Primary Abdominal Wall Research Articles

Classification of primary and incisional abdominal wall hernias

PurposeA classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable.MethodsSeveral members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias.ResultsTo distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome.ConclusionsA classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

Gastroschisis: a third world perspective

The incidence of gastroschisis is rising worldwide. In developed countries advances in neonatal intensive care (NICU) and the availability of total parenteral nutrition have improved survival for such patients, but in the third world mortality rates remain high. The aim of this study was to evaluate the impact of modern intensive care facilities on the mortality of babies with gastroschisis in Africa. A retrospective review of all neonates admitted with a diagnosis of gastroschisis at Inkosi Albert Luthuli Central Hospital in Durban over a 6-year period (2002-2007) was conducted. A total of 106 babies with gastroschisis presented during the review period. The prevalence of gastroschisis amongst neonatal surgical admissions increased from 6% in 2003 to 15% in 2007. 72% of patients weighed less than 2.5 kg at birth and 64% were premature (<37 weeks gestation). 91% were "outborn" with 71% delivered vaginally. Median maternal age was 22.6 years and 57% of mothers were primiparous. Primary abdominal wall closure was possible in 74% of patients. The overall mortality was 43% with sepsis being the leading cause. Staged closure was associated with a higher mortality than primary closure. The prevalence of gastroschisis amongst neonatal surgical admissions appears to be increasing. Most babies were "outborn" resulting in delays in diagnosis and referral for surgical management. Despite the availability of NICU and total parenteral nutrition the mortality remains high. Reduction in mortality will depend upon improvements in antenatal diagnosis, primary care and transportation, as well as a reduction in postsurgical sepsis.

Abnormal Primary Tissue Collagen Composition in the Skin of Recurrent Incisional Hernia Patients

Recurrence of incisional hernia may be as high as 50 per cent. Abnormal collagen I/III ratios have been observed within scar tissue of patients with recurrent incisional hernias. We sought to determine whether collagen composition in primary, nonscarred tissue was similarly affected in these patients. In this prospective, case-control study, nonscarred, primary abdominal wall skin and fascia biopsies were obtained in 12 patients with a history of recurrent incisional hernias and 11 control subjects without any history of hernia while undergoing abdominal laparoscopic surgery. Tissue protein expression of collagen I and III was assessed by immunohistochemistry followed by densitometry analysis. The collagen I/III ratio in skin biopsies from the recurrent hernia group was significantly less compared with control subjects (0.88 +/- 0.01 versus 0.98 +/- 0.04, respectively, P < 0.05). Fascia biopsies from patients with recurrent hernias was not significantly decreased in collagen I/III ratio compared with control subjects (0.90 +/- 0.04 versus 0.94 +/- 0.03, respectively, P = 0.17). Decreased collagen I/III ratios within the skin of patients with recurrent hernias not involved with scar or healing tissue suggest an underlying collagen composition defect. Such a primary collagen defect, in addition to abnormal scar formation, likely plays a significant role in the pathogenesis of recurrent incisional hernias.

A biomechanical study of the reinforced tension line (RTL) – a technique for abdominal wall closure and incisional hernias

BACKGROUND: The unacceptably high rates of incisional hernia after midline laparotomy and recurrent hernia after hernia operations led us to design a new suture technique of abdominal wall closure. METHODS: During 38 autopsies we opened the linea alba exactly at the midline. On one side we inserted a suture thread in the fascia, parallel to the fascial margin. Above this, one interrupted suture each was made in the epigastrium, the umbilical region and the hypogastrium. On the contralateral side we introduced suitable interrupted sutures without a longitudinal thread. All interrupted sutures were loaded with a tensiometer until the thread tore out of the tissue. The data were evaluated statistically by means of the Mann–Whitney U-test. RESULTS: The median rupture strength on the non-reinforced side was 67.5 N and on the reinforced side, 113.3 N (p < 0.0001). With the interrupted suture the rupture was caused by the suture cutting through the tissue in 77.2% of cases, while this could be avoided in all cases on the side treated with the reinforced tension line (RTL). CONCLUSIONS: The RTL suture technique reinforces the suture base to withstand an additional tensile load of 40 N. This simple technique can be used for primary abdominal wall closure as well as for incisional hernias and should be compared in the clinical setting in prospective randomized studies with conventional techniques.

