Infraumbilical Area Research Articles

Personalized injectional carboxytherapy for patients with early complications after low-temperature hardware cosmetic procedures

We conducted a clinical and instrumental examination in 62 patients diagnosed with E65 — localized fat deposition at the age of 28–42 years and body mass index (BMI) — 26–27, who received the cryolipolysis procedure (hardware non-surgical correction of local fat deposits) the day before on the infraumbilical area of the abdomen in order to correct local fat deposits. After 1–2 days, the patients began to complain of pronounced local edema and a change in sensitivity at the site of exposure to cryopressure. All patients underwent genetic testing on the Cosmetology panel before the start of treatment. When comparing the control and comparison groups, it was found that the use of an extended method of injectable carboxytherapy in the second comparison group with a high risk of inflammation and «weakness» of the vascular wall significantly improves the quality of life in terms of the dermatology life quality index (DLQI) compared to the first comparison group and the control groups. Edema decreases clinically, which correlates with a significant decrease in intradermal edema and dermal thickness in the first comparison group compared to the second comparison group and in the control group according to ultrasound examination with a 30 MHz sensor. Personalized injectional carboxytherapy is an effective factor in relieving complications after cryolipolysis.

Differences of the midline-crossing venous drainage pattern in supraumbilical and infraumbilical regions: Angiographic study using fresh cadavers.

Current clinical and anatomical studies show that the venous problem associated with the deep inferior epigastric perforator flap results from poor midline-crossing. We examined the venous anatomy of the infraumbilical midline area and the dynamic venous flow of the deep inferior epigastric perforator flap in nine fresh cadavers. All nine abdominal specimens were harvested between the subcostal margin and the groin crease. Two specimens were used to analyze the abdominal venous anatomy, one of which was divided into two hemi-abdominal specimens. The remaining seven specimens were harvested as deep inferior epigastric perforator flaps with one major paraumbilical perforator. Venous cannulation and serial angiographic agent injection were performed in several conditions. Each specimen was radiographed using a soft X-ray system. For additional information, computed tomography (CT) angiography-visualized superficial inferior epigastric veins (SIEVs) and the supraumbilical branch were analyzed. We noted that the venous drainage between the bilateral SIEVs was easier to configure in the supraumbilical area than in the infraumbilical area. Only one to two short polygonal venous networks connect the bilateral superficial inferior epigastric veins in the supraumbilical area; however, long and multiple polygonal venous networks connect the bilateral superficial inferior epigastric veins in the infraumbilical area, which could be a predisposing factor for venous congestion. The mean distance from the umbilicus upper border to evident supraumbilical midline crossover was 18.39±4.03 mm (range: 10.10–28.49) in CT angiograms. In cadaver specimens, the mean distance was 10.87±4.85 mm (range: 4.6–18.9). Supraumbilical midline crossover was more favorable than infraumbilical midline crossover in venous flow.

Influence of altitude on cerebral and splanchnic oxygen saturation in critically ill children during air ambulance transport.

The aim of the current study was to investigate how cerebral and splanchnic oxygen saturation (rSO2-C and rSO2-A) in critically ill children transported in air ambulance was affected by flight with cabin pressurization corresponding to ≥ 5000 feet. A second aim was to investigate any differences between cyanotic and non-cyanotic children in relation to cerebral and splanchnic oxygen saturation during flight ≥ 5000 feet. The variability of the cerebral and splanchnic Near Infrared Spectroscopy (NIRS) sensors was evaluated. NIRS was used to measure rSO2-C and rSO2-A during transport of critically ill children in air ambulance. rSO2 data was collected and stored by the NIRS monitor and extracted and analyzed off-line after the transport. Prior to evaluation of the NIRS signals all zero and floor-effect values were removed. The Pediatric Intensive Care Unit (PICU) at Astrid Lindgren Children's Hospital, Karolinska University Hospital in Stockholm, Sweden. In total, 44 critically ill children scheduled for inter-hospital transport by a specialized pediatric transport team were included in the study between January 2014 and January 2019 (convenience sampling). No interventions were conducted. All study patients were monitored with a cerebral NIRS-sensor placed over the forehead and an abdominal NIRS-sensor placed in the infra-umbilical area for cerebral and splanchnic regional oxygen saturation monitoring, rSO2-C and rSO2-A, respectively. Complete rSO2-C and rSO2-A data was obtained in 39 patients. Median age was 12 days. Cyanotic congenital heart malformations were present in 9 patients (23%). In 22 patients (56%) rSO2-C decreased at altitude ≥ 5000 feet and in 24 patients (61%) rSO2-A decreased at altitude ≥ 5000 feet compared to baseline (p<0.0001). In 25 patients (64%) the rSO2-C/rSO2-A ratio was greater at altitude ≥ 5000 feet than at baseline. A ratio ≥ 1 was seen in 77% of patients at altitude ≥ 5000 feet compared to in 67% of patients at baseline. Both cerebral and splanchnic oxygen saturation decreased at altitude ≥ 5000 feet compared to baseline. In most patients, both cyanotic and non-cyanotic, cerebral oxygen saturation was preserved more than splanchnic oxygen saturation.

