Epigastric Vessels Research Articles

Is previous radical prostatectomy a contraindication to minimally invasive inguinal hernia repair? A contemporary meta-analysis.

Traditionally, radical prostatectomy (RP) has been considered a contraindication to minimally invasive inguinal hernia repair. Purpose of this systematic review was to examine the current evidence and outcomes of minimally invasive inguinal hernia repair after RP. Web of Science, PubMed, and EMBASE data sets were consulted. Laparoscopic transabdominal preperitoneal repair (TAPP), robotic TAPP (r-TAPP), and totally extraperitoneal (TEP) repair were included. Overall, 4655 patients (16 studies) undergoing TAPP, r-TAPP, and TEP inguinal hernia repair after RP were included. The age of the patients ranged from 35 to 85 years. Open (49.1%), laparoscopic (7.4%), and robotic (43.5%) RP were described. Primary unilateral hernia repair was detailed in 96.3% of patients while 2.8% of patients were operated for recurrence. The pooled prevalence of intraoperative complication was 0.7% (95% CI 0.2-3.4%). Bladder injury and epigastric vessels bleeding were reported. The pooled prevalence of conversion to open was 0.8% (95% CI 0.3-1.7%). The estimated pooled prevalence of seroma, hematoma, and surgical site infection was 3.2% (95% CI 1.9-5.9%), 1.7% (95% CI 0.9-3.1%), and 0.3% (95% CI = 0.1-0.9%), respectively. The median follow-up was 18 months (range 8-48). The pooled prevalence of hernia recurrence and chronic pain were 1.1% (95% CI 0.1-3.1%) and 1.9% (95% CI 0.9-4.1%), respectively. Minimally invasive inguinal hernia repair seems feasible, safe, and effective for the treatment of inguinal hernia after RP. Prostatectomy should not be necessarily considered a contraindication to minimally invasive inguinal hernia repair.

Free Vascularized Scapula tip Flap to L5—S1 Vertebral Defect After Chronic Infection Related to Interbody Fusion Cage: A Case Report

ABSTRACTSeptic nonunion after vertebral fusion can lead to significant patient disability. The management of septic nonunions usually involves surgical debridement, bone fixation, and antibiotic therapy. Particularly challenging is lumbosacral vertebral nonunions, which necessitate a difficult surgical approach. We present a novel approach using a scapula tip free flap through an intra‐abdominal approach to reconstruct a L5–S1 vertebral defect after a septic nonunion. Our patient, 31‐year‐old man, with no medical conditions, had a fusion of L5–S1 due to severe lower back pain secondary to isthmic spondylolysis and spondylolisthesis. Despite multiple attempts of surgical fusion, postoperatively the patient developed a septic nonunion. Following a modified DAIR, the nonunion was reconstructed with a scapula tip bone flap 4 × 3 × 2 cm. The subscapular vessels were anastomosed to the deep inferior epigastric vessels after an intra‐abdominal inset. The patient was discharged at 15 days postoperatively without any complications. At 1‐year follow‐up the patient is pain‐free, off opiate analgesia with radiological evidence of fusion between the scapula tip, L5 and the S1 vertebral body. This case report describes the use, for the first time, of a free scapula tip, to a lumbosacral spinal defect. The use of the free scapula tip flap may be considered for reconstruction of osseous spinal defects due to its long pedicle and the unique bone shape.

Outcomes related to penile prosthesis reservoir removal: a 7-year multi-institutional experience.

