Midline Abdominal Incision Research Articles

Implementation of the small bites closure of abdominal midline incisions in clinical practice is correlated with a reduction in surgical site infections.

Small steps wound closure of midline laparotomy has been reported to decrease the incidence of incisional hernia development in two randomized controlled trials. The aim of the present study was to evaluate the effect of implementing the small steps wound closure technique in clinical practice with regards to the development of incisional ventral hernia (IVH) and surgical site infections (SSI) in clinical practice. Implementation of the small steps wound closure technique using the small tissue bites technique as the standard closure technique for abdominal midline incisions in our clinical practice was done in March 2015. For this study, all patients from June 2013 until June 2016 with a midline laparotomy, either long or small in case of specimen extraction in laparoscopic surgery, in either elective or emergency setting were included. Conventional large bite wound closure was compared to small steps wound closure with regards to the development of SSI, IVH as well as burst abdomen. A total of 327 patients were included. The small steps suture technique was used in 136 (42%) of the patients, whereas the conventional large bites suture technique was used in 191 patients (58%). A total of 54 patients in the large bites group developed SSI (28%) compared to 23 (17%) patients in the small steps group (p = 0.02). A total number of 10 patients (7%) developed IVH in the small steps group compared to 27 patients (14%) in the large bites group (p = 0.08). Implementation of small bites wound closure of abdominal midline incisions in clinical practice was correlated with a reduction in surgical site infections.

Atrophy of the Rectus Abdominis After Left-Side Donor Hepatectomy: Comparison of Upper Abdominal Midline vs Mercedes Incision

ObjectiveThis study of living liver transplant donors compared postoperative atrophy of the rectus abdominis after an upper abdominal midline incision vs a Mercedes incision. MethodsA total of 110 donors underwent left-side donor hepatectomy in our hospital from 2007 to 2016. We analyzed the postoperative computed tomography data of 102 cases 3, 6, and 12 months after surgery. Donors were categorized as having a midline incision (MID group, n = 39) or a Mercedes incision (MER group, n = 63). The rectus abdominis was assessed on computed tomography images, and the percentage of muscle thickness (PMT) was compared in the 2 groups. ResultsPatient age, sex, and body mass index did not differ in the 2 groups. Laparoscope-assisted hepatectomy was only performed in the MID group, while open hepatectomy was performed mainly in the MER group. The mean PMT of the rectus abdominis did not change 3, 6, and 12 months after surgery in the MID group but decreased to 80%, 76%, and 72% of the baseline value in the MER group 3, 6, and 12 months after surgery, respectively. The PMT values were significantly lower in the MER group than in the MID group at all 3 time points (P < .001). In the MER group, rectus abdominis atrophy was significantly worse on the right side than on the left. There was no significant difference in morbidity between the 2 groups. ConclusionIn living donor liver transplant, the Mercedes incision resulted in significantly greater atrophy of the rectus abdominis in donors compared with the midline incision.

Effect of Adding Dexmedetomidine to Bupivacaine in Ultrasound Guided Rectus Sheath Block: A Randomized Controlled Double-blinded Study

Background: Extended midline laparotomy incision is accompanied by intense pain postoperatively which affects patients’ physiology; therefore, good control of postoperative pain is mandatory to decrease the adverse effects on the body. Ultrasound-guided Bilateral Rectus Sheath Block (BRSB) is one of the options to achieve this goal. Objective: The study aimed to assess the analgesic potency of adding dexmedetomidine to bupivacaine in ultrasound-guided BRSB in cancer patients with a midline laparotomy incision. Methods: Sixty adult cancer patients planned for laparotomies with extended midline incision were included. Ultrasound-guided BRSB was performed immediately after the induction of anesthesia. Patients were classified randomly into two groups; B group, where only bupivacaine was used for BRSB and BD group in whom a mixture of bupivacaine and dexmedetomidine was used. Results: A significant decrease in visual analogue scale scores, total morphine consumption, postoperative nausea and vomiting and postoperative cortisol levels was observed in group BD. Conclusion: Dexmedetomidine as an adjuvant to bupivacaine in US-guided rectus sheath block bilaterally proved to be effective for proper pain management postoperatively in cancer patients after extended midline abdominal incision.

