Peritoneal Patch Research Articles

Eligibility of Circumferential Fence With the Autologous Peritoneal Patch for Venous Reconstruction in Right Lobe Living-Donor Liver Transplant: A Case Control Study.

: Our aim was to evaluate the eligibility of hepatic venous drainage technique using circumferential fence with peritoneal patch graft and saphenous vein graft in right lobe living-donor liver transplant. Between November 2007 and December 2017, our center performed 1413 rightlobe living-donor liver transplants. A circumferential fence was created using the peritoneal patch graft for venous drainage reconstruction in 31 of these patients. We compared data of these 31 patients with data of 62 patients who had circumferential fence created with cryopreserved homologous saphenous vein graft (1:2 ratio). Patients with anastomotic stenosis (n = 10) and without anastomotic stenosis (n = 69) were also compared. No statistically significant differences were found between the peritoneal patch graft group and the saphenous vein graft group in terms of clinical parameters, circumferential fence diameter, and postoperative anastomotic stenosis (7.1% vs 26.1%; P = .056). Postoperative anastomotic stenosis developed in 10 patients. No statistically significant differences were found between patients with and without anastomotic stenosis in terms of clinical parameters except for diameter of circumferential fence (P = .001). Diameter of circumferential fence less than 18 mm in patients with and without anastomotic stenosis was shown in 80% and 34.6% of patients, respectively (P = .02). Stenosis-free survival in saphenous vein graft group was significantly better than in the peritoneal patch graft group (P = .023). Our correlation analyses showed a strong correlation between diameter of circumferential fence and the tenosis rate in patients (P = .001). Autologous peritoneal patch graft can be used for creating circumferential fence for hepatic outflow in living-donor liver transplant patients if no better option is available. Despite high anastomotic stenosis rates, peritoneal fencing responded well to radiologic dilatation or stent applications and provided good long-term patency.

Autologous peritoneal patch for partial portal vein resection during left hemi hepatectomy (with video)

Autologous peritoneal patch for partial portal vein resection during left hemi hepatectomy (with video)

How to deal with vascular infiltration of hepatic veins during hepatectomy for colorectal liver metastases

Vascular resection combined with hepatectomy to treat colorectal liver metastases (CRLM) has become more common to improve resectability. The difficulty of predicting the need for vascular resection has pushed surgeons to use autologous substitutes during these challenging procedures. This is the case of a 65 years-old woman scheduled for hepatectomy after neoadjuvant chemotherapy for a CRLM. CT-Scan showed a 13mm nodule in Sg7 close to right hepatic vein (RHV). Sg1-4 volumetry was 24.6%. At intraoperative ultrasonography (IOUS) metastasis was contiguous to RHV but the continuity of the hyperechoic rim of the vein indicated the integrity of the venous wall. A wedge resection of Sg7 was planned. During the parenchymal transection, the venous wall of RHV looked very thickened at site of contact with the metastasis suggesting an infiltration. After RHV clamping, e-flowIOUS showed an inverted portal flow in Sg5-S8. Because of small future remnant liver in case of right hepatectomy, we decided to perform a wedge resection of Sg7 with partial lateral resection of RHV. The vein was reconstructed by a peritoneal patch (Fig. 1). The graft was interposed by two hemicontinuous sutures of 2stiches-monofilament (6-0). At the end of reconstruction e-flowIOUS demonstrated a regular RHV flow. Operative time was 240 minutes, blood loss 180cc. At pathological examination the vein was not infiltrated. Postoperative course was uneventful. ColorDoppler on POD5 revealed regular RHV flow. Vascular resection during hepatectomy for CRLM may allow to spare liver parenchyma. Peritoneum is an easily accessible and safe substitute for reconstruction of hepatic veins.

