Transverse Abdominal Incision Research Articles

The 6:1 short stitch SL-WL-ratio: short term closure results of transverse and midline incisions in elective and emergency operations

AimTo analyze laparotomy closure quality (suture/wound length ratio; SL/WL) and short term complications (surgical site occurrence; SSO) of conventional midline and transverse abdominal incisions in elective and emergency laparotomies with a longterm, absorbent, elastic suture material.MethodProspective, monocentric, non-randomized, controlled cohort study on short stitches with a longterm resorbable, elastic suture (poly-4-hydroxybutyrate, [p-4OHB]) aiming at a 6:1 SL/WL-ratio in midline and transverse, primary and secondary laparotomies for elective and emergency surgeries.ResultsWe included 351 patients (♂: 208; ♀: 143) with midline (n = 194), transverse (n = 103), and a combined midline/transverse L-shaped (n = 54) incisions. There was no quality difference in short stitches between elective (n = 296) and emergency (n = 55) operations. Average SL/WL-ratio was significantly higher for midline than transverse incisions (6.62 ± 2.5 vs 4.3 ± 1.51, p < 0.001). Results in the first 150 patients showed a reduced SL/WL-ratio to the following 200 suture closures (SL/WL-ratio: 5.64 ± 2.5 vs 6.1 ± 2.3; p < 0.001). SL/WL-ratio varied insignificantly among the six surgeons participating while results were steadily improving over time.Clinically, superficial surgical site infections (SSI, CDC-A1/2) were encountered in 8%, while 4,3% were related to intraabdominal complications (CDC-A3). An abdominal wall dehiscence (AWD) occurred in 22/351 patients (6,3%)—twice as common in emergency than elective surgery (12,7 vs 5,1%)—necessitating an abdominal revision in 86,3% of cases.ConclusionWe could show that a short stitch 6:1 SL/WL-ratio with a 2–0 single, ultra-long term, absorbent, elastic suture material can be performed in only 43% of cases (85% > 4:1 SL/WL-ratio), significantly better in midline than transverse incisions. Transverse incisions should preferably be closed in two layers to achieve a sufficient SL/WL-ratio equivalent to the median incision.Clinical Trials.gov IdentifierNCT01938222.

Congenital duodenal web causing partial obstruction with recurrent vomiting and abdominal distention in a toddler boy: a case report

BackgroundThe duodenal web is a thin, elongated, web-like structure that is one of the factors contributing to duodenal obstruction. Only 100 cases have been reported in the literature. We present a 2.5-year-old cachectic Afghan child who did not have any overt signs and symptoms of intestinal obstruction, like recurrent vomiting, abdominal distention, and weight loss. The web was discovered near the intersection of the third and fourth portions, which is an uncommon location for the duodenal web. The late presentation of congenital duodenal web with partial obstruction is rare but well-known and has been reported in this case.Case presentationA 2.5-year-old cachectic Afghan child who had recurrent vomiting and experienced abdominal distention was brought to Maiwand Teaching Hospital from the Jabelsuraj region of Parwan province. The patient was suffering from unusual signs and symptoms like recurrent vomiting, abdominal distention, weight loss, and constipation. The diagnosis of these anomalies was established by a detailed history, clinical features, and abdominal CT scan. In the computerized tomography scanning (CT-Scan) image reported, there was a web with stenosis and partial obstruction in the distal aspect of the third-to-fourth portion of the duodenum. After preoperative stabilization, the child was taken for surgery. The abdomen was opened by a right upper abdominal transverse incision. After web resection and duodenoplasty, the patient was shifted to the recovery room in satisfactory condition. The child was allowed to feed after 8 days, which he tolerated well.ConclusionCongenital duodenal web with partial obstruction is typically observed in the second and third years of life. It is suspected in patients with recurrent vomiting, abdominal distention, weight loss, and constipation. Partial obstruction may not have an overt presentation, making it a challenging diagnosis for general practitioners. Abdomen X-ray and CT scan usually confirm the diagnosis, and successful surgical intervention is recommended.

