Transversalis Fascia Research Articles

Management Of Inguinal Hernias In Adults In Mulongo: A Local Anesthesia Approach

Introduction: Inguinal hernia, passage through the transversalis fascia of a peritoneal diverticulum, is a common condition often requiring surgical intervention. It represents one of the most frequent reasons for consultation in surgery, with a worldwide incidence estimated at 4.6% of the population. Objective: Describe the epidemiological, clinical aspects and therapeutic modalities of sublocal hernia repair of inguinal hernias in adults in the territory of Mulongo. Materials and Methods: This descriptive cross-sectional and prospective study was conducted during a campaign of free general surgery operations in Mulongo, Haut-Lomami, DRC, between June 1, 2021 and December 31, 2021. Local anesthesia with xylocaine was used. The parameters evaluated were frequency, age, sex, anatomoclinical type, type of anesthesia and postoperative evolution. Results :A total of 162 patients were included. The mean age was 41.5 years (range: 18-70). There were 90.7% men, the sex ratio was 9.8. The hernia was simple in 95.6% of cases and located on the right in 50% of cases. In 4.4% of cases the hernia was operated on urgently (strangulated and engorged and painful). Postoperative pain was the most common postoperative complication found in 54.9% of cases. Conclusion: The management of inguinal hernias in adults in Mulongo is often carried out under local anesthesia, due to the high prevalence of this pathology in the professional context of patients. Inguinal hernia thus remains a significant problem in this region, justifying adapted approaches such as local anesthesia

"Deep rectus sheath block" or "anterior transversalis fascia block"? Investigating the mechanism of a novel ultrasound-guided technique.

"Deep rectus sheath block" or "anterior transversalis fascia block"? Investigating the mechanism of a novel ultrasound-guided technique.

Etiopathogenesis of oblique inguinal hernia, new concept of its surgical treatment, postoperative complications and their correction

Objective. To study the results of applying a new conceptual approach to the surgical treatment of oblique inguinal hernia in order to reduce the frequency of its recurrence and preserve the function of the male reproductive system. Materials and methods. The study is based on the results of topographic and anatomical examination of 50 unfixed male cadavers on the 1st day after death. As clinical material, 144 patients who were inpatients in the surgical department were involved in the study. Results. Patients of the main group (n=71) underwent hernioplasty according to the developed method. The control group included 73 patients operated on by the Lichtenstein method. The etiopathogenetic basis of oblique inguinal hernia and the causes of its recurrence, the frequency of which after open and laparoscopic use of mesh implants is 5 – 15%, were studied. It is after the use of these implants in the Lichtenstein operation that a complication no less important than recurrence occurs, which is a decrease or even loss of male reproductive function. Conceptually, the new approach is to eliminate the deep inguinal ring, move the spermatic cord under the transverse fascia, and create a new inguinal ring. Conclusions. The proposed method of hernioplasty has significant advantages over the Lichtenstein method of surgery, which are to prevent recurrence of the disease and preserve male reproductive function.

Ultrasound-guided transversalis fascia plane block or transversus abdominis plane block for recovery after caesarean section: A randomised clinical trial.

Caesarean section is a widely performed surgical procedure that often results in moderate-to-severe postoperative pain. If left untreated, this pain can lead to short-term and long-term consequences. Transversalis fascia plane (TFP) block and transversus abdominis plane (TAP) block are among the regional anaesthesia techniques employed for managing pain after a caesarean section. We aimed to compare the impact of these two blocks on the quality of recovery in patients undergoing elective caesarean section under spinal anaesthesia. A single-centre, double-blind, randomised trial. Operating room, postanaesthesia recovery unit, and ward in a tertiary hospital. Ninety-three patients (ASA 2 to 3) were recruited. After exclusion, 79 patients were included in the final analysis: 40 in the TFP block group and 39 in the TAP block group. After surgery, participants received either TFP block (20 ml 0.25% bupivacaine for each side) or TAP block (20 ml 0.25% bupivacaine for each side). The primary outcome was the difference in obstetric quality of recovery 11-Turkish (ObsQoR-11T) scores between groups. Secondary outcomes included pain scores, opioid consumption and incidence of opioid-related complications. The mean ObsQoR-11T score was higher in the TFP block group compared with the TAP block group (97.13 ± 6.67 points vs. 87.10 ± 9.84 points, respectively; P < 0.001). The pain scores in the TFP block group were slightly lower between postoperative 4 and 24 h. The mean total morphine consumption was 15.08 ± 2.21 mg in the TFP block group and 22.21 ± 3.04 mg in the TAP block group ( P < 0.001). More patients required rescue analgesia between 4 and 8 h in the TAP block group [2.00 (5.00%) vs. 9.00 (23.08%), P = 0.02]. No significant differences were observed between groups in terms of opioid-related side effects. TFP block used for analgesic purposes yielded a better quality recovery period than TAP block and also reduced opioid consumption. Clinicaltrials.gov (NCT05999981). http://links.lww.com/EJA/B6 .