Incisional negative pressure wound therapy does not reduce surgical site infections in abdominal midline incisions: a case control study

Purpose: There is evidence from various surgical specialties that incisional negative pressure wound therapy (iNPWT) might reduce postoperative surgical site infections (SSIs). In visceral and general surgery, there is varying evidence of its efficacy in reducing surgical site infections.Methods: A prospectively registered patient cohort of 43 patients with abdominal wall and visceral surgery received treatment with iNPWT and was compared to a matched retrospective cohort to analyze its effects on SSI occurrence and respective risk factors. Groups were matched by procedure, sex, body mass index and age. We used two different systems of iNPWT: (i) PREVENATM or (ii) self-made epicutaneous iNPWT from common VAC material.Results: We could not find a total reduction in postoperative SSIs by application of iNPWT. But within the iNPWT cohort, patients with self-made iNPWT suffered more often from SSIs compared to the commercial iNPWT subgroup. No patient specific risk factors could be identified to advocate the use of iNPWT.Conclusion: Our data do not support the use of an incisional negative pressure wound therapy on closed wounds in midline laparotomy incisions. Although, differences exist between the commmercial and self-made systems.

Dynamic creep properties of a novel nanofiber hernia mesh in abdominal wall repair.

Incisional hernia is the most common complication following abdominal surgery. While mesh repair is common, none of the current meshes mimic the physiology of the abdominal wall. This study compares suture only repair with polypropylene mesh and a prototype of a novel implant (poly-epsilon-caprolactone nanofibers) and their influence on the physiology of an abdominal wall in an animal model. 27 Chinchilla rabbits were divided into six groups based on the type of the implant. Midline abdominal incision was repaired using one of the compared materials with suture alone serving as the control. 6weeks post-surgery animals were killed and their explanted abdominal wall subjected to biomechanical testing. Both-hysteresis and maximum strength curves showed high elasticity and strength in groups where the novel implant was used. Polypropylene mesh proved as stiff and fragile compared to other groups. Poly-epsilon-caprolactone nanofiber scaffold is able to improve the dynamic properties of healing fascia with no loss of maximum tensile strength when compared to polypropylene mesh in an animal model.

Single injection ultrasound-guided rectus sheath blocks for children: Distribution of injected anesthetic.

Single injection ultrasound-guided rectus sheath blocks are used for postoperative analgesia after midline abdominal incisions, but the ultrasonographic spread of medication posterior to the rectus muscle has not been investigated. The primary goal of this study was to determine the ultrasound-measured medication spread superiorly and inferiorly after single injection ultrasound-guided rectus sheath blocks and to calculate the incidence of cases with spread up to the subcostal margin and below of umbilicus. The secondary goals were to correlate the spread with the volume of medication administered and with the patient's age, weight, height, sex, and body mass index. Pediatric patients who underwent single injection ultrasound-guided rectus sheath blocks and underwent data collection of ultrasonographic information on medication spread along the plane of the posterior rectus sheath were identified retrospectively from an acute pain service database at UPMC Children's Hospital of Pittsburgh. Sixty-eight children, 10.2±4.2 (mean±SD) years old, 41.7±17.9kg, 140±24.6cm, had complete data collection. Mean injected volume of ropivacaine was 8.3±2.8mL (right) and 8.2±2.8mL (left). The average spread was measured as 3.9±1.4cm (right) and 3.4±1.3cm (left) cranial to the umbilicus, and 1.5±1.6cm (right) and 1.6±1.4cm (left) caudal to the umbilicus. Complete spread up to the level of the subcostal margin was observed in 52.9% (n=36; right) and 36.8% (n=25; left) of cases. The spread correlated closely with the volume of injected ropivacaine (right: 0.556, P<0.001; left: 0.541, P<0.001). The spread below umbilicus was 70.6% (n=48, right) and 80.9% (n=55, left). There was a positive strong correlation (P<0.001) between total medication spread and age (right: 0.608; left: 0.538), weight (right: 0.600; left: 0.540), and height (right: 0.593; left: 0.526). After single injection ultrasound-guided rectus sheath blocks, incomplete cephalocaudal medication spread can be expected within the posterior rectus sheath.