Vascular resection during hepatectomy for liver malignancies: results from a tertiary center using autologous peritoneal patch for venous reconstruction

Vascular resection during hepatectomy for liver malignancies: results from a tertiary center using autologous peritoneal patch for venous reconstruction

Obstetric Vesicouterine Fistulas: About 26 Cases Managed at Cocody’s University Hospital (Abidjan-Cote d’Ivoire)

The aim of this work is to recall the etiopathogenic, diagnostic and therapeutic aspects of vesicouterine fistulas. This is a prospective study of 26 cases of obstetric vesicouterine fistula cared for in Cocody University Hospital Center (Abidjan, Cote d’Ivoire) between 07/09/11 and 24/04/2015. Early in the disease, patients were all in reproductive age with a different obstetrical history. The mean duration of the signs before diagnosis was 6 years. Etiologies are largely dominated by caesarean sections (69%) which four iteratives. The classic Youssef’s triad syndrome had represented 42.3%. Both hysterography and cystography were sufficient to establish the diagnosis of vesicouterine fistula in all cases. All patient underwent transperitoneal laparotomy repair. Peritoneal patch had been necessary in two cases and in four cases a hysterectomy was performed. Functional outcome was satisfactory. Vesicouterine fistula is a rare obstetric complication and very often iatrogenic. The good prognosis after repairing should not make us forget that this pathology seriously affects the quality of life of the patient. There must be a permanent and quality prevention.

Peritoneal Patch Used for Vascular Reconstruction of the Superior Mesenteric Vein Invaded by Locally Advanced Pancreatic Tumour

Peritoneal Patch Used for Vascular Reconstruction of the Superior Mesenteric Vein Invaded by Locally Advanced Pancreatic Tumour

Hepatic Vein Stenosis Developed During Living Donor Hepatectomy and Corrected with Peritoneal Patch Technique: A Case Report

An 18-year-old male living donor for his father with end-stage liver cirrhosis due to hepatitis B underwent an extended right lobe donor hepatectomy. The middle hepatic vein was visualised on the cut surface of the graft and dissected up to the confluence of the middle and left hepatic veins. After vascular clamping, right and middle hepatic veins were cut to removed the graft. While starting the stump closure, the clamp over the middle hepatic vein slipped and the vein stump sutured quickly under suboptimal exposure. Soon after this closure, the remnant liver showed increasing congestion. Intraoperative Doppler ultrasound revealed obstruction of venous outflow at the remnant left liver due to stenosis in the left hepatic vein. Under total hepatic vascular occlusion, the sutures were removed from the narrowed left hepatic vein. A 2 × 2 cm peritoneal patch from the subcostal area that was prepared to close the defect was sutured to the edges of the left hepatic vein defect. Venous congestion of the liver disappeared when the clamps were removed. Intraoperative Doppler ultrasound confirmed normal hepatic venous flow. The postoperative course of the donor was uneventful. There was no clinical, biochemical, or radiological problems at 47 months of follow-up. An autogenous peritoneal patch may be a good option to repair vascular defects, which are not suitable for primary sutures, due to easy accessibility and size adjustment, cost effectiveness, as well as relatively low risk of infection and thrombosis. Close dissection of the left hepatic vein during parenchymal transection over the middle hepatic vein can result in narrowing, particularly at the bifurcation of the middle/left hepatic veins that can cause congestion in the remnant liver. When we include the middle hepatic vein with the right graft, we now believe that dissection away from the left hepatic vein seems much more secure for donors.

The Peritoneum as a Natural Scaffold for Vascular Regeneration

ObjectiveThe peritoneum has the same developmental origin as blood vessels, is highly reactive and poorly thrombogenic. We hypothesize that parietal peritoneum can sustain development and regeneration of new vessels.Methods and ResultsThe study comprised two experimental approaches. First, to test surgical feasibility and efficacy of the peritoneal vascular autograft, we set up an autologous transplantation procedure in pigs, where a tubularized parietal peritoneal graft was covered with a metal mesh and anastomosed end-to-end in the infrarenal aorta. Second, to dissect the contribution of graft vs host cells to the newly developed vessel wall, we performed human-to-rat peritoneal patch grafting in the abdominal aorta and examined the origin of endothelial and smooth muscle cells. In pig experiments, the graft remodeled to an apparently normal blood vessel, without thrombosis. Histology confirmed arterialization of the graft with complete endothelial coverage and neointimal hyperplasia in the absence of erosion, inflammation or thrombosis. In rats, immunostaining for human mitochondri revealed that endothelial cells and smooth muscle cells rarely were of human origin. Remodeling of the graft was mainly attributable to local cells with no clear evidence of c-kit+ endothelial progenitor cells or c-kit+ resident perivascular progenitor cells.ConclusionsThe parietal peritoneum can be feasibly used as a scaffold to sustain the regeneration of blood vessels, which appears to occur through the contribution of host-derived resident mature cells.

