complication rate was 13.5% (n = 102). Women who underwent open surgery had a higher proportion of major complications (n = 53, 20.4% vs. n = 49, 9.9%, p < 0.001). In a multivariable regression analysis, Black race (aOR 95%CI 2.81 (1.60–4.92), p < 0.001), Hispanic ethnicity (aOR 95%CI 3.02 (1.42–6.43), p = 0.004), hypertension (aOR 95%CI 1.89 (1.08–3.30), p = 0.025), laparotomy (aOR 95%CI 1.64 (1.03–3.30), p = 0.025), concomitant enterotomy (aOR 95%CI 3.02 (1.26–7.21), p = 0.013), and hysterectomy (aOR 95%CI 2.59 (1.62–4.15), p < 0.001) were independently associated with major post-operative complications. In a subanalysis of laparoscopies only, Hispanic ethnicity, chronic hypertension, lysis of bowel adhesions, and hysterectomy were independently associated with major complications. In a subanalysis of laparotomies only, Black race and hysterectomy were independently positively associated with the occurrence of major complications.ConclusionThis study provides a current population-based estimate of short-term complications after surgery for colorectal endometriosis in the USA. The identified risk factors for complications can assist during preoperative shared decision-making and informed consent process.

A prospective observational study on etiology and management influencing outcome in operatively managed cases of acute intestinal obstruction in adults

Background: Acute intestinal obstruction (IO) is an important cause for acute abdomen in surgery which presents as abdominal pain, vomiting, distension, and constipation depending on the level and extent of obstruction of gastrointestinal tract. Early diagnosis of acute IO with understanding of various etiologies, use of better diagnostic techniques, and skillful operative management and good postoperative care, carries a good outcome. Aims and Objectives: The objective of the study was to find out the prevalence of various etiologies of acute IO and to study the various post-operative morbidity and mortality. Materials and Methods: This was a hospital-based observational study in the Department of General Surgery of Calcutta National Medical College and Hospital among patients with a diagnosis of acute IO during the study period of December 2016-April 2018. Results: Acute IO commonly affects male with a male: female ratio 7:3 and the most common occurrence in the age group of 40–59 years (30%). The most common etiology was obstructed/strangulated hernia (36%), followed by large bowel neoplasm (18%), adhesion (16%), intestinal tuberculosis (12%), and volvulus (10%). The most common surgical procedure performed was the resection of gangrenous bowel and creation of stoma (30%), followed by prosthetic repair of hernia (28%). The mortality rate of the present study was 12%. The morbidity rate was 46%attributing mainly to respiratory complications (30.4%) and surgical site infections (26.08%). Conclusion: This study demonstrates that the pattern of IO differs from the Western world with obstructed hernias being the most important cause and also emphasizes the fact that intestinal tuberculosis assumes a prominent role.

Clinical Predictive Factors Affecting Laparoscopic Approach in the Management of Ectopic Pregnancy: A Retrospective Cross-Sectional Study

Introduction: Ectopic pregnancy accounts for approximately 2% of all pregnancies and is the most common cause of pregnancy-related mortality in the first trimester. Our aim was to study the preoperative clinical factors affecting the choice of laparoscopic approach to tubal ectopic pregnancy. &#x0D; Materials and methods: This was a retrospective cross-sectional study of tubal ectopic pregnancy cases that were managed by laparoscopy at an academic university hospital in the period January 2010 to December 2018. Cases that were managed medically or conservatively and laparoscopic cases that were converted to laparotomy were excluded. Cases where the surgical approach of laparoscopy or laparotomy were determined by the patients’ choice were also excluded.&#x0D; Results: The laparoscopy rate was 49.4%. The mean age was 32.04 years. Compared with laparotomy, laparoscopy was significantly associated with low parity (less than 3) (p=0.008), a low level of initial beta-human chorionic gonadotrophin (p=0.032), fewer cases of adnexal mass (p=0.000451), hemoperitoneum (p=0.000072), ruptured ectopic (p=0.000261), and more cases of bowel adhesions (p=0.0095). There was no significant difference between laparoscopy and laparotomy regarding the risk factors of ectopic pregnancy. Salpingectomy and salpingostomy were not significantly different between the two surgical approaches (p=0.643). Twenty-eight laparoscopic cases were converted to laparotomy.&#x0D; Conclusion: The laparoscopic approach to ectopic pregnancy was affected by parity, presenting symptoms of pain and vomiting, mean initial beta-human chorionic gonadotrophin, the presence of adnexal mass, the presence of hemoperitoneum, and the rupture of the ectopic. Bowel adhesions were seen more frequently in laparoscopy than laparotomy. Salpingectomy and salpingostomy were no different between laparoscopy and laparotomy.