Extended Lichtenstein Repair for an Additional Femoral Canal Hernia.

The Lichtenstein procedure is one of the most performed surgeries worldwide. However, proper examination to exclude a femoral hernia is often not performed, resulting in a high number of missed hernias. For patients in whom a femoral hernia is suspected pre- or intraoperatively, we describe a novel surgical technique of a femoral extension to the classic Lichtenstein repair. We aim to investigate its safety and clinical outcome. Methods: The femoral-extended Lichtenstein is applied when a femoral hernia is suspected. The fascia transversalis is opened, the lacunar ligament incised, and the hernia reduced. A self-gripping mesh covers the femoral orifice equally on all sides. In a prospective single-center study, we compared 50 consecutive femoral-extended to 50 classic Lichtenstein repairs, evaluating operative time, patient-reported pain (intensity, duration), and recurrence. Results: The technique seems feasible and safe. Apart from 3 min additional surgical time, no difference in pain scoring or hernia recurrence was observed between both groups. Conclusions: We successfully introduced a femoral-extended Lichtenstein repair for patients with suspected femoral herniation.

The Analgesic Effect of Transversalis Fascia Plane Block After Caesarean Section Under Spinal Anaesthesia With Intrathecal Morphine: A Randomized Controlled Trial

The Analgesic Effect of Transversalis Fascia Plane Block After Caesarean Section Under Spinal Anaesthesia With Intrathecal Morphine: A Randomized Controlled Trial

Anatomical observations on 30 cadavers: new insights into the relationship between the posterior wall of the inguinal canal and the cremaster

PurposeClarify the composition of the Posterior wall of the Inguinal Canal(PWIC), the location and composition of the Transverse Fascia(TF), and the tissue origin of the Cremaster(C) by observing the anatomy of the inguinal region of the cadaver.Methods30 cadavers were dissected to observe the alignment of the muscles and fascia of the inguinal canal and the anterior peritoneal space. the anatomical levels of the posterior wall of the inguinal canal and the alignment of the Spermatic Cord(SC) were observed.Results(1) The posterior wall of the inguinal canal was white, bright, and tough tendon membrane-like tissue; (2) the transverse fascia was a thin fascial tissue with only one layer of membranous structure located in the abdominal wall under the abdominal wall on the side of the blood vessels of the peritoneal cavity; (3) the internal oblique muscle and its tendon membrane, and the transversus abdominis muscle and its tendon membrane extended on the surface of the spermatic cord, and fused and continued to the cremaster on the surface of the spermatic cord.Conclusions1. PWIC is mainly composed of Internal oblique muscle of abdomen (IOMA), Aponeurosis of internal oblique muscle of abdomen (AIOMA), Transverse abdominal muscle (TAM), and Transverse abdominal aponeurosis(TAA) as the following four types: (1) TAM and AIOMA fused to form a tendinous layer; (2) IOMA and TAM form the posterior wall of the muscle in the PWIC; (3) IOMA and AIOMA continue in the PWIC; 4) TAM and TAA continue in the PWIC. 2.TF is a thin fascial tissue with only one layer of membrane structure, TF is not involved in the composition of PWIC, so this fascia has nothing to do with resisting the occurrence of inguinal hernia. 3. The spermatic cord that travels in the inguinal canal is fixed to the lower wall of the inguinal canal by the tendon membrane of the cremaster, which is organized from the internal oblique and transversus abdominis muscles and their tendon membranes, The inguinal canal is a musculotendinous canal.

Preoperative CT findings predict the development of metachronous contralateral inguinal hernia after unilateral inguinal hernia repair: a single-center retrospective cohort study.

To identify potential clinical and preoperative CT risk factors that can predict the development of metachronous contralateral inguinal hernia (MCIH) after unilateral inguinal hernia repair (IHR). This study included unilateral inguinal hernia patients seen from 2016 to 2019 who underwent CT and subsequent IHR and had at least five years of follow-up. Preoperative CT scans were retrospectively reviewed for the presence of asymmetric spermatic cord fat and weakness of the transversalis fascia. The correlations of each CT feature and other clinical characteristics with the development of MCIH were calculated. The Kaplan-Meier model and multiple logistic regression were used to evaluate the associations among CT features, clinical variables and MCIH. A total of 677 male patients aged > 40 years were included in the study cohort. After more than 5 years of follow-up, 162 patients developed MCIH, representing an incidence of 23.9%. Patients with radical prostatectomy or peritoneal dialysis [P < 0.0001, HR 4.189 (95% CI 2.369 to 7.406)], primary left-sided IHR [P = 0.0032, HR 1.626 (95% CI 1.177 to 2.244)], and direct, femoral or pantaloon hernias were predisposed to MCIH. Asymmetric spermatic cord fat [P = 0.0002, HR 1.203 (95% CI 0.8785 to 1.648)] and weakness of the transversalis fascia [P < 0.0001, HR 7.914 (95% CI 5.666 to 11.05)] on preoperative CT were also identified as risk facts and demonstrated to be independent predictive factors for MCIH development. Asymmetric spermatic cord fat and weakness of the transversalis fascia were predictive factors for MCIH development. For decision making regarding prophylactic contralateral IHR at the time of index surgery, preoperative CT findings as well as clinical characteristics should be considered.

