Onlay Technique Research Articles

Keyhole retrosigmoid approach without watertight dural closure - Evaluation of a minimalistic approach.

The retrosigmoid craniotomy is a versatile surgical approach to the cerebellopontine angle though cerebrospinal fluid leak remains a concern, with a reported prevalence of 0-22 %. A host of closure materials and strategies have been proposed to achieve a watertight dural closure to varying degrees of success. We review our series of keyhole retrosigmoid craniotomies and describe our simple, standardized method of closure without watertight dural closure. A retrospective review of all retrosigmoid craniotomies performed by the senior author was completed. Closure was achieved by placing an oversized piece of gelatin in the subdural space. The dura is grossly approximated. An oversized sheet of collagen matrix is placed as an overlay followed by gelatin sponge in the craniectomy defect held in place with titanium mesh. The superficial layers are approximated. The skin is closed with a running sub-cuticular suture followed by skin glue. Patient demographics, cerebrospinal fluid leak risk factors, and surgical outcomes were determined. A total of 114 patients were included. There was one case (0.9 %) of CSF leak, which resolved with placement of a lumbar drain for 5 days. The patient had one defined risk factor (morbid obesity, BMI 41.0kg/m2). Obtaining a watertight dural layer closure has been the generally accepted strategy in preventing CSF leaks in a traditional retrosigmoid approach. In keyhole retrosigmoid approaches it may not be necessary by utilizing a simple gelfoam bolstered collagen matrix onlay technique potentially improving outcome measures including operative time.

Three-dimensional radiographic assessment of the mandibular retromolar donor site in different vertical facial growth types

PurposeTo assess volumetrically, the impact of vertical facial growth types (VGFT) on the retromolar area as a bone donor site Material and methods60 cone beam computed tomography (CBCT) scans of adult individuals were classified in three groups according to their SN-GoGn angle: hypodivergent group (hG) (33.33%), normodivergent group (NG) (30%) and hyperdivergent group (HG) (36.67%). Total harvestable bone volume and surface (TBV and TBS respectively), total cortical and cancellous bone volume (TCBV and TcBV respectively) and the percentage of cortical and cancellous bone volume (CBV and cBV respectively) were evaluated. ResultsThe whole sample showed a mean TBV of 1220.99±448.81mm³ and a mean TBS of 940.29±259.93mm². Statistically significant differences were found between the different outcome variables and the vertical growth patterns (p<0.001). TBS differs for the different vertical growth patterns with the highest mean of TBS observed in the hG group. TBV also significantly differs between the different vertical growth patterns (p<0.001) with the highest mean observed for the hG individuals. Significant differences in percentages of cBV and CBV were present between the hyper-divergent groups and the other groups (p<0.001) with the hyper-divergent group having the lowest percentage of CBV and the highest percentage of cBV. Conclusionhypodivergent individuals tend to have thicker bone blocks that can be used in onlay technique while thinner bone blocks harvested from hyperdivergent and normodivergent individuals can be used in three-dimensional grafting approach.

Hypospadias preputial flap onlay technique - Step by step

To present one way of performing onlay preputial flap for hypospadias. This procedure was performed following the methodology used in one hypospadias expert center to correct hypospadias in boys who are not elective for Koff procedure and in whom Koyanagi procedure is not needed. Operative details were described, and post-operative management were given as example. Long-term results of this technique showed a 10% complication rate (dehiscence, strictures or urethral fistulas) 2 years after surgery. This video is a step by step description of the onlay preputial flap technique giving the general methodology and also the details resulting from years of practice in one hypospadias expert center.

SJLA_2024_A18: Persistent Complex Seroma Treated by Capsulectomy and Argon Beam Coagulator

