Paramedian Defects Research Articles

A Dedicated Lightweight Titanized Mesh Prevents Incisional Hernias After Open Abdominal Aortic Aneurysm (AAA) Repair: Results of an Initial Prospective Cohort Study.

BackgroundIncisional hernia (IH) is a common, late complication of open repair of an abdominal aortic aneurysm (AAA), with a variable high incidence. A cohort study was conducted to investigate the role of a lightweight titanized mesh placed in the pre-peritoneal space after AAA repair. The primary endpoint was to determine the incidence of IH at eight weeks and 12 months.MethodsConsecutive patients who underwent open repair of AAA with the prophylactic implantation of a mesh after abdominal wall closure were recruited. The development of IH was evaluated using clinical examination, ultrasonography scan (USS), and computed tomography (CT) scan during the follow-up period.ResultsThirty-nine of 45 patients (34 male, 5 female, mean age 69.6 +/- 6.5 years) undergoing open repair of AAA over a five-year period via a preferred roof-top incision were analyzed for this study. One additional (2.5%) patient had the mesh explanted following a re-laparotomy for colonic ischemia and later developed an incisional hernia. There was no incidence of wound or mesh infection overall. One radiologically detected early IH closed spontaneously. There were five (12.8%) radiologically detected late cases of midline or paramedian defects beyond the one-year follow-up though this was not clinically significant; compared to this, there was no incidence of lateral defects in the wound (p<0.01, McNemar’s test).ConclusionThese preliminary results suggest that a dedicated lightweight titanized mesh is usable for primary reinforcement of rooftop incisions at the time of wound closure. Whilst this study supports the role of a mesh as a useful adjunct, larger studies and long-term follow-up would provide more sensitive assessments of its efficacy.

Laparoscopic ventral hernia repair with composite mesh: Analysis of risk factors for recurrence in 185 patients with 5 years follow-up

BackgroundLaparoscopic ventral hernia repair is widely used although its clinical indications are often debated. The aim of this study is to describe our surgical experience in order to establish the safety, efficacy, feasibility of laparoscopic ventral hernia repair and to identify the factors that influence the risk of recurrence in a group of patients treated with only one type of prosthetic mesh and by the same surgical team. Materials and methodsBetween January 2007 and December 2016, 512 patients were admitted to the General and Urgent Surgery Unit, with diagnosis of ventral hernia. Of these, 244 were operated laparoscopically and 268 in a traditional open surgery. In 244 patients treated by laparoscopy we always used a composite mesh: 185 Parietex™ Composite mesh (Medtronic-Covidien, Minneapolis, USA), the remaining other with other types of prosthetic mesh. The type and size of surgical defects, features of surgical technique, length of hospital stay, rate of conversion, morbidity, mortality, and rate of recurrence at 5 years follow-up were retrospective analysed on the 185 patients who underwent surgery with Parietex™ Composite mesh. ResultsWe performed 185 laparoscopic ventral hernia repair with Parietex™ Composite mesh: 108 (58%) for incisional hernias and 77 (42%) for primary abdominal wall hernias. Mean age was 58 years (19–80). The mean size of abdominal defect was 5 cm (1,5–18), mean BMI was 30,4 kg/m2 (21–47), mean overlap of the mesh was 5 cm (3–6). The mean operative time was 54 min (30–180) and conversion rate was 3,2%. In 61 patients (33%) we performed a transversus abdominis plane block (T.A.P. block) to reduce postoperative pain. The mean length of hospital stay was 5 days (1–26) (2 days, mean value, in patient with preoperative T.A.P. block). The mortality rate was 0%; overall morbidity was 15,6%. At 5-year follow-up we observed 13 (7%) hernia recurrences. The features of patients with recurrence were as follows: mean age 50 years (19–74), mean ASA Score 3 (2–3), mean BMI 31 kg/m2 (21–44), mean size of hernial defect 7,5 cm (larger diameter), mean overlap 4,5 cm (3–6). ConclusionsLaparoscopic repair of ventral hernia using composite mesh is an effective and safe procedure particularly suitable in the following cases: median and paramedian defects, diameter of defect between 5 and 15 cm, “swiss cheese” defects, obesity. In our experience the factors related to the patient and the surgical technique that may influence the onset of early or late recurrence as the follows: a defect size >5 cm (W2 of EHS Classification), an overlap of the mesh < 5 cm, a BMI of 30 kg/m2 or superior and the presence of significant comorbidities (ASA score: 3). Finally, we observed that the T.A.P. Block preoperative procedure can lead to reduced the clinical costs through a lower administration of analgesics used and a lower length of stay.