Subcutaneous onlay laparoscopic approach versus laparoscopic intraperitoneal onlay mesh repair of ventral hernia and correction of rectus diastasis: randomized controlled study

Background The association between ventral hernia and rectus abdominis diastasis is a common condition especially in multiparous women. Hernia correction alone without midline reinforcement increases the risk of hernia recurrence. Subcutaneous onlay laparoscopic approach (SCOLA) is a new minimally invasive procedure that allows the surgeons to do simultaneous correction of rectus diastasis and hernia mesh repair with low cost without the need for large transverse abdominal incision. Patients and methods 50 patients with non-complicated ventral hernia associated with rectus diastasis without significant redundancy in the skin of the abdominal wall were allocated randomly in 2 groups. 25 patients underwent SCOLA, and 25 patients underwent intraperitoneal on-lay mesh (IPOM) repair. Both techniques were compared as regard operative time, hospital stay, intra and postoperative complications, and recurrence rate. Results IPOM group experienced shorter operative time than SCOLA (115.27±10.54 vs 77.48±12.72) with no significant difference as regard intraoperative complications between both techniques. Although early postoperative pain was significantly less in SCOLA patients (P=0.021), IPOM group had earlier restoration of normal daily activities (P&lt; 0.001). No significant recurrence rate was considered in both groups apart from one case (4%) after IPOM repair. Conclusion SCOLA could be a good choice in the concurrent repair of ventral hernia and rectus diastasis without significant postoperative complications. In addition, the use of regular proline mesh instead of composite mesh significantly decreases the economic burden.

Modified circumumbilical approach for duodenal atresia repair : A scarless surgery

Background: Duodenal atresia is a common congenital anomaly causing neonatal intestinal obstruction. The definitive treatment is to restore the intestinal continuity. Laparotomy via upper transverse abdominal incision has been described by many authors as a standard approach for duodenal atresia repair. Here we report a case of newborn underwent duodenal atresia repair via modified circumumbilical approach with satisfactory postoperative outcome. Case presentation: This is a case of premature baby boy, born at 32-week gestation with a birth weight of 1.5kg. Antenatally he was detected to have double bubble sign which was confirmed upon postnatal abdominal radiograph, suggestive of duodenal atresia. He was noted to have a fleshy lump at the umbilicus presumed to be a patent vitello-intestinal duct from the referring hospital. Subsequently he developed umbilical swelling suspicion of umbilical hernia with incarceration and scheduled for emergency umbilical exploration. A circumumbilical incision was made and found to have an umbilical defect with omental herniation, instead of a patent vitello-intestinal duct. A proximal midline incision was made as an extension to the circumumbilical wound enabling a duodenal kocherization and subsequently had duodeno-jejujonostomy anastomosis for the duodenal atresia repair. Postoperative recovery was uneventful with appealing cosmesis. Conclusion: A modified circumumbilical incision is an attractive alternative approach for a duodenal atresia repair. Apart from its cosmetic advantage, the approach provides adequate exposure for similar outcome with transverse abdominal incision.

Invasion anomaly or neovascularization? A new surgical approach for cesarean delivery in pregnant women with invasive placenta accreta spectrum disorder accompanied by placenta previa.

The objective of study is to describe a new surgical approach to cesarean delivery in women with invasive placenta accreta spectrum (PAS) accompanied by placenta previa. Cesarean delivery was initiated with a transverse abdominal (Pfannenstiel) incision. A transverse incision was made above the vascular area in the lower uterine segment, and the fetus was delivered. The uterine fundus was removed from the abdomen and wrapped. Placental removal was started at posteriorly, continuing toward the anterior region. If dense adhesions were encountered, dissection was performed by inserting a finger between the adhesions to carefully separate them. It was recognized that two types of vessels develop to supply blood to the placenta. First, a perforating vessel emerges from adjacent tissues, entering the placental bed by perforating the uterine wall. Second, a superficial vessel runs along the uterine wall to enter the placental bed. The new emerging vessels were identified and ligated. Uterine sparing surgery was performed if the hemorrhage ceased. A cesarean hysterectomy was performed if hemorrhage did not cease. Eight cesarean deliveries were performed using this new surgical approach. Cesarean hysterectomy was performed in three patients in who want to sterilization diser and don't mind fertility preservation. Severe maternal morbidity, invasive procedures, intensive care unit admission, and relaparotomy were not required. The described new surgical approach provide surgeon to perform cesarean delivery without causing increase maternal morbidity and mortality. Although the approach is new and the study population is small, the results have acceptable rationality and applicability.

Periumbilical Anatomy of Scarpa's Fascia: Rationale Behind a "Modified Scarpa's" Abdominal Closure Technique.