Treatment of major vein injury with the hemostatic fleece TachoSil by interposing a peritoneal patch to avoid vein thrombosis: A feasibility study in pigs

Background:Vein lacerations in awkward locations are difficult to repair and carry high mortality. The hemostatic fleece, TachoSil, is effective in preventing intraoperative bleeding in different settings, but has not been recommended for use in large vein injury. TachoSil with a peritoneal patch interposed to avoid vein thrombosis has been reported as a method to obtain hemostasis in vein laceration, but further studies of this method are needed.Materials and Methods:A 1.5 × 1 cm defect was created in the vena cava in five pigs. A 26 × 32 mm peritoneal patch was applied on the coagulant side of a 48 × 48 mm TachoSil sheet, and used to cover the defect. Light compression with a wet sponge was applied for 3 min. No vascular suturing was performed.Results:Successful hemostasis was obtained in four out of the five pigs although the minimum TachoSil gluing zone surrounding the peritoneal patch was only 0–2 mm. The fifth pig died of hemorrhage 30 min after surgery due to a 4-mm stretch with no TachoSil gluing zone outside the peritoneal patch. At six days postoperatively the peritoneal patch was well integrated into the vein wall. After 28 days, the peritoneal patch was almost indiscernible from surrounding vein endothelium.Conclusions:Vein wall defects can be repaired using TachoSil with a peritoneal patch interposed to prevent contact between the thrombogenic TachoSil sheet and the vein lumen. An adequate TachoSil gluing zone all around the patch is essential.

Effective Hemostasis in Severe Mesenteric Vein Laceration with Tachosil(®), using a Low- or Non-thrombogenic Patch to Prevent Tachosil(®)-induced Thrombosis.

Fibrinogen- and thrombin-coated collagen fleece (FTCC) facilitates surgical hemostasis, and is of particular value during resection of parenchymatous organs. Since thrombosis may ensue if the preparation is unintentionally applied intravascularly, it has not been recommended for treating lacerations of large veins, and no previous reports describe its use in vein repair. Our observations in two patients suggest, however, that FTCC might be indicated for hemostasis in vein injury where vascular suture is difficult or not possible, provided a low- or non-thrombogenic patch is interposed to prevent FTCC-induced vein thrombosis. Our two patients had severe lacerations of the proximal superior mesenteric vein (SMV) not amenable to conventional vein repair. Rapid hemostasis was obtained without suturing using Tachosil(®), an FTCC preparation, covered with omentum. In the first patient hemostasis was obtained at the expense of vein thrombosis, apparently due to contact between the coagulant-containing side of Tachosil(®) and the inside of the vein wall. In our second patient we therefore put a small patch of parietal peritoneum on the section of the Tachosil(®) targeted to cover the vein tear to avoid direct contact between Tachosil(®) and the vein lumen. Ultrasound examination 3 days postoperatively, and autopsy 11.5 months later showed that the vein was widely patent with no stenosis or thrombus. Our observations in these two patients were that an FTCC-omentum pack alone secured rapid hemostasis in severe SMV laceration, and when a peritoneal patch was interposed between FTCC and a lacerated SMV, FTCC-induced vein thrombosis did not occur.

