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An improved jig simulating the abdominal wall and peritoneal cavity is described. It can be used to teach the techniques of abdominal wound closure and stoma formation. It has proved to be a valuable addition to our anastomosis workshops.
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The authors describe clinical cases of dermatolipectmy of the abdominal wall performed during the last 15 years: a group of six female patients with excess skin after rapid and excessive reduction of adipose tissue, a second group of 42 patients with cumulation of subcutaneous fat in the region of the hypogastrium with formation of massive skinfolds, the so-called clinical picture of "venter pendulus". The third group of 122 patients with excessive adipose tissue and skin combined with diastasis of the rectus abdominis muscles or even prolapse of the abdominal organs. Transverse puboinguinal dermatolipectomy was performed. In 56 patients, high transverse resection is not used by the authors. Vertical lipectomy in the median line was performed in three patients and combined transverse-vertical lipectomy in 104 patients. From the total number of 170, operations satisfactory from the aspect of the surgeon and in particular the patient, were achieved in 122 (71.7%) cases, good results in 43 (25.4%) and satisfactory results in 5 (2.9%).
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The diagnosis of ventral abdominal wall defect can now be made prior to birth. With this diagnosis, the family can make decisions and a planned optimal management can lead to a successful outcome. There were 31 cases of ventral wall defect identified at Chang Gung Memorial Hospital (CGMH) from January 1979 through March 1988. Twenty of them were classified as gastroschisis; among them, 17 (85%) were born in outside clinics and none of them had associated anomalies. In contrast, among 11 cases of omphalocele, there was a lower frequency of transferred cases (27% vs 85%), and 4 cases had additional defects, including two multiple anomalies and two bladder exstrophies. There were no significant differences between gastroschisis and omphalocele in the mortality rate (30% vs 36%), in the incidence of intrauterine growth retardation (IUGR) (30% vs 27%) and in the Cesarean section rate (15% vs 18%). All 4 cases of prematurity (less than 36 weeks of gestational age) expired after delivery and 2 of these had body weights of less than 1500 g. Three out of 5 cases delivered by Cesarean section expired; the mortality (60%) was higher than that of vaginal delivery (28%). All 3 cases were gastroschisis, 2 of them were transferred from outside clinics and all expired due to sepsis. The diagnosis of ventral wall defect should be made prenatally, with obstetric ultrasonography, maternal serum alpha-fetoprotein screening and fetal karyotyping. Therefore, fetal transport in utero to a referral center and optimal perinatal care for those fetuses with potentially correctable lesions can be well planned.
OBJECTIVES: To investigate whether fetal cardiac axis is affected by the presence of an abdominal wall defect (AWD) independent of congenital heart disease (CHD). METHODS: Video ultrasound records from fetuses with AWDs identified from 1991-2004 were reviewed. Still images of the fetal cardiac four-chamber view were digitized and two independent examiners measured the cardiac axis. A cardiac axis of >65 degrees or <25 degrees was considered abnormal. Maternal charts were reviewed for fetal echocardiogram results and neonatal charts were reviewed for confirmation of CHD and type of AWD. RESULTS: Of 17 fetuses with omphalocele and 42 fetuses with gastroschisis, 16 (27%) fetuses had an abnormal cardiac axis, while only seven (12%) had CHD. Fifty-nine percent of fetuses with omphalocele had an abnormal cardiac axis and 35% had CHD. Fourteen percent of fetuses with gastroschisis had an abnormal cardiac axis and 2% had CHD. Of 43 fetuses with a normal cardiac axis, only one had CHD. CONCLUSIONS: Fetal cardiac axis is often affected by the presence of an AWD independent of CHD. A normal cardiac axis in fetuses with AWDs is an accurate predictor of the absence of CHD, the negative predictive value being 97.7%.
Abdominal wall electromyography, using sticky surface patch electrodes placed on the rectus abdominus muscles, was used during noninvasive urodynamic studies in 60 children to detect straining. Straining, which usually was imperceptible to the examiner, occurred in 64 per cent of neurologically normal children. Urodynamics identified detrusor-sphincter dyssynergia during straining to void but reverted to normal when the same children voided without straining. Because the urodynamic findings that characterize detrusor-sphincter dyssynergia are mimicked by straining and other common urologic entities, the potential for misdiagnosis is great unless some assessment of intra-abdominal pressure is made during neurourologic testing.
