Anterior Abdominal Wall Fascia Research Articles

A study of clinical profile of ventral hernias in a tertiary care hospital

Introduction: Abdominal wall hernias are a familiar surgical problem. Millions of patients are affected each year, presenting most commonly with primary ventral, incisional, and inguinal hernias. A ventral hernia is defined by a protrusion of an organ or tissue through a defect in the anterior abdominal wall fascia. Ventral hernia constitute 4% of total hernia patient admitted in ward. The aim is to study the varied presentations, etiology, distribution according to age /sex, predisposing factors, anatomical distribution of ventral hernias. Materials and Methods: This is a prospective descriptive study. Present study was conducted over a period from August 2019 to August 2021. During the study period, 50 patients of ventral hernias were included. Results: Incisional hernias constituted 46% of all ventral hernias. Female preponderance was seen in incisional hernias with Female to male ratio is 1. 9:1, where as in epigastric and umbilical / para umbilical hernias male predominance was seen. Most of the ventral hernias presented in 4th to 6th decades. 78% of ventral hernias were uncomplicated at the time of presentation. Swelling was the most common complaint followed by pain.

A RETROSPECTIVE COMPARATIVE STUDY OF PREPERITONEAL VS ONLAY MESH REPAIR IN CASES OF VENTRAL HERNIAAT TERTIARY CARE INSTITUTE

Background: A ventral hernia is an abnormal protrusion of intra abdominal or preperitoneal content through the anterior abdominal wall fascia and muscle defect. Hernioplasty with prosthetic mesh is surgical treatment modality for all types of ventral hernia.There are various anatomic planes where mesh can be put. This study was planned to compare preperitoneal repair and onlay mesh repair in terms regarding their outcome. Methods: This is a retrospective study with total number of 112 cases of ventral hernia with prosthetic meshplasty was done. In all cases clinical history, preoperative examination findings, intraoperative and post operative findings were noted. All data was categorised according to where mesh was put intra-operatively in anatomical plane of preperitoneal or onlay. Statistical analysis of all data was done and outcome was measured. Results: Mean operative time was less in onlay hernioplasty than preperitoneal hernioplasty but over all complications were high in onlay hernioplasty.Preperitoneal hernioplasty method had lowest complications rate. Conclusions: Preperitoneal hernioplasty is better choice than onlay hernioplasty. AIM:To assess the better method from onlay meshplasty and preperitoneal meshplasty in cases of ventral hernia. OBJECTIVE: To compare the both methods on the bases of operative time ,speed of postoperative period recovery, and postoperative complications.

Clinical significance of anterior abdominal wall fascial in totally extraperitoneal herniorraphy

All fascia between the transversalis fascia of anterior abdominal wall and the peritoneum can be called the preperitoneal fascia clinically. According to the interfascial theory, the preperitoneal fascia is a multi-layer structure, and preperitoneal space was divided into two surgical planes including parietal and visceral by its membrane layers. Surgical planes of totally extraperitoneal herniorraphy (TEP) can be described as follow: for median region, surgery can be performed in parietal plane, that is avascular region filled with loose areolar tissues between the transversalis fascia and the preperitoneal fascia, which is called holy plane of TEP. For Doom region, surgery is transferred into viscecal plane, which is between the preperitoneal fascia and the peritoneum, due to the particularity of spermatic cord through the abdominal wall. For lateral region, the abdominal wall restores to normal structure, and surgery can be performed in parietal or viscecal plane. The preperitoneal fascia needs to be dissected during the transfer from parietal to viscecal plane. The concept of transformation can explain the formation mechanism of preperitoneal loop and no connection between Reztius space and Bogros space. The author has elucidated the significance of preperitoneal fascial anatomy of anterior abdominal wall in TEP based on clinical experience of TEP and authoritative literatures. Key words: Hernia; Laparoscopy; Inguinal hernia; Membrane anatomy

Hyperglycemia is associated with lower levels of urokinase-type plasminogen activator and urokinase-type plasminogen activator receptor in wound fluid

AimsWounds in patients with hyperglycemia show impaired healing. Plasminogen activation is crucial in several overlapping phases of wound healing process. In this study, we aimed i) to compare acute wound fluid in patients with hyperglycemia and normoglycemia, ii) to focus on the elements of plasminogen activation in the wound fluid, and iii) to determine if the acute wound fluid characteristics are associated with surgical site infections. MethodsIn a cohort of 54 patients, a closed suction drain was placed in the wound above the anterior abdominal wall fascia under the skin in order to collect postoperative acute wound fluid samples for 3 following days after colorectal surgery. Patients were classified as normoglycemic (n=25) or hyperglycemic (n=29; 17 with type 2 diabetes and 12 with stress induced hyperglycemia). Surgical site infection was defined according to the Centers for Disease Control criteria. The levels of urokinase-type plasminogen activator (uPA), urokinase-type plasminogen activator receptor (uPAr), plasminogen activator inhibitor-1 (PAI-1), interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), and fibroblast growth factor-1 (FGF-1) were measured in the wound fluid. ResultsCompared to normoglycemic subjects, patients with hyperglycemia had significantly lower levels of uPA and uPAr in the wound fluid despite similar or even higher circulating levels. There was no significant difference in IL-1β, TNF-α, PAI-1 and FGF-1 levels. In the whole study population, the wound fluid levels of uPA and uPAr were negatively correlated with circulating glucose levels. No difference was detected in the wound fluid characteristics of patients with and without surgical site infection. ConclusionPatients with hyperglycemia exhibit decreased levels of uPA and uPAr in the wound fluid, suggesting a local failure in plasminogen activation at the wound site.