Advancements in ectopic reservoir placement for inflatable penile prostheses.

Traditional reservoir placement (RP) into the space of Retzius during three-piece inflatable penile prosthesis implantation has been associated with serious bladder, iliac vessel, and bowel complications, encouraging the development of "ectopic" RP methods. In this study we sought to document an up-to-date, comprehensive analysis of ectopic RP techniques regarding both patient satisfaction and clinical complications. A PubMed, Ovid MEDLINE, and Cochrane Library literature search of English language articles from 1966 to 2023 with keywords "inflatable," "penile prosthesis," "reservoir," and "placement" gave 179 publications, 70 of which were included in a comprehensive chronology and investigation after review. Overall, 12 retrospective studies detailing 9 ectopic RP techniques were compared for discussion. Sufficient data for comparison were found for 9 ectopic RP methods: posterior/anterior to transversalis fascia (PTF/ATF); high submuscular (HSM); HSM "Five-Step" technique (HSM-FST); lateral retroperitoneal (LR); sub-external oblique (SEO); direct vision, transfascial (DVT); low submuscular with transfascial fixation (LSM w/ TFF); and midline submuscular reservoir (MSMR). Although rare, serious complications have occurred with the use of ectopic RP techniques: 2 bladder perforations on implantation with PTF RP, a delayed bowel obstruction with HSM RP, and a colonic injury in a patient with a history of colon surgery with LR RP. Generally, herniation is the most relevant clinical complication in ectopic RP. At the time of this review there was no reported herniation with LR, SEO, LSM w/ TFF, or MSMR, likely due to fixation steps and/or reinforced spaces. Regarding patient satisfaction, HSM, HSM-FST, and LSM w/ TFF had similarly high rates of patient satisfaction while other techniques had no patient satisfaction data available. Importantly, reservoir palpability/visibility relates directly to patient satisfaction. Levels of palpability and/or visibility were reported in patients who underwent PTF/ATF, HSM, HSM-FST, SEO, and LSM w/ TFF, whereas no palpability was reported in patients who underwent LR, DVT, and MSMR. Proper comparison of ectopic methods is not possible without standardized patient surveys, consistent complication reporting, and larger sample sizes, indicating the need for a large, prospective, multisurgeon trial.

MATHEMATICAL PREDICTION OF CHANGES IN THE LEVELS OF CD40-CD40L TRANSMEMBRANE PROTEIN SYSTEM ACROSS DIFFERENT ANALGESIA TECHNIQUES IN CHILDREN

The impact of the CD40-CD40L on the development of non-communicable neurological conditions is determined by abnormal CD40 expression and may be detrimental to nervous tissue function. Pain is one of the earliest psychophysical functions to develop. Postoperative complications causing pain should be addressed immediately. Regional analgesia techniques can speed up children’s recovery and reduce the need for opioids. They can also lower the incidence of postoperative nausea and vomiting, respiratory complications, and postsurgical pain intensity.The aim of this study was to present a mathematical model that predicts changes in CD40-CD40L levels in children who underwent surgery under various analgesic modalities within the fi rst fi ve days postoperatively. The autoregressive probability model was used to predict the behavior of the experimental data function within 29 days after surgery.Material and Methods. The children were divided into three groups. Group I consisted of 33 children who underwent anterior abdominal wall surgery under general anesthesia with morphine. Group II comprised 27 children who underwent anterior abdominal wall surgery under general anesthesia with the transversalis fascia plane block (TFPB). Group III included 27 children who underwent anterior abdominal wall surgery under general anesthesia with the TFPB, combined with the quadratus lumborum block 4 (QLB-4) via a single injection. The serum CD40L levels were evaluated using the immunoenzymatic assay method. The autoregressive model method based on the Burg algorithm was used to predict the behavior of the experimental data function. To automate the calculation of predictions based on the Burg method, the ‘predict’ function in РТС MathCad Prime 7.0 software was used. All clinical and laboratory studies were conducted in accordance with the World Medical Association Declaration of Helsinki ‘Ethical Principles for Medical Research Involving Human Subjects’. The study is a fragment of the research project of the Department of Children Diseases of Postgraduate Medical Education Faculty, Ivano- Frankivsk National Medical University «Health Status and Adaption of Children from the Precarpathian Region with Somatic Diseases, Their Prevention» 2021-2026, state registration number 0121U111129.Results. On the fi fth day after surgery, the serum CD40-CD40L levels were highest in children who received conventional opioid analgesia. There was no signifi cant diff erence observed between children in the TFPB and TFPB+QLB groups. On the 29th day after surgery, the predicted CD40-CD40L levels were lowest in children who received conventional opioid analgesia combined with the TFPB+QLB.Conclusions. The fi ndings obtained confi rmed the positive eff ect of combined analgesia using opioids and regional nerve block TFPB+QLB in children who received anterior abdominal surgery on suppressing immune mechanisms of pain syndrome involving the CD40-CD40L signaling system.