Background: Seroma formation is one of the most common events following ventral hernia repair. When mesh is used for the repair of larger and more complex incisional hernias, the risk of seroma formation increases. The mesh onlay technique, which requires more extensive dissection, is associated with an even greater incidence of seroma formation. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant. Methods: The aim of this report is to present a definitive management of a very challenging case of abdominal wall chronic complex seroma following herniorrhaphy with mesh approached by open capsulectomy and scarification of the remnant pseudocapsule. Results: Our patient is a 60 years-old male a status post low anterior resection with covering loop ileostomy for rectal cancer. His diverting stoma was taken off after completing the adjuvant chemotherapy treatment. Seven months later, the patient has developed an enlarging midline incisional hernia. This hernia was subsequently repaired by primary fascial closure with suprafascial onlay polypropylene mesh. Postoperatively, he developed a subcutaneous seroma which was initially treated with an abdominal binder without success. Over the following 3 months of observation, seroma was increasing in size. Discussion: Having recovered his acute condition, surgical intervention was planned. The patient underwent an excision and evacuation of the complex seroma and pseudocapsule. A 12-cm midline incision was made in line with the previous incision used for the hernia repair. The pseudocapsule of the seroma was encountered when the subcutaneous tissue was incised. The incision was carried superior, inferior, and laterally, and the capsule was exposed. The seroma opening sinus was expanded and fluid was evacuated. There were some fibrous dead tissues and coagulated dark blood. The anterior and lateral aspects of the pseudo capsule were excised. Furthermore, the posterior aspect was cleaned carefully using the curettage instrument without affecting the integrity of the mesh which was looking healthy and intact and without causing injury to the intraabdominal contents. Argon beam coagulator was used to scarify the remaining posterior aspect attaching to the mesh. Hemostasis was secured, and the wound was closed over a Jackson–Pratt drain. A pressure dressing and abdominal binder were applied. Conclusion: Factors leading to seroma following incisional herniorrhaphy are poorly understood. Many options are available for treating complicated abdominal wall seroms. capsulectomy and scarification of the remnant pseudocapsule were good option for the treatment of persistence complex seroma.

ONLAY VERSUS RIVES-STOPPA TECHNIQUES IN THE TREATMENT OF INCISIONAL HERNIAS.

In the surgical correction of large incisional hernias, the use of a prosthesis is essential in most cases regardless of the technique chosen. The preference is for the polypropylene prosthesis. To compare the onlay and Rives-Stoppa techniques in the correction of incisional hernias, their immediate results, complications, advantages, and disadvantages. Two groups of patients with incisional hernias were analyzed, submitted to the onlay (19 patients) and Rives-Stoppa (17 patients) techniques, and that used polypropylene prostheses. General epidemiological variables, perioperative data variables, and postoperative complications were assessed. The patients' epidemiologic profile was similar between both groups. The majority were women (58.4%), with a mean age of 65.5 years and a previous mean body mass index of 41.5 kg/m². The Rives-Stoppa technique was employed in most patients (52.7%). Those submitted to the onlay technique had longer abdominal drainage time and longer hospital stay, as well as a higher incidence of seromas and surgical wound infection. The incisional herniorrhaphy technique with the placement of a pre-peritoneal polypropylene mesh by the Rives-Stoppa technique was superior to the onlay due to lower rates of drain use, hospital stay, and postoperative complications.