The 3-piece inflatable penile prosthesis (IPP) is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the retropubic space (RPS) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition, or infection. In revision cases without infection, reservoir removal is sometimes optional. We reviewed outcomes and complications related to reservoir removal from a large multi-institutional series. We retrospectively reviewed databases at 6 institutions over 7years. Patients with artificial urethral sphincter, urethral sling, or mini-jupette were excluded. Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected, but only reservoir-related complications at surgery were included. Data were compared between the RPS and AES cohorts to evaluate differences with a χ2 test, with significance at P < .05. Of 215 cases, there were 172 RPS and 43 AES reservoirs. The mean patient age was 65.3years. An overall 131 procedures were due to malfunction and 49 to malposition of an IPP component; 35 were secondary to infection. Among those retained (n = 44), reasons included reuse, avoiding surrounding structure damage, and difficult dissection. Among those removed (n = 171), 15 required a counterincision. To determine the statistical difference between those removed from the RPS and an AES, the χ2 test result was P = .00059, indicating a significant difference in the need for a counterincision between the groups. Complications included bladder perforation (n = 1) in the RPS group and an avulsion of the epigastric vessels requiring abdominal exploration (n = 1) in the AES group. To determine the statistical difference between RPS and AES complications, the χ2 test result was P = .365, indicating no significant difference between the groups. Strengths include being a multi-institutional study with high-volume skilled implanters. Limitations include being a retrospective review, with implanters exclusively performing penoscrotal incisions and not utilizing an infrapubic approach. Last, there was a lack of long-term follow-up with these patients. Removal of an IPP reservoir remains safe, with few intraoperative complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counterincision to avoid injury to surrounding structures. Surgeons should also obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery.

A systematic review of 3D printing in autologous breast reconstruction

Aim: The use of three-dimensionally printed (3DP), patient-specific models in autologous breast reconstruction is gaining popularity, namely for their benefits in surgical planning and ability to aid in aesthetic outcomes. Furthermore, 3DP patient-specific models serve as a safe alternative to intraoperative surgical training and act as a useful tool for visualizing the intramuscular course of deep inferior epigastric perforator vessels. Despite demonstrated usefulness in other surgical specialties and areas of plastic surgery, there remains a significant gap in the literature exploring specific perioperative, preoperative, and intraoperative uses as well as the educational advantages of 3DP in autologous breast reconstruction. Methods: PubMed, MEDLINE, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched for all English language articles using specific MeSH terms (3dp OR 3D-print* OR three dimension* print*) AND (breast reconstruction). Only studies discussing the use of 3DP for surgical planning or as an educational tool in autologous breast reconstruction were included. Studies using 3DP as interventions or implants were excluded. Results: A total of 168 articles were identified, 13 of which were selected for inclusion. Risk of bias was low for 8 articles and moderate for 5 articles. Seven (53.8%) articles discussed 3DP usage in preoperative planning. Most papers (12, 92.3%) focused on 3DP models as guides for intraoperative identification of anatomical landmarks and 3DP molds as tools to achieve desired breast volume, shape, and projection. Only 4 (30.7%) articles discussed patient outcomes. Of the 4 (30.7%) articles that discussed education, only one of these properly assessed trainees and faculty using pre- and post-intervention surveys. Conclusion: The majority of 3DP research as an intraoperative guide and educational tool is concentrated outside of autologous breast reconstruction. Studies that do discuss this have found significantly higher success rates in dissecting true DIEP flaps when 3DP vascular modeling is used and can result in improved confidence and competence in surgical training for microsurgical anastomosis. Although 3DP has been shown to aid microsurgeons in preoperative planning, most research concentrates on the aid of this novel technology in dynamic, intraoperative decision making. Existing research has identified five 3DP breast molds, but studies have yet to compare these molds in a controlled setting to assess for superiority in feasibility and outcomes. There is little investigation into the usefulness of 3DP as an educational tool, and more research should be conducted as this methodology expands to cover more forms of autologous breast reconstruction.