ANGIOEMBOLISATION OF CREMASTERIC ARTERY FOR SCROTAL HAEMATOMA FOLLOWING HERNIAL REPAIR

Cremasteric artery is a branch of inferior epigastric artery supplying the cremaster muscle and coverings of the cord. The possible consequence of injury to this artery is scrotal haematoma. We present a case of haemorrhage from unexpected cresmastric artery injury post-hernioplasty treated with angioembolisation. To the best of our knowledge, this has not been reported in literature.&#x0D; A 66-year-old gentleman with left indirect inguinal hernia underwent a left inguinal hernioplasty in our institution with no immediate complications. However he presented to the emergency department the day after the procedure with complaints of rapidly worsening painful left scrotal swelling accompanied with symptoms of intestinal obstruction. Emergency laparotomy and re-do left hernioplasty was performed, revealing a strangulated inguinoscrotal hernia. Post-operatively, there was non-resolving scrotal swelling with a drop in the haemoglobin level; from 11.9g/dl to 8.5g/dl requiring packed cell transfusion. CT angiogram revealed active contrast extravasation from the left cremasteric artery. Angiographic run confirmed the finding and the left cresmatric artery was superselectively cannulated with a 1.9Fr microcatheter and embolization done with 0.5mm microcoil. Ultrasound scan 24-hour post-procedure showed patent proximal vessel. Clinically there was a reduction of the left scrotal swelling and the haemoglobin remained stable. &#x0D; Cremasteric artery courses laterally deep into the fascia transversalis entering the cord deep to the internal spermatic fascia to supply the cremaster muscle and coverings of the cord. This course renders the artery to be prone for injury during procedure such as hernioplasty; one of the possible consequences is scrotal haematoma. This artery is usually small in caliber and its identification is important for efficient and effective treatment.&#x0D; Angioembolisation is able to treat this injury with superior precision owing to its ability for localization and selective cannulation of the offending vessel.

FEATURES OF DEVELOPMENT AND FORMATION TOPOGRAPHIES OF THE VESICO-UMBILICAL TRIANGLE IN THE PRENATAL PERIOD OF HUMAN ONTOGENESIS

On the front abdominal wall, there is a section of the vesico- umbilical triangle, which is bounded on the sides by the umbilical arteries, and below by the bladder. In the available sources of scientifi c literature, there is practically no information on the patterns of prenatal morphogenesis and the formation of the topography of the area of the vesico- umbilical triangle of a person. However, accurate knowledge of the topography of the constituent formations of the vesico- umbilical triangle determines the choice of incision during operations and provides a theoretical explanation for the occurrence of various pathological conditions: umbilical, postoperative ventral hernias, abdominal cavity organ eventration, and the spread of purulent- infl ammatory processes.The purpose of the study was to clarify the features of prenatal morphogenesis and topographical- anatomical relationships of the vesico- umbilical triangle of a person.The study was conducted on the preparations of 7 embryos of 4-6 weeks, 14 pre-fetuses of 7-12 weeks, and 26 human fetuses aged from 4 to 10 months using the production of a series of histological sections, microscopy, macromicroscopic preparation, and injection of vessels.In embryos of 4.5-5.5 mm parietal- coccygeal length (PCL), the allantois is located in the direction of the abdominal wall, connecting with other structures in the area of the future umbilical ring. In the mesoderm of the allantois, there is a layer of vessels that form a system of umbilical vessels. On frontal sections of 10.5-12.0 mm PCL embryos, narrowing of the allantois duct is observed: a more gradual narrowing near the umbilical ring, and a sharper one closer to the cloaca. At this stage of embryogenesis, there is a clear division of the cloaca into ventral (urogenital sinus) and dorsal (rectal lining) sections.It was established that the bladder is formed from two sources – the body and top – from the caudal part of the allantois, the bottom, and neck – from the pelvic part of the genitourinary sinus. In the 3rd month of intrauterine development, the middle and deep layers of the vesico- umbilical triangle are formed, which are represented by the sheath of the rectus abdominis muscle, rectus and pyramidal muscles, prostatic and allantoic leaves. Fascial spurs, departing from the latter, divide the prostate space into four interfascial slits. The surface layer of the vesico- umbilical triangle is still poorly diff erentiated at this stage of intrauterine development. At the end of the 4th month of intrauterine development, the surface fascia of the vesico- umbilical triangle is formed as independent formations. During macro- microscopic dissection of the area of the vesico- umbilical triangle in 6-month-old fetuses, in addition to the fascial formations of the superfi cial layer, all the structures of the deep layer can be distinguished: the transverse fascia, the vestibular and allantoic fascial sheets, as well as two fascial spurs that divide the vestibular space into four interfascial gaps. From our point of view, it is appropriate to call the prostatic fascia and prostatic fi brous space vesico- umbilical.

