Tissue Protrusion Research Articles

Thoracic hernias: What the radiologist should know.

Thoracic hernias encompass the protrusion of thoracic contents through the thorax or intra-abdominal tissue into the thorax. They can be classified as diaphragmatic hernias - either congenital or acquired; pulmonary hernias - involving tissue protrusion through cervical fascia or intercostal spaces; and mediastinal hernias - including cardiac, intrapericardial and hiatal hernias. Prompt identification and classification of thoracic hernias rely on diagnostic imaging, primarily through computed tomography and magnetic resonance, to identify associated complications. This article comprehensively reviews thoracic hernias and their key imaging features.

Pseudochamber-Protected Keratoplasty (PPK) with a New Inter-Corneal Surgical Device Implant Technique in High-Risk Cases.

Background/Objectives: To describe the pseudochamber-protected keratoplasty (PPK) procedure with the new Endo-K Pro® implant technique and report the clinical outcomes in patients at high risk for penetrating keratoplasty (PKP). Methods: This case series study included patients who required a PKP and had a high risk for corneal transplant failure. All cases underwent the PPK procedure with simultaneous Endo-K Pro® implantation and had a minimum follow-up of 12 months. Graft survival was the primary outcome (defined as a clear graft with an endothelial cell density >500 cells/mm2). Central corneal thickness (CCT), corrected distance visual acuity (CDVA), intraocular pressure (IOP), and complication rate were the secondary outcomes. Results: Twenty-five eyes (twenty-five patients) were included. The mean follow-up was 23.64 ± 8.2 months (range: 12-36 months). Graft survival was achieved in 23 of the 25 cases (92%). One eye had to be re-transplanted due to persistent oedema secondary to uncontrolled IOP. In two cases (8%), the graft failed three months after surgery when an anterior pseudochamber collapsed due to direct contact of donor endothelium and host tissue. Six eyes experienced host tissue protrusion that was successfully managed using an Nd: YAG laser (two eyes) or injecting a cohesive viscoelastic into the pseudochamber (four eyes). CDVA increased significantly during the follow-up period. No significant changes were found in IOP. No intra- or postoperative complications were reported. Conclusions: PPK with the Endo-K Pro® implant seems to be an effective and safe surgical approach as an alternative in high-risk patients for PKP, allowing full-thickness corneal transplantation without performing an open-sky procedure.

Multifunctional hernia repair biopatch: Development, characterization, in vitro and in vivo evaluation

Incisional hernia, a prevalent postoperative complication, is characterized by the protrusion of organs or tissues through damaged abdominal wall. Predisposing factors for hernias include obesity, wound infections, immunosuppression, and comorbidities. However, hernia patches currently in use, including the commercial polypropylene (PP) patch, still have limitations in providing the mechanical and biological properties necessary for abdominal wall regeneration. In this study, three dimensional (3D) printing and coaxial electrospinning methods were combined to create a multifunctional double layered hernia repair biopatch to overcome these limitations. The double-layer design of the biopatch serves a multifunctional role in addressing incisional hernia models, with 3D printed ciprofloxacin (CIP) loaded polycaprolactone (PCL)/gelatin (Ge) scaffold (3DCIP) layer and coaxially electrospun PCL/Ge/κ-carrageenan (κ-C) nanofiber (NF) layers. While 3DCIP layers provides temporary mechanical reinforcement to the damaged abdominal wall, prevention of adhesions to internal organs, and reduction of surgical site infections, NF layer serves as tissue regeneration and fast wound healing. The developed multifunctional hernia biopatches underwent comprehensive physical and chemical characterization, followed by in vitro and in vivo evaluations. These evaluations included comparisons with a commercial PP patch, which was used as the control in the experiments. The study successfully fabricated multifunctional hernia biopatches with excellent antibacterial properties, high mechanical robustness, and strong biocompatibility.