Ventral hernia repair surgery after abdominal gunshot wound

Gunshot wounds to the abdomen frequently result in significant damage to the abdominal organs, which is accompanied by peritonitis and the further development of different complications (anastomotic leakage, formation of abscesses, repeated bleeding, etc.), which require repeated surgical interventions that contribute to the formation of postoperative ventral hernias. The surgical management of ventral hernias is challenging due to severe adhesion in the abdominal cavity (irrespective of the time period since the injury and the last surgical interventions), the difficulties in closing massive defects of the muscle‑aponeurotic component of the anterior abdominal wall, contracture of the anterior abdominal wall, and the development of the abdominal compartment syndrome in the postoperative period. As a result, there is still some debate over the best surgical treatment for postoperative ventral hernias. Objective — to carry out a comparative analysis of open and video‑assisted laparoscopic operations for the selection of the most optimal surgical strategy for the management of ventral hernias after gunshot wounds to the abdomen. Materials and methods. We analyzed the surgical treatment of 45 wounded patients with postoperative ventral hernias that developed after operations for abdominal gunshot wounds. The patients were treated at the Military Medical Clinical Center of the Southern Region (Odesa) from 2014 to 2021; 32 of them had penetrating gunshot wounds, and 13 patients had a closed gunshot wound to the abdomen with injuries to the abdominal organs. 66.7 % of those injured had one operation on their abdominal organs, 22.2 % had two operations, 6.7 % had three operations, and 4.4 % had five operations. The size of the hernia orifices and severity of recurrence risk were determined according to the SWE classification: W1 (width of the hernia orifices up to 4 cm) — 28.9 %, W2 (from 4 to 10 cm) — 44.4 %, and W3 (over 10 cm) — 26.7 % of patients. The patients who had laparoscopic hernia repair (LHR) (IPOM‑Plus method — 17 patients, sIPOM — 2 patients) belonged to the LHR group (n = 19). The patients who had open hernia repair (OHR) (IPOM‑Plus method — 7 patients, sublay technique — 11 patients, onlay technique — 8 patients) were added to the OHR group (n = 26). The patients of both groups did not statistically differ by age, nature of a gunshot injury, number of operations before hernia repair, or hernia parameters (all p &gt; 0.05). Results. Postoperative hernias after gunshot wounds are associated with pronounced adhesions in the abdominal cavity. The mean value of the peritoneal adhesion index averaged 11.7 ± 0.7 points (from 5 to 23 points) and did not statistically differ between groups: in the OHR group — 12.4 ± 0.9 points, in the LHR group — 10.8 ± 0.9 points (p = 0.339). Laparoscopic and open hernia repair in injured patients did not differ in the frequency of intraoperative complications — 19.2 % and 15.8 %, respectively (p = 0.766). There were fewer postoperative complications (10.5 % vs. 38.5 %, p = 0.036), a shorter operation duration — 79.5 ± 6.8 min vs. 105.9 ± 4.7 min, p = 0.002, a shorter bed‑day — 8.6 ± 0.4 days vs. 10.8 ± 0.5 days, p = 0.004, and fewer patients required narcotic analgesics within the first two days after surgery (p &lt; 0.05). During the one‑year follow‑up, no hernia recurrence or adhesion signs were detected in the groups. Conclusions. In the structure of postoperative ventral hernias after gunshot wounds to the abdomen, patients with open gunshot injuries predominate and amount to 71.1 % (р = 0.007). Among them, patients with combined and multiple wounds make up 65.6 %, while those with isolated wounds make up 34.4 % (р = 0.112); 33.3 % of patients require more than one operation before hernia repair. The laparoscopic IPOM‑Plus technique should be considered the operation of choice in the treatment of hernias after gunshot wounds to the abdomen. At the same time, for extensive cosmetic defects of the anterior abdominal wall, open operations are preferable, especially the IPOM‑Plus technique. If this is technically impossible, a sublay or onlay hernia repair using the tension‑free allohernioplasty technique should be performed.

НЕКОТОРЫЕ ТЕХНИЧЕСКИЕ АСПЕКТЫ SRM АЛЛОГЕРНИОПЛАСТИКИ ПОСЛЕОПЕРАЦИОННЫХ ВЕНТРАЛЬНЫХ ГРЫЖ И ИХ МАТЕМАТИЧЕСКОЕ ОБОСНОВАНИЕ

The article presents the results of surgical treatment of 103 patients with incisional hernias of median localization. The patients were divided into three clinical groups depending upon the method of surgical treatment. The first main group consisted of 42 patients who underwent retromuscular hernioplasty with synthetic prosthesis with tapered end. The other two groups were the patients of the comparison group. The second group consisted of 19 patients in whom traditional methods of retromuscular herniaplasty were used and the third group - 42 patients in whom the traditional technique of Onlay technique was used. In all patients, a material identical in chemical structure, polypropylene, was used as prosthetic implants. When performing prosthetic hernioplasty, optimal results were obtained in the first two groups of patients with a retromuscular position of synthetic implants. This variant of prosthetic hernioplasty gave lesser relapses, promotes the best anatomical and functional restoration of the anterior abdominal wall. At the same time, the use of the developed methods for cutting out and fixing synthetic implants in patients with incisional ventral hernias reliably (p &lt;0.05) reduces serous exudation by an average of 2.53 days (from 5.88±0.13 to 3.35± 0.07), and the duration of inpatient treatment is 5.78 days less (from 18.12±1.28 to 12.34±0.92) than in the comparison group. The improvement in clinical results is due to two main reasons. Firstly, cutting out tapered synthetic implants according to the proposed technique allows using synthetic implants of a smaller area for hernia surgery, while obtaining a full restoration of the anterior abdominal wall. Secondly, the proposed method for fixing synthetic implants makes it possible to “close” the hernial defect evenly from all sides. This explains the absence of relapses in this clinical group, which contributes to an increase in the efficiency of surgical interventions in patients with incisional ventral hernias of median localization.