314 Isolated Tuberculosis of Appendix: A Case Report

Abstract Introduction Stump appendicitis is a rare and delayed complication of appendectomy. In India, abdominal tuberculosis (TB) represents about 10% of the extra pulmonary TB and the appendix is involved in only about 1%. A combined occurrence of both conditions is very rare. Case Presentation A 24-year-old male presented to the General Surgery outpatients’ clinic with a 2-week history of right iliac fossa pain with no other associated symptoms. The patient had undergone an open appendectomy for perforated appendicitis 3 months prior to the current presentation. Per abdominal examination showed tenderness at the McBurney’s point. A CT abdomen revealed thickened and enhanced stump appendix along with adjacent fat stranding and multiple mesenteric nodes, suggestive of stump appendicitis. In light of the upward trend seen in white blood cell count, the patient was planned for a diagnostic laparoscopy and pre-anesthesia clearance was obtained. Intra-operatively, adhesiolysis of dense bowel and omental adhesions were performed. About 3.5 cm appendicular stump was resected. Micro-nodular peritoneal nodules were resected. The specimens were sent for histo-pathology examination. Results The postoperative period was uneventful with symptomatic relief. The biopsy of the stump described morphological features of caseating granulomatous inflammation, suggesting the possibility of tuberculosis while the peritoneal nodules showed infiltration of inflammatory cells. The patient was started on specific anti-tubercular treatment. Conclusions Appendicular TB is rare and of uncertain physiopathological etiology. The peculiarity of our case was the finding of abdominal TB presented as stump appendicitis. This may even be the first report with similar findings.

A load sharing principle in abdominal wall reconstruction follow-up &amp; case report: Strattice biologic mesh without the presence of adhesions

Background: The senior authors previously published a paper on abdominal wall reconstruction using Strattice acellular dermal matrix demonstrating effective aesthetic and functional results. Despite the common and effective use of Strattice acellular dermal matrix for abdominal wall reconstruction, insurance companies do not universally approve its usage. Critics of its usage state that its intra-abdominal effects are unknown. Purpose: To further demonstrate that Strattice acellular dermal matrix is a safe and durable method to reconstruct the abdominal wall with maximal outcomes, minimal intra-abdominal morbidity, and adhesion formation. Methods: A retrospective chart review was done on our patient who underwent abdominal wall reconstruction of a ventral hernia with component separation and placement of Strattice acellular dermal matrix several years prior. The patient happened to develop appendicitis several years post abdominal wall reconstruction, requiring laparoscopic appendectomy. Photographic analysis was used to document the Strattice and absence of adhesions. Results: Strattice acellular dermal matrix was successfully used in the underlay intra-abdominal position to reinforce a midline hernia repair and external oblique component separation. At three years post hernia repair, the patient had no evidence of hernia. CT-scan demonstrated well opposed rectus abdominus muscles. On laparoscopic examination of the intraperitoneal cavity during appendectomy, there was no evidence of bowel adhesions to the abdominal wall or Strattice acellular dermal matrix. The Strattice was lined with peritoneum. Conclusion: Successful repair of primary and recurrent abdominal hernia with Strattice acellular dermal matrix is effective. In our experience, the production of adhesions between the bowl and the intraperitoneal placed Strattice is low.

OC-123 COMPARISON OF COMPLICATION RATES BETWEEN INTRA- AND EXTRAPERITONEAL HERNIA REPAIRS

Abstract Aim With the emergence of new laparoscopic techniques, Intra-Peritoneal-Onlay-Mesh (IPOM) has fallen out of favor for repairing abdominal wall hernias due to reported complications, including adhesions and bowel injury, our aim is to compare complication rates in our center between intra- and extraperitoneal techniques. Material &amp; Methods A retrospective analysis was conducted on data from our certified hernia center from 2018 to 2021. All patients who underwent an umbilical, epigastric or incisional hernia-repair were included. The primary outcome measures were complications, including bowel injury and adhesions. Results A total of 188 patients underwent a hernia repair. 74 (39%) patients hat an umbilical hernia, 22 (12%) an epigastric hernia and 92 (49%) had an incisional hernia. Most patients (110–58%) were treated with laparoscopic IPOM, 14 (7,4%) of them underwent an open IPOM. 46 (25%) had hernias repaired with direct suture and the remaining patients were treated with other techniques, including open sublay and mini or less open sublay (MILOS). After an average follow-up of 36months, only two (1%) patients developed a mechanical ileus, one after laparoscopic and one after open IPOM surgery. Bowel lesions occurred in two (1%) patients who underwent open IPOM and direct suture hernia repairs. There was no difference in complications between the different surgical techniques. Conclusion Our study suggests that the different techniques for hernia repair have similar rates of complications. Further research is needed to determine the most effective and safe approach for hernia repair.

A three layered repair of a large perineal hernia: case report and review of the literature

BackgroundA symptomatic perineal hernia is an uncommon complication after abdominoperineal resection (APR). Repairs of such hernias can be achieved by usage of autologous flaps, synthetic mesh, or biologic mesh, which reduce bowel adhesions. Studies have shown that prophylactic repair of the pelvic floor with biologic mesh during APR, can reduce the incidence of perineal hernia.Case presentationA 71-year-old woman, after extended APR (eAPR) with primary closure of pelvic floor with absorbable mesh, presented to our outpatient clinic with a symptomatic, extensive perineal hernia. The patient underwent repair of the perineal hernia using a synthetic mesh and a bilateral gluteal flap procedure. In post operative care, signs of surgical site infection and a fluid collection demonstrated in a CT-scan, compelled a surgical drainage. A clear fluid negative for bacterial growth was drained and antibiotic treatment was initiated. After drainage, surgical site showed signs of significant improvement and patient was eventually discharged.ConclusionThe rise in reported incidence of perineal hernia after eAPR coupled with the scarcity of data regarding the preferable repair technique suggests that there is a significant need for further prospective comparative studies.