Efeitos das ondas de choque piezoelétrica na adiposidade localizada

Introdução: A terapia de ondas de choque piezoelétrica (TOC) é uma técnica não invasiva que visa a reduzir o tecido adiposo subcutâneo localizado. Objetivos: Investigar os efeitos da terapia ondas de choque piezoelétrica na redução da adiposidade subcutânea localizada. Métodos: Efetuou-se um estudo experimental, com 31 participantes, de 25 a 45 anos, do sexo feminino. Foram realizadas quatro sessões de tratamento, uma vez por semana com parâmetros da OC piezoelétrica. Procedeu-se à aplicação dinâmica na região infraumbilical; e estacionária, na supraumbilical, ambas no lado esquerdo. O lado direito não recebeu aplicação, tornando-se o lado controle. Resultados: Na aplicação da TOC piezoelétrica na forma estacionária, houve maior redução de tecido adiposo do que no modo dinâmico. Conclusão: Pode-se observar que a terapia por OC piezoelétrica promoveu uma redução da adiposidade localizada, com o modelo de equipamento escolhido e na dose proposta neste estudo, constatada nas análises de plicometria e ultrassonografia.

Effect of Decantation Time on Viability and Apoptosis in Adipocytes After Liposuction.

The effect of decantation time on viability and apoptosis in adipocytes has not been described. The objective of the study was to describe viability and apoptosis in adipocytes up to 2h after harvesting. Twenty patients who underwent esthetic liposuction from the abdomen were included. The lipoaspirate was obtained from the infra-umbilical area with the tumescent technique. Liposuction was performed with a 60-ml syringe and a 3-ml cannula. Lipoaspirates were centrifuged at 50g for 5min at 0, 60 and 120min after harvesting. One gram of fat was digested with 0.1% type 1 collagenase and incubated at 37 degrees for 30min. Adipocytes were counted on 10 random microscopic fields. Apoptosis was determined by TUNEL assay. A fluorescence microscope was used to visualize the staining nuclei and cells. Regarding viability, immediately after harvesting, 57.6 ± 18.9% of the cells were viable, whereas 60min after liposuction the viability decreased to 51.62 ± 8.8% and 120min after liposuction the percentage of viable cells was 46.8 ± 16.9%. The percentage of apoptotic cells at time 0 was 38.2 ± 8.0%, whereas it was 51.24 ± 8.1% at 60min and 62.9 ± 16.1% at 120min after collection. Apoptosis and mortality of adipocytes after liposuction increase directly proportional to the time of decantation. Lipoinjection should be performed as soon as possible after harvesting. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Severe abdominal pain and diarrhea \u2013 unusual multiple myeloma presentation with a severe prognosis: a case report