Laparoscopic iliopubic tract repair for asymptomatic contralateral occult inguinal hernia.

Metachronous contralateral inguinal hernia (MCIH) may occur after unilateral inguinal hernia (IH) repair, potentially as a result of occult IH (OIH). Contralateral OIH can be checked for during laparoscopic transabdominal hernioplasty for the treatment of unilateral IH. This study aims to assess the efficacy of laparoscopic iliopubic tract repair (IPTR) in treating contralateral OIH to reduce MCIH. The medical charts of 3165 patients aged > 18years who underwent laparoscopic transabdominal hernioplasty for unilateral IH from January 2013 to December 2021 were retrospectively reviewed. The patients were categorized into two groups based on contralateral OIH presence: negative OIH (nOIH, 2657 patients) and OIH (508 patients). In cases of OIH, IPTR was performed, involving suturing of the iliopubic tract and transversalis fascia arch. MCIH was indirect in 26 and direct in 4 patients in the nOIH group, and was direct in 3 patients in the OIH group. The incidence of indirect MCIH was higher in the nOIH group than in the OIH (1.0% [n = 26/2657] vs. 0.0% [n = 0/508], p = 0.048). There was no difference in postoperative complication rates, pain scores, return to daily life, or duration of hospitalization between the nOIH and OIH groups. Laparoscopic IPTR for OIH treatment is an effective method for reducing the risk of indirect MCIH.

Comparative evaluation of pre-emptive analgesic efficacy of Posterior Transversus Abdominis Plane block with Fascia Transversalis Plane Block in adult patients undergoing unilateral inguinal hernia repair: A prospective, randomized, single-blind, two-arm parallel study.

Abdominal wall blocks, in conjunction with multimodal analgesia, have demonstrated efficacy in providing post-operative analgesia, reducing opioid requirements in patients undergoing inguinal hernia repair. The inguinal region is primarily innervated by the ilioinguinal nerve (IIN) and iliohypogastric nerve (IIH). Posterior transverse abdominis plane block (pTAP) and fascia transversalis plane block (TFP) have been observed to reliably block IIN and IIH. We hypothesized that posterior TAP block (pTAP) owing to its potential paravertebral spread will provide better post-operative analgesia than TFP block in patients undergoing unilateral open inguinal hernia repair. This prospective, randomized, single-blind, two-arm parallel study was conducted over a duration of one year for which sixty patients undergoing unilateral open inguinal hernia repair under spinal anesthesia were enrolled. They were equally and randomly assigned to receive either preoperative pTAP block or TFP block. The primary aim of the study was to compare median static and dynamic NRS scores during a 24-hour period, with the secondary aim to compare the number of patients who required rescue analgesics in each group. All enrolled patients completed the study. Results showed no statistically significant difference in median static NRS scores between Group pTAP and Group TFP at the designated time of observation during the 24-hour period [1.2 (0.4-1.60 vs. 1 (0.6-1)]. Group pTAP reported a higher median dynamic NRS scores during the 24-hour period [2.6 (1.2-3) v/s 2 (1.6-2.4); P < 0.035], although this difference was clinically insignificant. The mean time to request for the first rescue analgesia was comparable (11.7 h v/s 12 h; P = 0.99). In all the patients of both groups, loss of pinprick and cold touch sensation was observed at T10, T12, and L1 dermatomal levels. However, sensory assessment at T6 and T8 levels showed variability between the two groups (P > 0.05). In conjunction with background analgesia and the use of dexamethasone as an adjuvant, both blocks (pTAP and TFP) were observed to be equally effective for post-operative pain relief with similar patient satisfaction scores.

Ultrasound guided quadro-iliac plane block: another novel fascial plane block.

