Extensive Subcutaneous Dissection Research Articles

OC-129 A new surgical technique for repair of rectus diastasis and associated hernia: description and initial experience

Abstract Aim Rectus diastasis (RD) is a common pathology, usually associated with midline hernias. Preaponeurotic surgical repairs have been described with complications derived from extensive subcutaneous dissection or suprafascial mesh placement. Other techniques place preperitoneal mesh but midline plication is not performed, with aesthetic disadvantages. We describe a new technique for the correction of ventral hernias associated with RD with midline plication and preperitoneal mesh (MPPM) and report our initial experience. Material and Methods We reviewed patients with RD and associated hernia surgically treated using the MPPM technique at our hospital from June 2021 to July 2022. The minimum follow-up time was 6 months. Results Forteen patients with RD and associated hernia were surgically treated with MPPM technique, with an average age of 64.1 years (range 38–82 years), 71.4% male and 28.6% female. The mean BMI was 28.8 Kg/m2 (range 18.6–40.0 Kg/m2). Three women (21.3%) had a mean of 1,3 previous pregnancies (range 0–2 pregnancies). The most common types of associated hernia with RD were primary midline hernia (50%), incisional hernia (21.4%), and recurrent midline hernia (28.6%). Half of the RD (50%) were M1-3 and the other half M2-3 (50%) as well as W1 (50%) and W2 (50%). The mean diameter of associated hernia was 3,2 cm (range 1–6 cm). Hematoma was observed in one patient (7,1%) in the first 30 postoperative days. No reccurence was recorded in the follow-up time. Conclusions The MPPM technique is a safe, reproducible and effective alternative for patients with abdominal wall hernia associated with RD.

Endoscopic Anterior Component Separation and Transversus Abdominus Release are not Associated with Increased Wound Morbidity Following Retromuscular Incisional Hernia Repair.

Traditional anterior component separation during incisional hernia repair (IHR) is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence (SSO) compared to IHR without component separation (CS). This was a retrospective single-center cohort study of patients undergoing open retromuscular IHR comparing patients with or without the use of CS. Retromuscular mesh repair was performed in all patients, and CS was obtained by eACS or TAR. The primary outcome was 90-day incidence of postoperative SSO. Secondary outcomes included length of stay (LOS), 90-day readmission, 90-day reoperation rate and 3-year recurrence rate. A total of 321 patients underwent retromuscular repair, 168 (52.3%) of whom received either eACS or TAR. The addition of eACS or TAR was associated neither with development of SSO (odds ratio: 1.80, 95% confidence interval: 0.94-3.46, P = 0.077) nor with hernia recurrence (hazard ratio 0.77, 0.26-2.34, P = 0.648). There was no significant difference between the groups regarding the frequencies of 90-day readmission or 90-day reoperation. eACS or TAR as adjuncts to open retromuscular IHR were not associated with increased wound morbidity or hernia recurrence.

P160 ENDOSCOPIC ANTERIOR COMPONENT SEPARATION OR OPEN TRANSVERSUS ABDOMINUS RELEASE ARE NOT ASSOCIATED WITH INCREASED WOUND MORBIDITY FOLLOWING INCISIONAL HERNIA REPAIR

Abstract Aim Traditional anterior component separation during incisional hernia repair is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence compared to incisional hernia repair without component separation. Material and Methods This was a retrospective cohort study of patients undergoing open, retro-rectus incisional hernia repair. Component separation during retro-rectus repair was performed using eACS or TAR. The primary outcome was 30-day incidence of postoperative surgical site occurrence. Secondary outcomes included length of stay, 30-day readmission, 30-day reoperation rate and 3-year recurrence rate. Results A total of 322 patients underwent retro-rectus repair, 168 (52%) of whom received either eACS or TAR. Addition of eACS or TAR was neither associated with surgical site occurrence, (odds ratio: 0.82, confidence interval: 0.40-1.68, P = 0.596) nor with hernia recurrence (hazard ratio 0.80, CI 0.27-2.40, P = 0.693). There was no significant difference between the groups regarding the frequencies of 30 day-readmission or 30-day reoperation. Conclusions The addition of eACS or TAR to a retro-rectus incisional hernia repair was not associated with increased wound morbidity or hernia recurrence.

Efficacy of Ultrasound-Guided Intermediate Cervical Plexus Block by Anterior Route for Perioperative Analgesia in Robotic Thyroidectomy by Retroauricular Approach: A Case Series.

Retroauricular or facelift approach for robotic thyroidectomy involves a long incision with extensive subcutaneous dissection causing severe pain and discomfort. Multimodal analgesic regimen with inclusion of intermediate cervical plexus block by anterior route provided excellent perioperative analgesia without affecting recurrent laryngeal nerve monitoring in 10 cases. All the patients were monitored with bispectral index (maintained 40-60) and extubated on table. Median numeric pain rating scale score in 24 hours postoperatively was 3. None of the cases had any significant complications on follow-up.