Primary abdominal wall clear cell carcinoma arising in a Caesarean section scar endometriosis

Endometriosis occurring in a surgical scar is well recognized and occurs mainly in patients with a history of hysterectomy or Caesarean section. Scar endometriosis, as well as endometriosis at other sites, can undergo malignant change. Endometrioid carcinoma is the most common malignant tumour arising in endometriosis. However, clear cell carcinoma can also occur but is unusual. To discuss the diagnosis and management of such a case. We report a case of primary clear cell carcinoma in endometriosis of a Caesarean section scar and review the literature. The patient presented with a large right lower quadrant abdominal wall mass within a Caesarean section scar. Histological examination revealed a clear cell carcinoma. The patient had a prior history of pelvic endometriosis. According to the Irish National Cancer Registry, this is the first reported case of a primary abdominal wall clear cell carcinoma developing within a Caesarean section scar in Ireland. Any lesion occurring in a Caesarean section scar with a history of previous endometriosis cannot be underestimated and warrants careful clinical follow-up and histological evaluation as appropriate.

Successful use of size-mismatched liver allografts in children by delayed primary closure of the abdominal wall.

Children who are too ill to await a liver graft of suitable size may be transplanted with a relatively oversized graft by leaving the abdominal wound partially open, the defect reduced being bridged with polypropylene mesh and the mesh reduced in stages until it can be removed and the wound directly closed. This technique has been used in seven children who received nine grafts (five reduced and four full size). Their mean age was 7.3 (range 0.5-11) months and mean weight 5.8 (range 2.3-7.2) kg. Progressive reduction in the size of the transplanted liver made primary closure possible in survivors in up to four stages. Over a follow-up period of 3 to 58 months, five of the nine grafts and five of the seven patients survived. No significant complications attributable to the technique were encountered. The technique of delayed primary abdominal wall closure may be of benefit in children at risk of graft failure because of a size-mismatched graft.

Biomechanik der Bauchdecke

Biomechanics of the Abdominal Wall In case of disturbed integrity of the abdominal wall, activities of daily life such as coughing, urination and defecation are seriously hampered. For these functions, an even contraction of all muscles of the abdominal wall is needed to increase the pressure in the inner abdominal space. This might be disturbed if the arrangement of the muscular structures is broken up. The tension in case of contraction is a great strain for the individual structures of the abdominal wall. The wellknown weak points are the groin, the navel and scar tissue, where the connective tissue tends to yield and move apart. Soft tissue ruptures in the abdominal wall are caused by tensile loadings resulting from abdominal muscle activity which the abdominal wall is not able to withstand. The anatomical features of the groin and the navel clearly show that their stress resistance is very low while the low stress resistance of scar tissue can be easily explained by its tissue consistency. Therefore, hernias occur in up to 30% of cases of primary laparotomy closures, and the treatment of incisional hernias is also associated with a high recurrence rate. Our static and dynamic studies show that even a primary abdominal wall closure after median laparotomy requires reinforcement. Furthermore, our study shows that the position of the mesh in relation to the abdominal wall structures is of secondary importance for reinforcement of the tissue (onlay versus sublay technique). However, the width of the mesh overlap is one of the determinants of a recurrent hernia. Therefore, the width should be adjusted to the size of the hernial opening. The fixation of the mesh in the tissue is also very important; nearly all recurrent hernias are caused by the mesh’s separation from the tissue.

Laparoscopic Ventral Hernia Repair: An Initial Institutional Experience

Background. Ventral and incisional hernias remain a problem for surgeons with reported recurrence rates of 25–50% for open repairs. Laparoscopic approaches offer several theoretical advantages over open repairs.Materials and methods. All patients undergoing a laparoscopic ventral hernia repair from April to December 2000 were prospectively entered in a database. Patients underwent repair with expanded polytetrafluoroethylene dual mesh. Full-thickness abdominal wall nonabsorbable sutures and 5-mm tacks were placed circumferentially.Results. Of 32 patients, 15 underwent incisional repair, 13 had repair of a recurrent incisional hernia, and 4 had repair of a primary abdominal wall defect. Two procedures [2/32; 6.3%] were converted to open, one for loss of abdominal domain and one for neovascularization due to cirrhosis. There were two early recurrences [2/30; 6.7%]. Both of these failures occurred in patients with hernia defects extending to the inguinal ligament, preventing placement of full-thickness abdominal wall sutures inferiorly. Average operating time was 128 ± 42 min (range 37–225 min). Average length of stay was 1.8 days [range 0–7 days]. There were no transfusion requirements or wound infections. One patient underwent a small bowel resection after completion of repair. One patient required drainage of a seroma 4 weeks after the procedure.Conclusions. Laparoscopic ventral hernia repair can be safely performed with an acceptable early recurrence rate, operative time, length of stay, and morbidity. Securing the mesh with full-thickness abdominal wall sutures in at least four quadrants remains a key factor in preventing early recurrence.