V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP

You have accessJournal of UrologyCME1 Apr 2023V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP Melissa Moran, Alain Kaldany, Krishna Doppalapudi, Arnav Srivastava, and Sammy Elsamra Melissa MoranMelissa Moran More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Krishna DoppalapudiKrishna Doppalapudi More articles by this author , Arnav SrivastavaArnav Srivastava More articles by this author , and Sammy ElsamraSammy Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with multiple abdominal surgeries often harbor hostile abdomens with significant bowel adhesions. It is thus difficult to obtain safe transperitoneal access when placing robotic trocars. An extraperitoneal approach, in contrast, allows for safe entry into the abdomen. In the case of a mid to distal ureteral stricture requiring extraperitoneal Boari flap ureteral reimplantation, the conventional multiport approach would be suboptimal as arm spacing would be insufficient. Here we demonstrate our surgical technique and the feasibility of a single port (SP) extraperitoneal Boari flap ureteral reimplantation. METHODS: A 70-year-old female with a history of rectal cancer treated with multiple abdominal surgeries and chemoradiation was diagnosed with a distal right ureteral stricture. She was offered SP robotic ureteral reimplantation for definitive management. The patient was positioned in steep Trendelenburg with a left-sided tilt. A 4 centimeter (cm) incision was created over the right lateral aspect of the abdomen 8 cm above the anterior superior iliac spine, and the retroperitoneal space was entered. The SP access port was placed and the robot was docked. The ureter was identified crossing the iliac vessels and was dissected proximally and distally. Once scar tissue was encountered, the ureter was transected. The bladder was mobilized and the medial umbilical ligament was cut. The distance from the ureter to the bladder was measured, and a Boari flap of this length was created. The posterior ureter was then spatulated and a Boari flap anastomosis was performed. The bladder was closed in a Heineke-Mikulicz fashion and a double-J ureteral stent was placed in the right ureter. The bladder was distended to ensure a watertight closure. A drain was placed and the Foley catheter was exchanged. RESULTS: The operative time was roughly three hours, with 50 milliliters of estimated blood loss. On post-operative day one, the drain was removed and patient was discharged home. Imaging two weeks later showed improved hydronephrosis with no urine extravasation, and the Foley catheter was removed. The ureteral stent was removed at four weeks post-operatively. Ultrasound and renal scan three months later demonstrated improved hydronephrosis with preserved renal function and no evidence of obstruction. CONCLUSIONS: To our knowledge, this is the first video demonstrating an SP extraperitoneal Boari flap ureteral reimplantation. This approach is feasible and allows a surgeon to safely and effectively perform a primarily retroperitoneal procedure without entering a hostile abdomen. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e80 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Melissa Moran More articles by this author Alain Kaldany More articles by this author Krishna Doppalapudi More articles by this author Arnav Srivastava More articles by this author Sammy Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

Menstrual, fertility and psychological impacts after uterine compression sutures for postpartum hemorrhage: a prospective cohort study

BackgroundUterine compression suture is an important conservative surgical technique in managing atonic postpartum hemorrhage. In this study, we aim to evaluate the subsequent menstrual, fertility and psychological outcomes after uterine compression sutures.MethodsThis was a prospective cohort study between 2009 and 2022 conducted in a tertiary obstetric unit (6000 deliveries per year) in Hong Kong SAR. Women with primary postpartum hemorrhage successfully treated with uterine compression sutures were followed-up in postnatal clinic for two years after delivery. Data on menstrual pattern were collected during each visit. Psychological impact after uterine compression suture was assessed using a standardized questionnaire. Subsequent pregnancies were identified by territory-wide computer registry and telephone interviews. Women with postpartum hemorrhage treated with uterotonic agents only were chosen as controls.ResultsIn our cohort (n = 80), 87.9% of women had return of menses within six months after delivery. Regular monthly cycle was observed in 95.6% of women. Majority of women reported similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) as compared before. Among eight (11.8%) women who reported hypomenorrhea after uterine compression sutures, two cases of Asherman’s syndrome were diagnosed. Among 23 subsequent pregnancies (16 livebirths), no significant differences in outcome were observed except more omental or bowel adhesions (37.5% vs. 8.8%, p = 0.007), recurrence of hemorrhage (68.8% vs. 7.5%, p < 0.001) and repeated compression sutures (12.5% vs. 0%, p = 0.024) were seen in women with previous compression sutures. Over half of the couple declined future fertility after uterine compression sutures with 38.2% of women recalled unpleasant memories and 22.1% reported life-long adverse impact especially tokophobia.ConclusionMajority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. However, they had higher intrapartum risk of visceral adhesions, recurrence of hemorrhage and repeated compression sutures next pregnancy. Furthermore, couple could be more susceptible to negative emotional impact.