COMPLETE REVERSAL OF TRANS-TENTORIAL AND SUB-FALCINE BRAIN HERNIATION WITH CRANIECTOMY: A SUCCESSFUL CASE REPORT

Introduction: Brain herniation, or brain code, is a critical condition caused by elevated intracranial pressure, leading to abnormal brain tissue protrusion. Chronic herniations may be linked to developmental defects and remain asymptomatic, while acute herniations are life-threatening, especially after neurosurgery. Case Presentation: A 25-year-old female with Glioblastoma multiforme presented with facial weakness. Initially suspected as Bell’s Palsy, her condition rapidly worsened, leading to coma and signs of raised intracranial pressure. A CT scan revealed a brain tumor with associated edema, hemorrhage, and multiple herniations. Emergency craniectomy and subsequent medical management showed initial improvement, but she later developed ischemia and infarction, resulting in her death. Discussion: Timely diagnosis and intervention are crucial in managing brain herniation. Clinical signs and cranial nerve assessments are vital for diagnosis. Management focuses on reducing intracranial pressure through medical and surgical means. Early intervention is key to better outcomes, though the prognosis can be poor due to underlying conditions like Glioblastoma multiforme. Conclusion: Effective management of brain herniation requires timely surgical and medical intervention. This case illustrates the rapid progression and complexity of brain herniation, emphasizing the importance of early and comprehensive treatment.

Rives-Stoppa Repair Versus Bilateral Inguinal Hernioplasty: A Comprehensive Review of Surgical Techniques and Patient Outcomes.

Hernia repair surgery is a common procedure to address the protrusion of organs or tissues through weakened muscles or connective tissue. This review compares two prominent surgical techniques for hernia repair: the Rives-Stoppa repair and bilateral inguinal hernioplasty. The Rives-Stoppa repair involves a posterior approach with extensive mesh placement suitable for complex and recurrent hernias. In contrast, bilateral inguinal hernioplasty focuses on simultaneously repairing bilateral hernias, potentially reducing operative time and enhancing recovery. This review examines each approach's technical aspects, including incision methods, mesh placement, and closure techniques. Patient outcomes, such as postoperative pain, recovery time, recurrence rates, and quality of life, are critically analyzed based on current research and clinical data. Economic considerations are also evaluated, encompassing each technique's cost-effectiveness and economic impact. By synthesizing these findings, this review aims to provide valuable insights for surgeons, healthcare providers, and policymakers in optimizing hernia repair strategies. The evolving landscape of surgical techniques and materials underscores the importance of ongoing research to refine practices and improve outcomes for patients undergoing hernia repair surgery.

Reversible Cerebral Vasoconstriction Syndrome And Fibromuscular Dysplasia: An Epiphenomenon Or A Causal Relationship?

Abstract Fibromuscular dysplasia (FMD) is a rare non-atherosclerotic arterial disease that primarily affects middle-aged Caucasian women. Carotid web (CW) is a variant of FMD characterized by a non- atheromatous, membrane-like tissue protrusion into the carotid bulb. Reversible cerebral vasoconstriction syndrome (RCVS) is defined by severe headaches and reversible narrowing of cerebral arteries, which typically resolves within three months. While most RCVS cases have identifiable triggers, a significant portion occurs without known causes. Recent studies have reported a high prevalence of neurovascular abnormalities in RCVS patients. We present a case of a thirty-year-old woman with a sudden-onset severe headache, diagnosed with RCVS associated with carotid web. The patient had no ischemic involvement and responded well to flunarizine treatment. Follow-up imaging showed no stenosis. This case highlights a potential association between carotid web and RCVS, suggesting that FMD may contribute to vascular hyperreactivity and presents as a risk factor for RCVS. Further investigations are needed to understand the underlying mechanisms connecting these two vascular disorders.

Anomalies of the Mesenchyme (Meninges and Skull)—Defects of Neural Tube Closure: Cephalocele and Other Calvarial and Skull Base Defects; Intracranial Lipomas; Arachnoid Cysts; Nonsyndromic and Syndromic Craniosynostoses