Coincidence of Connective Tissue Growth Factor Expression with Fibrosis and Angiogenesis in Postoperative Peritoneal Adhesion Formation

Purpose: To investigate the relationship between connective tissue growth factor (CTGF) and fibrosis and angiogenesis in postoperative peritoneal adhesion formation. Methods: Adhesions were performed in 35 rats by creation of a peritoneal patch. Animals were sacrificed at 7 different time-points over 3 weeks. Adhesions and uninjured peritoneum from all animals were assessed by Northern blotting for CTGF and collagen-I mRNA and by immunohistochemistry for CTGF localization, degree of fibrosis and angiogenesis. Results: Persistent adhesions formed in all animals. CTGF and collagen-I mRNA were increased in adhesions compared to uninjured peritoneum (p < 0.05 for both). The temporal expression pattern depicted delayed peak levels of collagen-I mRNA with increasing tendency for both transcripts at the end of the observation period. Fibrosis within adhesions correlated positively with time after surgery (r = 0.85; p < 0.001) and showed typical signs of chronic tissue fibrosis at later time points. Angiogenesis was detected in adhesions but not in uninjured peritoneum (p = 0.001) and coincided with the spatial and temporal expression of CTGF protein in fibroblasts and vascular endothelial cells. Conclusions: The co-expression of CTGF with increasing fibrosis and angiogenesis in postoperative peritoneal adhesions suggests a role for CTGF as critical molecule in fibrous adhesive disease and target for future adhesion prevention.

Expression of connective tissue growth factor in intra-abdominal adhesions.

Connective tissue growth factor stimulates fibroblast proliferation and extracellular matrix deposition in many fibrotic disorders. The aim of our study was to determine the expression pattern of connective tissue growth factor in postoperative intra-abdominal adhesions. Adhesions were created in 46 Sprague-Dawley rats by complete dissection and resuturing of a peritoneal patch 2 cm in diameter, lateral from the midline incision. Animals were killed at postoperative Days 3, 6, 9, 12, 15, 18, and 21 and the adhesions scored on a scale of 0 to 5. Tissue samples from adhesion areas and from uninvolved peritoneum were evaluated by Northern and Western blotting for temporal connective tissue growth factor mRNA and protein expression, respectively. Immunohistochemical analysis was performed for connective tissue growth factor localization. Adhesions formed in all animals after surgery and were confined to the peritoneal patches. Adhesion formation increased across time, with significant correlation between adhesion scores and postoperative days (r = 0.329, P = 0.026). Connective tissue growth factor mRNA concentrations were significantly elevated in adhesion tissue throughout the three-week period when compared with normal peritoneum (P = 0.012); peak levels occurred between Days 6 and 15. Western blots demonstrated connective tissue growth factor protein expression in adhesions from Days 6 to 21, in contrast to negligible bands in normal peritoneum. Fibroblasts within the adhesive tissue, but not in uninjured peritoneum, stained positive for connective tissue growth factor by immunohistochemistry. We have demonstrated a specific temporal and spatial expression pattern for connective tissue growth factor in intra-abdominal adhesions during a three-week postoperative time course. According to what is known about the functional role of connective tissue growth factor in fibrogenesis, our findings warrant further investigations addressing a causal relationship between this growth factor and fibrous adhesion formation.

A Novel Method for Preventing Postoperative Adhesions in the Rat Model

Despite the great efforts made to prevent postoperative adhesions, an ideal therapy is yet to be identified. The aim of the current study was to investigate the effect of intraperitoneal liquid paraffin on adhesion prevention. A peritoneal patch was excised from the right iliac fossa, and left uterine cornuectomy was performed in 24 female Sprague-Dawley rats. The raw areas and the peritoneum were painted with a cotton swab soaked in liquid paraffin in 12 rats (study group) and with a dry cotton swab in 12 (controls). After one month, both groups were subjected to a second-look laparotomy. All animals of the control group showed dense fibrous adhesions. Of the study group, two rats showed thin filmy adhesions, while the remaining 10 had no adhesions. Complications from liquid paraffin were not encountered. Liquid paraffin reduces postoperative adhesions presumably through forming a thin film over the raw area, thus giving the raw area a chance to heal and meanwhile preventing gut adhesions to it. The method is simple, easy, safe and cost-effective. Further studies are required to support the results before applying the procedure on humans.