Heterotopic Ossification in the Abdominal Wall after Exploratory Laparotomy

Heterotopic bone formation in abdominal incisions is a recognized but uncommon sequela of abdominal surgery. On the other hand, the formation of ectopic bone is a well-recognized complication following arthroplasty of the hip. Heterotopic ossification of midline abdominal incision scars is a subtype of myositis ossificans traumatica. Ectopic bone formation of midline abdominal incisions may cause regional pain or discomfort in the patient after surgery. If symptomatic, treatment is complete excision with primary closure. Radiologically, it is important to distinguish this benign entity from postoperative complications. We report a 69-year-old male who underwent exploratory laparotomy for traumatic small bowel perforation. A segment of abnormal hard tissue was found in the abdominal wall. Heterotopic ossification may occur at various sites and is a recognized but infrequent sequela of exploratory laparotomy. This case highlights clinical and etiological features of this finding.

Midline preperitoneal repair for incarcerated and strangulated femoral hernia

ObjectiveFemoral hernias constantly present as incarceration or strangulation and require emergency surgery. Incarcerated and strangulated femoral hernia repair remains challenging and controversial. The aim of our study was to analyze the efficacy of preperitoneal tension-free hernioplasty via lower abdominal midline incision for incarcerated and strangulated femoral hernia.MethodsData of 47 patients who underwent emergency surgery for incarcerated or strangulated femoral hernias from January 2009 to December 2017 were retrospectively analyzed. According to the surgical incisions, they were divided into two groups: the observation group (21 cases) had a lower abdominal midline incision, and the control group (26 cases) had a traditional inguinal incision. General data of patients, intraoperative findings, operative time and postoperative complications were compared.ResultsPatient characteristics showed that the two groups were comparable.15 cases (31.9%) underwent intestinal resection, and 32 cases (68.1%) underwent first-stage tension-free repair in total. The rate of first-stage tension-free hernioplasty was significantly higher in the observation group (18/21, 85.7% vs 14/26 53.8%, P = 0.020). No additional incision was required in the observation group, while six cases of the control group (23.1%) had an additional incision for intestinal resection and anastomosis (P = 0.026). Mean operative time (53.6 ± 24.7 min vs 77.9 ± 36.5 min, P = 0.012) and the length of hospital stay (6.3 ± 4.2 days vs 10.3 ± 6.9 days, P = 0.020) were significantly shorter in the observation group. The time of return to normal physical activity resulted significantly reduced compared to the control group (9.2 ± 4.1 days vs 13.3 ± 6.6 days, P = 0.017). The total incidence of postoperative complication (including chronic pain, foreign body sensation, hernia recurrence, wound infection and seroma/hematomas) in the observation group was lower (14.3% vs 42.3% P = 0.037). There were two recurrences in the control group. No mesh-related infection and no mortalities in two groups.ConclusionsMidline preperitoneal approach for incarcerated and strangulated femoral hernia is a convenient and effective technique. It can improve the rate of first-stage tension-free repair of incarcerated femoral hernia and allow intestinal resection through the same incision, and with lower rate of postoperative complications.

Analysis of Risk Factors for Incisional Hernias and its Management

Introduction: Incisional hernia is a common problem after abdominal surgery. Patients present with pain, swelling and intestinal obstruction. It may be repaired by either anatomical suturing or mesh repair.Methods: It is a prospective observational study conducted in Western Regional Hospital and Fewa City Hospital, Pokhara from 2013 to 2016. A total of consecutive 100 patients admitted in these hospitals during the study period were included.Results: Incisional hernia is more common in females (M : F = 1 : 3.8), and in 30 - 50 years age group (60%). Major risk factors were wound infection (30%), overweight (25%), and postoperative cough (10%). It is found to be more associated with gynecological (65%), than gastrointestinal operations, and more so with lower abdominal midline incision (65%). It is found to occur mostly within one year (60%) of primary surgery than later. Even 24% of the patients had first symptom within six months. Mesh repair (92%) was the preferred standard surgical treatment for incisional hernia.Conclusion: Overweight females of age range between 30 - 50 years with history of gynecological operations by lower abdominal midline incision are more prone to develop incisional hernia. This incidence increases when there is wound infection. Mesh repair is the choice of operation for incisional hernia. J-GMC-N | Volume 11 | Issue 01 | January-June 2018, Page: 16-20