Sling suspension: a new technique of treating uterine prolapse

To report a novel surgical technique of laparoscopic extraperitoneal sling suspension for uterine prolapse and evaluate its efficacy. A total of 21 consecutive patients of symptomatic uterovaginal prolapse with POP-Q (pelvic organ prolapse quantification system) stage ≥ 2 and aged 59 (42-76) years were enrolled for this procedure between September 2011 and December 2012. In brief, uterus was suspended to anterior abdominal wall fascia using an inelastic nonabsorable mesh extraperitoneally under laparoscopic guidance. The outcomes of interest included total operative duration, estimated blood loss, surgical length of stay POP-Q score change and quality of life questionnaire in pelvic floor distress inventor [PFDI-20] and pelvic floor impact questionnaire [PFIQ-7]. Follow-ups were scheduled at 1, 6 and 12 months and then annually. Comparisons were made between at preoperation and 6 and 12 months. The surgical success was defined as both subjective cure and significant improvement of POP-Q. This procedure was performed successfully in all patients. The estimated blood loss 10 (10-40) ml, operative duration 30 (25-90) minutes and postoperative hospital stay 1 (1-5) day. There were no major intraoperative or postoperative complications. The median follow-up was 20 (12-26) months. There were significant improvements in POP-Q measurements of Ba and C (P < 0.01) and quality-of-life scores (P < 0.01) at 6 and 12 months. The subjective cure rate was 100% and surgical success rate at 12 months 100%. This new sling suspension technique for uterine prolapse is safe, well-tolerated and effective so that it offers a simple alternative of laparoscopic uterine suspension.

Risk Factors for Incisional Hernia and Parastomal Hernia after Colorectal Surgery

See Article on Page 299-303 Incisional hernias, with an incidence of 9 to 38%, remain one of the most common complications after an incision of the abdominal wall [1-3]. An incisional hernia is defined as a protrusion of intraperitoneal structures through a defect in the anterior abdominal wall fascia [4]. This means that wound healing often fails to occur when multiple predisposing factors, including surgical site infection, malnutrition, diabetes, immunosuppression, and morbid obesity, are present [5]. Incisional hernias are almost universally regarded as technical failures. Technical factors are related to suture material selection, type of fascial closure, ratio of suture to incision length [5]. In spite of many advances, such as new procedures for closing the abdominal wall and new suture materials, the incidence of incisional hernias has not been reduced in recent decades because the developments of incisional hernias is also related to many factors affecting the patients. Surgical site infection is one of the important risk factors for the development of an incisional hernia. Recently, Murray et al. [6] analyzed the incidence of incisional hernias related with surgical site infection in colorectal surgery. They reported that patients with a surgical site infection were 1.9 times more likely to have an incisional hernia than those without a surgical site infection (36.3% vs. 18.8%, P ≤ 0.01). In clean-contaminated and contaminated surgery, such as colorectal surgery, the incidence of surgical site infection has been reported as 3 to 30% [7, 8]. Thus, in colorectal surgery, more effort to prevent surgical site infection is needed. Morbid obesity is another important risk factor for the development of an incisional hernia and a parastomal hernia [9, 10]. Schreinemacher et al. [9] reported that hernias were more prevalent in patients with morbid obesity (body mass index of 30 and higher) and in patients with a temporary stoma wound (25.8% vs. 59.1%). De Raet et al. [10] reported that a waist circumference in excess of 100 cm increased the risk of developing a parastomal hernia (odds ratio, 1.009; 95% confidence interval, 1.002 to 1.016). Other factors, such as anemia, hypoproteinemia, malnutrition, diabetes, immunosuppression, male gender, and old age, are related to surgical wound dehiscence and incisional hernias [11]. Conditions that increase abdominal pressure, such as coughing, vomiting, distention, and ascites, also increase the incidence of incisional hernias. Surgeons have to be aware of poor wound healing conditions to prevent incisional hernias. Perioperative efforts to reduce risk factors and to select proper technical methods of wound closure are essential if the incidence of incisional hernias is to be reduced.