Intraoperative observation of Scarpa's fascia (SF) has suggested attenuation in the periumbilical region. This study's purpose was to objectively evaluate SF anatomy in the periumbilical region and assess clinical outcomes of a novel, modified SF closure technique of transverse abdominal wall incisions that only reapproximates SF where it is definitively present. Women were identified who had undergone abdominal magnetic resonance (MR) angiography before their abdominal-based autologous breast reconstruction that used the modified SF closure technique. Statistical analysis of SF presentation on the MR images was performed. Intraoperative measurements from dissected panniculectomy specimens were used to validate MR analysis. Donor site complications were recorded in patients undergoing modified SF closure. Sixty-six patients were included in the retrospective MR imaging analysis; this revealed an average attenuation of SF of 4.7 cm (SEM = 0.25 cm), 4.5 cm (SEM = 0.23 cm), 4.6 cm (SEM = 0.23 cm), and 4.2 cm (SEM = 0.22 cm) to the left of, right of, cranial to, and caudal to the umbilicus, respectively. The mean surface area of radiologic SF absence was 56.3 cm 2 (SEM = 3.57 cm 2 ). There was a significant difference in SF presentation based on patient age ( P = 0.013) and body mass index ( P = 0.005). Five of the 66 patients (7.6%) experienced abdominal closure site complications. This study objectively confirms that there is attenuation of SF in the periumbilical region, describes a novel SF closure technique, and provides evidence to support its adoption when closing transverse abdominal wall incisions.

6:1 Suture or Wound length ratio with the short stitch technique – a reality check on practicability and short term outcome

Aim: To analyze laparotomy closure of conventional midline and transverse abdominal incisions in elective and emergency laparotomies with a longterm, absorbent, elastic suture material. Method: Prospective, single centre, non randomised, controlled cohort study on short stitches with a longterm resorbable, elastic suture (material: poly-4-hydroxybutyrate) aiming at a 6:1 suture to wound (SL/WL) length ratio in midline and transverse, primary &amp; secondary laparotomies for elective &amp; emergency surgery. Results: We included 351 patients (♂: 208; ♀: 143), midline (n=194), transverse (n=103) and a combined midline/transverse L-shaped (n=54) incisions. There was no stitch performance quality difference between elective (n=296) and emergency (n=55) operations, while results in the first 150 patients showed a significantly reduced SL/WL-ratio to the following 200 suture closures (SL/WLratio: 5.64±2.5 vs 6.1±2.3, p&lt;0.001). Average SL/WL-ratio in general was better for midline than transverse incision sutures (6.62±2.5 vs 4.3±1.51, p&lt;0.001). SL/WL-ratio varied among the 6 surgeons participating, although results steadily improved and eventually approximated each other. Conclusions: We could show that a 6:1 SL/WL-ratio with a 2-0 single, ultra-long term, absorbent, elastic suture material can be significantly performed better in midline than transverse incisions. Transverse incisions should preferably be closed in 2 layers in order to achieve a sufficient SL/WL-ratio equivalent to the median incision. While on an individual level, results varied between surgeons, quality will improve and eventually approximate.

Pediatric metanephric adenoma with Fanconi-Bickel syndrome: a case report and review of literature.

BackgroundMetanephric adenoma (MA) is a rare benign renal tumor that resembles renal cell carcinoma and Wilms’ tumor in radiological as well as pathological appearance. It can present at any age or gender, and it is extremely rare in the pediatric age group with less than 50 reported cases. Fanconi–Bickel syndrome (FBS) is a rare autosomal recessive disorder of carbohydrate metabolism. Herein, we report a rare incidence of MA in a boy with a genetically confirmed FBS who underwent a nephron-sparing surgery.Case presentationA 21-month-old boy was referred to the pediatric urology clinic for further evaluation of an incidentally discovered left renal mass. His laboratory investigations showed normal renal function, hypophosphatemia, high blood glucose level, markedly elevated serum alkaline phosphatase, and low serum vitamin D. Blood picture showed signs of polycythemia and urinalysis showed glucosuria and aminoaciduria. Genetic testing was positive for Fanconi–Bickel syndrome. Radiological investigations were carried out with abdominal ultrasound and computerized tomography (CT) with intravenous contrast documented a sharply marginated peripheral hypoechoic hypovascular homogeneously enhancing mass at the upper pole of the left kidney measuring 2.0 × 1.8 × 2.0 cm. The child was admitted and started on supportive treatment until his medical condition was stabilized, then underwent elective open left partial nephrectomy via a left upper transverse abdominal transperitoneal incision. The excised renal mass was sent for histopathological assessment and was found to be a tumor composed of tightly packed tubules with no mitotic figures or necrosis and scanty cytoplasm consistent with MA. After good hydration and tumor resection, his polycythemia gradually improved. The patient was discharged home in a good condition with his proper replacement therapies. His follow-up abdominal ultrasound after 12 months showed no signs of recurrence.ConclusionsMetanephric adenoma is extremely rare in the pediatric age group, especially in those who have a FBS. The only way to diagnose and treat this tumor is by surgical resection as most patients are asymptomatic. A nephron-sparing surgery is better for this age group in which the future renal function is considered.