BACKGROUND: Sufficient propofol or fentanyl doses necessary to prevent the response to skin incision do not necessarily attenuate hemodynamic responses during surgery. The goal of this study was to characterize the pharmacodynamic interaction between propofol and fentanyl with respect to the suppression of somatic or hemodynamic responses after three stimuli: skin incision, peritoneum incision, and abdominal wall retraction. METHODS: Propofol and fentanyl were administered via computer-assisted continuous infusion to provide equilibration between plasma-blood and biophase concentrations. Patients were randomized to nine groups that received predetermined concentrations of fentanyl (from 0 to 9 ng/ml). Each patient was administered different target concentrations of propofol. Somatic and hemodynamic responses were measured before and after each of three different stimulations: skin incision (si), peritoneum incision (pi), and abdominal wall retraction (ret). The propofol plasma concentrations at which 50% of the patients did not respond to each type of stimulation (Cp50si, Cp50pi, and Cp50ret) were calculated by fitting the Loewe synergistic model. RESULTS: For propofol alone, Cp50si, Cp50pi, and Cp50ret were 12.9, 17.1, and 19.4 microg/ml, respectively. Increasing the fentanyl concentration markedly reduced propofol Cp50si, Cp50pi, and Cp50ret for somatic response, indicating the potential synergistic interaction of both drugs. During the prestimulation period, fentanyl did not decrease systolic blood pressure; however, propofol specifically decreased systolic blood pressure. Both drugs had a synergistic drug interaction on the systolic blood pressure increase after various surgical stimulations. Fentanyl and propofol concentrations that suppressed both the 50% probability of somatic response and the 50% probability of moderate hemodynamic change defined by the 15% systolic blood pressure increase over the prestimulation value were 3.6 ng/ml and 2.5 microg/ml for skin incision, 8.4 ng/ml and 1.6 microg/ml for peritoneum incision, and 5.9 ng/ml and 5.1 microg/ml for wall retraction, respectively. CONCLUSIONS: The anesthesia requirements for stimuli that are more intense than skin incision should be considered during abdominal surgery. Somatic and hemodynamic responses varied depending on the type of surgical stimuli.
Difficulty with evacuation (DWE) is common in individuals with spinal cord injury (SCI). Numerous studies have concluded that constipation, impaction, and incontinence cause significant morbidity and, collectively, constitute an important quality-of-life issue in individuals with SCI. Colonic motor activity was assessed using a solid-state manometry probe. We report here that colonic pressure activity is depressed during sleep compared to that observed in able-bodied controls. In addition, pressure activity was decreased during sleep compared to pre-sleep and post-sleep. We suspect that this may contribute to delayed colon transit time after SCI. In addition, since contraction of the abdominal wall musculature plays a role in normal defecation, we assessed whether an abdominal belt with implanted electrodes would improve DWE. In this respect, we demonstrated that neuromuscular stimulation of the abdominal wall improves a number of indices of defecatory function, including time to first stool and total bowel care time.
The objective of this work has been to characterize stress relaxation in the polymer material on applying different levels of constant strain. The meshes were strained at values of 5.2%, 5.4% and 5.6% which are the values at which the mesh is strained in clinical use for the repair of abdominal walls. Laws have been obtained to model the viscoelastic behavior at different strains for this material. Finally, fracture studies were carried out by environmental scanning electron microscopy to determine the fracture mechanisms of these meshes. Besides, the implantation of the meshes was practised in two different layers of abdominal wall: the superficial or preaponeurotic layer and deep or preperitoneal layer, showing the neoformation of connective tissue on the mesh, which tended to be organized differently in each layer studied; more roughly and densely in the superficial layer than in the deep one.
BACKGROUND: Both pneumoperitoneum and blind needle and trocar insertion may cause complications: because of the well-known physiological effects, CO2 insufflation is not indicated in patients with impairment of cardiorespiratory function and high-risk patients; injuries to underlying viscera and vessels by needles and trocars have been reported even when the open technique is used. METHODS: A technique which combines abdominal wall suspension by a new subcutaneous lifter (LaparoTenser) and optical trocar (OptiView) insertion has been evaluated in a random series of 22 patients undergoing various laparoscopic procedures. The optic trocar was inserted without previous insufflation, but low-pressure (1-5 mmHg) pneumoperitoneum was associated during the course of the procedure in 16 cases. RESULTS: The exposure of the operating field was good or sufficient in 21 cases (95%), while the placement of the optical trocar was always safe. One complication related to the insertion of the subcutaneous needles of the wall lifter occurred (suprafascial hematoma). CONCLUSIONS: The subcutaneous retractor allows the use of conventional cannulae and the combination of abdominal wall suspension with or without low-pressure pneumoperitoneum, thus enhancing the quality of exposure with no effect on the hemodynamic and respiratory functions.
Eighteen patients with a prenatal diagnosis of fetal abdominal wall defect were delivered by cesarean section and repaired either immediately (begun within 15 min, n = 9), or by the traditional (delayed) method (n = 9, average delay = 4.4 h). Neonates repaired immediately had comparable gestational ages and birthweight, however, subjectively had less edematous bowel with less fibrous peel. These fetuses were more likely to be closed primarily (7/9 vs. 4/9), spent less time on a ventilator (8.1 vs. 17.9 days), seemed to be fed sooner (7.6 vs. 17.9 days), and discharged home earlier (14.3 vs. 24.0 days). Our results suggest that for fetuses delivered by cesarean section, early defect repair may reduce bowel edema and fibrous peel formation thus facilitating primary closure, with earlier ventilator weaning, feeding and discharge home.