LAPAROSCOPIC TREATMENT OF RIGHT INGUINAL HERNIA RE-RECURRENCE

Abstract We report the case of an 81-year-old man presenting with a right inguinal hernia re-recurrence. He had undergone a laparoscopic transabdominal preperitoneal hernioplasty in 2001. The recurrence occurred in 2021, and therefore, he had to be treated with an open approach. Past medical history included arterial hypertension, COPD, coronary artery stenting for ischemic heart disease, stage II chronic renal failure. Previous surgeries consisted of bilateral iliac arteries, percutaneous angioplasty and stenting with a right femoral arterial access, laminectomy of L3–L5, and laparoscopic cholecystectomy. Surgical procedure Laparoscopy confirmed a right hernia re-recurrence. Herniated ileal loop was completely reduced. Peritoneal incision was performed with a lateral-to-medial approach. The mesh was dissected away from the pre-peritoneal fat. The shrunk mesh was pulled downwards to allow the identification of the epigastric vessels, which were then dissected according to a cranial-to-caudal approach. The large hernia sac was completely reduced thus exposing the re-recurrence orifice. Dissection was carried out towards the Bogros’ space. Epigastric vessels were detached from the mesh thus allowing to expose the medial part of the myopectineal orifice. Cooper’s ligament and pubic symphysis were therefore identified. The epigastric and spermatic vessels were freed from the mesh only after the critical view of the myopectineal orifice (MPO) was achieved. The mesh was completely mobilized from the peritoneum and removed. A “landing zone” was obtained, a 15 × 10 cm self-fixating mesh positioned around the re-recurrence orifice. Peritoneum closure was performed by means of a 3–0 running barbed suture from medial to lateral.

Surgical anatomy of transversus abdominis muscle for transversus abdominis release.

Transversus abdominis release (TAR) is a myofascial release technique which helps in surgical repair of large ventral abdominal wall defects. In this procedure, the medial margin of muscular part of transversus abdominis (TA) is of great importance. Hence, the authors sought to describe the extent of medial margin of TA muscle. The surgical steps of TAR were performed in 10 formalin-fixed cadavers and distance between medial margin of TA muscle, lateral margin of rectus abdominis, to linea alba at five anatomical levels were documented respectively. The distance between the inferior epigastric vessels and the medial border of TA muscle was also noted. The TA muscle was within the posterior rectus sheath in all cadavers, at the xiphisternum (R, 61.6 mm; L, 58.9 mm), and at midway between xiphisternum and umbilicus (R, 25.4 mm; L, 27.1 mm). The TA muscle exited the posterior rectus sheath between this point and the umbilicus. The mean incongruity at the next three levels were -24.6 mm, -24.9 mm, and -22.9 mm respectively on the right and -21.4 mm, -19.9 mm, and -18.9 mm respectively on the left. The mean distance between the medial border of TA and inferior epigastric vessels was 18.9 mm on the right and 17.2 mm on the left. The muscular part of TA was incorporated within the posterior rectus sheath above the umbilicus, and it completely exited the rectus sheath at the umbilicus. This is contrary to the traditional understanding of posterior rectus sheath formation.

Analysis of Vascular Anatomy in Deep Inferior Epigastric Perforator Flap

Abstract Objectives The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. One of the existing challenges of the procedure is maintaining a pedicle of suitable length and diameter for flap survival. In this study, we analyzed the vascular anatomy of bi-pedicle DIEP flap cases in terms of the vessel diameter, the rate of secondary venae comitantes, and pedicle length to determine the efficacy of microvascular anastomosis and venous drainage. Methods We retrospectively evaluated 108 patients who underwent immediate breast reconstruction using free bi-pedicle DIEP flaps between 2012 and 2019. The patient characteristics, diameters of the deep inferior epigastric artery (DIEA) and accompanying veins (DIEVs), DIEA pedicle length, vessel re-anastomosis rate, flap failure rate, and fat necrosis were recorded. Results Comparison of the right side and left side diameters and pedicle lengths obtained showed no significant differences (p &gt; 0.05). A total of 148 sides (68.52%) of flaps had double venous drainage, whereas 68 sides (31.48%) of flaps had one. Vein congestion occurred in 5 cases, and all involved with just one DIEV anastomosis. No arterial occlusions were observed. Conclusions This is an analysis of extensive clinical data in terms of DIEA, DIEV, and pedicle length. The low vein congestion rate observed reveals adequate venous drainage was achieved in the DIEV system for DIEP reconstruction. Adequate deep inferior epigastric vessel pedicle length and vessel size, as well as greater than 60% of flaps with secondary DIEV, may allow comfortable microsurgery with reduced complications.