We report a novel block technique aimed to provide lumbosacral, abdominal, and hip analgesia: The quadro-iliac plane (QIP) block. A cadaveric examination that evaluates the spread of QIP block. Cadaver laboratory. One unembalmed cadaver. Bilateral ultrasound-guided QIP blocks on cadavers with 40 mL of methylene blue %0.5 each side. Dye spread in cadaver. There was staining in the deep interfascial plane of the erector spinae muscles. Extensive staining of the interfascial plane corresponding to the posterior aspect of the quadratus lumborum muscle (QLM) was observed. There was extensive staining on the anterior surface of the QLM. There was spread of dye traversing along the transversalis fascia and significantly infiltrating retroperitoneal fat tissue. Bilateral staining of the ilioinguinal and iliohypogastric nerves was observed. On the right, there was minimal staining over the subcostal nerve. There was dye present bilaterally within the deep regions of the transverse processes. The lumbar plexus was stained on both sides. The local anesthetic applied from a place where the QLM reaches its largest volume and the fascial plane creates a closed gap in the caudal area may exhibit a more rounded and extensive spread.Quadro-iliac plane block, involves the administration of local anesthetic to the posterior aspect of the QLM at its origin from the iliac crest. According to our cadaver study, this technique may be a promising option for alleviating acute and chronic pain in the lumbosacral, lower abdominal, and hip regions.

(022) Penile Implant Reservoir Placement: The Current Utilized Various Techniques and the Associated Outcome: Systematic Review and Meta-Analysis

Abstract Introduction Many innovations in the field of inflatable penile prosthesis (IPP) has been emerged. Since the introduction of the IPP, reservoir positioning in the space of Retzius (SOR) was considered the classical approach that had been utilized for many years. However, in certain group of patients, reservoir insertion in such space might be difficult or even risky. As a result, many alternatives for the reservoir placement outside the SOR has emerged with the intent of safe and reliable reservoir placement. Objective To conduct a systematic review for the studies evaluating the outcomes of different techniques used for IPP reservoir placement to look for possible superiority of any approach over others. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed and Google scholar were used to look for articles published up to January 2023. Original articles reporting different techniques for IPP reservoir placement and evaluating the associated outcomes were included. Data regarding study design, sample size, approach of reservoir placement, surgical technique, device type and reported outcomes (infection rate, bladder/bowel/vascular injury, reservoir herniation, mechanical failure, auto-inflation, reservoir palpability and patients’ satisfaction) were collected. Pooled proportion was calculated and included in the meta-analysis. The Newcastle-Ottawa scale was used for assessing the quality of the studies. Results A total of 23 articles meeting the inclusion criteria, all were retrospective reviews. 11 compared more than one technique for reservoir placement whereas 12 described a single technique. In total, techniques for 6 main different reservoir locations has been reported, including SOR (7 studies), submuscular/subrectus (6 studies), Lateral retroperitoneal (1 study), subcutaneous (1 study), sub external oblique (1 study) and intraperitoneal (1 study). Another 7 modifications have been described for the SOR technique (traditional SOR, accessing SOR using blunt scissor in post-prostatectomy patients, accessing SOR using blunt scissor in virgin cases, dilating SOR using catheter balloon, accessing SOR under direct vision, accessing SOR through external oblique fascia incision, and the addition of The Tubing Hitch&amp;Lasso, Intussusception Anchor technique (THALIA)). Another 6 modifications for the submuscular/subrectus approach have been described (posterior to transversalis fascia (PTF), anterior to transversalis fascia (ATF), high submuscular, subrectus using counter incision, subrectus with the addition of THALIA, low submuscular with trans-fascial-fixation (TFF)). None of the studies have proven the superiority of one technique over others, with most of the techniques has comparable intra-operative and post-operative outcomes (table 1). The addition of anchoring step (THALIA or TFF) resulted in neglected risk of reservoir herniation, however, related studies has small sample size with no comparison groups. Meta-analysis for the studies of SOR (n=7) and submuscular/subrectus (n=6) groups showed a statistically significant difference only in the herniation rates (figure 1). 10 studies were of strong quality (8 stars) while the remaining 13 studies were of poor quality. Conclusions Modest evidence suggests a comparable favorable outcome of various approaches used for IPP reservoir placement. The lack of enough prospective trials, short term follow up, and diversity in the techniques prescribed prevent the ability to build strong evidence. For the purpose of supporting the superiority of any technique, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

(394) Penile Implant Reservoir Placement: The Current Utilized Various Techniques and the Associated Outcomes: Systematic Review and Meta-analysis