AbstractWithin the embryonic head, a layer of mesenchyme envelops the brain beneath the surface ectoderm. This cranial mesenchyme is responsible for the formation of the meninges, the calvaria (upper portion of the skull), and the scalp's dermis. Irregular development of these structures, particularly the meninges and the calvaria, is associated with notable congenital defects in humans, such as defects in neural tube closure. Anencephaly is the most common neural tube defect (NTD) and one of the most severe malformations of the central nervous system; it consists in the complete or partial absence of the brain, associated with the absence of the bones of the cranial vault. Iniencephaly is an uncommon congenital NTD characterized by abnormalities in the occipital region, including rachischisis of the cervicothoracic spine and a fixed retroflexion deformity of the head. Unlike anencephaly, in iniencephaly, there is a skull cavity and a normal-looking skin that entirely covers the head and the medullary retroflex area. Cephaloceles are congenital abnormalities distinguished by the protrusion of meninges and/or brain tissue through a naturally occurring defect in the skull bone. This anomaly is typically covered by skin or mucous membrane. Intracranial lipoma is a relatively uncommon and generally benign tumor that occurs in an abnormal location within the brain; it probably represents a disturbance of the differentiation of the primordial meninges: for unknown causes, the meningeal mesenchyme can differentiate into adipose tissue. Arachnoid cysts are sacs filled with cerebrospinal fluid (CSF) situated between the brain or spinal cord and the arachnoid membrane. Typically, these cysts originate within CSF cisterns and gradually expand their boundaries. Craniosynostosis is the early fusion of one or more cranial sutures. It can occur spontaneously, be associated with a syndrome, or have a familial connection. It can involve one or multiple cranial sutures. Pfeiffer's, Crouzon's, and Apert's syndromes are among the more prevalent syndromic craniosynostoses.

A Comparative Study of Elective Sublay Versus Onlay Repair for Non-complex, Small, and Medium-Size Incisional Hernia: Post-operative Complications in a Tertiary Hospital in Ranchi, India.

The most difficult hernia surgery is the repair of the ventral hernia, which is caused by aberrant organ or tissue protrusions through the abdominal wall. Factors like obesity, smoking, and chronic medical conditions contribute to their formation. Surgical strategies have evolved from anatomical repair to mesh hernioplasty, with mesh placement playing a significant role in outcomes. The ideal anatomical location for mesh placement remains debated due to varying results. So, the objective of the study is to compare early postoperative complications, surgical site infection, and incidence of recurrence between sublay and onlay mesh placement repair of incisional hernias of <10 cm in diameter, at a tertiary hospital in Ranchi. This retrospective comparative study was conducted over a period of January 2022 to January 2024 at the Rajendra Institute of Medical Science, Ranchi, India. During the study period, 96 patients were operated on, and their demographic details, along with their position of mesh placement and postoperative complications (seroma formation, wound infection, postoperative hospital stays, and recurrence), were retrieved from the hospital data. Comparisons between onlay and sublay groups in terms of post-operative complications were made. Within the study period, a total of 96 patients were operated on for incisional hernia. In this study, 36 (37.5%) were male and 60 (62.5%) were female, with a male-to-female ratio of 0.6:1. Out of the total number of patients, 56 (58.4%) had a past history of emergency surgery. It was observed that there was a higher incidence of seroma formation in the onlay group compared to the sublay with a statistical significance p-value of 0.027. The incidence of wound infection was found to be statistically significant (p-value = 0.035) between the onlay and sublay groups. In a period of six-month follow-up, three patients of the total study population had an incidence of recurrent incisional hernia, of which two from the onlay group and one from the sublay group were present, and there was no statistical significance (p-value > 0.5). Based on our retrospective analysis, we can say that there is a lower incidence of postoperative complications and recurrence in sublay repair, along with a shorter postoperative hospital stay, making it a preferred method of repair over onlay.

Zooplankton studies warn abnormal protrusions on the copepods from coastal environments under anthropic impacts

Faced with a global scenario where the etiology of abnormal tissue protrusions in copepods and their ecological consequences are unclear, it is crucial to seek a better understanding about these abnormalities. In this study, supported by images confocal laser microscope, scanning electron microscopy and histological analysis, the levels and distribution of morphological abnormalities in copepods were analysed. The analysis of zooplankton samples from Todos-os-Santos Bay showed the occurrence of two types of abnormalities on the body surfaces of copepods. The images clearly showed that the abnormalities in the prosome were formed between the somites from a rupture of the intersomatic membrane, causing a process of herniation of the internal tissues, with part of the digestive tract projected outside the body. Abnormalities in the urosome observed by scanning electron microscopy showed continuity of the copepod intestine, forming a rectal prolapse. Overall, this study highlights a significant reduction in indices of zooplankton community structure and abnormal tissue protrusions, evidencing a pathological condition in copepods from coastal environments under anthropic impacts.