Endovascular and percutaneous embolization of a giant post traumatic arteriovenous fistula of inferior epigastric vessels

BackgroundArteriovenous fistulas involving the anterior abdominal wall can result from trauma. Such fistulas may remain asymptomatic and undetected for a prolonged duration of time. They tend to recruit multiple arterial feeders with remodelling in the feeding arteries, making them challenging to treat.Case presentationWe discuss a rare case of a 60-year-old male who presented with complaints of a progressive painless swelling in right lower abdomen. There was a history of blunt injury to abdomen at the same site during alleged road traffic accident 3 years ago. On CT angiography, an arteriovenous fistula was localised to the anterior abdominal wall arising predominantly from the right inferior epigastric artery with a giant venous sac and terminating as a tortuous single venous channel into the right external iliac vein. Few other small feeders were also seen arising from branches of right superior epigastric artery along Winslow’s pathway. The main challenge in endovascular management of this patient was embolization of a high flow shunt with a large venous sac and multiple arterial feeders. The dominant arterial feeder was embolized using vascular plug. The superficial location of the lesion offered an additional percutaneous window besides endovascular approach. The venous sac was percutaneously accessed and embolized using n-butyl cyanoacrylate after balloon occlusion of outflow vein. On follow up ultrasonographic evaluation at 3 months, near complete thrombosis of the venous sac was achieved.ConclusionsTraumatic arteriovenous fistulas involving the inferior epigastric vessels are rare clinical entities. CT angiogram and digital subtraction angiography help in the optimal diagnosis and treatment planning. The use of mechanical embolization devices to cause flow arrest offers an opportunity to use liquid embolic agents which offer better percolation within the lesion. Interventional radiology offers an ideal management of these complex high flow fistulas with a good technical success and acceptable safety profile.

Assessing the prophylactic use of the superficial inferior epigastric vessels (SIEV) for the super – Drainage of deep inferior epigastric perforator flaps (DIEPS), correlated to patient demographic, anatomical and operative risk factors

Assessing the prophylactic use of the superficial inferior epigastric vessels (SIEV) for the super – Drainage of deep inferior epigastric perforator flaps (DIEPS), correlated to patient demographic, anatomical and operative risk factors

A novel pedicle extension for lumbar artery perforator flaps: a case report

In this case, the authors describe the novel use of anterolateral thigh vessels as an alternative pedicle extension graft to the deep inferior epigastric vessels in autologous breast reconstruction.

(184) Gender-Affirming Abdominal Phalloplasty

Abstract Introduction Phalloplasty can alleviate gender dysphoria in transgender individuals. Various techniques exist and selection of phalloplasty technique depends on patient preference, body habitus, and surgeon experience. Objective We demonstrate the creation of a neophallus using a pedicled abdominal flap using live surgical footage. Methods The patient was a 19 year old transmasculine individual who had been on gender-affirming hormone therapy for 3 years and desired a neophallus to align external appearance with his gender identity. The flap is designed using a fasciocutaneous flap based off the inferior epigastric and superficial circumflex iliac vessels, with innervation from the ilioinguinal nerve. Perfusion is assessed using fluorescence imaging prior to tubularization. Rotational flaps are used to cover the abdominal wound. Results The patient had an uneventful recovery after 48 hours of bedrest and was discharged on post-operative day 4 without complications. He has recovered well without any complications at 6 months postoperatively. Patients may elect to undergo next staged phalloplasty procedures with or without urethroplasty at least 6 months afterwards. Conclusions A pedicled abdominal flap phalloplasty is a safe and effective option for patients desiring a more easily concealed scar and fewer complications compared to alternative techniques. Disclosure No.