Use of Abdominoplasty Technique and Marlex for Closure of a Major Abdominal Wall Defect

Surgical resection of extensive primary or secondary abdominal wall tumours leads to major defects requiring reconstruction. The present case report describes the use of Marlex (polypropylene) mesh (CR Bard Inc, USA) with Mitek GII suture anchors (Mitek Products, USA) and an abdominoplasty technique to close a defect involving the entire lower half of the abdominal wall.

Intestinal atresia with gastroschisis: A selective approach to management

Background: The association of bowel atresia with gastroschisis is well recognized, but the ideal management is less certain. Methods: The records of 10 infants with gastroschisis and intestinal atresia treated between 1991 and 1997 in a single neonatal surgical unit were reviewed. Results: Ten infants had midgut atresias: 5 small intestine, 1 jejunum and colon, and 4 colonic. Of the 6 with small bowel atresias, 4 had primary abdominal wall repair with electively delayed primary anastomosis at 21 to 46 days, 1 had decompressing tube jejunostomy at 11 days at the time of secondary abdominal closure, and 1 initial jejunostomy. Of the 4 with colonic atresia alone, 3 had perforation or infarction of the proximal colon at birth, 2 had a primary stoma, and 2, who did not have initial colostomy or anastomosis, required reoperation for increasing abdominal distension at 11 and 23 days. Complications were recorded in 6 patients: 2 had necrotizing enterocolitis after which 1 developed malabsorption, 1 had distal bowel obstruction after delayed primary anastomosis treated with a Bishop-Koop ileostomy at 50 days, 2 had stoma stenosis, and 1 had stoma prolapse. None died, and at 1 year 9 were within the normal range for body weight, and details of 1 are not known. Conclusions: At birth, diagnosis of atresia often is uncertain, and the bowel is difficult to repair or exteriorize. For proximal atresias, delayed primary repair is a safe satisfactory approach. At birth, distal atresias are more obvious, often complicated by perforation or infarction, and may benefit from early enterostomy. J Pediatr Surg 35:1323-1325. Copyright © 2000 by W.B. Saunders Company.

A CASE OF SPIGELIAN HERNIA AND REVIEW OF 15 DOMESTIC CASES

Spigelian hernia is extremely rare among primary abdominal wall hernias. This report describes a case of Spigelian hernia in a 78-year-old woman, with a review of the literature. At the level of 4cm below the umbilicus, a soft bulge was observed by the lateral border of rectus abdominis muscle. By abdominal computed tomography, the aponeurosis according with the region of the bulge was defected. A Spigelian hernia was diagnosed and the patient was operated on. The hernia sac was found under the aponeurosis of external oblique muscle and reduced into the abdominal cavity. The sac and hernia opening were closed by nonabsorbable suture and the fragile portion was reinforced with a Marlex® mesh. Spigelian hernia is an abdominal hernia occurs between the semilunar line and the lateral border of rectus, and only 15 cases have been reported in the domestic literature. For the diagnosis of this disease, a confirmation of the presence of the aponeurotic defect using computed tomography is useful. For the method of treatment, a closure of the hernia opening with prosthetic meshes is available.