Comparative study between the sublay versus onlay techniques of mesh hernioplasty in case of ventral hernias

Background: Abdominal hernias are common surgical conditions that can be presented as emergency and elective surgeries. Ventral hernia repair has always been a major challenge for surgeons. The mesh hernioplasty method has been considered the golden option for preventing or minimizing the incidence of recurrence, but the question is where surgeons should place the mesh or onlay. Objective: To compare the onlay versus sublay technique for ventral hernia in terms of performance and outcome. Methodology: Prospective study (120) of patients undergoing ventral hernia repair. We collect our cases for three years from (May 1, 2017 to May 2020) and will continue until (January 2022). Sixty patients were treated with onlay mesh repair (group A) and 60 patients were treated with underlay mesh repair (group B). Data collected in both groups were performed with respect to operative time, placement, and time required for drain removal, wound infection, and recurrence rate. Follow-up was performed every three months for 24 months. Data were analyzed using SPSS version 18, Fisher's exact test as appropriate; a p-value less than 0.05 was considered statistically significant.Results: In the sublay group, seroma formation was found in two patients (3.33%), while in 12 (20%) in the onlay group. Wound infection was found in one patient (1.66%) in the sublay group and 6 (10%) in the onlay group. no septic mesh was removed in the sublayer group, one mesh was removed in the onley type. In the onlay group, recurrence was found in 4 patients (6.66%), while no recurrence occurred in the sublay group. Conclusion: Sublay mesh hernioplasty is a better alternative to onlay mesh hernioplasty for all forms of ventral hernias.

Ultra-Fine Polyethylene Hernia Meshes Improve Biocompatibility and Reduce Intraperitoneal Adhesions in IPOM Position in Animal Models.

(1) Introduction: The intraperitoneal onlay mesh technique (IPOM) is widely used to repair incisional hernias. This method has advantages but suffers from complications due to intraperitoneal adhesion formation between the mesh and intestine. An ideal mesh minimizes adhesions and shows good biocompatibility. To address this, newly developed multifilamentous polyethylene (PET) meshes were constructed from sub-macrophage-sized monofilaments and studied regarding biocompatibility and adhesion formation. (2) Methods: We investigated fine (FPET, 72 filaments, 11 µm diameter each) and ultra-fine multifilament (UFPET, 700 filaments, 3 µm diameter each) polyethylene meshes for biocompatibility in subcutaneous implantation in rats. Adhesion formation was analyzed in the IPOM position in rabbits. Geometrically identical mono-filamentous polypropylene (PP) Bard Soft® PP meshes were used for comparison. Histologic and immune-histologic foreign body reactions were assessed in 48 rats after 7 or 21 days (four mesh types, with two different mesh types per rat; n = 6 per mesh type). Additionally, two different mesh types each were placed in the IPOM position in 24 rabbits to compile the Diamond peritoneal adhesion score after the same timeframes. The biocompatibility and adhesion score differences were analyzed with the Kruskal–Wallis nonparametric statistical test. (3) Results: Overall, FPET and, especially, UFPET showed significantly smaller foreign body granulomas compared to PP meshes. Longer observation periods enhanced the differences. Immunohistology showed no significant differences in the cellular immune response and proliferation. UFPET demonstrated significantly reduced peritoneal adhesion formation compared to all other tested meshes after 21 days. (4) Conclusions: Overall, FPET and, especially, UFPET demonstrated their suitability for IPOM hernia meshes in animal models by improving major aspects of the foreign body reaction and reducing adhesion formation.

Acellular Tissue Engineered Pericardial Patch Urethroplasty: A New Horizon of Substitution Urethroplasty.

