Bilateral rectus muscle turning-over for complicated and eventrated abdominal wall hernias: results of a novel method.

PURPOSE: We present a technique for covering large midline loss of abdominal wall using a novel method by autologous tissues. METHODS: Twenty-two patients (body mass index = 35,6 ± 6,9 kg/m2) were involved in the prospective cohort study. Acute and elective cases were included. The gap area was 450.1 ± 54 cm2. The average width of the midline gap was 16,3 ± 3,2 cm. The rectus muscles were mobilized from its posterior sheath. Both muscles were turned by180º medially, so that the complete abdominal wall gap could be covered without considerable tension. Changes in intra-abdominal pressure, quality of life and hernia recurrency were determined. RESULTS: There was no significant increase in the intra-abdominal pressure. Wound infection and seroma occurred in four cases. Bleeding occurred in one case. Pre- and post-operative quality of life index significantly improved (23 ± 13 vs. 47 ± 6; p = 0,0013). One recurrent hernia was registered. The procedure could be performed safely and yielded excellent results. The method was applied in acute cases. The intact anatomical structure of rectus muscles was essential. CONCLUSIONS: The midline reconstruction with bilateral turned-over rectus muscles provided low tension abdominal wall status, and it did not require synthetic mesh implantation.

Bilateral rectus muscle turning-over for complicated and eventrated abdominal wall hernias: results of a novel method

ABSTRACT Purpose: We present a technique for covering large midline loss of abdominal wall using a novel method by autologous tissues. Methods: Twenty-two patients (body mass index = 35,6 ± 6,9 kg/m2) were involved in the prospective cohort study. Acute and elective cases were included. The gap area was 450.1 ± 54 cm2. The average width of the midline gap was 16,3 ± 3,2 cm. The rectus muscles were mobilized from its posterior sheath. Both muscles were turned by180º medially, so that the complete abdominal wall gap could be covered without considerable tension. Changes in intra-abdominal pressure, quality of life and hernia recurrency were determined. Results: There was no significant increase in the intra-abdominal pressure. Wound infection and seroma occurred in four cases. Bleeding occurred in one case. Pre- and post-operative quality of life index significantly improved (23 ± 13 vs. 47 ± 6; p = 0,0013). One recurrent hernia was registered. The procedure could be performed safely and yielded excellent results. The method was applied in acute cases. The intact anatomical structure of rectus muscles was essential. Conclusions: The midline reconstruction with bilateral turned-over rectus muscles provided low tension abdominal wall status, and it did not require synthetic mesh implantation.

[Significance of the computed tomography assisted morphometry in the surgical planning of eventrated abdominal wall hernias]. / A komputertomográfia jelentosége az eventerált, óriás hasfali sérvek mutéteinek tervezésében.

INTRODUCTION: The eventrated, giant abdominal wall hernias represent a considerable challenge in our practice. Presently, preoperative evaluation of the musculo-aponeurotic elements of the abdominal wall by CT imaging is not part of routine planning of surgery. AIM: Evaluation of the abdominal wall hernia progression in time. Moreover, follow up the changes of the abdominal wall structures following series of intraabdominal surgeries. METHOD: Abdominal CT imaging were performed on the 1st, 3rd, 6th, 12th, 18th, and 24th postoperative months after the primary series of surgeries in the cases of 12 patients, whose reconstructive surgeries were not possible. A prospective data collection was applied. Changing of the bilateral rectus muscle morphology, the evolution in time of the midline gap, and the progressive dynamism of the midline wall defects were determined. RESULTS: A characteristic and progressive midline defect enlargement could be settled. Data analysis yielded that the combined width of the bilateral rectus muscles is sufficient to cover the midline abdominal wall defect, although there is an "optimal" timeframe for performing the intervention. CONCLUSION: CT evaluation of abdominal wall prior to reconstructive surgeries of loss of abdominal wall domain has a strong significance on determining and designing the adequate surgical procedure. Orv. Hetil., 2017, 158(7), 257-263.

Incarcerated and eventrated abdominal wall hernia reconstruction with autologous double-layer dermal graft in the field of purulent peritonitis-A case report.