Totally laparoscopic surgery for a hydrocele of the canal of Nuck extending from the abdominal cavity to the subcutaneous space: a case report

BackgroundHydrocele of the canal of Nuck (HCN) is a rare disease, and its indications for laparoscopic surgery are not well-established.Case presentationA 53-year-old woman was referred to our hospital due to an uncomfortable thumb-sized inguinal mass. Preoperative computed tomography scan and magnetic resonance imaging revealed a hydrocele extending from the abdominal cavity around the left deep inguinal ring via the inguinal canal to the subcutaneous space. The patient was diagnosed with HCN protruding into the abdominal cavity and extending to the subcutaneous space. Laparoscopy can easily access the hydrocele protruding into the abdominal cavity. Furthermore, laparoscopic hernioplasty can be superior to the anterior approach for females. Hence, laparoscopic surgery was performed. After transecting the round ligament of the uterus, a tense 3-cm hydrocele was dissected with it. In order to approach the hydrocele distal to the deep inguinal ring, the transversalis fascia was incised medially to the inferior epigastric vessels. The subcutaneously connected hydrocele was excised from the incision. Then, the enlarged deep inguinal ring was reinforced using a mesh with the laparoscopic transabdominal preperitoneal approach. The patient was discharged 2 days postoperatively. Laparoscopic resection can be more effective for a hydrocele protruding into the abdominal cavity as it facilitates an easy access to the hydrocele. Moreover, laparoscopic resection of a hydrocele extending from the inguinal canal to the subcutaneous space via a transversalis fascia incision can be safer, with low risk of injury to the inferior epigastric vessels. The incised transversalis fascia and the enlarged deep inguinal ring due to the HCN were simultaneously repaired with the laparoscopic transabdominal preperitoneal repair. There are two reports on laparoscopic resection via a transversalis fascia incision for HCNs located between the inguinal canal and the subcutaneous space, which does not require intraperitoneal hydrocelectomy. However, this is the first report on laparoscopic resection of large HCNs protruding into the abdominal cavity and extending beyond the inguinal canal into the subcutaneous space via intraperitoneal hydrocelectomy and a transversalis fascia incision.ConclusionsLaparoscopic surgery with transversalis fascia incision can be useful for HCNs extending from the abdominal cavity to the subcutaneous space.

Strategic Approaches to Intraflap Anastomosis: Navigating Conjoined DIEP Flap Reconstruction-A Comprehensive Roadmap.

For patients desiring autologous breast reconstruction without adequate abdominal tissue volume, the deep inferior epigastric perforator (DIEP) flap may be stacked or combined with other flaps for bilateral reconstruction. Various combinations of anastomoses have been described in the literature. We sought to describe a framework for intraflap anastomoses. A retrospective review of 17 patients who underwent conjoined DIEP flaps with intraflap anastomoses with a single surgeon was performed. Patient demographics, comorbidities, operative details, and complications were reviewed. A framework scheme was developed for the type of intraflap anastomosis performed. Between 2016 and 2020, 17 patients underwent conjoined DIEP flaps for unilateral breast reconstruction. Fourteen patients had delayed reconstruction. Eleven patients underwent an intraflap anastomosis in which a medial perforator on the left hemiabdomen flap was anastomosed with a distal lateral row perforator in the right hemiabdomen flap (type A). Four patients underwent an intraflap anastomosis in which a left lateral perforator was anastomosed to a right distal lateral row perforator (type B). Two patients underwent an intraflap anastomosis in which the left superficial inferior epigastric vessel was anastomosed to a right lateral row perforator (type C). Complications included reoperation (11.8%), partial flap loss (5.9%), seroma (23.5%), and hematoma (11.8%). We report a detailed framework for intraflap anastomoses of conjoined DIEP flap reconstruction including superficial inferior epigastric artery/superficial inferior epigastric vessel options. Knowledge of this comprehensive framework will allow surgeons to identify the type of intraflap anastomoses required for the anatomy they encounter and will standardize reporting of surgical technique in the literature.

Single-incision laparoscopic transabdominal preperitoneal repair in the treatment of adult female patients with inguinal hernia.