Flap Necrosis After Large Myelomeningocele Repair Using Good Wound Care and Secondary Intention: Case report

Abstract Myelomeningocele (MMC) is the commonest type of neural tube defect; it represents a protrusion of neural tissue from a bony defect. Treatment of myelomeningocele depends on the size of the defect; with small ones, reconstruction with primary closure or local single flaps may be sufficient, while large (more than 5-8 cm) defects require more complicated reconstructive techniques. Flap necrosis is a major complication of large myelomeningocele repair. In our case, we discuss a new proposed method in post-surgical flap necrosis management based on good wound care, wound coverage, and healing by secondary intention

Comparative Clinical Implications of Calcified versus Non-Calcified Tissue Protrusion After Coronary Stent Implantation.

The prognostic implications of calcified versus non-calcified tissue protrusions (TPs) following stent implantation remain undetermined. This study aimed to evaluate the differential clinical outcomes associated with calcified and non-calcified TP morphologies. Employing intravascular ultrasound (IVUS), we identified calcified TPs as calcium fragment extrusions permeating the stent struts, while non-calcified TPs were characterized as plaque and/or thrombus extensions through the stent into the arterial lumen. The primary endpoint encompassed target lesion failure (TLF), comprising cardiac death, target vessel myocardial infarction, clinically driven target lesion revascularization (TLR), or stent thrombosis, assessed in patients with a follow-up period exceeding one year. Of 1033 patients subjected to pre- and post-intervention IVUS, 62 exhibited calcified TPs (6.0%), and 279 presented non-calcified TPs (27.0%), forming the basis of this analysis. Multivariable linear regression indicated calcified nodules as a significant predictor of calcified TP [Odds Ratio (OR) 2.47; 95% Confidence Interval (CI) 2.33 to 2.62; P <0.001], with ST-segment elevation myocardial infarction emerging as an inverse correlate [OR 0.82; 95% CI 0.73 to 0.93; P = 0.004]. Two-year data revealed a higher incidence of TLF in patients with calcified TPs versus their non-calcified counterparts (11.3% vs 2.2%, P <0.001), and a marked increase in clinically driven TLR (9.7% vs 1.4%, P <0.001). Calcified TPs were independently correlated with increased TLF risk in the adjusted model [Hazard Ratio (HR) 2.47; 95% CI 1.17 to 5.16; P = 0.027]. After drug-eluting stent implantation, IVUS-identified calcified TPs correlate with adverse clinical outcomes compared to non-calcified TP formations.

Clinical Significance of Coronary Healed Plaques in Stable Angina Pectoris Patients Undergoing Percutaneous Coronary Intervention.

Coronary healed plaques (HPs) reportedly have high vulnerability or show advanced atherosclerosis and a risk of rapid plaque progression. However, the prognosis of stable angina pectoris (SAP) patients with HPs undergoing percutaneous coronary intervention (PCI) remains under-investigated. We analyzed 417 consecutive lesions from SAP patients undergoing pre- and post-intervention optical coherence tomography (OCT) for which HPs were defined as having a layered appearance. We investigated the differences in clinical and lesion characteristics, and post-PCI outcomes between HPs and non-HPs. To account for differences in clinical characteristics, propensity score matching was performed between the groups. HPs were observed in 216 lesions (51.8%) in the total cohort. In the propensity-matched cohort (n=294), HPs had higher rates of angiographic-B2/C lesions (77.6% vs. 59.2%, P<0.001), OCT-lipid-rich plaques (40.8% vs. 25.9%, P=0.007), macrophages (78.2% vs. 44.2%, P<0.001), greater luminal area stenosis (73.5±11.0% vs. 71.5±10.3%, P=0.002), and a higher prevalence of post-stenting irregular tissue protrusion (45.1% vs. 14.7%, P<0.001) than non-HPs. In the total cohort, target lesion revascularization (TLR)-free survival was poorer for HPs (log-rank test 7.66; P=0.006), and Cox proportional hazards analysis showed HP as an independent predictor of TLR (hazard ratio, 5.98; 95% confidence interval, 1.72-20.82; P=0.005). In SAP patients, HPs had greater complexity of lesions and higher vulnerability, which may have contributed to the poorer post-PCI outcomes.