INTRODUCTION: Double-layer dermal grafts are used for the management of complicated abdominal wall hernias in obese, high risk patients. The method has not yet been used in case of emergency in septic/dirty environment. CASE REPORT: A 76-year old female patient (BMI 36.7kg/m2) was admitted with mechanical bowel obstruction and sepsis caused by a third time recurred, incarcerated and eventrated abdominal wall hernia. During the emergency surgery perforation of the terminal ileum and the ascending colon was detected, along with a feculent peritonitis and extended abdominal wall necrosis. Extended right hemicolectomy and necrectomy of the abdominal wall were performed. The surgery resulted in an abdominal wall defect measuring 223cm2, for the management of which direct closure was not possible. Using a specific method, an autologous dermal graft was prepared from the redundant skin. The first dermal graft was placed under the abdominal wall with 5cm overlap, and the second layer was placed onto the first layer with 3cm overlap in a perforated fashion. The operating time was 250min. No significant intra-abdominal pressure elevation was measured. No reoperation was performed. On the fifth postoperative day, the patient was mobilised. She was discharged in satisfactory general condition on the 18th postoperative day. There is no recurrent hernia 8 months after the surgery. DISCUSSION: Abdominal wall reconstruction was possible in a necrotic, purulent environment by using a de-epithelised autologous double layer dermal graft, without synthetic or biological graft implantation. The advantage of the procedure was cost-effectivity, and the disadvantage was that only in an obese patient is the sufficient quantity of dermal graft available. CONCLUSION: A homogeneous internal and perforated outer dermal graft was suitable for bridging the abdominal gap in the case of an obese, high risk patient. Autologous dermal grafts can be a safe and feasible alternative to biological meshes in emergency abdominal wall surgeries. Evaluation of a case series can be the next cornerstone of the method described above.

The role of radical surgery in the management of CEAP C5/6 and lipodermatosclerosis.

Aim Analysis of the radical removing of the dermatosclerotic tissues and ulcer(s) with perforator veins dissection as well as local wound and standard compression treatment of CEAP C5/6 stage in a prospective comparative cohort study. Primary endpoint is to compare the results of the one-year follow-up regarding quality of life, vein clinical severity score, and ulcer healing process. Secondary endpoint is the precise presentation of the surgical technique. Tertiary endpoint is to demonstrate the photo-documented results of the postoperative wound treatment protocol. Method Clinical and statistical comparison of radical surgery versus solely wound care and compression in a cohort of 15 patients in each group (Groups 1, 2). In Group 1, radical removing of the dermatosclerotic pannicule and leg ulcer, perforator vein dissection, great saphenous vein, or small saphenous vein was performed. Quality of life , pain intensity, vein clinical severity score and patients' load capacity were compared. The tissue oxygen saturation changes were monitored via near infra-red spectroscopy. Results Both groups were statistically comparable. Wound healing in the operated group was 100% versus 60% in the second one, the difference was significant, p = 0.006. The quality of life: 45.33 versus 36.8, p < 0.001, intensity of leg restless and pain: 2.28 versus 5.3, p < 0.001, changes of vein clinical severity score: 5.27 versus 20.93, p < 0.001, changes of tO2sat: 19.00 versus 6.07 in the upper third of the leg p < 0.001, proved significantly better in group 1 compared to 2. Load capacity was significantly better in group 1 than 2 at the end of the study. The average wound healing time was 113 days in group 1. Conclusion The radical surgery provides significantly better results, considering quality of life, vein clinical severity score, load capacity than the conservative treatment in this study.

[The role of autografts in the treatment of complicated incisional hernias]. / Az autograftok szerepe a komplikált hasfali sérvek kezelésében.

INTRODUCTION: Complicated incisional hernias (at least one time recurrent and/or multilocular and/or infected synthetic mesh) still represent a significant problem. AIM: Presentation of operating techniques desribed so far, as well as publication of a novel procedure and results invented by the authors. METHOD: Between 01/2011 and 09/2015, 41 patients with recurrent and/or infected incisional hernias with or without entero- and subcutaneous fistulas were operated using the method of the s.c. double-layer autologous tension free dermal flap technique. An accurate follow-up method and a continuous registration of the results was conducted in case of every patient. The body mass index (BMI) and presence of diabetes mellitus (DM) were distinguished factors out of the patients' clinical data. Surgical complications, bulking or laxity, recurrence and the patients' satisfactory index - among other things - were recorded considering the procedure. Patients' clinical data and results: Average age was 59.2 years (13 male / 28 female) in the cohort. 1, 2, 3 times recurrent incisional hernias had 12, 23, 6 patients, respectively. Average BMI was 32,1 kg/m2. 12 patients were treated with type II diabetes. 13 patients had entero- or subcutaneous fistulas and/or infected synthetic meshes at the time of operations. Average follow-up time was 32 months (2-58 months). Seroma formation was registered in 13 cases (31.7%). Fistula formation was registered in one case (2.4%). Bulking formation or laxity was observed in 3 patients (7.3%) and recurrence was noticed in 3 patients (7.3%), 13, 17 and 19 months later in the postoperative period. All the entero- and subcutaneous fistulas developed prior to the last procedure were completely healed. There was no lethal outcome. CONCLUSION: The method developed by the authors is recommended and suitable for the solution to complicated and/or infected incisional abdominal wall hernias especially in cases of obese (BMI ≥ 25 kg/m(2)) and diabetic, high risk patients. After acquiring the precise operative technique, the method is safe, feasible and it comes along with lower complication and recurrence rate, compared to other applied and well established ones. Further clinical trials need to be conducted in the future in order to be evaluated definetely this procedure.