BackgroundMultiple myeloma is a hematologic disease with high mortality rates all over the world. The diagnosis has always been challenging since the first case was reported in 1844. For that reason the diagnostic criteria have evolved over years to include the features of the disease more comprehensively. Unusual presentations are infrequent and a diagnostic challenge. For this reason we report this rare case in which diarrhea and abdominal pain were the initial presenting symptoms of multiple myeloma with a plasmacytoma.Case presentationAn 87-year-old Hispanic man with a past medical history of hypertension, diabetes, and constipation, presented to an emergency department complaining of severe generalized abdominal pain and profuse diarrhea for 3 days. A physical examination revealed generalized pallor and dehydration but no signs of abdominal peritoneal irritation. Laboratory tests revealed neutrophilia and an elevated total protein. He received intravenously administered fluids and antibiotics. His abdominal pain became localized in the infraumbilical area and a small mass was palpated on the right lower quadrant on subsequent examination. An abdominal computed tomography scan showed a tumor lesion surrounded by fluid collection and a computed tomography-guided biopsy of the lesion confirmed it to be a plasmacytoma. A bone marrow biopsy revealed plasmatic cell augmentation but his beta-2 microglobulin levels were inconclusive. The diagnosis of multiple myeloma was finally confirmed with urine immunofixation. Bortezomib was initiated to decrease disease progression, but unfortunately 4 days later he developed acute pulmonary edema, had a cardiac arrest, and died.ConclusionsThis case illustrates the protean initial manifestations of multiple myeloma and the importance of an accurate diagnosis. Our patient’s initial presentation with gastrointestinal complaints is rare and the plasmacytoma location is even rarer, providing a challenging diagnostic problem. Prompt recognition of multiple myeloma is critical to institute appropriate therapy and prevention of disease progression.

485: Effect of trocar entry location in Twin Twin Transfusion Syndrome (TTTS) on gestational age at delivery

Fetal laser surgery (FLS), which is the standard therapy for TTTS, requires a percutaneous entry using a trocar-cannula; in rare cases a laparoscopic assisted approach is required. The aim of this study was to evaluate if location of trocar entry into abdominal/intrauterine cavity plays a role in gestational age at delivery. This is a prospective observational cohort study of 318 monochorionic-diamnotic pregnancies with TTTS undergoing FLS, performed at a single institution. Trocar entry location (TEL) was categorized based on abdominal quadrant area from 1 to 8 (Fig. 1). Area 8 represent the laparoscopic-assisted approach, which was not included being a more invasive procedure. Descriptive analysis was performed to obtained gestational age (GA) at delivery for each abdominal TEL (Fig. 1). Then two main groups of TEL were identified with a similar mean of GA at delivery; these were subsequently divided into 2 groups: TEL-A (areas 1 and 2, n=37) and TEL-B (areas 3-7, n=281) (Fig. 1). Preoperative, and intraoperative variables were compared between the two groups. Stepwise linear regression analysis (p<0.05) was performed for GA at delivery to evaluate the effect of TEL, and was adjusted for potential confounding factors. Mean GA at delivery in weeks was lower in TEL-A 29.2 ± 5 vs. TEL-B 31.0 ± 4 (p=0.02) (Fig. 2). TEL-A had a higher incidence of chorioamnionitis 16% vs, 5%, however this difference did not reach statistical significance (p=0.08). There were also no differences in PPROM and neonatal survival rates. TEL-A had higher use of a 9Fr cannula 12% vs. 2.5% (p=0.05). No differences in other preoperative and operative variables were seen. After adjusting for other possible risk factors, the TEL-A remained a significant contributing factor associated with a decrease in gestational age at delivery by 2.2 weeks (Table 1). In our study other significant factors involved in reducing GA at delivery were GA of laser procedure, body mass index and preoperative cervical length (Table 1). Percutaneous trocar entry location in the midline suprapubic and infraumbilical area (TEL-A) results in a 15 day reduction in gestational age at delivery after TTTS treatment. This finding could be correlated with the proximity of these entry locations to the cervix causing possible disruption of the fetal membrane in the lower uterine segment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Homeotic and Embryonic Gene Expression in Breast Adipose Tissue and in Adipose Tissues Used as Donor Sites in Plastic Surgery.