Re-evaluation of superficial fascia of anterior abdominal wall: a computed tomographic study

Understanding the topographic anatomy of the membranous layer of superficial fascia of anterior abdominal wall may help in explaining the body contour deformities and provide the anatomic basis for surgical corrections. Existing controversies in the presence and extent of membranous layer of the superficial fascia of anterior abdominal wall among anatomists and misinterpretation of its anatomical description by clinicians provoked us to re-evaluate the superficial fascia of anterior abdominal wall. Fifty CT scans of abdominal region of either sex were studied to see the vertical and horizontal extent of membranous layer. The membranous layer was clearly seen in whole of the anterior abdominal wall except for few cases where either it was not clear superiorly in zone 1 (16%) or inferiorly in zone 3 (6%). On combining the horizontal and vertical extent of membranous layer in each and every individual, altogether eight types of patterns were obtained. Out of these patterns, four were present in females and all the eight types in males. The membranous layer is present in whole of the anterior abdominal wall and it divides the superficial fascia into three layers: superficial fatty layer, intermediate membranous layer, and deep fatty layer. If membranous layer is not clear in CT scan the reason could be the absence of deposition of fat in deep compartment.

Rectus abdominis vaginoplasty after anterior exenteration for urologic malignancy

IntroductionVaginal resection is occasionally required in female patients who undergo anterior exenteration for invasive lower urinary tract malignancy. We have used a rectus abdominis myocutaneous flap to reconstruct the vagina and perineum after extensive local resection of bladder and urethral carcinoma. Technical considerationsEither a left or right rectus flap is used. Once anterior exenteration, partial vaginectomy, and urinary diversion are completed, the median infraumbilical incision is extended superiorly to form an elliptical skin paddle centered over the superior half of the muscle. The superior epigastric vessels are ligated, the cephalad end of the muscle is divided at the level of the costal margin, and the flap is progressively elevated out of the rectus sheath by sequentially dividing the lateral perforating nerves and vessels. As the muscle is elevated, the inferior epigastric pedicle is carefully preserved and followed inferiorly to its origin from the external iliac artery. Once a length of muscle sufficient for it to reach the perineum is mobilized, the flap is carried transpelvically. For complete vaginal reconstruction, the flap may be inverted into a tube, with the cephalic portion anchored to the perineum. Alternatively, the skin paddle may be used to fill tissue defects in the vagina and pelvic floor. The anterior abdominal wall fascia and skin edges at the donor site are closed primarily. We have successfully applied this technique in 4 patients who underwent anterior exenteration for invasive bladder and urethral carcinoma. ConclusionsRectus abdominis vaginoplasty is a viable surgical option for reconstruction after anterior exenteration with vaginal resection for invasive cancer of the bladder and urethra.

The role of peritoneal lavage in the management of stab wounds to the abdomen

In a 2 year period, 237 patients presented with stab wounds to the lower chest and anterior abdomen. Ninety-six patients were discharged from the emergency room after negative findings on wound exploration. There were no apparent missed injuries but two wound infections in this group for an overall morbidity of 2.1 percent. One hundred forty-one patients underwent exploratory laparotomy. Seventy-seven required emergency laparotomy because of hemodynamic signs of blood loss or peritonitis. Sixty-four patients whose only indication for laparotomy was penetration of the anterior abdominal wall fascia by local wound exploration underwent peritoneal lavage before laparotomy. If 50,000 red blood cells/mm 3 in the lavage fluid had been used to select patients for observation, the incidence of negative laparotomy would have been reduced from 58 to 3.2 percent, and only one significant visceral injury would have been missed. Peritoneal lavage in properly selected patients, used in combination with local wound exploration and careful clinical observation, can be a useful diagnostic modality both in predicting significant visceral injury and in lowering the incidence of negative findings at laparotomy in patients with stab wounds to the abdomen.

Fixation of Celestin tube to the anterior abdominal wall: A new technique

Palliative intubation in the management of an unresectable carcinoma of the esophagus can be accomplished by "push through" or "pull through" techniques. The most frequently encountered complication is tube dislodgment-proximal or distal migration. Dislodgment occurs more freqeuntly with the "push through" tubes such as the Souttar tube than with the "pull through" tubes such as the Celestin tube. The incidence of migration reported for the "pull through" tubes varies from 3 to 14 per cent. In order to prevent migration, we sutured the tube to the anterior abdominal wall in 6 patients. The sixth patient developed a gastrocutaneous fistula and fasciitis at the point of anterior abdominal wall fixation. In the next 4 cases, we used a two-suture technique, in which no single suture passed from the gastric lumen to the anterior abdominal wall fascia. The Celestin tube was fixed to the gastric wall over a Dacron felt pledget and this pledget was then anchored to the rectus fascia. This technique has prevented both migration of the tube and complications related to gastric perforation.