562 Effect of liraglutide on streptozotocin-induced diabetic rat testis

The global prevalence of diabetes mellitus is on rise. Diabetes is associated with changes in testicular tissue and thus affecting reproductive functions. Liraglutide is a glukagon-like peptide-1 receptor agonist and stimulates insülin secretion. The present study is the first to investigate the effect of liraglutide on testis histology and reproductive parameters in streptozotocin-induced diabetic rats. Twenty seven mature male Sprague-Dawley rats were randomly divided into three gropus, i.e, healthy control, diabetic control and liraglutide-treated diabetic rats. Diabetes was induced by two doses of streptozocin in a 3 day period (30 mg/kg; i.p). Treatment group was enjected with liraglutide (Novo Nordisk, Denmark) enjections (0.3mg/kg/12 h s.c) for 12 weeks. Animals were anesthetized by ketamine (60mg/kg/i.p) and xylazine (7.5mg/kg/i.p). Serum levels of total testosterone, LH and FSH were analysed by sandwich enzyme immunoasey method. Testicular tissues were dissected out of a whole via midline abdominal incision and underwent to histological analyses. Testicular damage, apoptosis and neovascularisation were also evaluated by VEGF and Bcl-2 using immunohistochemistry methods.

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in patients with previous lower abdominal surgery.

We have performed laparoscopic totally extraperitoneal (TEP) repair for inguinal hernia repair for the last 20years. We use two balloon dilators (sphere and kidney type) to dissect the preperitoneal space for the TEP repair. It may be difficult to obtain exposure in patients who previously underwent lower abdominal surgery, because of adhesions to the abdominal wall. We reviewed our experience with inguinal hernia repairs to retrospectively analyze factors that limit the laparoscopic TEP approach. From 2006 to 2016, 313 patients (281 men and 32 women) underwent laparoscopic TEP inguinal hernia repair at Yuki Hospital. The medical records of these patients were reviewed, and data for patients who previously underwent lower abdominal surgery were analyzed. Eighty-four patients previously underwent lower abdominal surgery including appendectomy (N = 23), inguinal hernia repair [N = 45; including contralateral TEP repair (N = 26), ipsilateral anterior approach (N = 11)], and laparotomy with a lower abdominal midline incision (N = 22). TEP repair was successfully completed in 75 patients (75/84; 89%) and the procedure changed in nine patients to an anterior approach (N = 5), or transabdominal preperitoneal (TAPP) repair (N = 4). The reasons for changing the procedure included difficulty to develop the operative field (N = 5), violation of the integrity of the peritoneal envelope (N = 2), and intraoperative bleeding (N = 2). Seven patients had a contralateral inguinal hernia after TEP repair. The majority of patients with an inguinal hernia and previous lower abdominal surgery underwent successful laparoscopic TEP repair. There is no need to avoid the laparoscopic TEP approach, even in patients with a history of previous lower abdominal surgery. However, patients after TEP repair of a contralateral inguinal hernia may be at increased risk for peritoneal injury and the approach may need to be changed.

To Mesh or Not To Mesh? That Is the Question!

To Mesh or Not To Mesh? That Is the Question!