Autologous fat grafting has become an essential procedure in breast reconstructive surgery. However, molecular knowledge of different adipose donor sites remains inadequate. Tissue regeneration studies have shown that it is essential to match the Hox code of transplanted cells and host tissues to achieve correct repair. This study aims to provide a better molecular understanding of adipose tissue. Over the course of 1 year, the authors prospectively included 15 patients and studied seven adipose areas: chin, breast, arm, abdomen, thigh, hip, and knee. The first step consisted of the surgical harvesting of adipose tissue. RNA was then extracted and converted into cDNA to study gene expression levels of 10 targeted genes by real-time polymerase chain reaction. Forty samples from Caucasian women with a mean age of 48 years were studied. The expression of PAX3, a marker of neuroectodermal origin, was significantly higher in the breast, with a decreasing gradient from the upper to lower areas of the body. An inverse gradient was found for the expression of HOXC10. This expression profile was statistically significant for the areas of the thigh and knee compared with the breast (p < 0.0083). Breast fat may have a specific embryologic origin compared with the knee and thigh. The reinjection of adipocytes from the infraumbilical area leads to the transfer of cells highly expressing HOXC10. This study raises questions about the safety of this procedure, and future studies will be required to examine molecular modifications of adipose cells transferred to a heterotopic location. Therapeutic, V.

Calcified Abdominal Pregnancy with Five Years of Evolution (Lithopedion): A Case Report

Lithopedion is a rare phenomenon resulting from an extra-uterine pregnancy that advances to fetal demise and calcification and there are less than 300 cases reported in 400 years of medical literature. This rare condition was first described by a surgeon of the Arabic era of medicine in the 10th century. This case report is a 26-year-old, multiparous woman who had presented a lower abdominal pain for long time and she had never attended in pre-natal clinic. She came to our hospital with pain and tumoral mass in infra-umbilical area and then we referred to radiology center, after that ultrasound examination of radiology center demonstrated an extra-uterine abdominal 30-week pregnancy measuring the femoral length, this for first diagnosis of radiology center. After laparotomy was performed we met an oval shaped mass that attached the omentum in peritoneal cavity and this mass was a fetus retention of 5 years without calcified ovular membranes but the fetus was calcified so this type is called lithopedion that describes according to the Kuechenmeister classification in 1881. She made good post-operative recovery after extraction the stone baby.

Transcutaneous electrical nerve stimulation can reduce pain during diagnostic hysteroscopy and endometrial biopsy: a randomized, controlled trial

To assess the effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS) to relieve pain during office diagnostic histeroscopy and endometrial biopsy. Randomized, controlled trial. Between August 2012 and February 2013, 40 women that would be submitted to office diagnostic hysteroscopy and endometrial biopsy were randomized in two groups. In group I, they were submitted to application of TENS with Tanyx® in infra-umbilical area during the procedure. In group 2, women were forwarded straight to hysteroscopy. All procedures were performed using a semi-rigid 3.5mm minihysteroscope with a 30 degrees grade optic, followed to endometrial biopsy with Novak curette. Women were asked to rate their degree of pain during the two phases (hysteroscopy and biopsy) according to a VAS (visual analogic scale) ranging from 0 to 10, where 0 was “no pain” and 10 was “unbearable pain”. The variables were compared using t Student test. In group which received TENS, women related significantly lower level of pain than patients which did not both during diagnostic hysteroscopy (5.80 ± 2.19 vs. 2.30 ± 1.34, p=0.0001) and endometrial biopsy (4.70 ± 1.53 vs. 7.95 ± 1.93, p=0001). TENS can relieve pain during office diagnostic hysteroscopy and may be an useful tool to reduce the burden of these procedures. Nevertheless, larges trials which neutralize the placebo effect are necessary to confirm its real efficacy.

Scarpa Fascia Preservation during Abdominoplasty

Scarpa fascia preservation has been suggested as a way of reducing complications associated with conventional abdominoplasty. A prospective randomized study was conducted to evaluate the effect on results and complications of preserving the Scarpa fascia during a full abdominoplasty. This was a single-center study conducted from August of 2009 to February of 2011. Patients were assigned randomly to one of two procedures: classic full abdominoplasty (group A) or a similar type of abdominoplasty except for the preservation of the Scarpa fascia and the deep fat compartment in the infraumbilical area (group B). Four surgeons were involved in the study. Several variables were determined: general characteristics, time to suction drain removal, total volume of drain output, length of hospital stay, systemic complications, local complications, and aesthetic result. A total of 160 full abdominoplasties were performed in women (group A, 80 patients; group B, 80 patients) equally divided by the four involved surgeons. There were no statistically significant differences between groups with respect to general characteristics, complications (except for the seroma rate), and aesthetic result. The Scarpa fascia preservation group had a highly significant reduction of 65.5 percent on the total drain output, 3 days on the time to drain removal, and 86.7 percent on the seroma rate. Preservation of the Scarpa fascia during an abdominoplasty had a beneficial effect on patient recovery, as it reduced the total drain output, time to drain removal, and seroma rate without compromising the aesthetic result.