Forehead Reconstruction with Microvascular Flaps: Utility of Aesthetic Subunits

Current literature describes the forehead as one aesthetic subunit of the face. We argue for the usefulness of aesthetic forehead subunits when microvascular flap reconstruction is required. Key to utilization of microvascular flaps for restoration of forehead subunits is an understanding of the patient population and defect characteristics most amiable to treatment. We conducted an International Review Board-approved retrospective chart review of nine consecutive patients who had undergone free flap reconstruction for large forehead defects. The patients' foreheads included one paramedian defect; one central and paramedian defect; four central, paramedian, and lateral defects; and three lateral defects. Seven patients had ulnar forearm flaps and two had anterolateral thigh flaps. The success rate was 100%. A forehead subunit classification system has been devised that provides a suitable option for cases that benefit from distant tissue replacement in a single stage, while preserving the principles of aesthetic replacement.

MORGAGNI’S HERNIA: BELIEVING IS SEEING

The original description by Morgagni of the anterior diaphragmatic defect that bears his name implies a paramedian defect and this may be true when acquired in adulthood. In contrast, the anterior diaphragmatic defect that is observed in children is central rather than paramedian, as is often assumed. Its central retrosternal location has been confirmed by various methods, but is most clearly evident on laparoscopy.

The staircase technique for treatment of cancer of the lower lip: A report of 36 cases

Purpose: This article reports the authors' experience with treatment of lower lip cancer using the staircase technique. Patients and Methods: Thirty-six patients with stage T1 or T2 cancers of the lower lip were treated. Results: No recurrences were observed during a 6- to 32-month follow-up. All patients showed excellent aesthetic results and no microstomia. Conclusions: The staircase technique can be used to close defects of up to two thirds of the lower lip. Two bilateral symmetric flaps are used for median defects; 2 bilateral asymmetric flaps are used for paramedian defects greater than 20 mm; and only 1 contralateral flap is required for paramedian defects up to 20 mm. © 2001 American Association of Oral and Maxillofacial Surgeons

The external oblique flap for reconstruction of the rectus sheath.

Despite the availability of synthetic materials and distant fascial flaps, primary closure of ventral abdominal defects with contiguous tissues remains the preferred solution. Increased experience with such defects in the lower abdomen, particularly at the time of bilateral rectus muscle transposition, led in 1985 to the investigation of an external oblique abdominis flap for closure of the anterior rectus sheath. From October of 1985 to October of 1990, 33 patients underwent repair of bilateral lower rectus abdominis defects with the help of bilateral external oblique flaps. Each of the patients had undergone synchronous chest or breast reconstruction using a transverse rectus abdominis musculocutaneous flap including bilateral rectus muscle pedicles. Although all patients in this study had undergone double-pedicle rectus muscle procedures, not all patients having had double-pedicle rectus muscle procedures required this maneuver. External oblique flaps were performed at the time of rectus sheath repair only if fascia could not be approximated without tearing. After closure of the bilateral paramedian defect, synthetic mesh overlay was added only if the direct closure still appeared excessively tight. At the time of advancement of the external oblique muscle and fascia, the internal oblique abdominis muscle and lateral cutaneous nerve of the thigh were preserved. Of the 33 patients who underwent this procedure, 7 required the addition of mesh overlay. Thirty-two patients healed uneventfully with a remarkably solid ventral abdominal wall. One patient developed an early postoperative hernia subsequent to a major and prolonged abdominal-wall infection and abscess. Patient follow-up ranged from 1 to 36 months, with a mean of 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)

A bilateral total cleft of lip and hard and soft palate and transverse cleft face with an atypical paramedian defect of the lower lip and lower jaw on the right side: A case report of a new syndrome?

A three-month-old male baby who has a complete bilateral cleft of the lip and hard and soft palate, and a right unilateral transverse facial cleft, with an atypical paramedian defect of the lower lip and jaw is reported in detail. As these associated malformations are very rare, it may represent a new dysmorphic syndrome.