Abstract Introduction Many innovations in the field of inflatable penile prosthesis (IPP) has been emerged. Since the introduction of the IPP, reservoir positioning in the space of Retzius (SOR) was considered the classical approach that had been utilized for many years. However, in certain group of patients, reservoir insertion in such space might be difficult or even risky. As a result, many alternatives for the reservoir placement outside the SOR has emerged with the intent of safe and reliable reservoir placement. Objective To conduct a systematic review for the studies evaluating the outcomes of different techniques used for IPP reservoir placement to look for possible superiority of any approach over others. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed and Google scholar were used to look for articles published up to January 2023. Original articles reporting different techniques for IPP reservoir placement and evaluating the associated outcomes were included. Data regarding study design, sample size, approach of reservoir placement, surgical technique, device type and reported outcomes (infection rate, bladder/bowel/vascular injury, reservoir herniation, mechanical failure, auto-inflation, reservoir palpability and patients’ satisfaction) were collected. Pooled proportion was calculated and included in the meta-analysis. The Newcastle-Ottawa scale was used for assessing the quality of the studies. Results A total of 23 articles meeting the inclusion criteria, all were retrospective reviews. 11 compared more than one technique for reservoir placement whereas 12 described a single technique. In total, techniques for 6 main different reservoir locations has been reported, including SOR (7 studies), submuscular/subrectus (6 studies), Lateral retroperitoneal (1 study), subcutaneous (1 study), sub external oblique (1 study) and intraperitoneal (1 study). Another 7 modifications have been described for the SOR technique (traditional SOR, accessing SOR using blunt scissor in post-prostatectomy patients, accessing SOR using blunt scissor in virgin cases, dilating SOR using catheter balloon, accessing SOR under direct vision, accessing SOR through external oblique fascia incision, and the addition of The Tubing Hitch&amp;Lasso, Intussusception Anchor technique (THALIA)). Another 6 modifications for the submuscular/subrectus approach have been described (posterior to transversalis fascia (PTF), anterior to transversalis fascia (ATF), high submuscular, subrectus using counter incision, subrectus with the addition of THALIA, low submuscular with trans-fascial-fixation (TFF)). None of the studies have proven the superiority of one technique over others, with most of the techniques has comparable intra-operative and post-operative outcomes (table 1). The addition of anchoring step (THALIA or TFF) resulted in neglected risk of reservoir herniation, however, related studies has small sample size with no comparison groups. Meta-analysis for the studies of SOR(n=7) and submuscular/subrectus(n=6) groups showed a statistically significant difference only in the herniation rates (figure 1). 10 studies were of strong quality (8 stars) while the remaining 13 studies were of poor quality. Conclusions Modest evidence suggests a comparable favorable outcome of various approaches used for IPP reservoir placement. The lack of enough prospective trials, short term follow up, and diversity in the techniques prescribed prevent the ability to build strong evidence. For the purpose of supporting the superiority of any technique, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

(393) Advancements in Ectopic Reservoir Placement for Inflatable Penile Prostheses

Abstract Introduction Traditional reservoir placement (RP) into the space of Retzius (SOR) during three-piece inflatable penile prosthesis (IPP) implantation has been associated with dire bladder, iliac vessel, and bowel complications, leading many surgeons to pioneer alternative, “ectopic” methods. Despite the extensive literature on ectopic RP, there is little direct comparison of these techniques to one another with respect to efficacy and/or safety. Objective To document an up-to-date, comprehensive analysis of ectopic RP techniques regarding both patient satisfaction and clinical complications. Methods A PubMed literature search of English language articles from 1986-2023 with keywords “inflatable,” “penile prosthesis,” “reservoir,” and “placement” gave 113 publications, 62 of which were included in a comprehensive chronology and investigation after abstract review (last updated 7/3/2023). Analysis of published data yielded 12 retrospective studies detailing 8 ectopic RP techniques that were included for comparison (Table 1). Results Of the ectopic RP methods explored, 8 have sufficient data for comparison: posterior &amp; anterior to transversalis fascia (PTF &amp; ATF); high submuscular (HSM); high submuscular ‘Five-Step’ technique (HSM-FST); lateral retroperitoneal (LR); sub-external oblique (SEO); direct vision, transfascial (DVT); low submuscular with transfascial fixation (LSM w/ TFF); and midline submuscular reservoir (MSMR). Although rare, serious complications have occurred in ectopic RP: PTF reports 2 bladder perforations on implantation, HSM reports a delayed bowel obstruction, and LR reports a colonic injury in a patient with a history of colon surgery. When unsure, a counterincision can be used to lower risk of violating fascial planes and causing visceral injury. Aside from these cases, herniation is the most relevant clinical complication in ectopic RP. There is no reported herniation with LR, SEO, LSM w/ TFF, or MSMR, likely due to fixation steps and/or reinforced spaces. Reports of newer ectopic strategies often have small sample sizes and limited follow-up which potentially under- or overestimate complication rates, indicating a need for more robust longitudinal study. In regards to patient satisfaction, HSM, HSM-FST, and LSM w/ TFF have high and similar rates of patient satisfaction while other techniques do not provide data. In addition to increased rates of reporting, a validated patient survey is needed to standardize comparison of efficacy and patient perspective between different techniques. Importantly, reservoir palpability/visibility relates directly to patient satisfaction. PTF &amp; ATF, HSM, HSM-FST, SEO, and LSM w/ TFF report levels of palpability and/or visibility while LR, DVT, and MSMR have no reported palpability. Conclusions Without standardized patient surveys, consistency in complication reporting, and larger sample sizes, it is impossible to properly compare different ectopic methods. The prosthetic community needs a large, prospective, multisurgeon study comparing ectopic methods to each other, not just to SOR. Until such data is available, implanters should assess different methods in regards to their unique benefit and complication profiles, becoming experts in those that can best serve their patient population. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant: AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast // Investor: Sprout.

