Presentation of an open entry technique for laparoscopy through a congenital defect in the umbilical fascia.

OBJECTIVE: We present and describe a modification of the Hasson open entry technique to gain access to the abdominal cavity for laparoscopy in which a congenital defect in the umbilical fascia is identified for entry into the peritoneum and insertion of the primary port. METHODS: A single centre, prospective, observational, pilot study has been conducted with no change in clinical practice. Data regarding the success of the technique, time to laparoscope insertion, complications and patient risk factors were collected and presented. RESULTS: The team enrolled 114 patients that had the St Helier technique attempted for entry in the abdominal cavity. Entry was achieved for all patients. The technique had 82.5 % success rate while this reduced to 65 % in patients with previous laparoscopies. The mean time to insertion of the laparoscope was 220 s, and there was no significant difference in success with variation in BMI. We recorded no minor or significant intra-operative complications. The superficial wound infection rate was 2.6 % with no other postoperative complications identified at 6-week follow-up. CONCLUSIONS: The presented technique is a safe and successful method of laparoscopic entry with a presumed shorter time until laparoscope insertion than other techniques used. The absence of complications could be attributed to the avoidance of sharp dissection of the umbilical fascia. The less invasive nature could reduce risks of hematoma, infection or hernia that are associated with the standard entry techniques used. Formal studies of long-term outcomes are required, as well as evaluating use in emergency and contaminated cases.

Effects of Cesarean Section and Vaginal Delivery on Abdominal Muscles and Fasciae.

Background and objectives: Possible disorders after delivery may interfere with the quality of life. The aim of this study was to ascertain whether abdominal muscles and fasciae differ in women depending on whether they experienced transverse cesarean section (CS) or vaginal delivery (VA) in comparison with healthy nulliparous (NU). Materials and methods: The thicknesses of abdominal muscles and fasciae were evaluated by ultrasound in 13 CS, 10 VA, and 13 NU women (we examined rectus abdominis (RA); external oblique (EO); internal oblique (IO); transversus abdominis (TrA); total abdominal muscles (TAM = EO + IO + TrA); inter-rectus distance (IRD); thickness of linea alba (TLA); rectus sheath (RS), which includes anterior fascia of RS and posterior fascia of RS (P-RS); loose connective tissue between sublayers of P-RS (LCT); abdominal perimuscular fasciae (APF), which includes anterior fascia of EO, fasciae between EO, IO, and TrA, and posterior fascia of TrA). Data on pain intensity, duration, and location were collected. Results: Compared with NU women, CS women had wider IRD (p = 0.004), thinner left RA (p = 0.020), thicker right RS (p = 0.035) and APF (left: p = 0.001; right: p = 0.001), and IO dissymmetry (p = 0.009). VA women had thinner RA (left: p = 0.008, right: p = 0.043) and left TAM (p = 0.024), mainly due to left IO (p = 0.027) and RA dissymmetry (p = 0.035). However, CS women had thicker LCT (left: p = 0.036, right: p < 0.001), APF (left: p = 0.014; right: p = 0.007), and right IO (p = 0.028) than VA women. There were significant correlations between pain duration and the affected fasciae/muscles in CS women. Conclusions: CS women showed significant alterations in both abdominal fasciae and muscle thicknesses, whereas VA women showed alterations mainly in muscles. Thinner RA and/or dissymmetric IO, wider IRD, and thicker LCT and APF after CS may cause muscle deficits and alteration of fascial gliding, which may induce scar, abdominal, low back, and/or pelvic pain.

Congenital Spigelian hernia and ipsilateral cryptorchidism: a new syndrome?

Spigelian hernia (SH) is a rare ventral interstitial hernia occurring through a defect in the transversus abdominis aponeurosis (Spigelian fascia). Spigelian fascia is found between the lateral border of the rectus abdominis muscle and the semilunar line, which extends from the costal cartilage to the pubic tubercle. In other words, Spigelian line is where the transversus abdominis muscle ends in an aponeurosis characterized by a congenital or acquired defect in the Spigelian aponeurosis. Pediatric cases of SH are either congenital or acquired due to trauma, previous surgery or increased intra-abdominal pressure. SH in combination with ipsilateral cryptorchidism may constitute a new syndrome, as such cases are extremely rare in the literature is new syndrome is characterized by the following congenital, ipsilateral disturbances: SH, absence of inguinal canal and gubernaculum and the homolateral testis found within the Spigelian hernia sac (a hernia sac containing undescended testis). The aim of this study is to emphasize some typical findings of this specific entity, and, hence, the necessity for a thorough investigation of the origin of the SH.