Modifications of classical vesico-urethral suspension, according to Marshall-Marchetti-Krantz, are in widespread use among numerous operations for urinary incontinence, on account of their mild direct effect on both the urethra and bladder neck region. However, dysuria and dyspareunia may be quite frequent consequences later on because of retrosymphysial adhesions and rigid fixation of the vagina. We have, therefore, adopted an approach by which the advantages of mobile sling suspension are combined with indirect elevation of the urethrovesical junction, in that the vagina is fixed to strips obtained from the aponeurosis of the abdominal wall or from lyophilised dura mater. Fascial origin and dura anchorage in the abdominal wall are conducive to achieving a pronounced ventrocranial pull, and involvement of the rectus musculature in bridle action was found to add to the elevation effect in stress situations. A detailed account is given of the surgical technique. The method is contra-indicated or at least not fully sufficient only in cases of severe pelvic floor insufficiency or descensus of the vagina. Twenty-eight women have undergone this operation, within one year, with 20 of them (71 per cent) being relieved from complaints and five (18 per cent) substantively improved. Stress quotient and transmission factor are favourably affected, in terms of urodynamics, while ventral urethrovesical fixation is improved, in terms of radiography. Postoperative uroflow parameters have stayed normal. Problems of co-habitation did not occur. The small number of cases and lack of long-time results, therefore, cannot prevent the authors from recommending the technique for verification by re-use.
BACKGROUND: Wound infection and sepsis leading to incisional hernia development are common after emergency colonic operations. Later on, while being operated on to correct an incisional hernia, most of these patients will need colonic resection or bowel continuity reestablishment. Simultaneous treatment of incisional hernias in patients with colostomy or colonic disease remains a difficult challenge, considering the reluctance of most surgeons to treat both conditions at the same time, especially when prosthetic repair is needed. STUDY DESIGN: The aim of this study was to analyze the short-term results of patients undergoing colonic resection or bowel continuity reestablishment and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. Over a period of 6 years, 20 patients were operated on for colonic problems associated with incisional hernias, including 8 Hartmanns' colostomies, 6 colostomies or ileostomies with colonic mucous fistulas, 3 postoperative colocutaneous fistulas, a paracolostomic hernia, a Chagas' megacolon, and a pseudotumoral diverticulitis. A "rule of three" statistical analysis was used to estimate the maximum risk of adverse effects, concerning mesh-related morbidity, after 1- and 2-year followup. RESULTS: A major complication occurred in a patient who developed an anastomotic leakage and secondary wound infection; the patient was treated with parenteral nutrition and antibiotics. Other complications included a minor wound infection, a seroma, and a chronic sinus. One patient died from postoperative problems unrelated to the surgical technique. The occurrence of postoperative wound infection did not prevent mesh incorporation. Followup ranging from 1 to 7 years detected no hernia recurrences; 13 patients were followed for 2 years or more. Our results suggest that risk of mesh-related morbidity does not exceed 15.8% (3 of 19) within the first year and 23.1% (3 of 13) for 2 years followup, with 95% confidence. CONCLUSIONS: We concluded that prosthetic repair of incisional hernias associated with simultaneous colonic operations was possible, allowing abdominal wall anatomy reestablishment. There is no reason to believe that abdominal wall prostheses must be avoided in contaminated operations when an adequate surgical technique is used.
We present a case of rectus sheath hematoma compounded by anterior abdominal wall haemorrhage. Its clinical and anatomical relationship is discussed.
One hundred and twenty abdominal wall defects were notified to the Northern Region Fetal Abnormality Survey in the five years 1988 to 1992. Gastroschisis occurred in 56, exomphalos in 43, amnion rupture in 11, ectopia vesicae in seven and ectopia cordis in three. Ultrasound failed to identify gastroschisis in 14 and incorrectly diagnosed exomphalos in eight. There was no associated chromosome abnormality and the survival rate, excluding first trimester loss, was 87%. Ultrasound failed to identify exomphalos in ten and incorrectly diagnosed gastroschisis in two. Another structural abnormality was present in 40% and a chromosome anomaly in 28%. Excluding spontaneous first trimester loss, the survival rate was 34%. Delivery of babies away from the regional paediatric surgical centre did not adversely affect the outcome in gastroschisis or exomphalos although closure was delayed, on average, by 2 h. There was one survivor of 11 fetuses with amnion rupture sequence. Six of the seven babies with ectopia vesicae and two of the three with ectopia cordis survived.