Women have a 3% lifetime chance of developing an inguinal hernia, which is not as common in men. Due to its cosmetic benefits, single-incision laparoscopic transabdominal preperitoneal (SIL-TAPP) inguinal hernia repair is becoming increasingly popular in the management of inguinal hernia in women. However, there are no studies comparing the safety and applicability of SIL-TAPP repair with conventional laparoscopic transabdominal preperitoneal (CL-TAPP) inguinal hernia repair for the treatment of inguinal hernia in women. To compare the outcomes of SIL-TAPP and CL-TAPP repair in adult female patients with inguinal hernia and to estimate the safety and applicability of SIL-TAPP repair in adult female inguinal hernia patients. We retrospectively compared the clinical information and follow-up data of female inguinal hernia patients who underwent SIL-TAPP inguinal hernia repair and those who underwent CL-TAPP inguinal hernia repair at the Affiliated Hospital of Nantong University from February 2018 to December 2020 and assessed the long-term and short-term outcomes of both cohorts. This study included 123 patients, with 71 undergoing SIL-TAPP repair and 52 undergoing CL-TAPP repair. The two cohorts of patients and inguinal hernia characteristics were similar, with no statistically meaningful difference. The rate of intraoperative inferior epigastric vessel injury was lower in patients in the SIL-TAPP cohort (0, 0%) than in patients in the CL-TAPP cohort (4, 7.7%) and was significantly different (P < 0.05). In addition, the median [interquartile range (IQR)] total hospitalization costs were significantly lower in patients in the SIL-TAPP cohort [$3287 (3218-3325)] than in patients in the CL-TAPP cohort [$3511 (3491-3599)]. Postoperatively, the occurrence rate of trocar site hernia was lower in the SIL-TAPP cohort (0, 0%) than in the CL-TAPP cohort (4, 7.7%), and the median (IQR) cosmetic score was significantly higher in the SIL-TAPP cohort [10 (10-10)] than in the CL-TAPP cohort [9 (9-10)]. SIL-TAPP repair did not increase the incidence of intraoperative and postoperative complications in female inguinal hernia patients. Moreover, female inguinal hernia patients who underwent SIL-TAPP repair had a lower probability of trocar site hernia and inferior epigastric vessel injury than female inguinal hernia patients who underwent CL-TAPP repair. In addition, female inguinal hernia patients who underwent SIL-TAPP repair reported a more aesthetically pleasing postoperative abdominal incision. Therefore, SIL-TAPP repair is a better option for the treatment of inguinal hernias in women.

Subtotal Thigh Flap for Large Abdominal Wall Defect Reconstruction in Patient With Recurrent Dermatofibrosarcoma Protuberans: A Case Report and Literature Review.

Harvesting an adequate-sized flap is challenging for reconstructing large defects on the abdominal wall. A subtotal thigh flap would be one of the choices as it provides a well-vascularized large flap with muscle components. Moreover, dermatofibrosarcoma protuberans (DFSP) is a low-grade dermal neoplasm with a high recurrence rate. There is still no consensus on the extent of resection to prevent a recurrence. We present a case of a patient who underwent the reconstruction of a large abdominal wall defect with a subtotal thigh flap after the resection of recurrent DFSP. A 59-year-old man killed from a recurrent huge mass in the lower abdomen with an invasion of the small intestine. His baseline characteristics and records of operations, medications, and outcomes were reviewed. After tumor excision, a 28 × 30-cm subtotal thigh flap was harvested from his left thigh to reconstruct the abdominal defect. A microvascular anastomosis with left deep inferior epigastric vessels was made eventually. The flap was in good condition, and the donor site was covered with a split-thickness skin graft. Subtotal thigh flap may be considered for large abdominal wall defect reconstruction as it allows good perfusion of relatively large skin paddles compared with other free flaps. Also, patients with DFSP need definite margin-free resection and close follow-up to prevent a recurrence.