Totally laparoscopic surgery for a hydrocele of the canal of Nuck extending from the abdominal cavity to the subcutaneous space: a case report

BackgroundHydrocele of the canal of Nuck (HCN) is a rare disease, and its indications for laparoscopic surgery are not well-established.Case presentationA 53-year-old woman was referred to our hospital due to an uncomfortable thumb-sized inguinal mass. Preoperative computed tomography scan and magnetic resonance imaging revealed a hydrocele extending from the abdominal cavity around the left deep inguinal ring via the inguinal canal to the subcutaneous space. The patient was diagnosed with HCN protruding into the abdominal cavity and extending to the subcutaneous space. Laparoscopy can easily access the hydrocele protruding into the abdominal cavity. Furthermore, laparoscopic hernioplasty can be superior to the anterior approach for females. Hence, laparoscopic surgery was performed. After transecting the round ligament of the uterus, a tense 3-cm hydrocele was dissected with it. In order to approach the hydrocele distal to the deep inguinal ring, the transversalis fascia was incised medially to the inferior epigastric vessels. The subcutaneously connected hydrocele was excised from the incision. Then, the enlarged deep inguinal ring was reinforced using a mesh with the laparoscopic transabdominal preperitoneal approach. The patient was discharged 2 days postoperatively. Laparoscopic resection can be more effective for a hydrocele protruding into the abdominal cavity as it facilitates an easy access to the hydrocele. Moreover, laparoscopic resection of a hydrocele extending from the inguinal canal to the subcutaneous space via a transversalis fascia incision can be safer, with low risk of injury to the inferior epigastric vessels. The incised transversalis fascia and the enlarged deep inguinal ring due to the HCN were simultaneously repaired with the laparoscopic transabdominal preperitoneal repair. There are two reports on laparoscopic resection via a transversalis fascia incision for HCNs located between the inguinal canal and the subcutaneous space, which does not require intraperitoneal hydrocelectomy. However, this is the first report on laparoscopic resection of large HCNs protruding into the abdominal cavity and extending beyond the inguinal canal into the subcutaneous space via intraperitoneal hydrocelectomy and a transversalis fascia incision.ConclusionsLaparoscopic surgery with transversalis fascia incision can be useful for HCNs extending from the abdominal cavity to the subcutaneous space.

Spinal Anestezi Altında Sezaryen Doğumda Postoperatif Analjezi için Transversalis Fasya Plan Bloğunun Transversus Abdominis Plan Bloğuyla Karşılaştırılması: Retrospektif Bir Çalışma

Objective: Transversalis fascia plane (TFP) and transversus abdominis plane (TAP) blocks are used for postoperative analgesia in many lower abdominal procedures such as cesarean section. This study aimed to retrospectively compare the postoperative effects of TFP and TAP blocks for postoperative multimodal analgesia in patients who underwent cesarean section under spinal anesthesia. Methods: We retrospectively searched electronic medical records to identify patients who underwent cesarean section under spinal anesthesia between November 2021 and June 2022. A total of 497 patients were identified, and 120 patients were included that meet our criteria in our analysis. The patients were divided into three groups: TFP, TAP, and control. Data were obtained from the files of the patients. Results: The block groups had significantly lower numeric rating scale (NRS) scores, less non-steroidal anti-inflammatory drug consumption, and lower complications than the control group. No opioid consumption was observed in the block groups. Although no non-steroidal anti-inflammatory drug consumption until the 4th hour and no opioid consumption until the 8th hour were observed in the control group, the need for additional analgesics increased as time passed. While the TFP group needed analgesics later than the TAP group, the NRS scores and total analgesic consumption were lower (p&lt;0.001). Patient satisfaction was higher in the block groups than in the control group (p&lt;0.001). Conclusion: Transversalis fascia plane and TAP blocks are effective as part of multimodal analgesia in cesarean section. The TFP block is superior to the TAP block in terms of pain scores, additional analgesic requirements, and patient satisfaction. Keywords: Cesarean section, postoperative pain, ultrasound-guided regional anesthesia, transversus abdominis plane block, transversalis fascia plane block