Fat-augmented latissimus dorsi myocutaneous flap for total breast reconstruction: A report of 54 consecutive Asian cases

Immediate fat grafting to the latissimus dorsi myocutaneous (LD) flaps is a breakthrough that addresses the issue of insufficient volume of LD. However, the use of this procedure in Asian patients has not yet been reported. Retrospective chart reviews were conducted on 54 Japanese cases of total breast reconstruction using fat-augmented LD flaps at our hospital from September 2017 to June 2019. There were 24 immediate reconstruction cases, 18 immediate two-stage reconstruction cases, nine delayed reconstruction cases, and three delayed two-stage reconstruction cases. Median age was 46 years (range, 29-69 years), and median body mass index was 21.5 (17-33.8). Median mastectomy specimen and flap weight was 225 g (123-993) and 225 g (130-796), respectively. The median volume of fat graft was 114 ml (46-305) for the LD flap and 58 ml (15-200) for the pectoralis major muscle. Of the 53 completed reconstruction cases, 38 (71.7%) achieved sufficient volume with the initial operation and six (11.3%) required additional fat grafting. The proportion of cases in the immediate reconstruction group, which achieved sufficient volume in the initial operation was significantly higher than those of the other three reconstruction groups (p = 0.007). Total breast reconstruction with fat-augmented LD flaps is a viable procedure for thin patients who have insufficient abdominal tissue, for those who wish to avoid abdominal scars, and for those in whom abdominal flaps have already been used. The procedure allows for large volume transplantation even with small skin paddles, which allows for smaller skin paddles to be designed without the need for extensive subcutaneous dissection.

Laparoscopic ovariectomy with a single-port multiple-access device in seven African lionesses (Panthera leo)

CASE DESCRIPTION 7 privately owned female African lions (Panthera leo) that had been bred for public exhibition and were housed in outdoor pens were evaluated prior to undergoing elective ovariectomy. CLINICAL FINDINGS All animals were healthy. Median age was 15 months (range, 9 to 34 months), and median body weight was 71 kg (156 lb; range, 48 to 145 kg [106 to 319 lb]). TREATMENT AND OUTCOME Surgical sterilization by means of single-incision laparoscopic ovariectomy was elected. A 2- to 3-cm-long skin incision was made just caudal to the umbilicus, and a single-port multiple-access device was bluntly inserted through the incision. Traction was maintained with stay sutures to provide counterpressure, and three 5-mm-diameter cannulae were introduced through the device's access channels with a blunt trocar. The abdomen was insufflated to a pressure of 12 mm Hg with CO2. Each ovary was grasped and suspended with a standard 36-cm-long laparoscopic grasper, and ovariectomy was performed with a 5-mm vessel sealer and divider device. Because of the depth of subcutaneous fat, extensive subcutaneous dissection was necessary to insert the single-port device. In contrast, fat content of the mesovarium was minimal and did not vary markedly among animals. Subjectively, single-incision laparoscopic ovariectomy was easily performed, but all surgeons had experience in laparoscopic surgery. Median duration of the surgical procedure was 29 minutes (range, 21 to 49 minutes). No perioperative complications were encountered. CLINICAL RELEVANCE Findings suggested that the single-incision laparoscopic technique may be an acceptable, minimally invasive option for ovariectomy of large felids.

Endoscopic anterior component separation: a novel technical approach.

Open anterior release of the external oblique fascia to enable midline closure of large abdominal wall defects is associated with relevant morbidity due to extensive subcutaneous dissection. Using endoscopic techniques, wound complications can be minimized. However, identification of the correct entry point (e.g. for balloon trocar insertion) can be challenging especially in adipose patients. We therefore present a technical modification facilitating the entire procedure. A novel technique for endoscopic anterior component separation using a trocar system allowing blunt and sharp dissection under direct vision is described. This brief communication also contains our initial experience and learning curve with this novel approach. Endoscopic release of the external oblique fascia was successfully performed 29 times in a total of 15 patients. Body mass index accounted for 30.8kg/m2 (median; range 21.6-42.5). Transverse width of midline defect accounted for 7cm (median; range 4-12). Subsequent hernia repair was successfully done using sublay mesh reinforcement (n=13) or a laparoscopic intraperitoneal onlay mesh procedure (n=2) with midline closure in all cases. One hematoma was seen at site of release managed conservatively. Using a trocar system allowing blunt and sharp dissection under direct vision may be a viable option for the endoscopic anterior component separation.

Ventral Midline Preputial Approach to the Caudal Abdomen in Male Dogs.