Buccal mucosal graft is the best autologous material for substitution urethroplasty. However, in cases where buccal mucosa is unavailable, a non-autologous tissue like acellular tissue-engineered pericar- dial patch can be very helpful. Our study is a small approach regarding the success and durability of acellular tissue-engineered pericardial patch as a substitution tissue in urethroplasty. A total of 22 patients underwent acellular tissue-engineered pericardial patch substi- tution urethroplasty using dorsolateral onlay technique for long segment urethral stricture, for a period of twoyears. Observations and comparison were made in terms of postoperative change in maximum urinary flowrate (Qmax), resolution of obstructive lower urinary tract symptoms, improvement in retrograde urethrogram and complications encountered, with buccal mucosal graft urethroplasty as a historical control. Out of these 22 patients, 18 patients had successful outcomes considering maximum flow rate (Qmax)> 10 mL/s on uroflowmetry, resolved obstructive lower urinary tract symptoms, and normal postoperativeretrograde urethrogram, whereas four patients were considered a failure because of Qmax <10 mL/s, unre- solved obstructed lower urinary tract symptoms and recurrence of urethral stricture on retrograde urethro-gram and development of urethrocutaneous fistula. Acellular tissue-engineered pericardial patch substitution urethroplasty can be a useful alternative to autologous tissue substitution, especially where the buccal mucosal graft is unavailable for urethroplasty.

Horizontal ridge augmentation in the anterior maxilla with in situ onlay bone grafting: a retrospective cohort study.

This study aimed to introduce a digitally guided in situ autogenous onlay grafting technique and compare its effectiveness with the conventional (ex situ) onlay technique in augmenting horizontal bone defects of the anterior maxilla. This retrospective cohort study included 24 patients who had received autogenous onlay bone grafts combined with guided bone regeneration (GBR) in the anterior maxilla. Fourteen patients were recruited into the in situ onlay grafting group (EG), and 10 were recruited into the ex situ onlay group (CG), defined by the donor sites. The clinical parameters, radiographic changes, micro-CT, and histological processes were evaluated after a mean follow-up period of 1.7years. The horizontal bone width reflected significant bone modeling over time (p < 0.001) in the first 6months. Multivariable analysis showed that the treatment modality (grouping) was a critical factor positively associated with vertical bone height alteration. However, neither the alteration rate of horizontal bone width nor the bone volume was associated with the treatment modality. The number of periosteal screws per graft positively affected horizontal contour maintenance (p < 0.05). No significant differences were observed between the groups in the clinical parameters (complications, success rate, and peri-implant parameters). The micro-CT and histological outcomes were similar between the groups. Despite the limitations of this study, in situ onlay grafting combined with GBR was an effective and reliable approach for horizontal bone augmentation in the anterior maxilla and appeared to demonstrate better stability in vertical bone remodeling. This study introduces a modified and minimally invasive technique of onlay grafting for horizontal bone augmentation. This in situ onlay grafting demonstrates superior stability in vertical bone remodeling. The trial registration number is ChiCTR2100054683.

Buccal ureteroplasty options, techniques, long-term results

Purpose of the study. Surgical treatment of extended strictures and obliterations of the ureter is still a complicated problem of modern urology. The aim of the study was to analyze our own experience of ureteral replacement plastic surgery with buccal graft, i.e buccal ureteroplasty (BU) with its extended strictures/obliterations.Patients and methods. We’ve observed 25 patients who underwent BU. The lower third of the ureter was affected in 3 (12.0 %) cases, the lower third and the mouth of the ureter was affected in 7 people (28.0 %), the middle third in 2 (8.0 %), the upper third in 5 patients (20.0 %), the combined lesion of the upper third of the ureter and the pelvic‑ureteral segment (PUS) was in 8 (32.0 %) patients. All patients underwent repeated operations on a ureter, all revealed a significant comorbid background. The surgery was performed with a tubularized buccal graft in 13 (52.0 %), the onlay technique was applied in 12 (48.0 %). Laparoscopic surgery was performed in 10 (40.0 %) patients, surgical aid was carried out in an open way in 15 (60 %).Results. Severe complications according to the Clavien‑Dindo classification, requiring hospitalization of patients in the intensive care unit with organ dysfunction, as well as lethal outcomes were absent. The follow‑up period of patients ranged from 1 to 57 months (an average of 14.7 months). One patient after laparoscopic BU with a tubular graft had a short (1 mm) stenosis in the anastomosis area for 6 months of follow‑up, which was successfully eliminated by laser endoureterotomy. During the entire follow‑up period, residual hydronephrosis was recorded in 4 patients (16.0 %) against the background of complete patency of the anastomosis. A control flexible ureteroscopy performed in 16 (64.0 %) patients did not reveal rejection of the buccal graft. There are still 20 patients under our supervision.Conclusion. Our experience shows that the implementation of BU is possible on any part of the VMP using various techniques. This operation can be regarded as the "second" line of surgical treatment of strictures and obliterations of the ureter, especially after unsuccessful attempts of other reconstructions in a group of patients with severe concomitant pathology.