Diaphragm Function Before and After Neuromuscular Blockade in Rats

Neuromuscular blocking agents (NMBA; e.g., rocuronium bromide; ROC) are used during general anesthesia to inhibit nicotinic acetylcholine receptors and paralyze the diaphragm. Diaphragm function is inferred using the “train‐of‐four ratio” via electrical stimulation of a peripheral nerve. Since the diaphragm is clinically inaccessible, few studies have directly evaluated diaphragm function post‐reversal by NMBA. The current agent of choice for reversal of NMBA is neostigmine. However, neostigmine has multiple side effects such as hypotension, arrhythmia, and respiratory distress. Sugammadex (SUG) is a newer drug that inhibits ROC via direct encapsulation and is purported to have fewer side effects. We developed a model to assess diaphragm contractile function and oxygen levels in the rat using direct electrical stimulation of the phrenic nerve. The purpose of this study was to evaluate diaphragm contractile function and tissue oxygen levels before, during, and after administration of ROC and SUG. Female Sprague‐Dawley rats (n=6, 269 ± 3 g) were anesthetized with sodium pentobarbital (50 mg/kg, ip). A tracheal cannula was inserted to permit mechanical ventilation. Catheters were placed in the right common carotid artery for tracking arterial pressure and obtaining blood gases, and in the right jugular vein for administration of anesthetic and drugs. A midline abdominal incision was made to expose the diaphragm. The central tendon was cut and the left phrenic nerve was sectioned. Stimulating electrodes were placed on the right phrenic nerve. The central tendon of the right hemidiaphragm was connected to a load cell interfaced with a muscle tension analyzer. The right hemidiaphragm was stimulated via the phrenic nerve (1Hz, 6V) and partial pressure of oxygen in the interstitial space (PiO2; phosphorescence quenching) and contractile function were measured simultaneously. Contractile function and PiO2 were allowed to reach a new steady state after administration of both ROC and SUG. At the onset of diaphragm stimulation, PiO2 fell from 52 ± 3 to 21 ± 4 mmHg, while tension increased from resting (5.1 ± 0.3 g) to 17.4 ± 2.7 g during twitch contractions. Administration of ROC abolished twitches and tension fell rapidly to 4.0 ± 0.6 g within 30 ± 5 s. Concomitantly, PiO2 rose to 46 ± 3 mmHg over 224 ± 18 s. Reversal of ROC with SUG resulted in a restoration of twitch tension to 14.7 ± 2.2 g over 80 ± 13 s and a fall in PiO2 to 22 ± 4 mmHg over 144 ± 16 s. Once the new steady state was achieved, phrenic nerve stimulation was stopped and PiO2 recovered to 46 ± 4 mmHg over 225 ± 40 s. Throughout the experiment mean arterial pressure and heart were unaffected by either ROC or SUG. These results demonstrate the sugammadex effectively reverses the effects of rocuronium and rapidly restores diaphragm contractile function without impairing tissue oxygen levels or mean arterial pressure.Support or Funding InformationSupported by a grant from the KCOM Graduate Program Committee.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

MP26-14 ROBOT ASSISTED RETROPERITONEAL LYMPH NODE DISSECTION OF POST CHEMOTHERAPY RESIDUAL MASS – A SINGLE CENTER EXPERIENCE OF 18 PATIENTS

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2018MP26-14 ROBOT ASSISTED RETROPERITONEAL LYMPH NODE DISSECTION OF POST CHEMOTHERAPY RESIDUAL MASS – A SINGLE CENTER EXPERIENCE OF 18 PATIENTS AMITABH SINGH, Jiten Jaipuria, Saroj Baidya, Raghubir Bhardwaj, JALAJ JAIN, and Sudhir Rawal AMITABH SINGHAMITABH SINGH More articles by this author , Jiten JaipuriaJiten Jaipuria More articles by this author , Saroj BaidyaSaroj Baidya More articles by this author , Raghubir BhardwajRaghubir Bhardwaj More articles by this author , JALAJ JAINJALAJ JAIN More articles by this author , and Sudhir RawalSudhir Rawal More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.872AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Retroperitoneal lymph node dissection (RPLND) is a well-established treatment for post chemotherapy residual mass in non-seminomatous germ cell tumor (NSGCT) as it has diagnostic as well as therapeutic advantage. Although the open RPLND is gold standard, but due to high postoperative morbidity and poor cosmesis due to long midline abdominal incision laparoscopic retroperitoneal lymph node dissection (L-RPLND), robot assisted laparoscopic retroperitoneal lymph node dissection(RA-RPLND) has been described. The proposed advantages of RA-RPLND are good cosmesis, shorter hospital stay, less post-operative pain and reduced compilation rate. We describe our experience of robot assisted retroperitoneal lymph node dissection (RA-RPLND) and comparison to historic cohort of L- RPLND in terms of surgical, pathological and oncological outcome. METHODS A total of 18 patients underwent RA - RPLND between September 2011 to September 2017 in our Institute. Study was started on January 2015 so data were collected retrospectively and prospectively regarding demography of patients, tumor characteristic, surgical, pathological and oncological outcomes. Short term and medium term outcomes were also recorded RESULTS Mean age of patients was 28 years and mean body mass index was 21.51 kg/m2. RA - RPLND was successfully completed in all 18 patients. Mean console time, estimated blood loss and length of hospital stay were 180.78 min, 207.89 ml and 4.31 days respectively. The mean yield of lymph node was 20. Matted lymph nodal mass was found in 4 patients and one patient had only single large retroperitoneal para-aortic mass of size 8.5x6x4.5 cm. In 10 patients modified RPLND was done and in 1 patient only large para-aortic post chemotherapy mass was excised. Out of 18 patients, 15 patients underwent nerve preserving RPLND. Only 12 patients of nerve preserving RPLND have antegrade ejaculation. Histopathological examination revealed necrosis in 14 patients whereas mature teratoma was noticed in 4 patients with one of these showing sarcomatoid differentiation too. After mean follow up period of 19.5 months, no retroperitoneal recurrence was reported. 6 patients developed chyle leak in immediate post-operative period, of these 2 patients were managed conservatively with dietary modification and octreotide, 2 patients underwent lymphangiogram and embolization and another 2 patients underwent exploratory laparotomy and ligation of cysterna chyli. CONCLUSIONS RA - RPLND is safe and feasible for post chemotherapy residual mass with acceptable complication rate. Ours is a largest reported series till date. In literature authors have mentioned series of 7-8 cases. Though larger studies are required to establish its diagnostic and therapeutic utility © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e342 Advertisement Copyright & Permissions© 2018MetricsAuthor Information AMITABH SINGH More articles by this author Jiten Jaipuria More articles by this author Saroj Baidya More articles by this author Raghubir Bhardwaj More articles by this author JALAJ JAIN More articles by this author Sudhir Rawal More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Optimized wound closure using a biomechanical abdominal model.