Hybrid modeling techniques for 3D printed deep inferior epigastric perforator flap models

BackgroundDeep Inferior Epigastric Perforator Flap (DIEP) surgical procedures have benefited in recent years from the introduction of 3D printed models, yet new technologies are expanding design opportunities which promise to improve patient specific care. Numerous studies, utilizing 3D printed models for DIEP, have shown a reduction of surgical time and complications when used in addition to the review of standard CT imaging. A DIEP free flap procedure requires locating the inferior epigastric perforator vessels traversing and perforating the rectus abdominis muscle, perfusing the abdominal skin and fatty tissue. The goal of dissecting the inferior epigastric perforator vessels is complicated by the opacity of the fatty tissue and muscle. Previous attempts to 3D print patient specific models for DIEP free flap cases from CT imaging has shown a wide range of designs which only show variations of perforator arteries, fatty tissue, and the abdominis rectus muscle.MethodsTo remedy this limitation, we have leveraged a voxel-based modeling environment to composite complex modeling elements and incorporate a ruled grid upon the muscle providing effortless ‘booleaning’ and measured guidance.ResultsA limitation of digital surface-based modeling tools has led to existing models lacking the ability to composite critical anatomical features, such as differentiation of vessels through different tissues, coherently into one model, providing information more akin to the surgical challenge.ConclusionWith new technology, highly detailed multi-material 3D printed models are allowing more of the information from medical imaging to be expressed in 3D printed models. This additional data, coupled with advanced digital modeling tools harnessing both voxel- and mesh-based modeling environments, is allowing for an expanded library of modeling techniques which create a wealth of concepts surgeons can use to assemble a presurgical planning model tailored to their setting, equipment, and needs.Trial registrationCOMIRB 21–3135, ClinicalTrials.gov ID: NCT05144620.

705 Assessment of a Novel Low-Cost Abdominal Box Simulator for Laparoscopic Skills Training

Abstract Aim To create a low-cost abdominal box simulator and assess its validity for Hassan’s entry technique and visiport. Method A low-cost abdominal box simulator was created using a metal box skeleton. This was covered in a layer of cling-film simulating the peritoneum. Red and blue tubing was placed over this creating the inferior epigastric vessels. A posterior rectus sheath was created on either side using a white cotton sheet whilst thick red woollen socks were used to simulate the rectus abdominus muscles. The entire surface was then wrapped in a thick canvas to simulate the anterior rectus sheath. Finally, a commercial skin with subcutaneous tissue was affixed and the umbilicus demarcated using a pen. This simulator was used by 30 surgical trainees (ST3 to ST7) attending a laparoscopic skills course who were asked to provide feedback on the simulator for both Hassan’s entry technique, visiport entry and the introduction of secondary ports. Results The simulator was rated 10/10 for validity as well as ease of use for Hassan’s open entry technique, visiport and secondary port insertion by all 30 of the trainees. Feedback highlighted that using the simulator trainees were able to see all layers of the abdomen and gain excellent haptic feedback. The model was described as realistic as trainees were able to identify each layer of the abdomen as they performed open or visiport entry. Conclusions A low-cost abdominal box simulator can easily be reproduced using our technique and used to train trainees effectively.

Deep inferior epigastric vessels for free scapular flap phalloplasty

We aimed to present our 20-year experience of using the deep inferior epigastric vessels as recipient vessels for free scapular flaps phalloplasty and evaluate the outcomes. Penile reconstruction was performed using a free scapular flap between 2000 and 2020 by the same surgical team. Deep inferior epigastric vessels were used in all the cases. The surgical techniques and outcomes were described. Overall, 73 patients used the deep inferior epigastric artery (DIEA) as the recipient artery. Regarding the recipient veins, 2 veins were anastomosed in 72 (98.6%) patients, 1 deep inferior epigastric vein (DIEV) was used in 1 patient, 2 DIEV in 14, 1 DIEV + superficial inferior epigastric vein (SIEV) in 13, 1 DIEV + superficial circumflex iliac vein (SCIV) in 38, great saphenous vein (GSV) + SCIV in 4, and GSV + SIEV in 3. The mean age and body mass index of the study cohort was 28 years and 24.3 kg/m2, respectively. The shortest follow-up time was 7 months. Eleven patients had flap-related complications. Three patients were readmitted to the operating room within 24 hours, and 2 of them underwent salvage procedures with venous revision. Two patients lost the entire flap. One patient with 3-cm distal portion necrosis required surgical intervention. Three patients experienced urethral necrosis. DIEA is a suitable receptor artery for inflow. The DIEV, SIEV, and SCIV are available options for venous drainage according to the patient anatomical characteristics. The GSV can be an excellent backup for outflow and salvage procedures.

