Ventral Fascia Research Articles

Präperitoneale umbilikale Netzplastik (PUMP): Indikationen, Technik und Resultate

The principle of the preperitoneal umbilical mesh plasty (PUMP) technique is placement of the prosthesis in the extraperitoneal space, posterior to the rectus muscles, followed by ventral fascia closure. Difficulties can arise from preperitoneal dissection, mesh insertion, deployment, and positioning. 81 elective patients underwent preperitoneal repair of primary umbilical or epigastric hernias sized from 2 - 4 cm between January 2015 and March 2018 and were prospectively collected in the Herniamed database and retrospectively analysed. The same general technique was applied, but over time three different types of mesh devices were used. The experience from these cases and the gradual change between the implants during the observation period is described in this study. No intraoperative complications were recorded. Postoperative complications occurred in 6 of 81 patients (7.4%) with the need for unplanned re-operation in 3 cases. Seventy-six of 81 patients (93.8%) attended the one year follow-up evaluation. Three of 76 patients (3.9%) suffered recurrence and five patients (6.6%) requires treatment for chronic pain. Surgeons must work with the implant that best suits their patients' needs and that also provides good results and adequate working comfort. The PUMP technique performs well for ventral hernias sized between 2 and 4 cm without the need of midline reconstruction due to diastasis of the rectus muscles. It enables a local extraperitoneal mesh augmentation without the risk of intraperitoneal complications. PUMP repair lowers the risk of recurrence in comparison with suture repair without increasing the risk of complications.

Congenital Megaprepuce: Surgical Approach

To describe surgical procedure and results of Congenital Megaprepuce (CMP) that consists in phimosis and megaprepuce; glans and corpora trapped into pre-pubic fat; incomplete micturition with typical "ballooning" aspect. Genitoplasty with penoscrotal separation (GPS) was performed at Pediatric Surgery Department of Hospital Nord - Marseille, between July and December 2010, in 5 uncircumcised children with CMP, by the same surgeon. Transversal incision at the ventral penoscrotal junction was used, with shaft bipartition and Buck's ventral fascia exposition. The inner layer of prepuce was resected while the outer layer was preserved for coverture of the penile shaft. The dorsal foreskin was medially and longitudinally incised to obtain adequate length of the dorsal shaft. The first middle dorsal suture was made using PDS 6.0 and completed in ventral direction with interrupted stitches. The urinary catheter was placed and hydrocolloid duoderm dressing used. Perioperative prophylactic antibiotic was given and pain control achieved with paracetamol and codeine. All patients presented urinary troubles before surgery. Skin penile coverage was complete in all patients with cosmetically and functionally satisfying results; no complication was observed at 12 months mean follow-up. CMP is a specific entity of "inconsistent penis." Surgical treatment should be discussed at diagnosis, resolving micturition troubles. GPS is a simple and reproducible procedure by experienced surgeons. Excellent cosmetic and functional results are obtained at mean follow-up, even if long-term results are required. GPS can be useful in other malformations of the penile shaft.

A Chimeric Flap Model in Dogs

Prelamination is sometimes required for reconstruction of specialized organs. The purpose of this study was to create a chimeric flap model in dogs for prelamination. The anatomy of the deep and superficial caudal epigastric vessels, which supply the rectus abdominis muscle and superficial ventral fascia, respectively, were measured in 14 dogs. Their lengths were ~30 mm with the arteries averaging 1.4 mm and veins, 2.5 mm in diameter. These vessels shared a 10-mm-long common trunk with the artery averaging 2 mm and the vein, 3.2 mm in diameter. Chimeric flaps were successfully raised in six dogs based on the common vascular trunk, and they remained well perfused 3 weeks after prelamination. The perfusion territory of the abdominal skin measured 25 cm long and 10 cm wide with methylene blue injection. This study suggests that the caudal epigastric system can be a suitable chimeric flap model in dogs.

Development of the human hypogastric nerve sheath with special reference to the topohistology between the nerve sheath and other prevertebral fascial structures

Semi-serial sections from the lumbosacral region of nine fetuses (8-25 weeks gestation) were examined to clarify the lumbar prevertebral fascial arrangement. The prevertebral fasciae became evident after 12 weeks of age. After 20 weeks of age, the hypogastric nerve (HGN) was sandwiched by two fascial structures; the ventral fascia which seemed to correspond to the mesorectal fascia, whereas the dorsal fascia corresponded to the presacral fascia. These fasciae or the HGN sheaths extended laterally along the ventral aspects of the great vessels and associated lymph follicles. The ventral fascia is, to some extent, fused with the mesocolon descendens on the left side of the body. Notably, the lateral continuation of these two fasciae also sandwiches the left ureter, but not the right ureter, presumably due to modifications by the left-sided fusion fascia. A hypothetical common sheath for the HGN and ureter (i.e., the ureterohypogastric or vesicohypogastric fascia) might thus be an oversimplification. Before retroperitoneal fixation, the morphology of the peritoneal recess along the mesocolon descendens and mesosigmoid suggested interindividual differences in location, shape, and size. Therefore, in adults the ease of surgical separation of the rectum and left-sided colon from the HGN seems to depend on interindividual differences in the development of the embryonic peritoneal recess. On the caudal side of the second sacral segment, fascial structures were restricted along and around the HGN, pelvic splanchnic nerve, and pelvic plexus. The rectal lateral ligament thus seems to represent a kind of migration fascia formed by mechanical stress.