Suturing techniques for midline abdominal wall incisions vary between surgeons. This study uses a biomechanical abdominal model to assess tissue stretch using different suturing techniques for midline laparotomy closure. Deformation tests were performed on the linea alba of 48 porcine abdominal walls. Each pattern was tested three times at pressures ranging from 0 to 20 kPa using different continuous suturing techniques and a control. There was a sevenfold improvement when the best performing bite separation and bite width ([5, 16] mm) was compared with the most poorly performing combination ([15, 4] mm). The traditional bite and width separation ([10, 10] mm) and the recently proposed combination ([5, 5] mm) may not be optimal, and substantial improvements in surgical outcome may be achieved by changing to a [5,16]-mm combination. These findings suggest using a small bite separation (5 mm) and large bite width (16 mm) during abdominal wound closure may be optimal. Surgical relevance Suturing techniques for midline abdominal wall incisions vary between surgeons. This experimental study suggests substantial potential for improved tissue apposition by changing the suturing approach from the traditional clinical recommendation of 10 mm for both bite separation and bite width to a bite separation of 5 mm and a bite width of 16 mm. These findings support recent European Hernia Society guidelines and the recent randomized STITCH (Suture Techniques to Reduce the Incidence of The inCisional Hernia) trial, which found that small separations are more effective than large separations, but suggest that they should be combined with large bite depths.

Peri-operative Rectus Sheath Fentanyl-levobupivacaine Infusion vs. Thoracic Epidural Fentanyl Levobupvacaine Infusion in Patients Undergoing Major Abdominal Cancer Surgeries with Medline Incision