Reconstruction of the vena cava with the peritoneum

Background: Reconstruction of the vena cava with an autologous vein requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of vena cava reconstruction using the peritoneum. Methods: A 2.5 × 2.5 cm piece of peritoneum was resected from 7 pigs weighing 30 to 40 kg. An oval window (long axis: 1.5 cm) was made in the infrarenal vena cava. This was repaired with the peritoneal patch fixed in alcohol. Results: In 2 animals sacrificed at 5 hours, there was no evidence of thrombosis, but there was fibrin clot on the patches. Two animals sacrificed on day 8 exhibited excellent patency of the vena cava. Complete endothelialization of the patch was noted at day 15. At 6 weeks, the vena cava was healed. No infections or other problems were noted. Conclusions: The peritoneum is an accessible and safe substitute for reconstruction of the vena cava.

Enterocutaneous fistula 14 years after prosthetic mesh repair of a ventral incisional hernia: A life-long risk?

THE PATIENT was an 82-year-old woman with Munchausen syndrome who had undergone multiple abdominal operations, including appendectomy, cholecystectomy, hysterectomy, bilateral salpingooophorectomy, splenectomy, adhesiolysis, and right hemicolectomy. She also had undergone three operations to repair a recurrent ventral incisional hernia. The last repair, in which Marlex mesh was used, had been performed 14 years before. In that procedure a subfascial technique was used, with the mesh being secured to the edges of the fascial defect. Tissue interposition between small-bowel loops and mesh was not possible because of a lack of omentum as a result of the prior operations. The patient had been in relatively good health for the last 14 years until she experienced spontaneous drainage of enteric contents from the midabdominal wall. She had no signs of sepsis, although she was malnourished. A fistulogram confirmed communication with the midjejunum. No mucosal irregularities were seen on the small-bowel series. A CT scan of the abdomen did not reveal any intraperitoneal collections. An 8-week trial of bowel rest, total parenteral nutrition, and somatostatin failed to spontaneously close the fistula. After the patient was nutritionally repleted, an exploratory laparotomy to resect the enterocutaneous fistula was performed. At the time of surgery, multiple adhesions were present between bowel loops . A loop of jejunum was densely adherent to the mesh, which had eroded into the bowel wall in one area (Figure). We resected this segment of jejunum, as well as all of the involved mesh, and performed a primary stapled anastomosis. The patient’s abdominal fascia was severely attenuated and, after excision of the remaining mesh, a 4 × 6-cm defect was present. The wound was closed with retention sutures, and the area of the fascial defect was allowed to heal by secondary intention. The postoperative course was complicated only by delayed return of bowel function, and the patient was discharged on postoperative day 13, tolerating a regular diet.

A Free Peritoneal Patch Does Not Affect the Leakage Rate but Increases Stricture Formation of a Cervical Esophagogastrostomy

Background: Healing of a cervical esophagogastrostomy is frequently impaired, resulting in a higher incidence of leakage and stricture formation, as compared to an intrathoracic anastomosis. Lack of mesothelial factors is hypothesized to contribute to this impaired anastomotic healing. The aim of this prospective study was to determine whether a free peritoneal patch around a cervical esophagogastrostomy can improve anastomotic healing. Methods: In 23 consecutive patients a free peritoneal patch was fixed around a cervical esophagogastrostomy. Results were compared to those of a historical control group of 41 patients. Clinical and/or radiographic leakage and stenosis requiring endoscopic dilatation were used as endpoints. Results: Three patients died in the early postoperative period (in-hospital mortality 3/64 = 5%). Leakage rate was 13% (3/23) in the group with a patch and 15% (6/41) in the control group (p = 0.90). At 6-month follow-up, the incidence of stenosis was significantly higher (65%) in the group with a patch, compared to 31% in the control group (p = 0.02). Conclusion: A peritoneal patch does not affect the leakage rate but increases the incidence of postoperative stenosis of a cervical esophagogastrostomy. Therefore, its clinical application is contraindicated.

Urologic complications after implantation of aortofemoral blood vessel prosthesis

After implantation of aorto-femoral grafts, primary ureteral lesions and secondary ureteral obstructions are the most important urological complications. Surgical repair carried out as quickly as possible, including reanastomosis without tension and covering with a peritoneal patch or omentum interposition, seems the best means of preventing secondary complications. In the case of secondary obstructions, the interval between implantation of the graft and the diagnosis of obstruction has to be considered. A wait-and-see strategy is justified in the case of early obstruction without symptoms during the 1st year because of the high rate of spontaneous remission. Obstructions that appear more than 1 year after operation or symptomatic obstructions have to be treated immediately (i.e. duodenojejunal stent, percutaneous nephrostomy). If repeated obstructions after removal of stents or nephrostomies are noted, surgical repair seems to be indicated. Stents or nephrostomies as definitive procedures are appropriate only in patients in whom surgical revision is not possible or desirable.

