Large Muscular Defect Research Articles

Dual Application of Mesh through Hybrid Technique in Large Incisional Hernia: A Case Report

Although single mesh insertion is recommended for simple incisional hernia, there is no established treatment of choice for severe incisional hernia accompanied with large muscular defects. Single mesh insertion cannot provide sufficient mechanical force, and muscle flaps could lead to donor site morbidity while also requiring longer operation times. In this case, dual application of mesh through a hybrid technique could be a good option. A 46-year-old woman with rectus abdominis muscle defect due to previous surgery visited our clinic with abdominal bulging. Abdomen-pelvis computed tomography demonstrated a 6.5×11.5 cm rectus abdominis defect along with small bowel herniation. We decided to reinforce the existing hybrid intraperitoneal onlay mesh technique through additional insertion of suprafascial mesh to prevent recurrence and minimize complications. The patient’s abdominal contour was well preserved postoperatively for 1 year. We believe dual-layer mesh insertion through a hybrid approach could be a better alternative for severe incisional hernia with large muscle defects because of its treatment efficacy, short operation time, simple technical requirements, and absence of donor or flap complications.

Biological versus synthetic patch for the repair of congenital diaphragmatic hernia: 8-year experience at a tertiary center

PurposeThe aim of this study is to compare outcome between small intestinal submucosal (SIS) and polytetrafluoroethylene (PTFE) patches in patients with congenital diaphragmatic hernia (CDH) with large muscular defects. Material and methodsWe performed a retrospective review of prospectively collected data of patients who underwent CDH repair from January 2011 to June 2019, with a minimum follow-up of 1 year. Data were collected regarding length of stay (LOS), mortality and recurrence. Kaplan-Meier analyses was used. ResultsIn the study period, 195 patients with CDH were admitted, 176 underwent surgical repair and 19 died before surgery. Sixty-two (35%) required a patch. Over the last 5 years, our institution transitioned from the use of all SIS to all PTFE. SIS was used in 18 cases and PTFE in 25. Overall survival rate was 89% (174/195). There was no significant difference regarding LOS and mortality. Nine patients (50%) of SIS and 1 (4%) of PTFE repairs recurred (P < 0.01; log-rank test P < 0.01), with a time course of recurrence of 18 (SD = 13) and 8 months, respectively. Median follow-up was 60 months (SD: 23) for the SIS group and 26 (SD: 10) for the PTFE group. ConclusionA significant lower recurrence was found using PTFE patches instead of SIS for the repair of large CDH. Level of evidenceLevel 3. Retrospective comparative study.

Generation of a Functioning and Self-Renewing Diaphragmatic Muscle Construct.

Surgical repair of large muscular defects requires the use of autologous graft transfer or prosthetic material. Naturally derived matrices are biocompatible materials obtained by tissue decellularization and are commonly used in clinical practice. Despite promising applications described in the literature, the use of acellular matrices to repair large defects has been only partially successful, highlighting the need for more efficient constructs. Scaffold recellularization by means of tissue engineering may improve not only the structure of the matrix, but also its ability to functionally interact with the host. The development of such a complex construct is challenging, due to the complexity of the native organ architecture and the difficulties in recreating the cellular niche with both proliferative and differentiating potential during growth or after damage. In this study, we tested a mouse decellularized diaphragmatic extracellular matrix (ECM) previously described by our group, for the generation of a cellular skeletal muscle construct with functional features. The decellularized matrix was stored using different conditions to mimic the off‐the‐shelf clinical need. Pediatric human muscle precursors were seeded into the decellularized scaffold, demonstrating proliferation and differentiation capability, giving rise to a functioning three‐dimensional skeletal muscle structure. Furthermore, we exposed the engineered construct to cardiotoxin injury and demonstrated its ability to activate a regenerative response in vitro promoting cell self‐renewal and a positive ECM remodeling. Functional reconstruction of an engineered skeletal muscle with maintenance of a stem cell pool makes this a promising tool toward future clinical applications in diaphragmatic regeneration. stem cells translational medicine 2019;8:858&869

Modern concepts for the treatment of fecal incontinence.

Anal incontinence is estimated to be present in approximately 2% of the total population. However, the incidence of this disorder increases with age, affecting up to 11% of men and 26% of women after the age of 50 years. In general, the causes of long-standing fecal incontinence may be divided into anorectal or congenital malformations, perineal trauma (due to surgery or accident), pudendal nerve lesions with or without muscular injury, and low-motor neuron lesions. Classical surgical treatment includes direct repair of the circumscribed gap in the anal sphincter, the so-called overlapping sphincteroplasty or anal repair. In the short term, this method was shown to be very effective in improving continence. Surgical repair of a diffuse weakness of the pelvic floor by application of the postanal repair method has led to more controversial results. While the short-term results are frequently beneficial, full continence is rarely achieved in the long run, especially in patients with imparied pudendal nerve function. All currently used surgical methods focus on the direct mechanical approach to the pelvic floor muscles and/or the anal sphincter. Therefore, the response to this kind of therapy is limited by the presence of a simultaneously existing neurogenic lesion (pudendal nerve damage), as well as by the magnitude and intensity of muscular injury. These problems have been addressed by the development of new methods that focus on the replacement of large muscular defects (Dynamic Graciloplasty) and the treatment of neurogenic causes of fecal incontinence (Sacral Nerve Stimulation-SNS).

Persistent atrioventricular canal: Surgical experiences

Sixteen patients with common A-V canal have been operated on, the last eight by a technic of annuloplastic suture. The over-all mortality was 37.5 per cent. Of the last eight patients operated on, only one died. The factors contributing to mortality were large muscular defects of the interventricular septum, persisting mitral insufficiency and postoperative A-V heart block.