Management of gastroschisis with concomitant jejuno-ileal atresia

Background : The incidence of jejuno-ileal atresia in neonates concomitantly found to possess gastroschisis has been reported to be 5% to 25%. Initial treatment for this condition has not been well established. Methods : Thirteen newborns with gastroschisis and coexisting jejuno-ileal atresia, were identified and treated at our institution over the past 16 years (1978 through 1996). Patient characteristics at presentation, surgical therapy, and complications at extended follow-up were reviewed. Results : All neonates were preterm (mean gestational age, 35.2 ± 2.0 weeks) and of low birth weight (2.1 ± 0.4 kg). Atresia types II, IIIa, IIIb, and IV were identified at the initial surgical procedure in one, eight, one, and three patients respectively; however, one synchronous small bowel atresia went unrecognized. A primary anastomosis was fashioned in 8 of 13 newborns, the creation of which did not influence length of hospitalization, length of total parenteral nutrition (TPN) requirement, complication rate, or survival; however, reoperation was required in two of eight patients to mediate anastomotic complications. Atresia associated with intestinal gangrene or perforation was treated by primary anastomosis in three of six patients and the remaining three by enterostomy. Primary abdominal wall closure was possible in 10 of 13 patients; a Silon pouch was required in three. All nine survivors (69%) displayed protracted small bowel dysfunction requiring TPN (mean TPN duration of 3.6 ± 3.0 months; range, 1 to 11). Mortality in four patients was a consequence of severe prematurity, Silon pouch wound sepsis, or TPN-induced cirrhosis. Conclusions : When technically feasible, restoration of intestinal continuity by primary anastomosis is a reasonable treatment option in patients with coexisting gastroschisis and jejuno-ileal atresia. Favorable outcome is as much a function of supportive care and parenteral nutrition as the type of surgical repair performed for either the intestinal or the abdominal wall defect.

Use of Doppler ultrasonography in the evaluation of liver blood flow during silo reduction of a giant omphalocele

Despite the utility of prosthetic silo reduction techniques, surgical treatment of giant omphaloceles containing herniated liver may result in acute compromise of hepatic vascular flow. The authors report a case of an infant with a giant omphalocele containing liver, in whom hepatic vascular compromise was suspected during the course of prosthetic visceral reduction. Doppler ultrasonography performed on the herniated liver through the prosthetic silo demonstrated triphasic vascular flow in the liver as well as normal hepatic venous flow and vena caval flow, and permitted continued gradual visceral reduction and a safe, delayed primary abdominal wall closure on the seventh day of life. Doppler ultrasonography performed through the silo may be an important diagnostic adjunct during the visceral reduction phase of staged abdominal wall closure in infants with giant omphaloceles.

Gastroschisis wringer clamp: A safe, simplified method for delayed primary closure

When primary abdominal wall closure in a newborn with gastroschisis cannot be accomplished safely, placement of a reinforced Silastic silo facilitates delayed primary closure (DPC). In this report we describe our experience with the gastroschisis wringer clamp (GWC). The GWC is an autoclavable, 140-g, aluminum alloy device reminiscent of an old wringer washing machine. It consists of two apposing serrated rollers that pull the Silastic silo through a slotted base plate. This protects the intestine and converts the circular defect into a vertical slit to ease DPC. The GWC is adjusted daily on the awake newborn in the nursery and the magnitude of each adjustment is gauged by the infant's cardiac and pulmonary status. For the past 10 years we have cared for 116 newborns with gastroschisis. The average birth weight was 2,530 g (range, 1,380 to 3,300 g). Eighty-six infants (74.1%) have undergone primary closure. The remaining 30 infants (25.9%) were treated by placement of a Silastic silo and application of the GWC, forming the basis of this report. The DPC operation was performed an average of 6.7 days (range, 3 to 23 days) following the application of the silo. Extubation was usually possible prior to the DPC, with the mean length of mechanical ventilation being 3.8 days. Three patients developed serious complications including two dehiscences of the silo-fascia interface. There were no deaths in this group of 30 patients. The GWC offers many technical advantages and can be easily reversed when the infant's cardiopulmonary status deteriorates. We advocate its adoption as a method of choice in the newborn with gastroschisis who requires DPC.

Temporary closure of the abdominal wall by use of silicone rubber sheets after operative repair of ruptured abdominal aortic aneurysms

Management of patients after operative repair of abdominal aortic aneurysms can be further complicated if primary closure of the abdominal wall cannot be technically accomplished or is associated with profound increases in intraabdominal and peak inspiratory pressures. We recently treated five patients with ruptured abdominal aortic aneurysms and one patient with a ruptured thoracoabdominal aneurysm whose abdominal incisions had to be closed with a Dacron reinforced, silicone sheet. All patients were hemodynamically unstable either at admission to the hospital or became so during operation. Four patients required the insertion of a silicone rubber sheet at the primary operation because of massive retroperitoneal hematoma or edema of the bowel wall or both. Incisions in two patients were closed primarily, but the patients required reexploration and secondary closure with silicone rubber sheets because of the development of marked increases in peak inspiratory pressures, intraabdominal pressures, and decreased urinary output. Four of the six patients subsequently underwent successful removal of the silicone rubber sheets with delayed primary closure of the abdominal wall, and two others died before removal. The patient with the ruptured thoracoabdominal aneurysm died on postoperative day 20 because of pulmonary sepsis but had a healed abdominal incision. The three surviving patients have been discharged. A silicone rubber sheet may be necessary for closure of the abdominal wall after repair of ruptured abdominal aortic aneurysm in patients where primary abdominal wall closure is impossible or where it results in compromise in respiratory or renal function.