Background and Objectives: The gold standard for acute postoperative pain management in major abdominal surgeries is thoracic epidural analgesia (TEA) and this was proved by a lot of studies, systematic reviews and metaanalyses. However, TEA is sometimes contraindicated and may cause serious risks. Rectus Sheath Block (RSB) is effective for the abdominal surgeries with midline abdominal incisions as local anesthetics will be injected within the posterior rectus sheath bilaterally leading to intense pain relief for the middle anterior wall extending from the xiphoid process to the symphysis pubis. The aim of the study was to assess intra and post-operative RSB versus intra and post-operative TEA, in patients undergoing elective major abdominal cancer surgery with midline incisions. Methods: This randomized, blinded, was registered at www.clinicaltrials.gov at no.: “NCT03460561” and was approved by local ethics committee of South Egypt Cancer Institute, Assiut University, Egypt. One hundred adult patients, (ASA grade II and III), scheduled for major elective abdominal cancer surgery with Medline incision, were randomly divided into two groups, (50 patients each); TEA group: patients in this group received TEA with standard GA and intra-operative analgesia was started before skin incision by injecting epidural bolus dose of 0.1 ml/kg of (0.125% levo-bupivacaine+fentanyl 2 μg/ml). Postoperative analgesia was provided through PCEA by injecting a bolus dose of 3 ml then continuous infusion of 0.1 ml/kg of mixture of (0.0625% levo-bupivacaine+fentanyl 2 μg/ml) for 48 hours postoperative. RSB group: patients in this group received standard GA plus ultrasound (U/S) guided rectus sheath block by a volume of 20 mL of (0.25% levo-bupivacaine+fentanyl 30 μg) in saline on either side. Before end of surgery and before closure of abdominal wall, bilateral surgically placed catheters in rectus sheath plane aiming to provide post-operative analgesia using the following; 20 mL of (0.125% levo-bupivicaine+Fentanyl 30 μg) every 12 hours in to each catheter for 48 hours. Perioperative hemodynamics (MAP and HR) were recorded. Postoperative pain was assessed over 48 hour post operatively using (VAS). Total fentanyl consumption, Peak expiratory flow rate (PEFR), postoperative and side effects of the drugs and duration of ICU and hospital stay were recorded. Results: We found a significant reduction in VAS pain scores (at rest and during cough) in both group at all postoperative period but fentanyl consumption was significantly lower in TEA group. Also we found a significant reduction in intra-operative hemodynamics (mean arterial pressure and heart rate) in TEA group in comparison to RSB group while there was minimal statistically significant reduction in postoperative MAP and heart rate. The incidence of other postoperative complications such as sedation, nausea and vomiting were comparable in both groups. Conclusion: Rectus sheath block was not inferior to thoracic epidural analgesia in reduction of pain intensity after major abdominal cancer surgeries, and associated with hemodynamic stability along the 48 hours postoperative without procedure related adverse events or decreasing PEFR.

Creation of a Rodent Model of Abdominal Aortic Aneurysm by Blocking Adventitial Vasa Vasorum Perfusion

The adventitial vasa vasorum (VV) provides oxygen and nourishment to the aortic wall. Hypoxia in the aortic wall can cause enlarged abdominal aortic aneurysms (AAAs). This article introduces and describes a standard protocol used to induce AAAs through adventitial VV hypoperfusion created with a combination of polyurethane catheter insertion into the aortic lumen and suture ligation of the infrarenal abdominal aorta. The protocol involves the use of male rats weighing 300-400 g, which are provided food and water ad libitum. After laparotomy with a ventral midline abdominal incision, exfoliation of the aorta is performed, which blocks blood flow from the perivascular tissue. Aortotomy involving a small incision adjacent to the renal artery branches is performed, and a polyurethane catheter is inserted using an 18-gauge indwelling needle. After repairing the incision, tight ligation of the aorta over the catheter blocks VV blood flow from the proximal direction through the aortic wall without disturbing the aortic blood flow. This technique can induce an AAA with progressive aortic dilatation. The greatest benefit of this model is that VV hypoperfusion causes tissue hypoxia and the development of an infrarenal AAA, which has morphological and pathological characteristics similar to those of a human AAA.

Creation of a Rodent Model of Abdominal Aortic Aneurysm by Blocking Adventitial Vasa Vasorum Perfusion.

The adventitial vasa vasorum (VV) provides oxygen and nourishment to the aortic wall. Hypoxia in the aortic wall can cause enlarged abdominal aortic aneurysms (AAAs). This article introduces and describes a standard protocol used to induce AAAs through adventitial VV hypoperfusion created with a combination of polyurethane catheter insertion into the aortic lumen and suture ligation of the infrarenal abdominal aorta.The protocol involves the use of male rats weighing 300-400 g, which are provided food and water ad libitum. After laparotomy with a ventral midline abdominal incision, exfoliation of the aorta is performed, which blocks blood flow from the perivascular tissue. Aortotomy involving a small incision adjacent to the renal artery branches is performed, and a polyurethane catheter is inserted using an 18-gauge indwelling needle. After repairing the incision, tight ligation of the aorta over the catheter blocks VV blood flow from the proximal direction through the aortic wall without disturbing the aortic blood flow. This technique can induce an AAA with progressive aortic dilatation.The greatest benefit of this model is that VV hypoperfusion causes tissue hypoxia and the development of an infrarenal AAA, which has morphological and pathological characteristics similar to those of a human AAA.