Short Phase Efficacy of Autologous Peritoneum as a Pericardial Substitute

The risks associated with resternotomy are largely related to loss of pericardial integrity. No satisfactory substitute for pericardium has been identified. The structural similarity between pericardium and peritoneum prompted an assessment of the latter as a biologic substitute. Two peritoneal patches were harvested from four juvenile swine, which then underwent left thoracotomies. In each pig, two pericardial defects were created and repaired with fresh and glutaraldehyde treated autologous peritoneal patches. Three weeks post operatively, the chest and abdomen were re-explored and the patches evaluated. In all cases, extrapericardial adhesions were insignificant. On gross examination of the intrapericardial surfaces, the fresh patches appeared smooth and glistening, with neither degenerative changes nor adherence to the epicardium. The treated patches were easily separated from the epicardium in two cases, but the other two patches were moderately to severely adherent. Histologic examination demonstrated well preserved morphology in all patches. C proline uptake and autoradiography revealed preserved fibroblast viability in the fresh patches. Intra abdominally, in all cases, there was complete reperitonealization without adhesion formation. In conclusion, fresh autologous peritoneum performed well as a pericardial substitute after heart surgery.ASAIO Journal1995; 41:226-229.

Short Phase Efficacy of Autologous Peritoneum as a Pericardial Substitute

The risks associated with resternotomy are largely related to loss of pericardial integrity. No satisfactory substitute for pericardium has been identified. The structural similarity between pericardium and peritoneum prompted an assessment of the latter as a biologic substitute. Two peritoneal patches were harvested from four juvenile swine, which then underwent left thoracotomies. In each pig, two pericardial defects were created and repaired with fresh and glutaraldehyde treated autologous peritoneal patches. Three weeks post operatively, the chest and abdomen were re-explored and the patches evaluated. In all cases, extrapericardial adhesions were insignificant. On gross examination of the intrapericardial surfaces, the fresh patches appeared smooth and glistening, with neither degenerative changes nor adherence to the epicardium. The treated patches were easily separated from the epicardium in two cases, but the other two patches were moderately to severely adherent. Histologic examination demonstrated well preserved morphology in all patches. C proline uptake and autoradiography revealed preserved fibroblast viability in the fresh patches. Intra abdominally, in all cases, there was complete reperitonealization without adhesion formation. In conclusion, fresh autologous peritoneum performed well as a pericardial substitute after heart surgery.

Efficacy of autologous peritoneum as a biological membrane in cardiac surgery

The risks for reoperative cardiac surgery are related to the presence of intrapericardial adhesions and the possibility of catastrophic injury at repeat sternotomy. In an attempt to develop an improved pericardial substitute and vascular patch, the feasibility of using autologous peritoneum was evaluated. Twelve mongrel dogs were studied. A peritoneal-rectus fascia patch, including the overlying posterior rectus sheath was harvested, via a lateral abdominal incision, and stored in normal saline. In the first group of six animals, a pulmonary artery (PA) window was created and then closed with the peritoneal-rectus fascia patch. In the second group a secundum atrial septal defect was created and then closed with the peritoneal patch on cardiopulmonary bypass (CPB). In each animal, the peritoneal-rectus fascia patch was used to permit pericardial closure. Autopsies performed at 90 days postoperatively revealed only slight intrapericardial adhesion formation and a mild epicardial reaction. Histological examination of the peritoneal-rectus fascia patches revealed intact morphology with active fibroblasts and smooth muscle cells. Proline 14C absorption and autoradiography detected viable cells in the implanted patches. These findings suggest that a peritoneal-rectus fascia allograft could be useful as a biological membrane, and as a satisfactory pericardial substitute in the development of strategies to reduce the risk for reoperative cardiac surgery.