Dermolipectomía asociada al tratamiento quirúrgico de las hernias incisionales en pacientes obesos

ObjetiveTo evaluate the results of the surgical treatment of ventral hernias in obese patients when a dermolipectomy is associated. Material and methodsA prospective series of cases was design. 61 obese patients with an incisional hernia were treated and a dermolipectomy was associated. The inclusion criteria were: patients with abdominal ventral hernia in the middline, at umbilical or infraumbilical area, with a hernia defect equal or higher than five centimeters, and patients with Body Mass Index higher than 30kg/m2. ResultsThe mean age was 49. All patients were female except three men. The mean body mass index was 33.3kg/m2. The hernia defect was higher than 10cm in 25 patients (40.98%), and between 5 and 10cm in 36 patients (59.01%). Mesh repair was performed by Rives technique in 58 (95.08%) cases and pre-aponeurotic procedure in 3 cases (4.91%). The morbidity of the series was 25.9% (18 patients): seromas in 6 patients (9.8%), bleeding 3 patients (4.9%), partial infection of the prosthesis in 1 patient (1.6%), partial necrotic lesions in the skin scar in 7 patients (11.4%) and recurrent hernia in 1 patient (1.6%). The mean days in hospital was 2.1. ConclusionsDermolipectomy associated to the ventral hernia repair in obese patients with umbilical or infraumbilical defects is an adequate alternative procedure that does not add considerable morbidity, may reduce recurrence rates and improve aesthetic results.

Scarpa Fascia Preservation during Abdominoplasty: A Prospective Study

Preservation of the Scarpa fascia has been suggested as a way of lowering complications associated with conventional abdominoplasty. Objective evidence regarding this strategy is lacking. The purpose of this investigation was to evaluate the effect of preserving the Scarpa fascia in the infraumbilical area during a full abdominoplasty. A prospective study was performed at a single center from November of 2005 to November of 2007 of the patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, classic full abdominoplasty; and group B, full abdominoplasty with preservation of infraumbilical Scarpa fascia. Several variables were determined: age, body mass index, previous surgical procedures, comorbid conditions, specimen weight, time to suction drain removal, total volume of drain output, and length of hospital stay. A total of 208 full abdominoplasties were performed (group A, 143 patients; group B, 65 patients). There was no statistically significant difference between groups with respect to body mass index, previous abdominal operations, comorbid medical conditions, or weight of the surgical specimen (p > 0.05). The group with preservation of the Scarpa fascia had an average reduction of the total amount of drain output of more than 50 percent (p < 0001). This group also had an average reduction of 2.0 days until the time to drain removal (p < 0.001) and 1.9 days of the hospital stay (p < 0.001). Preservation of the Scarpa fascia during abdominoplasty has a beneficial effect on patient recovery, as it reduces the total drain output, time to drain removal, and length of hospital stay.

Cardiac Effects of Electrical Stun Guns: Does Position of Barbs Contact Make a Difference?

The use of electrical stun guns has been rising among law enforcement authorities for subduing violent subjects. Multiple reports have raised concerns over their safety. The cardiovascular safety profile of these devices in relationship to the position of delivery on the torso has not been well studied. We tested 13 adult pigs using a custom device built to deliver neuromuscular incapacitating (NMI) discharge of increasing intensity that matched the waveform of a commercially available stun gun (TASER(R) X-26, TASER International, Scottsdale, AZ, USA). Discharges with increasing multiples of output capacitances were applied in a step-up and step-down fashion, using two-tethered barbs at five locations: (1) Sternal notch to cardiac apex (position-1), (2) sternal notch to supraumbilical area (position-2), (3) sternal notch to infraumbilical area (position-3), (4) side to side on the chest (position-4), and (5) upper to lower mid-posterior torso (position-5). Endpoints included determination of maximum safe multiple (MaxSM), ventricular fibrillation threshold (VFT), and minimum ventricular fibrillation induction multiple (MinVFIM). Standard TASER discharges repeated three times did not cause ventricular fibrillation (VF) at any of the five locations. When the barbs were applied in the axis of the heart (position-1), MaxSM and MinVFIM were significantly lower than when applied away from the heart, on the dorsum (position-5) (4.31 +/- 1.11 vs 40.77 +/- 9.54, P< 0.001 and 8.31 +/- 2.69 vs 50.77 +/- 9.54, P< 0.001, respectively). The values of these endpoints at position-2, position-3, and position-4 were progressively higher and ranged in between those of position-1 and position-5. Presence of ventricular capture at a 2:1 ratio to the delivered TASER impulses correlated with induction of VF. No significant metabolic changes were seen after standard NMI TASER discharge. There was no evidence of myocardial damage based on serum cardiac markers, electrocardiography, echocardiography, and histopathologic findings confirming the absence of significant cardiac effects. Standard TASER discharges did not cause VF at any of the positions. Induction of VF at higher output multiples appear to be sensitive to electrode distance from the heart, giving highest ventricular fibrillation safety margin when the electrodes are placed on the dorsum. Rapid ventricular capture appears to be a likely mechanism of VF induction by higher output TASER discharges.