Temporary closure of the abdominal wall by use of silicone rubber sheets after operative repair of ruptured abdominal aortic aneurysms

Management of patients after operative repair of abdominal aortic aneurysms can be further complicated if primary closure of the abdominal wall cannot be technically accomplished or is associated with profound increases in intraabdominal and peak inspiratory pressures. We recently treated five patients with ruptured abdominal aortic aneurysms and one patient with a ruptured thoracoabdominal aneurysm whose abdominal incisions had to be closed with a Dacron reinforced, silicone sheet. All patients were hemodynamically unstable either at admission to the hospital or became so during operation. Four patients required the insertion of a silicone rubber sheet at the primary operation because of massive retroperitoneal hematoma or edema of the bowel wall or both. Incisions in two patients were closed primarily, but the patients required reexploration and secondary closure with silicone rubber sheets because of the development of marked increases in peak inspiratory pressures, intraabdominal pressures, and decreased urinary output. Four of the six patients subsequently underwent successful removal of the silicone rubber sheets with delayed primary closure of the abdominal wall, and two others died before removal. The patient with the ruptured thoracoabdominal aneurysm died on postoperative day 20 because of pulmonary sepsis but had a healed abdominal incision. The three surviving patients have been discharged. A silicone rubber sheet may be necessary for closure of the abdominal wall after repair of ruptured abdominal aortic aneurysm in patients where primary abdominal wall closure is impossible or where it results in compromise in respiratory or renal function.

Xiphoomphaloischiopagus tripus conjoined twins: Successful separation following abdominal wall expansion

A case of xiphoomphaloischiopagus tripus conjoined twins is reported. Particular emphasis was paid to the large abdominal wall defect that would be produced by separation, and the complications resulting from the use of intraperitoneal Silastic tissue expanders are described. As a result of adequate tissue expansion and the use of a vascularized pedicle graft from the fused limb, primary abdominal wall and pelvic closure was possible without complications of wound healing. The consistent finding of a shared lower urinary tract with one ureter from each infant entering each bladder should be anticipated in this type of twinning.

Gastroschisis: A 15-year experience

Between January 1, 1971 and December 31, 1985, 59 cases of gastroschisis were treated at Hôpital Sainte-Justine in Montreal. In the period before 1978, 6 of 19 patients (31.6%) were closed primarily at the time of surgery and 13 of 19 patients (68.4%) had silon pouch closure. After 1978, 33 of 40 patients (82.5%) had primary closure and 7 of 40 (17.5%) had a silon pouch. Our overall mortality rate was 13.6%. The complication rate for the primary closure group was 25.6% with a 12.8% (5/39) mortality rate, interestingly, in the higher birth weight group. Those closed with a silon pouch had a 75% complication rate, mostly infectious, with 15% mortality. Neither low birth weight nor gestational age influenced mortality. A significant difference in the length of hospital stay was observed. This was 33.6 days for the primary closures and 56 days for the silon pouch closures. Our series demonstrates a definite favorable trend in the results of treatment of this malformation. The most important factor affecting these results is a change in surgical approach. Primary abdominal wall closure, being usually possible, should always be attempted. We also note an association between high birth weight and death due to bowel dysmotility.

Congenital abdominal wall defects: Gastroschisis and omphalocele

Congenital abdominal wall defects: Gastroschisis and omphalocele

Primary abdominal wall abscess diagnosed by ultrasound.

Ultrasound was used to diagnose and demonstrate an anterior abdominal wall abscess of unknown cause in a diabetic woman. This condition may mimic major abdominal disorders and, in our patient, appeared as acute cholecystitis. The use of ultrasound is simple, quick, painless, and without known adverse side effects. The diagnosis may be more easily and accurately established than by routine roentgenography.