3D‐reconstruction and functional properties of GFP‐positive and GFP‐negative granule cells in the fascia dentata of the Thy1‐GFP mouse

Granule cells of the mouse fascia dentata are widely used in studies on neuronal development and plasticity. In contrast to the rat, however, high-resolution morphometric data on these cells are scarce. Thus, we have analyzed granule cells in the fascia dentata of the adult Thy1-GFP mouse (C57BL/6 background). In this mouse line, single neurons in the granule cell layer are GFP-labeled, making them amenable to high-resolution 3D-reconstruction. First, calbindin or parvalbumin-immunofluorescence was used to identify GFP-positive cells as granule cells. Second, the dorsal-ventral distribution of GFP-positive granule cells was studied: In the dorsal part of the fascia dentata 11% and in the ventral part 15% of all granule cells were GFP-positive. Third, GFP-positive and GFP-negative granule cells were compared using intracellular dye-filling (fixed slice technique) and patch-clamp recordings; no differences were observed between the cells. Finally, GFP-positive granule cells (dorsal and ventral fascia dentata) were imaged at high resolution with a confocal microscope, 3D-reconstructed in their entirety and analyzed for soma size, total dendritic length, number of segments, total number of spines and spine density. Sholl analysis revealed that dendritic complexity of granule cells is maximal 150-200 mum from the soma. Granule cells located in the ventral part of the hippocampus revealed a greater degree of dendritic complexity compared to cells in the dorsal part. Taken together, this study provides morphometric data on granule cells of mice bred on a C57BL/6 background and establishes the Thy1-GFP mouse as a tool to study granule cell neurobiology.

Multilayer Reconstruction of Abdominal Wall Defects With Acellular Dermal Allograft (AlloDerm) and Component Separation

Multiple techniques have been employed for the repair of abdominal incisional hernias with varying rates of success. Primary fascial apposition and prosthetic implantation have been associated with high rates of secondary recurrence, infection, and other complications, often due to insufficient alleviation of tension and implant intolerance. This study evaluates the repair of incisional and recurrent abdominal hernias with multilayered acellular dermal allograft (AlloDerm; LifeCell Corporation, Branchburg, NJ) and musculofascial separation. Patients with incisional or recurrent abdominal hernias were treated between January 2003 and March 2004. The surgical technique involved musculofascial release of the external oblique, followed by a double-layer implantation of dermal allograft. The primary allograft layer was placed as an "underlay" interposition, sutured under moderate tension beneath the fascial edges of the defect. When minimal tension remained, the native fascial margins of the defect were directly repaired. A second allograft layer was then placed and sutured to the superficial aspect of the ventral fascia to complete the repair. Data were reviewed retrospectively. Sixteen patients were treated. There were 10 males and 6 females, mean age 56 years (range 44--72 years). Fifteen patients (94%) had previous hernia repair procedures, and 6 patients (38%) had undergone 2 or more previous procedures. Nine patients (56%) were treated with hernia site infections or prosthetic exposure. Mean follow-up is 16 months (range 9 to 23 months). There were 2 seromas (13%). One patient (6%) developed a wound dehiscence with allograft exposure that healed by secondary intention. There were no recurrences. By minimizing tension and providing a durable biocompatible matrix for support, component separation with bilaminar acellular dermal allograft should be considered for the repair of complex and recurrent ventral hernias.

Cooperativity between Far Upstream Enhancer and Proximal Promoter Elements of the Human α2(I) Collagen (COL1A2) Gene Instructs Tissue Specificity in Transgenic Mice

Interaction between the proximal (-378) promoter and the far upstream (-20 kb) enhancer is essential for tissue-specific expression of the human alpha2(I) collagen gene (COL1A2) in transgenic mice. Previous in vitro studies have shown that three Sp1 binding sites (around -300) are part of a cytokine-responsive element and that two TC-rich boxes (around -160 and -125) and a CBF/NFY consensus sequence (around -80) confer optimal promoter activity by interacting among themselves and with the upstream Sp1 sites. Here we report that mutations of the Sp1 binding sites, TC-rich boxes or CBF/NFY consensus sequence lead to reduced transgene activity, thus underscoring the functional interdependence of the proximal promoter elements. Loss of the Sp1 binding sites was associated with loss of transgene expression in osteoblasts, whereas elimination of the CBF/NFY binding site (alone or in combination with the TC-rich boxes) was correlated with a lack of activity in the ventral fascia and head dermis and musculature. Additionally, transgene expression in skin fascia fibroblasts depended on the integrity of the Sp1 binding sites and TC-rich boxes, and on their physical configuration. Evidence is also presented suggesting cooperativity between cis-acting elements of the far upstream enhancer and proximal promoter in assembling tissue-specific protein complexes. This study thus reiterates the complex and highly combinatorial nature of the regulatory network governing COL1A2 transcription in vivo.