Plastie abdominale après grossesse gémellaire : à propos de 30 cas

Introduction Compared to single motherhood, the twin pregnancy results in important aesthetic and functional sequelae of the abdominal wall. The considerable uterine growth involves a musculocutaneous diastasis of both the supraumbilical and the infraumbilical area. This study presents the modified abdominoplasty technique with an inverted T scar as the appropriate treatment of supraumbilical and infraumbilical musculocutaneous defects. Methods and materials This series reviews a total of 30 female patients of 35 years on average. There was no cases obesity or smoking reported. Surgical treatment consisted in a skin and fat resection following an inverted T scar design and associated to a muscle plication. In 6 patients it has been necessary to repeat the procedure in 6 months time. Results All 30 patients resolved with an aesthetic and functional improvement. No instances of abdominal diastasis recidivation occurred. Ther were no complication observed and no impact on the healing process was referred. Conclusion on of the main differences between single and gemellary pregnancies is that the second ones are concerned by an abdominal diastasis marked on both a vertical and a transversal direction. The complete surgical treatment sometimes includes a second intervention. Clinical results and luck of complications suggest that the T-type abdominoplasty associated to a muscle retightening offers an appropriate surgical treatment of patients concerned.

Laparoscopic surgical management of perforative peritonitis in enteric fever: a preliminary study.

Early surgery in enteric perforation is the only accepted form of treatment in modem day medicine and gives excellent results. Exploratory laparotomy continues to be the mainstay of surgical treatment and several different procedures are recommended in literature. Between January 1998 and November 2001, we have successfully managed 6 consecutive cases of enteric perforation laparoscopically with complete resolution of the disease. There were 4 males and 2 females in our study. The mean time of presentation to us was 38 hours after the perforation (range 22 hours to 63 hours). The mean age was 32 years (range 28 years to 43 years). All patients presented with free air under the diaphragm. A laparoscopic approach was carried out through a 10 mm supraumbilical port and two 5 mm additional ports in the midline infraumbilical area and the left iliac fossa area. Simple one layer closure of the perforation was carried out with 2-0 silk intracorporeally and the peritoneal cavity was washed out and adequately drained. All perforations were localised to the terminal ileum and were single in number. The mean operating time was 54 minutes-(range 42 to 75 minutes). All patients received parenteral ofloxacin and metrogyl. Postoperative recovery was uneventful in all patients and there were no major complications. All patients were discharged from hospital by the 4th postoperative day. Follow up over a period of 12 to 16 months revealed all patients to be in normal health. We strongly recommend a first line laparoscopic approach in all patients with typhoid perforation; as it is a safe and effective method of managing such cases.

Endoscopic omental harvest.