Delayed diagnosis and management of a congenital intranasal meningoencephalocele in a 24-year-old male

Background: Intranasal meningoencephalocele is a rare congenital malformation. It is defined by protrusion of cerebral tissue and meninges through a defect in the skull base. Serious complications usually occur in early childhood, however, symptoms occasionally can wait until adulthood. Case Presentation: We report a case of a 24-year-old male who had a congenital intranasal meningoencephalocele with recurrent episodes of bacterial meningitis. After a delayed diagnosis, he eventually underwent Endoscopic Endonasal Repair of Meningoencephalocele via 'Bath-plug' technique. Conclusions: To prevent improper management, it is crucial that ENT colleagues, to whom these cases are primarily present, are well informed about this unusual condition. For the purpose of preventing further neurological problems, thorough neuroimaging evaluations and successful surgical repair are important. The 'Bath-plug' technique for anterior skull base cerebrospinal fluid leak repair is effective for a wide range of situations.

Current Surgical Management of the Inguinal Hernias

Definition: Inguinal hernias are characterized by the protrusion of tissues through a weakness in the abdominal wall in the inguinal region. They are divided into direct and indirect hernias, with anatomical differences influencing the choice of surgical technique. Types of Hernias and Surgical Management: The surgical approach is based on individual and symptomatic considerations. Asymptomatic hernias may be observed, while symptomatic ones usually require intervention. Mesh repair is a common technique, with both open and laparoscopic repair options. The choice is based on the patient's anatomy and the surgeon's experience. Complications: Despite progress, recurrences remain a concern. Careful selection of technique and attention to mesh placement can reduce this rate. Postoperative complications, such as infections and chronic pain, are also concerns to consider. Discussion: The discussion focuses on the choice between open and laparoscopic repair techniques. Adaptation to the patient's individual conditions, such as age and comorbidities, is essential. Research and innovation continue to play a crucial role in improving outcomes and preventing complications. Conclusions: The surgical management of inguinal hernias is a balance between tradition and innovation. Collaboration between surgeons and constant research are critical to advancing the field. The individualized approach and continuous improvement of techniques and materials will continue to provide patients with a better quality of life and more positive outcomes in the future.

An Endoscopic Endonasal Attempt at Pediatric Meningoencephalocele Repair.

Meningoencephalocele is an abnormal skull base protrusion of fluid, brain tissue, and meninges that can lead to nasal obstruction, meningitis, and Cerebrospinal Fluid (CSF) rhinorrhea. This condition can be managed operatively through an open craniotomy or a less invasive endoscopic approach. Here, we report a case of an 18-month-old female who presented with a meningoencephalocele that was part of the Sakoda complex, a rare neurosurgical phenomenon consisting of meningoencephalocele, agenesis of the corpus callosum, and cleft lip/palate. The patient was initially treated with the endoscopic transsphenoidal approach with subsequent open craniotomy.

A Nasal Columellar Base Stabilizing Suture Technique.

To achieve a more aesthetic and narrower columella, most of the required changes concern the middle and base of the columella. Narrowing and reshaping the columellar base require a sequential approach with good anatomical knowledge and aesthetics analysis. The columellar base is a three-dimensional structure that must be analyzed following three axes: transverse (thickness or width), frontal (height), and sagittal (nasolabial angle). Sutures that aim to close the distance between the medial crura footplates frequently result in modifying the nasolabial angle because of caudal protrusion of the columellar soft tissue. Methods to keep an adequate nasolabial angle are needed. A transverse columellar base stabilizing suture acting on these three axes, which enables maintenance of results after columellar base management, is described in this article.

The Height and Mobility of Protruding Plaque After Carotid Artery Stenting Are Associated with Postoperative Ischemic Lesions.