A comparison of praevia and non-praevia outcomes in placenta accreta spectrum cases: A single centre analysis.

Placenta accreta spectrum (PAS) causes severe maternal morbidity and mortality. Antenatal diagnosis can optimise maternal outcomes and reduce the risk of complications. PAS cases where the placenta is not low lying are suggested to be more difficult to diagnose antenatally and are potentially associated with different outcomes. The aim was to compare factors associated with births in PAS pregnancies with and without placenta praevia at a single tertiary centre over 15years. A retrospective review of all births complicated by PAS was conducted from a site-specific database. Cases with and without a placenta praevia were analysed to compare differences in maternal risk factors, outcomes and histological diagnosis. Between June 2006 and July 2020 there were 134 cases of PAS, 106 with placenta praevia. Cases without praevia were less likely to have a history of previous caesarean section and to be admitted for delivery planning or with antepartum haemorrhage. A higher proportion of cases without praevia were delivered at term, with no overall difference in emergency or elective deliveries. There was a significantly lower rate of hysterectomy in the non-praevia group. The overall estimated blood loss was significantly lower in those without praevia. Suspected PAS without placenta praevia is at lower risk of hysterectomy and massive blood loss. The management approach can be tailored accordingly, with good operative outcomes with transverse abdominal and uterine incisions. Antenatal diagnosis can be difficult to accurately predict the degree of invasion, and a higher level of suspicion is required.

Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis.

Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.

The Impact of COVID-19 Pandemic on Follow-up Refusal Rate in a Surgical Randomized Controlled Trial

Introduction: Refusal to follow-up may affect the course of the ongoing randomized controlled trials (RCT). The aim of this study was to evaluate the impact of COVID-19 pandemic on follow-up refusal rate in an ongoing surgical RCT. Methods: The study group comprised 107 participants enrolled in an ongoing surgical RCT designed to compare mass with layered closure of transverse abdominal incisions with respect to incisional hernias. Study group was divided into patients who were scheduled to have follow-up visit before (pre-COVID) and after (post-COVID) April 1st 2020. Follow-up refusal rate was compared in both groups. Results: Follow-up refusal rate in pre-COVID group was 18.52% (10 out of 55 patients) , whereas in post-COVID group it was 50% (26 out of 52 patients; p=0.0004). Median value of age during scheduled follow-up day was 60 years and the distance from patients place of living was 151 km. The pandemic particularly increased refusal rate in patients living >151km from hospital (p <0.0001), patients older than 60 years (p=0.006), and in female patients (p=0.005). Conclusions: COVID-19 pandemic leads to remarkable increase in follow-up refusal rate among participants enrolled in RCT’s, particularly in females, older patients, and in those living in a long-distance from the centre.

Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial.