Anterior substitutional urethroplasty using a biomimetic poly-l-lactide nanofiber membrane: Preclinical and clinical outcomes.

The aim of this study is to investigate the feasibility and efficacy of a novel biomimetic poly‐l‐lactide (PLLA) nanofiber membrane in repairing anterior urethral strictures from both preclinic and clinic. Biomimetic PLLA membrane was fabricated layer by layer according to the structure of human extracellular matrix. Microstructure, tensile strength, and suture retention strength were fully assessed. Before the clinical application, the safety and toxicology test of the biomimetic PLLA membrane was performed in vitro and in experimental animals. The patients underwent urethroplasty used dorsal onlay or lateral onlay technique. Then, they were followed up for 1 month, 3 months, 6 months, and then annually after the surgery. The mechanical experiments showed well property for application. Biomimetic PLLA membrane was safe according to the in vitro and animal studies. Then, a total of 25 patients (mean age 48.96 years) were included in the study from September 2016 to December 2018. After a mean follow‐up of 33.56 months, 20 patients successfully treated with biomimetic PLLA membrane. Five patients (2 bulbar and 3 penile) suffered postoperational urethral stricture recurrence. None of infection or urinary fistula or any other adverse events related to the use of biomimetic PLLA membrane were observed during the follow‐up period for all patients. The preliminary result confirmed the feasibility and efficacy of the biomimetic PLLA membrane as a novel material for anterior urethral repair. The long‐term effects with more patients should be investigated in further studies.

An observational study to compare the outcomes of onlay technique with combined onlay-plug technique of mesh hernioplasty in inguinal hernia

Background: Inguinal Hernia is a common entity in general surgical practices across the world. Its management though appears to be straightforward, could still be a nightmare for a surgeon if not dealt with proper attention and care. Lichtenstein’s mesh hernioplasty is still one of the most popular surgeries performed for inguinal hernia repair across the world. At our institute, we commonly perform this surgery with either Onlay mesh hernioplasty technique or combined Onlay-Plug mesh technique. The double mesh placement had always kept us engaged in regards to its post-operative outcomes and its advantage over single onlay mesh. We were also keen to take the subject due to the scarce availability of the recent literature.Methods: This prospective observational study was conducted in the Department of Surgery, Dr. Hedgewar Hospital, Aurangabad, Maharashtra, India on 200 patients who were randomly and equally divided into two groups. Patients in Group A underwent Onlay mesh hernioplasty surgery, while patients in Group B underwent combined Onlay-Plug mesh hernioplasty surgery. Post-operative outcomes were assessed in both groups for a period of six months.Results: There was a significant difference between the two groups in terms of post-operative pain, scrotal edema, cord tenderness, and wound infection as patients in Group 2 who underwent combined Onlay-Plug mesh repair were found to have more incidences of the above-mentioned post-operative outcomes.Conclusions: Single Onlay mesh placement is sufficient. There is no significant benefit of keeping an additional Plug/Inlay mesh in patients undergoing tension-free mesh inguinal hernioplasty as per our findings.

Compare the Efficacy and Safety between Onlay Versus Sublay Mesh Repair for Para-Umbilical Hernia