Tissue protrusion (TP) is a possible cause of cerebral infarction after carotid artery stenting (CAS). Using optical frequency domain imaging (OFDI) and angioscopy, we investigated the relationship between the morphological features of TP and postoperative new ischemic lesions on magnetic resonance imaging (MRI)-diffusion weighted imaging (DWI) after CAS. Fifty patients who underwent CAS and subsequent poststenting intravascular evaluation using both OFDI and angioscopy were included. CAS was performed for proximal protection via the femoral artery approach, and intravascular evaluation with OFDI and angioscopy were performed after stent placement. We compared the background and poststenting intravascular findings between patients with and without postoperative new ischemic lesions on MRI-DWI. TP was observed in 42 patients (84%), and postoperative new ischemic lesions on MRI-DWI were observed in 32 patients (64%). The frequency of TP did not differ between the 2 groups, but the height of TP was higher in the DWI-positive group (0.62mm vs. 0.29mm, P=0.0028), and mobile TP was observed only in the DWI-positive group. The height of TP (P= 0.023) was an independent predictor of new periprocedural ischemic brain lesions after CAS, and its cut-off value for mobility was 0.55mm on the receiver operating characteristic curve (area under the curve, 0.93). The height of TP on OFDI and mobile-TP on angioscopy after CAS were associated with postoperative new ischemic lesions on MRI-DWI. The intravascular evaluation using OFDI and angioscopy could be helpful for a detailed evaluation of TP.

Dumanian Technique for Repair of Complex Incisional Hernias

Incisional hernia is protrusion of tissue at or near the site of an incision from a previous surgery. It is a challenging procedure to repair complex incisional hernias. Most of the numerous reconstructive techniques are unable to achieve goals of hernioplasty owing to various factors being planar mesh impose the risk of pain and infection whereas conventional suture repairs can fail due to suture pull through, rupture or slipping of knot. The open components separation technique (CST) creates large undermining skin flaps especially useful in patients with complex hernias who require judicial approximation of the midline fascia. Another novel technique for repair of such hernias is the Dumanian Technique : using mesh as a suture material and has been shown to improve the ultimate tensile strength (UTS) and thus prevent surgical failure. Both the techniques are implemented in our case to achieve successful abdominal closure.

Ultrasonography of the Explanted Uterus in Placenta Accreta Spectrum: Correlation With Intraoperative Findings and Gross Pathology.

To better understand placenta accreta spectrum (PAS) by correlating postoperative ultrasonographic findings of the explanted uteroplacental interface with intraoperative findings and gross pathology. We enrolled consecutive pregnant patients aged 18 years and older with a prior cesarean delivery and antenatal diagnosis of lower uterine segment PAS who planned to undergo hysterectomy into this prospective, descriptive study. All underwent cesarean hysterectomy with standardized intraoperative photography. Ultrasonography of explanted postsurgical uteruses was performed by expert radiologists to obtain standard detailed images of the myometrial-placental interface and other areas of interest. Sagittal views of the gross pathologic specimen were photographed. We correlated the intraoperative, ultrasonographic, and gross pathologic findings as a study team and report four consistent patterns that emerged from this systematic evaluation. Thirty-four consecutive eligible patients were enrolled. The following consistent observations emerged: 1) The uteroplacental interface in the explanted specimen was smooth and distinct. At the point of maximal placental protrusion, the myometrium was imperceptible, but the placenta was confined by a smooth thin echogenic line of uterine serosa (the scar shell) unless surgically disrupted. 2) Every specimen of PAS grade 2-3 showed placenta bulging through the lower uterine segment in the region of prior hysterotomy. 3) Placentas extended to, but not through, the uterovesical interface or scar shell. Dense adhesive disease was found between the placenta and bladder. There were no cases of true bladder invasion. 4) Placental extension beyond the serosa (invasion) has a distinct appearance on postoperative ultrasonography with irregular frond-like protrusion of placental tissue. This appearance was always the result of surgical manipulation and was not present before delivery of the neonate. These findings suggest that PAS severity is likely mediated by progressive scar dehiscence and uterine remodeling, not placental invasion. This challenges the existence of in situ invasive percreta as it is currently described.

Recurrent Spigelian Hernia: case report

The protrusion of adipose tissue, peritoneal sac or abdominal viscera in the anterolateral region of the abdomen can configure the so-called Spigelian hernia. A 53-year-old patient with comorbidities is admitted for reoperation of Spiegel's hernia. Aging and the presence of obesity, multiparity and previous surgery may have predisposed the appearance of this type of hernia. For recurrence, obesity may have been a contributing factor, although factors related to the surgical procedure and the hernia itself should also be considered. Spiegel's hernia is a rare abdominal hernia whose treatment is surgery, bearing in mind the risks of recurrence and the possibilities of mitigating them.