To compare the early results of mass and layered closure of upper abdominal transverse incisions. Contrary to midline incisions, data on closure of transverse abdominal incisions are lacking. This is the first analysis of a randomized controlled trial primarily designed to compare mass with layered closure of transverse incisions with respect to incisional hernias. Patients undergoing laparotomy through upper abdominal transverse incisions were randomized to either mass or layered closure with continuous sutures. Incisional surgical site infection (incisional-SSI) was the primary end-point. Secondary end-points comprised suture-to-wound length ratio (SWLR), closure duration, and fascial dehiscence (clinicatrials.gov NCT03561727). A total of 268 patients were randomized to either mass (n=134) or layered (n=134) closure. Incisional-SSIs occurred in 24 (17.9%) and 8 (6.0%) patients after mass and layered closure, respectively (P =0.004), with crude odds ratio (OR) of 0.29 [95% confidence interval (95% CI) 0.13-0.67; P =0.004]. Layered technique was independently associated with fewer incisional-SSIs (OR: 0.29; 95% CI 0.12-0.69; P =0.005). The number needed to treat, absolute, and relative risk reduction for layered technique in reducing incisional-SSIs were 8.4 patients, 11.9%, and 66.5%, respectively. Dehiscence occurred in one (0.8%) patient after layered closure and in two (1.5%) patients after mass closure (P >0.999). Median SWLR were 8.1 and 5.6 (P <0.001) with median closure times of 27.5 and 25.0 minutes (P =0.044) for layered and mass closures, respectively. Layered closure of upper abdominal transverse incisions should be preferred due to lower risk of incisional-SSIs and higher SWLR, despite clinically irrelevant longer duration.

Management of Congenital Duodenal Obstruction by Diamond-Shaped Duodenoduodenostomy

A prospective study of 20 patients with clinical diagnosis of duodenal obstruction done at pediatric surgery center in AL Khanssa maternity and children Teaching Hospital in Mosul from December 2006-January 2010, a detailed case-record of 20 consecutive newborn patients treated for duodenal obstruction. The aims of the study was to analyze our experience and to evaluate the clinical presentation, diagnosis, postoperative care, and outcome in infants with duodenal obstruction.The 20 patients were classified according to classification system modified from James A. O’Neill: duodenal web, atresia , annular pancreas and malrotation.The presumptive diagnosis and decision regarding the need for surgery was based on clinical findings and investigation of plain abdominal radiographs in all patients without the need of dye study. Abdominal ultrasound examination was done for all patient to evaluate the associated renal anomalies and echocardiogram was done for 15 patients because of suspicion of congenital heart disease.other laboratory investigation including complete blood count, serum electrolyte, blood urea and total serum bilirubin were done for all patients.the management strategy for all patients was outlined as follows: After initial evaluation, a nasogastric tube (NGT) was placed for gastric decompression. The operative procedures performed through supra umbilical transverse abdominal incision. The type of duodenal obstruction was assessed after mobilizing the ascending and transverse colon to the left and identifying any associated malrotation. Kocherization of duodenum then performed and a transpyloric tube was passed to determine if a windsock abnormality was present . In duodenal atresia intraoperatively injection of saline or air into the distal segment was done to rule out a second atresia. Using a single layer of interrupted suture with posterior knots tied inside and anterior knots tied outside by using 5-0 or 6-0 Vicryl (polyglactin) o Polydiaxonone suture(PDS) 5/0 to complete the anastamosis. The age of our patients were ranging from1day to 16 days and divided in to two groups from 1 up to 7 days. The Common clinical findings in our patients were bilious emesis, upper abdominal distension, failure to pass meconium . And accordingly the incidence of each symptoms and signs.The available investigations in our center at any time was the plain abdominal x ray, the finding in plain x-ray of abdomen was double bubble sign in 18(90%)of the patients and single gastric gas shadow in 2(10%) of patient. Abdominal ultrasound examination was done for all patients locking for any associated anomalies especially of the urinary tract. The finding was ectopic kidney in 1(5%) and hydronephrosis in 1(5%) of our patient. Echocardiography has been performed in 15 patients , abnormal in 2 male babies one of them had VSD and another one had ASD. Careful examination and follow up locking for associated anomalies were done and their types and percentile shows male patient have more associated anomalies than female.

Clear-cell carcinoma originating from cesarean section scar: two\xa0case reports\xa0