Objective: To compare the efficacy and safety between onlay mesh technique and sublay mesh technique in patients undergoing paraumbilical hernia repair. Study Design: Retrospective/Observational Place &amp; Duration: In the department of surgery, Muhammad Teaching Hospital, Peshawar and Fauji Foundation Hospital, Rawalpindi and conducted during the period from March 2021 to August 2021. Methods: A total of 166 patients with both genders having ages 18 to 65 years who were undergoing para-umbilical hernia repair were included. Patients demographic including age, gender were recorded after informed consent. Patients were equally divided into two groups Group O and Group S. Group O (83 patients) received onlay mesh technique and Group S (83 patients) received sublay technique. Outcomes such as post-operative pain, wound infection, seroma formation and hospital stay were recorded and compare the results between both groups. Results: In group O 48 (57.83%) patients and in group S 47 (56.63%) patients were females while 35 (42.17%) and 36 (43.37%) patients were males in group O and S. There was significant difference in term of post-operative pain 6.01+2.26 vs 3.58+1.44 (P-value &lt;0.05). In group O 14 (16.87%) patients and in group S 4 (4.82%) patients had wound infection. 8 (9.64%) patients in Group O and 2 (2.40%) patients in Group S had seroma. Mean Hospital stay in days was high in Group O compared to Group B 5.32+1.74 vs 2.46+1.38 days (p=&lt;0.05). There was a statistical significant difference regarding efficacy between both procedures with p-value 0.036. Conclusion: We concluded that sublay mesh technique for para-umbilical hernia repair was safe and effective with very low rate of complications as compared to onlay mesh procedure. Keywords: Paraumbilical Hernia Repair, Onlay Mesh Technique, Sublay Mesh Technique, Outcomes.

Case Report: Large bone defect reconstruction in lower extremities with ipsilateral transposition fibular graft with combined inlay and onlay technique using plate and screw fixation (fibula pro tibia technique)

Introduction: Management of large bone defect is a challenging problem. Hahns, in 1884, introduced the first use of fibula pro tibia to bridge a large defect of the tibia due to chronic osteomyelitis. In this case, we did a transposition of the ipsilateral fibular with inlay and onlay technique using a locking plate and screw into the defect of the tibia. Case presentation: A 20-year-old male came to our emergency department at RSUD Dr. Saiful Anwar, Malang, Indonesia with an open fracture grade III B of his left lower leg. We found a large defect of the tibia approximately 7.5 cm after regular wound care for ten months. Then, we performed ipsilateral transposition fibular graft with combined inlay and onlay technique using a locking plate and screw fixation. No infections occurred and there was progressive callus formation with extending ossification along the periosteal tissue in the four-month postoperative evaluation. There was no leg length discrepancy, and the union sign showed that the patient could achieve full range of movement (ROM) and walk with crutches without pain with a Lower Extremity Functional Scale (LEFS) score of 62. Discussion: Contralateral fibula graft carries a high risk of endangering the unaffected limb. The ipsilateral fibula can be utilized to replace the missing segment with minimal morbidity. The purpose of combining ipsilateral fibular transport with the inlay and onlay technique is to minimalize the gap defect between fracture fragments, therefore enhancing the union rate of the bone. Conclusion: The fibula pro tibia technique can be used as an alternative treatment option for large gap bone defects in lower extremities with minimal complication.

ONLAY VERSUS SUBLAY TECHNIQUES FOR INCISIONAL HERNIA REPAIR: 30-DAY POSTOPERATIVE OUTCOMES.

The development of an incisional hernia is a common complication following laparotomy. It also has an important economic impact on healthcare systems and social security budget. The mesh reinforcement of the abdominal wall was an important advancement to increase the success of the repairs and reduce its long-term recurrence. The two most common locations for mesh placement in ventral hernia repairs include the premuscular (onlay technique) and retromuscular planes (sublay technique). However, until now, there is no consensus in the literature about the ideal location of the mesh. The aim of this study was to compare the two most common incisional hernia repair techniques (onlay and sublay) with regard to the complication rate within the first 30 days of postoperative care. This study analyzes 115 patients who underwent either onlay or sublay incisional hernia repairs and evaluates the 30-day postoperative surgical site occurrences and hernia recurrence for each technique. We found no difference in the results between the groups, except in seroma formation, which was higher in patients submitted to the sublay technique, probably due to the lower rate of drain placement in this group. Both techniques of mesh placement seem to be adequate in the repair of incisional hernias, with no major difference in surgical site occurrences.

Comparison of Post-Operative Complications Between Sublay and Onlay Mesh Repair in Incisional Hernia