Surgical site infection and its associated factors following cesarean section: a cross sectional study from a public hospital in Ethiopia

BackgroundA cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby. Surgical site infections are a common surgical complication among patients delivered with cesarean section. Further it caused to increase maternal morbidity, stay of hospital and the cost of treatment.MethodsHospital based cross-sectional study was conducted to assess the magnitude of surgical site infection following cesarean Site Infections and its associated factors at Lemlem Karl hospital July 1, 2013 to June 30, 2016. Retrospective card review was done on 384 women who gave birth via cesarean section at Lemlem Karl hospital from July 1, 2013 to June 30, 2016. Systematic sampling technique was used to select patient medical cards. The data were entered by Epi info version 7.2 then analyzed using Statistical Package for Social Sciences windows version 20. Both bivariate and multivariate logistic regression was done to test association between predictors and dependent variables. P value of < 0.05 was considered to declare the presence of statistically significantly association.ResultsAmong 384 women who performed cesarean section, the magnitude of surgical site infection following cesarean section Infection was 6.8%. The identified independent risk factors for surgical site infections were the duration of labor AOR=3.48; 95%CI (1.25, 9.68), rupture of membrane prior to cesarean section AOR=3.678; 95%CI (1.13, 11.96) and the abdominal midline incision (AOR=5.733; 95%CI (2.05, 16.00).ConclusionsThe magnitude of surgical site infection following cesarean section is low compare to other previous studies. The independent associated factors for surgical site infection after cesarean section in this study: Membranes rupture prior to cesarean section, duration of labor and sub umbilical abdominal incision. In addition to ensuring sterile environment and aseptic surgeries, use of WHO surgical safety checklist would appear to be a very important intervention to reduce surgical site infections.

The Analgesic Efficiency of Ultrasound-Guided Rectus Sheath Analgesia Compared with Low Thoracic Epidural Analgesia After Elective Abdominal Surgery with a Midline Incision: A Prospective Randomized Controlled Trial.

BackgroundUltrasound-guided rectus sheath blockade has been described to provide analgesia for midline abdominal incisions. We aimed to compare thoracic epidural analgesia (TEA) and rectus sheath analgesia (RSA) with respect to safety and efficacy.MethodsSixty patients who underwent elective laparotomies through a midline incision were assigned randomly to receive either continuous TEA (TEA group, n = 31) or intermittent RSA (RSA group, n = 29). The number of patients who required analgesia, the time to first request analgesia, the interval and the cumulative morphine doses consumption during 72 hours postoperatively, and pain intensity using visual analog score (VAS) at rest and upon coughing were reported in addition to any side effects related to both techniques or administered drugs.ResultsWhile 17 (54.84 %) patients were in the TEA group, 25 (86.21%) patients in the RSA group required analgesia postoperatively, P = 0.008. Cumulative morphine consumed during the early 72 hours postoperatively median (interquartile range) = 33 mg (27 - 39 mg), 95% confidence interval (28.63 - 37.37 mg) for the TEA group. While in the RSA group, it was 51 mg (45 - 57 mg), 95% CI (47.4 - 54.6 mg), P < 0.001. The time for the first request of morphine was 256.77 ± 73.45 minutes in the TEA group versus 208.82 ± 64.65 min in the RSA group, P = 0.031. VAS at rest and cough were comparable in both groups at all time points of assessment, P > 0.05. The time to the ambulation was significantly shorter in the RSA group (38.47 ± 12.34 hours) as compared to the TEA group (45.89 ± 8.72 hours), P = 0.009. Sedation scores were significantly higher in the RSA group, only at 12 hours and 24 hours postoperatively than in TEA group, with P = 0.041 and 0.013, respectively. The incidence of other morphine-related side effects, time to pass flatus, and patients satisfaction scores were comparable between both groups.ConclusionsContinuous TEA had better opioid sparing effects markedly during the early 72 hours postoperatively than that of intermittent RSA with catheters inserted under real-time ultrasound guidance, both had comparable safety perspectives, and RSA had the advantage of early ambulation. RSA could be used as an effective alternative when TEA could not be employed in patients undergoing laparotomies with an extended midline incision, especially after the first postoperative day.