BackgroundClear-cell carcinoma arising from the surgical cesarean section scar is very infrequent. The present study reports two patients with clear-cell carcinoma arising from an abdominal wall scar 20 and 23 years after their last cesarean section.Case presentationBoth Iranian patients had prior cesarean sections nearly 20 years earlier. Patients 1 and 2 had transverse and vertical abdominal incisions, respectively. The initial clinical presentation was a huge lower abdominal mass at the site of the previous cesarean section scar. Both patients underwent abdominal wall mass biopsy. The histological analysis revealed the presence of malignancy. Both patients underwent full-thickness resection of the abdominal wall mass. All surgical margins were tumor-free; however, patient 1 had a very narrow tumor-free margin near the pubic symphysis. As the imaging report of patient 2 revealed the presence of a pelvic mass, the exploration of the intraperitoneal space, simple total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and the excision of enlarged pelvic lymph nodes were performed during the surgery. Six cycles of paclitaxel and carboplatin every 3 weeks as adjuvant chemotherapy was administered for both patients after the surgery. One of the patients had disease recurrence 5 months after the termination of chemotherapy, and the other is still disease-free. These two patients had similar pathology and received a similar initial adjuvant treatment; however, they were different in terms of the direction of tumor spread, tumor distance from the pubic symphysis, status of tumor margins, and surgical procedures.ConclusionsWe encountered distinct prognoses in the clear-cell carcinoma of cesarean section scars presented herein. The researchers can recommend complete surgical excision of the abdominal wall mass with wide tumor-free margins, exploration of the abdominopelvic space, TAH, and BSO during the first surgery.

BUPIVACAINE WITH MAGNESIUM SULPHATE VS BUPIVACAINE ALONE IN TRANSVERSUS ABDOMINIS PLANE BLOCK FOR POSTOPERATIVE ANALGESIA IN TOTALABDOMINAL HYSTERECTOMY PATIENTS: A RANDOMISED CONTROL TRIAL.

Background: Postoperative (PO) pain relief following major surgeries had been a challenging task. Adequate pain control is essential for early mobilisation and wellbeing of surgical patients. Incidence of PO pain following abdominal surgeries is higher when transverse lower abdominal incisions are done as in Total Abdominal Hysterectomy (TAH). Performing Transversus Abdominis Plane (TAP) block reduces the PO pain. Various adjuvants like clonidine, epinephrine and magnesium sulphate have been added to local anaesthetics to prolong the duration of TAPblock. The aim of this study was to investigate the effects of adding MgSO4 as an adjuvant to bupivacaine in TAP block for PO analgesia in patients undergoing TAH under spinal anaesthesia. Methods: 100 patients belonging to ASA1 or 2 scheduled for TAH under Sub Arachnoid Block (SAB) were randomly assigned into two groups- BM and B. All patients were given SAB with 15 mg of 0.5% hyperbaric Bupivacaine and TAH was done. USG guided TAPblock was given once SAB sensory level regressed to T8 dermatome. Group BM received 16ml 0.25% Bupivacaine (40mg) with 150 mg magnesium sulphate injected on each side while Group B received 16 ml 0.25% Bupivacaine only. Patients were asked to rate their pain on a 10 cm VAS scale at time 0 (time of completion of TAPblock),2,4,6,12 and 24 hours. Rescue analgesia with Inj. morphine was provided whenever VAS score was &gt; 3. Results: Patients in magnesium sulphate group had prolonged analgesia as compared to the control group. The heart rate and blood pressure response were signicantly lower in that group. Morphine requirement for PO analgesia was also signicantly reduced in group BM. No complications were seen in either group. Conclusion: Adding Magnesium sulphate to Bupivacaine in TAP block in TAH patients prolonged the duration of PO analgesia.

Variation in abdominal wall closure techniques in lower transverse incisions: a nationwide survey across specialties.

Lower transverse abdominal incisions are typically used by obstetricians/gynecologists and colorectal surgeons. The suture technique and choice of material when closing the abdomen is an essential factor to decrease the risk of incisional hernia. We conducted a nationwide survey among obstetricians/gynecologists and colorectal surgeons investigating the surgical handling of the fascia, rectus muscle, subcutis, peritoneum, and skin, in lower transverse incisions. All departments of obstetrics/gynecology and departments of surgery performing colorectal surgery in Denmark were invited to participate. An online questionnaire was sent to consultant obstetricians/gynecologists and colorectal surgeons. The survey consisted of demographic information together with questions on surgical details. The study was reported according to STROBE guidelines. A total of 252 (64.5%) consultants provided a complete response to the survey. We found that 98.0% of the colorectal surgeons and 65.8% of the obstetricians/gynecologists used monofilament suture when closing the fascia. The majority of the colorectal surgeons used continuous suture and small bites technique. This was only the case for half of the obstetricians/gynecologists. Approximately two thirds of the colorectal surgeons and one third of the OB/GYN used the suture length to wound length ratio > 4:1. Furthermore, we found significant differences between the groups in the handling of subcutis, peritoneum, and skin. We found significant variation in abdominal wall closure techniques in lower transverse incisions. Disagreement between the current guidelines within the specialties together with insufficient evidence on the closure of lower transverse incisions emphasizes the need for education as well as further studies.