To describe a ventral midline preputial approach to the caudal abdominal cavity of male dogs. Retrospective clinical study. Client-owned dogs (n=12). Medical records of dogs which underwent a ventral midline preputial approach to the caudal abdominal cavity were reviewed. The procedure, outcome, and complication were recorded. Dogs underwent the preputial approach to the caudal abdominal cavity for various conditions. All dogs had an uneventful postoperative recovery and no major complications were recorded until suture removal at 10-14 days postoperative. Two dogs had minor complications treated conservatively which resolved. The use of ventral midline preputial approach is an option for access to the caudal abdomen. The approach preserves the protractor preputii muscles, obviates ligation of the branches of the caudal superficial epigastric vessels and eliminates the need for extensive subcutaneous dissection.

Medical talc and seroma formation following ventral hernia repair

In the current issue, Parameswaran and colleagues discuss the use of medical talc, 8 g in a slurry, for seromadesis. In their retrospective review of a prospectively collected database over a 5-month period, 21 consecutive patients were treated prophylactically with talc in the subcutaneous space. They compared this with outcomes in a previous group of 116 patients who had an aerosolized fibrin sealant sprayed in the subcutaneous space. Furthermore, all patients had an onlay repair with a lightweight polypropylene mesh and the drains were placed in the subcutaneous space for a period of 14 days or until drainage was \50 mL in 24 h. They report a 76 % seroma and a 43 % wound infection rate, and 33 % of patients required an intervention for their seroma. These numbers are significantly higher than any reported previously in the literature. Consequently, they terminated the study early. Ventral hernia repair is one of the most common procedures performed by general surgeons today, with 300,000 performed annually in the United States alone. As herniorrhaphy techniques have progressed, an increasing number of patients are undergoing a component separation and/or concomitant panniculectomy, which require a wide subcutaneous dissection during their ventral hernia repair (OVHR/WSD). These procedures carry a high wound complication rate ranging from 33 to 66 % [1]. In our previously published data, postoperative seromas were the most common postoperative modifiable predictor for wound complications after OVHR. Despite multiple previous efforts to reduce seroma formation in the past, seromas were still seen in up to 50 % of surgeries involving extensive subcutaneous dissection [2, 3]. Talc is a hydrous magnesium silicate that is safe, very efficacious and most commonly used agent in the treatment of malignant or chronic pleural effusions (Cochrane review). We began spraying talc in the subcutaneous space of all OVHR/WSD in January 2009. In July 2011, we published our first study on talc in the subcutaneous space on 74 patients who underwent OVHR/WSD and compared it to 106 previous patients who met inclusion criteria [4]. All patients had dissection out to the anterior axillary line and had placement of the mesh in an underlay fashion either in the pre-peritoneal or retrorectus locations. We demonstrated a significant decrease in seroma interventions (20.8 vs. 2.7 %), cellulitis (39.6 vs. 20.6 %), drain duration (25.6 vs. 14.6 days) and even early hernia recurrence rates (8.5 vs. 0 %). In subsequent studies, we have demonstrated a decrease in pain scores at 1 month as well as renal insufficiency on days 3 and 4 post-op, which may be due to decreased third space fluid loss in the operative field. There are a several differences between the two studies; as Paramaswaran and colleagues point out in their discussion, our 2011 study had the mesh placed in an underlay fashion in 100 % of patients; whereas, the current study looked only at patients with an onlay mesh. While previously we and others have done multiple animal and human studies using talc in different spaces throughout the body, this is the first to our knowledge that adds talc to an interface that includes a prosthetic material thereby perhaps impeding the inflammatory reaction between two vascularized surfaces which may be required for seromadesis. In our original description, talc was only used in patients requiring significant subcutaneous dissection, extending to the anterior axillary line. Given that only 6 of the 21 This comment refers to the article available at doi:10.1007/s10029-013-1097-4.

A Comparison of Postoperative Pain After Conventional Open Thyroidectomy and Transaxillary Single-Incision Robotic Thyroidectomy: A Prospective Study

The aim of this study was to compare conventional open thyroidectomy with robotic thyroidectomy in terms of postoperative pain. We compared the intensity of postoperative pain experienced by patients who received conventional open thyroidectomy (n = 45) versus those who underwent robotic thyroidectomy (n = 45). During surgery, we carefully controlled the anesthetic conditions. All the patients underwent a total thyroidectomy with ipsilateral central compartment node dissection. Postoperative pain in the 2 groups was compared using a visual analog scale and the amount of rescue analgesic at 30 min, 4 h, 1, 2, 3, and 10 days after surgery. The postoperative pain at 30 min and 4 h after surgery were 3.0 ± 0.9 and 2.6 ± 0.9 (p = .066) and 4.9 ± 1.3 and 4.4 ± 1.3 (p = .055) in the conventional open group and the robotic group, respectively. The mean pain scores at 1, 2, 3, and 10 days after surgery were 3.8 ± 1.3 and 3.0 ± 1.3 (p = .001), 2.6 ± 1.2 and 2.0 ± 0.9 (p = .005), 1.7 ± 0.9 and 1.3 ± 0.6 (p = .034), and 0.9 ± 0.7 and 1.2 ± 1.1 (p = .093), respectively. No significant differences were observed between the 2 groups in terms of postoperative rescue analgesic use (1.1 ± 1.1 and 0.8 ± 0.9, p = .264). Even though robotic thyroidectomy using the transaxillary technique requires a more extensive subcutaneous dissection than conventional open thyroidectomy, robotic thyroidectomy does not result in more postoperative pain or use of analgesic when compared with open thyroidectomy.