Ventral Rectus Fascia Closure on Top of Mesh Hernia Repair in the Sublay Technique

Sublay prosthetic herniorrhaphy has become a widely accepted procedure for incisional hernias. To evaluate the effect of fascia closure on top of mesh repair on infection, and the recurrence rate, the authors reviewed their data regarding herniorrhaphy in the sublay technique. This study was a retrospective analysis of 175 consecutive patients who underwent hernia repair by implantation of prostheses by means of the Stoppa-Rives technique from December of 1994 to December of 2001. All 175 patients had the mesh implanted in the subfascial plane, 130 received a light-weight or heavy-weight polypropylene mesh (Vypro or Prolene) (74 percent), eight had a polyester mesh (Mersilene) (5 percent), and 37 had an expanded polytetrafluoroethylene patch (Gore-Tex) (21 percent). After sublay mesh positioning, the mesh could not be covered by the fascia in 50 cases; in 31 of these cases, a second mesh was placed into the fascial defect. To evaluate the influence of the fascia closing procedure on top of the sublay mesh, three groups were differentiated: initial fascia closure (n = 125), no fascia closure and concomitant mesh interposition (n = 31), and no fascia closure without mesh interposition (n = 19). After a mean follow-up of 20 months, 11 deep prosthetic infections (8 percent) and 15 hernia recurrences (9 percent) were observed. There was an increased risk of mesh infection when the fascia could not be closed, but there was no influence of fascia closure on hernia recurrence. When the fascia was left open, the placement of a second mesh inlay technique reduced mesh infection. The authors' data give evidence that closing the ventral fascia after mesh repair in the sublay position is beneficial. When the edges of the hernia defect could not be approximated, the suturing of a second mesh into the fascia defect was a useful tool for reducing the prosthetic infection rate; however, no significant influence on hernia recurrence was observed.

Circumferential mesh in abdominal wall reconstruction: indications, technical notes and case report.

The authors describe an original technique of abdominoplasty aiming at correcting ventral muscles, hypotonia, and relaxation, especially in formerly obese patients, pluriparae women, and patients with neuromuscular impairment. The technique encloses regular dermolipectomy, laparocele or hernia reduction (if existing), ventral fascia plication on the midline, and suprafascial application of a purposely built polypropylene mesh. The mesh consists of three continouos segments: two lateral, wider, rectangular segments to be fixed on the ventral area and one central and narrower (like a belt) segment to be inserted posteriorly into the deep subcutaneous tissue above the dorsal muscles and the spine. The vehicle of inserting circumferential mesh includes introducing a smooth, hollow rod through a small lateral skin access. Then, the two lateral segments are extended and criss-crossed over the abdominal muscles and are fixed to the iliac periosteum. This allows the dorsal and ventral muscles to be contained and supported by the mesh during prolonged standing and exercise.

Paramedian Insertion of Tenckhoff Catheters with Three Purse-String Sutures Reduces the Risk of Leakage

Starting peritoneal dialysis (PD) immediately after insertion of a peritoneal dialysis catheter is essential in some patients. However, due to a poor insertion technique, leakage may occur in up to 20% of patients after insertion of a peritoneal dialysis catheter, for example, in the midline. PD was started in 50 consecutive patients (age range 7-81 years). Under local anesthesia the Tenckhoff catheter was inserted about 3 cm lateral to the linea alba (mostly to the right) near the navel. The ventral and dorsal fasciae of the rectus muscle were split sagitally before entering the peritoneal membrane by a small incision. One purse-string suture fixed the peritoneal membrane around the inner cuff, while the second suture fixed the dorsal fascia of the rectus muscle around the outer side of the cuff. A third suture was placed around the catheter in the ventral fascia. Dialysis in all our patients was started peroperatively, initially by the use of 1 L of peritoneal dialysis fluid (Dianeal, Baxter Medical AB, Sweden). Bed rest for 2 or 3 days was requested of and performed by most patients. Only one early and no late leakages occurred. At reoperation of the patient with the leak, the second suture was found to have been loosened. The technique is easy to handle and enables immediate dialysis. The risk for leakage is very low.