Abstract A07: Transcriptional profiling confirms appendiceal adenocarcinoma is distinct from colorectal cancer, in vivo models needed

Abstract Background: Despite mounting data revealing that appendiceal neoplasms are quite distinct from colorectal cancers (CRC), these rare tumors are most often treated with chemotherapy designed for CRC. The rarity of appendiceal neoplasms has made it difficult to conduct prospective or randomized clinical trials to guide therapy for these tumors; this issue is confounded by the fact that much heterogeneity exists between multiple histopathologic subtypes, including noninvasive mucinous neoplasms, mucinous and nonmucinous adenocarcinomas, carcinoids, goblet cell carcinoids, and signet ring cell carcinomas, as well as between high- and low-grade tumors. Recent large-scale genomic profiling efforts have identified frequent activating mutations in GNAS, a G-protein-coupled receptor (52% of mucinous adenocarcinomas, 72% of pseudomyxoma peritoneii (PMP), with a strong enrichment in low-grade tumors (χ2 p &amp;lt; 0.0001). Currently available preclinical models of appendiceal tumor are very rare, and to the best of our knowledge models of low-grade, GNAS mutant appendiceal adenocarcinoma are nonexistent. Given that there is no effective systemic treatment for these low-grade tumors, here we try to address this need by generating in vivo and in vitro models of appendiceal cancer and coupling them with transcriptomic analyses to identify potential therapeutic targets in this molecularly distinct tumor type. Methods: After prospectively obtaining informed consent, tumors from surgical resection of 13 patients with appendiceal adenocarcinoma were molecularly profiled with RNAseq and full-exome DNAseq. The histology and grade of these tumor was confirmed by expert pathology review and consisted of a mix of well (n = 4), moderate (n = 4), and poorly (n = 5) differentiated tumors. For the generation of in vivo models, fresh tumors were harvested and 0.5 cm3 tumor blocks were mixed with Matrigel and planted directly into the peritoneal cavity of nude mice by means of a 1-cm transverse abdominal incision performed under aseptic conditions. Results: Unsupervised clustering of the transcriptomic profiles of the 13 appendiceal tumors revealed that tumors of similar grade clustered together. This was as expected given that histologic grade has been shown to be the most critical prognostic feature for appendiceal adenocarcinomas. When clustered with colorectal tumors from TCGA, the appendiceal tumors demonstrated much greater similarity to each other than the colorectal tumors, consistent with previous reports of significant differences in the somatic mutation profiles of appendiceal and colorectal tumors. Conclusions: Appendiceal adenocarcinoma is a distinct disease from colorectal adenocarcinoma. High- and low-grade appendiceal tumors display marked differences in genomic and transcriptomic profiles; the creation of additional preclinical models of each will be critical for the development of appendix cancer-specific therapy. Citation Format: John Paul Shen, Saikat Chowdhury, Ji Wu, Keith Fournier, Scott Kopetz, Kanwal Raghav. Transcriptional profiling confirms appendiceal adenocarcinoma is distinct from colorectal cancer, in vivo models needed [abstract]. In: Proceedings of the AACR Special Conference on the Evolving Landscape of Cancer Modeling; 2020 Mar 2-5; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2020;80(11 Suppl):Abstract nr A07.

Abdominal Closure and the Risk of Incisional Hernia in Aneurysm Surgery – A Systematic Review and Meta-analysis

Patients with abdominal aortic aneurysms (AAAs) have a high prevalence of incisional hernia following open repair. The choice of incision and closure technique has a significant impact on this post-operative complication. Multiple techniques exist, as well as various comparative analyses, but clinical consensus is lacking. The objective was to perform a systematic review and meta-analysis of AAA laparotomy and closure technique and the risk of incisional hernia development. The systematic review was performed according to the PRISMA guidelines. A literature search of all original research published until January 2019 was made. Outcome measures were surgical approach, closure technique, hernia rates, length of follow up, and method of hernia recognition. Groups were divided according to method of abdominal incision and closure technique. Differences in outcome between closure techniques were expressed as risk ratios with 95% confidence interval (CI) using a random effects model. Fifteen studies were included with a cumulative cohort of between 388 and 3 399 patients compared in each group. Abdominal closure with a suture to wound length ratio of more than 4:1 compared with less than 4:1, RR 0.42 (95% CI 0.27–0.65), and abdominal closure with mesh compared with without mesh augmentation, RR 0.24 (95% CI 0.10–0.60) reduced the risk of incisional hernia. There were no significant differences in incisional hernia rate between transverse abdominal incision vs. vertical midline incision, RR 0.57 (95% CI 0.31–1.06) and between midline transperitoneal vs. all retroperitoneal incisions, RR 1.19 (95% CI 0.54–2.61). Choice of abdominal closure technique after aneurysm surgery impacts the risk of developing incisional hernia. The use of a supportive mesh significantly reduces the risk of incisional hernia in vertical midline incisions. The same is true if a suture to wound ratio of more than 4:1 is used.