Single-incision laparoscopic transabdominal preperitoneal hernioplasty: 1,054 procedures and experience

PurposeAlthough there have been numerous studies on single-incision laparoscopic inguinal hernia repair (SIL-IHR), the short- and long-term outcomes in patients from a large single institution who underwent single-incision laparoscopic transabdominal preperitoneal hernioplasty (SIL-TAPP) have rarely been reported. The purpose of this study is to evaluate the short- and long-term outcomes of SIL-TAPP and its safety and feasibility in patients from a large single institution.MethodsThe details of 1,054 procedures in 966 patients who underwent SIL-TAPP at the Affiliated Hospital of Nantong University from January 2015 to October 2022 were retrospectively analysed. SIL-TAPP was performed completely through the umbilicus using conventional laparoscopic instruments. Short-term and long-term outcomes of SIL-TAPP were collected by outpatient and telephone follow-ups. In addition, we further compared the operation time, length of postoperative hospital stay, and postoperative complications of patients with simple and complicated unilateral inguinal hernias.ResultsA total of 1,054 procedures were performed for 878 unilateral inguinal hernias and 88 bilateral inguinal hernias. In total, there were 803 (76.2%) indirect inguinal hernias, 192 (18.2%) direct inguinal hernias, 51 (4.8%) femoral hernias and 8 (0.8%) combined hernias. The mean operative time was 35.5 ± 17.0 min for unilateral inguinal hernias and 51.9 ± 25.5 min for bilateral inguinal hernias. There was one (0.1%) conversion to two-incision laparoscopic transabdominal preperitoneal hernioplasty. No intraoperative haemorrhages, inferior epigastric vessel injury or nerve damage occurred. Postoperative complications were minor and could be resolved without surgical intervention. The mean length of hospital stay was 1.3 ± 0.8 days. The median follow-up was 44 months, no trocar hernia occurred, and there was one (0.1%) recurrence. The operation time in the complicated inguinal hernia group was significantly higher than that in the simple inguinal hernia group (38.9 ± 22.3 vs. 35.0 ± 15.6, p = 0.025). The length of postoperative hospital stay and complication rate of the complicated inguinal hernia group were slightly higher than those of the simple inguinal hernia group, but the difference was not statistically significant.ConclusionSIL-TAPP is safe and technically feasible, and both short- and long-term outcomes are acceptable.

OC-076 LAPAROSCOPIC TAPP REPAIR FOR A LUMBAR HERNIA. STEP-BY-STEP SYSTEMATIZATION

Abstract Aim Lumbar hernias are a rare clinical entity and surgical treatment is constantly evolving and changing. We propose a systematization step-by-step guiding a safe and effective repair with similar conditions to the inguinal region. Material &amp; Methods The patient lies down in a dorsal decubitus position with a 45° elevation of the hernia side. The first port is in the umbilicus access, and the accessory ports are along the middle line. Start the dissection by marking the anatomical limits that involve the semilunar lines, epigastric vessels, spine, and imaginary line between the iliac crest and 11 th rib. Releasing the peritoneal flat until visualizing the psoas iliacus and quadratus muscles until the 11 th ribs, preserving the avascular plane avoids nerves and vascular damage. Hernia sac reduction. Placement of a polypropylene mesh (24×22 cm) covering all the dissected areas. Mesh fixation using absorbable sutures. Closure of the peritoneum.Vacuum maneuver and bulge compression. Results Systematic standardization was applied to all patients. The mean operative time was 90 min. Outpatient surgery was achieved with a fast return to usual activity. The procedures were performed without intraoperative complications, mortality, or conversion to open surgery. Conclusions The step-by-step guide for landmarks and tips provides a safe and effective repair of this rare entity. Finally, clinical studies are needed to measure the impact of this technique's implementation in lumbar hernia repair.