Objective: To compare the post-operative complications between sublay and onlay mesh repair in incisional hernia. Materials &amp; Methods: This randomized controlled trial was conducted at Department of Surgery, Sandeman Provincial Hospital Quetta from May 2019 to November 2019. Total 250 patients with incisional hernias for more than 3 months, having age 20-40 years either male or female were selected. Then selected patients were placed randomly into two groups i.e. Group A (Sublay group) &amp; Group B (Onlay group), by using lottery method. Patients were called for follow up 15th day for post-operative complications in term of wound infection and seroma formation. Results: The mean age of patients in group A was 34.73 ± 4.32 years and in group B was 34.51 ± 4.67 years. Out of these 250 patients, 161 (64.40%) were female and 89 (35.60%) were males with female to male ratio of 1.8:1. Wound infection was seen in 07 (5.60%) patients in group A (Sublay technique) and 17 (13.60%) patients in group B (Onlay technique) with p-value of 0.033. Seroma formation was seen in 09 (7.20%) patients in group A (Sublay technique) and 26 (20.80%) patients in group B (Onlay technique) with p-value of 0.002. Conclusion: This study concluded that rate of wound infection and seroma formation is less after sublay mesh repair for incisional hernia as compared to onlay repair. Keywords: Hernia, incisional, onlay, sublay, seroma.

Long Term Evaluation of Paraumbilical Hernioplasty by Onlay Technique

Objective: To evaluate long term results of paraumbilical hernioplasty by onlay technique. Material &amp; Methods: This prospective study was started in Jan 2017 and completed in Oct 2021. A total number of 196 patients having paraumbilical hernia were included in the study by convenient sampling. Patients with recurrent, strangulated and obstructed hernia as well as patients with ulcerated skin over the hernia were excluded from the study. All the patients were operated under general anesthesia with muscle relaxants. A non-absorbable standard prolene mesh (15x15 cm or 30x30 cm) was used and fixed with prolene 3-0 suture. Redivac drain was used over the mesh for minimum of three days. After discharge, all the operated cases were advised to visit the outpatient department after one week, one month, three months, six months, one year and two years. Maximum follow-up was two years and minimum was one year to assess the long term complication including recurrence. Demographic data along with diagnosis, complication, were collected and analyzed with Excel 2019. Results: Total 196 patients were operated for paraumbilical hernia. From which 53 were male and 143 were female. Minimum age was 18 years old and oldest patient was 78 years old. Average age was 40.19± 10 years, median age was 38 years. Seroma was seen in 04 patients. Superficial wound infection was observed in 02 patient no deep-seated infection was reported in our study. During three months of follow-up, numbness was noted in 03 patients and 02 patients had pain at the operation site during manual work. After two years recurrence was observed in two female patients, who failed to control their weight. Conclusion: Paraumbilical hernia is very common presentation in female patients. In order to prevent complication of hernia like, incarceration, strangulation and obstruction, early repair of the hernia is recommended in all the cases. Onlay mesh hernioplasty is one of the safest techniques which is relatively easy procedure, has a short learning curve with promising results. It has a low recurrence rate. Keywords: Onlay Mesh hernioplasty, Paraumbilical Hernia, PUH.

PROSPECTIVE COMPARATIVE STUDY ON OUTCOMES OF VENTRAL ONLAY BUCCAL MUCOSAL GRAFT URETHROPLASTY WITH OR WITHOUT FIBRIN GLUE.

Objectives: We described the use of brin glue in ventral onlay Buccal Mucosal Graft Urethroplasty (BMGU) in patients of bulbar urethral stricture and compared the outcome without brin glue. Methods: Sixty patients underwent bulbar urethroplasty with ventral onlay buccal mucosal graft and were included in this study. They were divided into 2 groups with 30 in each with group 1 with brin glue and group 2 without brin glue. The urethra was mobilized from the corpora cavernosa and opened along its ventral surface. The buccal mucosal graft was applied in the standard ventral onlay technique. Intraoperative evaluation included the lengths of surgery, stricture, and admission. Patients were followed up at 3 and 6 months in the outpatient department and primary outcome measures, that is, IPSS and Qmax were recorded at each follow-up along with complications if any. Results: No signicant difference was observed in mean lengths of surgery, stricture and admission, and distribution of pre-op IPSS and Qmax between the two groups. While a signicant difference was observed in distribution of IPSS and Qmax between the two groups at 3 months and 6 months follow-up. Distribution of early complications was observed at 3 weeks follow-up after surgery with a peri catheter RGU in both groups. 3 patients were presented with a leak in group 1 and 4 patients in group 2. At 3 months 2 patients were showing complications while at 6 months follow-up only 1 patient was showing complications in each group. Conclusions: The use of brin glue represents a slight but signicant step toward the perfection of the surgical technique of bulbar urethral reconstruction.