Laparoscopic versus open-component separation: a comparative analysis in a porcine model

Background The ideal surgical treatment for complicated ventral hernias remains elusive. Traditional component separation provides local advancement of native tissue for tension-free closure without prosthetic materials. This technique requires an extensive subcutaneous dissection with division of perforating vessels predisposing to skin-flap necrosis and complicated wound infections. A minimally invasive component separation may decrease wound complication rates; however, the adequacy of the myofascial advancement has not been studied. Methods Five 25-kg pigs underwent bilateral laparoscopic component separation. A 10-mm incision was made lateral to the rectus abdominus muscle. The external oblique fascia was incised, and a dissecting balloon was inflated between the internal and external oblique muscles. Two additional ports were placed in the intermuscular space. The external oblique was incised from the costal margin to the inguinal ligament. The maximal abdominal wall advancement was recorded. A formal open-component separation was performed and maximal advancement 5 cm superior and 5 cm inferior to the umbilicus was recorded for comparison. Groups were compared using standard statistical analysis. Results The laparoscopic component separation was completed successfully in all animals, with a mean of 22 min/side. Laparoscopic component separation yielded 3.9 cm (SD 1.1) of fascial advancement above the umbilicus, whereas 4.4 cm (1.2) was obtained after open release ( P = .24). Below the umbilicus, laparoscopic release achieved 5.0 cm (1.0) of advancement, whereas 5.8 cm (1.2) was gained after open release ( P = .13). Comments The minimally invasive component separation achieved an average of 86% of the myofascial advancement compared with a formal open release. The laparoscopic approach does not require extensive subcutaneous dissection and might theoretically result in a decreased incidence or decreased complexity of postoperative wound infections or skin-flap necrosis. Based on our preliminary data in this porcine model, further comparative studies of laparoscopic versus open component separation in complex ventral hernia repair is warranted to evaluate postoperative morbidity and long-term hernia recurrence rates.

Laparoscopic component separation in the single-stage treatment of infected abdominal wall prosthetic removal

The ideal surgical treatment for complicated ventral hernias remains elusive. Traditional component separation provides local advancement of native tissue for tension-free closure without prosthetic materials. This technique requires an extensive subcutaneous dissection, with the division of perforating vessels predisposing to skin flap necrosis and complicated wound infections. The laparoscopic separation of components provides a minimally invasive alternative to open techniques, while eliminating the potential space and subsequent complications of large skin flaps. We report our initial experience with a minimally invasive component separation with early postoperative outcomes. We retrospectively reviewed the medical records of all patients who underwent a minimally invasive component separation for abdominal wall reconstruction during the resection of an infected prosthetic. Pertinent details included baseline demographics, reason for contamination, operative technique and details, postoperative morbidity, mortality, and recurrence rates. Between August 2006 and January 2007, seven patients were identified who underwent a laparoscopic component separation. There were four males and three females, with a mean age of 54 years (range 34-84), mean American Society of Anesthesiologist (ASA) score of 3.2 (range 3-4), and mean body mass index (BMI) of 37 kg/m2 (range 30-45). The reason for contamination included exposed non-healing mesh (6) and contaminated fluid collection around the mesh (1). Residual defect size following the removal of all prosthetics was 338 cm2 (range 187-450). The mean operative time was 185 min (range 155-220). Laparoscopic component separation enabled tension-free primary fascial reapproximation in all patients. Three postoperative complications occurred, including superficial surgical site infection (1), respiratory failure (1), and hematoma (1). There was no mortality in this series. During an average follow-up period of 4.5 months, no recurrences were identified. This study shows that a minimally invasive component separation is feasible and can result in minimal postoperative wound morbidity in these complex patients. Long-term follow-up is necessary to evaluate the outcomes with respect to recurrence rates.

Treatment of the particularly fatty neck and the short-interval secondary facelift

In patients with normal body weight but with large accumulations of submental and cervical fat, good results can be obtained by an extensive subcutaneous dissection, carefully sculpted removal of the excess fat, and relatively limited work on the platysema. For some patients there may be an indication for a secondary facelift involving skin dissection alone within a relatively short interval.