Strength of small-bites abdominal wall closure using different suturing methods and materials in an experimental animal model.

PURPOSE: Using small instead of large bites for laparotomy closure results in lower incidence of incisional hernia, but no consensus exists on which suture material to use. This study aimed to compare five different closure strategies in a standardized experimental setting. METHODS: Fifty porcine abdominal walls were arranged into 5 groups: (A) running 2/0 polydioxanone; (B) interlocking 2/0 polydioxanone; (C) running size 0 barbed polydioxanone; (D) running size 0 barbed glycolic acid and trimethylene carbonate; (E) running size 0 suturable polypropylene mesh. The small-bites technique was used for linea alba closure in all. The abdominal walls were divided into a supra- and infra-umbilical half, resulting in 20 specimens per group that were pulled apart in a tensile testing machine. Maximum tensile force and types of suture failure were registered. RESULTS: The highest tensile force was measured when using barbed polydioxanone (334.8 N ± 157.0), but differences did not reach statistical significance. Infra-umbilical abdominal walls endured a significantly higher maximum tensile force compared to supra-umbilical (397 N vs 271 N, p < 0.001). Barbed glycolic acid and trimethylene carbonate failed significantly more often (25% vs 0%, p = 0.008). CONCLUSION: Based on tensile force, both interlocking and running suture techniques using polydioxanone, and running sutures using barbed polydioxanone or suturable mesh, seem to be suitable for abdominal wall closure. Tensile strength was significantly higher in infra-umbilical abdominal walls compared to supra-umbilical. Barbed glycolic acid and trimethylene carbonate should probably be discouraged for fascial closure, because of increased risk of suture failure.

Treatment of recurrent inguinal hernia after TransInguinal PrePeritoneal (TIPP) surgery: feasibility and outcomes in a case series.

BACKGROUND: TransInguinal PrePeritoneal (TIPP) inguinal hernia repair (IHR) combines an open anterior approach with a preperitoneal position of the mesh. Advantages include reduced chronic postoperative inguinal pain, low recurrence rates and quick recovery. Critics have expressed concerns that recurrent IHR after TIPP could be difficult and with an increased risk of complications due to the formation of scar tissue in both the anterior and posterior anatomical inguinal planes. This study reports feasibility and outcomes of recurrent IHR after TIPP repair. METHODS: Patients who underwent recurrent IHR after TIPP between January 2013 and January 2015 in a single hernia-dedicated teaching hospital were included. Exclusion criteria were femoral hernia, incarcerated hernia and reasons for unreliable follow-up. Electronic medical records were assessed retrospectively to register surgical outcomes and complications. RESULTS: Thirty-three patients underwent surgical repair of recurrent inguinal hernia after TIPP. Twenty patients were treated with a "re-TIPP when possible" strategy; resulting in 13 successful re-TIPPs and 7 conversions to Lichtenstein repair. Eleven patients underwent a primary Lichtenstein's repair, the remaining two patients underwent recurrent IHR using other techniques (TransREctus sheath PrePeritoneal and TransAbdominal PrePeritoneal repair). Mean time of surgery was 44.7 min (standard deviation 16.7). There was one patient (3.0%) with a re-recurrent inguinal hernia during follow-up. Other minor complications included urinary tract infection. CONCLUSION: These results indicate that after TIPP it is feasible and safe to perform re-surgery for recurrent inguinal hernia with an anterior approach again. For these recurrences, a Lichtenstein repair can be performed, or a "re-TIPP if possible" strategy can be applied by experienced TIPP surgeons, tailored to the intraoperative findings. Whether a re-TIPP has advantages over Lichtenstein should be evaluated in a prospective manner.

Use of the Humeral Head as a Reference Point to Prevent Axillary Nerve Damage during Proximal Fixation of Humeral Fractures: An Anatomical and Radiographic Study.

INTRODUCTION: Treatment of proximal humeral fractures with plate osteosynthesis or intramedullary nail fixation in humeral shaft fractures with a proximal locking bolt carries the risk of iatrogenic injury of the axillary nerve. The purpose of this anatomical study is to define a more reliable safe zone to prevent iatrogenic axillary nerve injury using the humeral head instead of the acromion as a (radiographic) reference point during operative treatment. MATERIALS AND METHODS: Anatomical dissection and labeling of the axillary nerve and branches was performed on 10 specially embalmed human specimens. Standard AP and straight lateral radiographs were made. The distances were measured indirectly from the cranial tip of the humerus to the axillary nerve on radiographs. RESULTS: The median distance from the cranial tip of the humerus to the axillary nerve was 52 mm. The mean number of axillary nerve branches was 3. The distances from the cranial tip of the humerus to the nerve (branch) varied from 23 to 78 mm. The median distance from the proximal (anterior) branch was 36 mm, to the second branch 47 mm, 54 mm to the third branch and 73 mm to the fourth branch. The axillary nerve moves along with the humerus in cranial and caudal direction when the subacromial space varies. CONCLUSION: This study shows that the position of the axillary nerve can be better determent using the cranial tip of the humerus as a reference point instead of the acromion. Furthermore, it is unsafe to place the proximal locking bolts in the zone between 24 mm and 78 mm from the cranial tip of the humerus. The greatest chance to cause a lesion of the main branch of the axillary nerve is in the zone between 48 mm and 58 mm caudal from the tip of the humeral head. HOW TO CITE THIS ARTICLE: Theeuwes HP, Potters JW, Bessems JHJM, et al. Use of the Humeral Head as a Reference Point to Prevent Axillary Nerve Damage during Proximal Fixation of Humeral Fractures: An Anatomical and Radiographic Study. Strategies Trauma Limb Reconstr 2020;15(2):63-68.