Abdominal Closure and the Risk of Incisional Hernia in Aneurysm Surgery - A Systematic Review and Meta-analysis.

Patients with abdominal aortic aneurysms (AAAs) have a high prevalence of incisional hernia following open repair. The choice of incision and closure technique has a significant impact on this post-operative complication. Multiple techniques exist, as well as various comparative analyses, but clinical consensus is lacking. The objective was to perform a systematic review and meta-analysis of AAA laparotomy and closure technique and the risk of incisional hernia development. The systematic review was performed according to the PRISMA guidelines. A literature search of all original research published until January 2019 was made. Outcome measures were surgical approach, closure technique, hernia rates, length of follow up, and method of hernia recognition. Groups were divided according to method of abdominal incision and closure technique. Differences in outcome between closure techniques were expressed as risk ratios with 95% confidence interval (CI) using a random effects model. Fifteen studies were included with a cumulative cohort of between 388 and 3 399 patients compared in each group. Abdominal closure with a suture to wound length ratio of more than 4:1 compared with less than 4:1, RR 0.42 (95% CI 0.27-0.65), and abdominal closure with mesh compared with without mesh augmentation, RR 0.24 (95% CI 0.10-0.60) reduced the risk of incisional hernia. There were no significant differences in incisional hernia rate between transverse abdominal incision vs. vertical midline incision, RR 0.57 (95% CI 0.31-1.06) and between midline transperitoneal vs. all retroperitoneal incisions, RR 1.19 (95% CI 0.54-2.61). Choice of abdominal closure technique after aneurysm surgery impacts the risk of developing incisional hernia. The use of a supportive mesh significantly reduces the risk of incisional hernia in vertical midline incisions. The same is true if a suture to wound ratio of more than 4:1 is used.

Application of hidden incision in specimen extraction of robot-assisted laparoscopic pediatric radical nephrectomy

To investigate the value of hidden incision applied to specimen extraction in children's robot-assisted laparoscopic radical nephrectomy. The clinical data of robotic-assisted laparoscopic radical nephrectomy in our hospital were retrospectively analyzed. The patients were treated with 60° lateral position and the eyepiece Trocar was located at the umbilical contralateral margin. The operation hole 1 is located 6-7 cm above the anterior median line (depending on the abdominal wall space of the child), and the operation hole 2 is located at the intersection of the anterior median line and the lower transverse Pfannenstiel, Trocar sneaked under the skin, and then inserted into the abdominal cavity (1.5cm above the operation hole 2) , if the auxiliary hole is needed, the auxiliary hole Trocar is placed on the affected side of the lower abdominal transverse line. All the operations are performed with radical resection. The specimen was placed in the specimen bag, then extend the lower abdominal transverse incision (the length of the incision is the smallest diameter of the kidney), the specimen bag is taken through the incision (Pfannenstiel incision), and the wound is partially injected with ropivacaine mesylate. Postoperative routine cefuroxime to prevent infection, no analgesic pump. A total of 7 patients with robot-assisted laparoscopic radical nephrectomy were enrolled in our hospital from August 2015 to February 2019, including 4 boys, 3 girls, 5 left side, 2 right side. The average length of the incision is 6.5cm (5.5-7.0cm). All the specimens were completely removed. The average postoperative hospital stay was 4.5 days (4-7 days). There was no active bleeding, splitting, infection in the postoperative wound, the average follow-up time is 25m (4-46m), no scar hyperplasia was observed. The hidden incision (Pfannenstiel incision) can be safely and effectively applied to specimen extraction in children's robot-assisted laparoscopic radical nephrectomy.