An omental flap is useful in reconstructive surgery, but harvesting such a flap generally requires laparotomy. However, endoscopic surgery facilitates harvesting an omental flap without open laparotomy. We performed endoscopic omental harvest in two patients. We described the procedure of endoscopic omental harvest, which is different from that reported previously. Four access ports were required: two placed lateral to the right rectus margin, one placed lateral to the left rectus margin, and one placed in the infraumbilical area. The stomach was suspended from the peritoneum for the dissection of the gastric rami. The vessels from the gastroepiploic arcade to the greater curvature of the stomach were individually clipped and divided. The omentum then was dissected to the transverse colon and the lower portion of the omentum was dissected along the transverse colon. Finally, the right side of the omentum was dissected. The omentum was transferred using the right gastroepiploic vessels for anastomosis. The advantages of endoscopic harvest are an inconspicuous scar, minimal operative pain, and early recovery. The disadvantages include a long procedure time. At the present time, endoscopic harvest of the left side of the omentum is problematic because of difficulty in identifying the left omental artery and the risk of injury to the spleen. However, these limitations will likely be resolved in the future.

Scarless infraumbilical abdominal lifting.

If liposuction considerably improves abdominal contours, notably in the infraumbilical area, the results are reduced, or imperfect, for stretched abdomens, or with older persons, whose derma contains less elastic fibers. In this last case, a tightening by cutaneous and adipose suprapubic resections is most usually necessary. This tightening becomes possible due to fixation to the pubis of the fibrous and fibrous vasculars tracts connecting the fascia to the superficial fat. After initial proportional liposuction, shift expansion of the upper half of the superficial dermoadipose level of the infraumbilical abdomen and retraction of its lower half result in a harmonious, strengthened, and tightened abdominal surface, without remaining visible scars.

Unbalanced cross circulation in conjoined twins

Case 1. This is a pair of ischiopagus tripus conjoined twins. They lvere fused face-to-face from qphoid process to the pel\is and were lying obliquely at approximately 110 degrees to one another. During the growing stage before separation, twin X became significantly malnourished in spite of having a good appetite. On the contrary, twin B looked healthy and well nourished although he ate \-cry little. Selecti\-e angiogram from the aorta of twin A showed a communicating inferior mesenteric artery (IhLA) with active blood flowing from twin .I to twin B (Fig. 1). No portal system could be seen by this aortogram in twin -4; although the portal system of twin B could be identified easily at the late phase. The systolic blood pressure was aromid 40 to 50 mm Hg in twin -I3 lvhereas it was between 68 and SO mm Hg in twin B. Urine amount was much less in twin A than in twin B. Unbalanced cross circulation with much blood flow from twin -1 to twin B was highly suspected. The separation operation was performed successfully when the twins were 2 years 2 months old and weighed 17.5 kg. A 4 mm IM.- and several 5 to 8 mm pelvic venous communications were identified and divided during the operation. ,titer the separation, blood pressures in both babies became similar, ranging between 70 and 80 mm Hg. Their urine amounts lvere also similar. Their body weights became the same 6 months later. Case 2. A pair of xiphoomphalopagus conjoined n\ins were delivered with a combined body weight of 3984 gm. The!; were joined face to face from rhe lower sternum down to the infraumbilical area. Tachypnea and tachycardia occurred in twin B from the third day after deliye?. Blood pressure was low in twin .A and high in twin B with an apparent discrimination, even though the same amountS of milk and intravenous fluid

A CASE OF HAIRY CELL LEUKEMIA PRESENTING WITH A SPLENOMA WHICH OFFERED DIFFICULTY IN DIAGNOSIS

A 52-year-old woman was seen at the hospital for close examination, because she was pointed out having a splenoma at a nearby hospital when she visited there complaining of abdominal distention. There were no fever, anemia, and jaundice. No superficial lymph nodes were palpated. In the abdomen the spleen extending from an area under the left costal arch to the infraumbilical area was palpated. Abdominal CT and echography revealed a giant splenoma with homogenous internal structure. The liver had no morphological abnormalities nor tumor shadow. No lymph node swelling was also shown. There were no hepatitis nor abnormal findings in peripheral blood (white blood cell fraction), blood biochemical tests, tumor markers, neutrophilic Al-p value, and bone marrow picture. No causative disease for the splenoma was able to be determined preoperatively, and a possibility of lymphoma arising in the spleen or leukemia was not ruled out. So, splenectomy was performed in order to diagnose and to alleviated the symptoms. The excised spleen was 1, 860 g in weight and 24.3×14.7×5.8cm in size. Pathologically it was diagnosed as hairy cell leukemia. This disease is uncommonly encountered, but we should entertain it as a probable differential diagnosis for giant splenoma. This paper presents this case with a review of the literature.