Abnormal dartos fascia in buried penis and hypospadias: Evidence from histopathology.

INTRODUCTION: The importance of the pathology of the dartos fascia in hypospadias and buried penis is still debatable. Understanding the properties of connective tissue of dartos fascia in hypospadias and buried penis may give a clue to the underlying mechanism. OBJECTIVE: This study aimed to compare connective tissue and vascularization of dartos fascia between normal penis, buried penis, and hypospadias. STUDY DESIGN: We conducted this prospective study from May 2013 to November 2016. We collected dartos fascia specimens from three groups: buried penis, hypospadias, and normal penis as control. All of the patients underwent primary surgery in all groups. Patients with penile abnormalities, such as phimosis or Balanitis Xerotica Obliterans (BXO) were excluded from the normal penis group. We compared the fibers between these groups using Masson trichrome histochemical staining, Gomori's silver impregnation staining, Weigert resorcin-fuchsin staining, and CD31 immunohistochemistry staining for evaluation of collagen fibers, reticulin fibers, elastin fibers, and endothelial cells of blood vessels, respectively. The collagen fibers, reticular fibers, elastic fibers, and vascular vessels were counted with ImageJ and manually calibrated and counted and were analyzed using the one-way ANOVA test. The assessment conducted by two pathologists was blinded, without knowing the clinical diagnosis of patients. RESULTS: There was a total of 60 patients with 20 patients in each group. Collagen fibers for most cases of buried penis and hypospadias showed thicker but fewer collagen fibers than the normal penis. There was a reduction of total collagen and elastin of dartos fascia in hypospadias and buried penis cases. On the other hand, the ratio of reticulin fibers, which represents collagen type III to total collagen, was increased compared to normal penis. DISCUSSION: Although the dartos fascia in buried penis and hypospadias is thick and inelastic when palpated or during traction/counter traction, it is well-vascularized tissue. This inelastic dartos fascia tissue is an abnormal tissue, but its characteristics are not similar to fibrotic tissue. However, further study with a larger sample is warranted and should differentiate the degree of chordee in patients with hypospadias and buried penis. CONCLUSIONS: There was a difference between connective the tissue of dartos fascia in buried penis and patients with hypospadias compared with normal penis. Inelastic dartos fascia tissue in patients diagnosed with buried penis and hypospadias is an abnormal tissue. Therefore, it is suggested that this tissue is excised during reconstructive surgery. Further research is needed to unveil the pathophysiology of the condition.

Hematoma de Morel Lavallée gigante en la rodilla derecha: reporte de un caso / Giant Morel Lavallée hematoma in the right knee: case report

RESUMEN Se presenta el caso del paciente de 36 años de edad, con antecedentes de acondroplasia que desde hace 7 meses sufrió una lesión traumática no de gravedad en la rodilla derecha. La cual comienza a aumentar de volumen con contenido líquido fluctuante. Fue puncionado en dos ocasiones obteniéndose líquido serohemático; al no resolver y continuar aumentando de tamaño, se le plantea que es portador de un hematoma seroso de Morel Lavallée, que se produce por la fricción entre el tejido celular subcutáneo y la fascia. Su localización es infrecuente en la rodilla por lo que se decide presentar el caso ya que en la literatura revisada; no aparece ningún caso descrito. Por lo que constituye el objetivo principal de este trabajo, describir su proceder y la eficacia del tratamiento quirúrgico, con el que se obtuvo resultado satisfactorio (AU).

ABSTRACT We present the case of a patient aged 36 years, with antecedents of achondroplasia who 7 months ago suffered a non serious traumatic lesion in the right knee. The volume of the lesion began to increase with a fluctuant fluid contain. It was punctured twice draining serohematic fluid; it did not solve and the size increased more and more, so the patient was said that he had a serous Morel Lavallée hematoma, produced by the friction between the subcutaneous cell tissue and fascia. Its location in the knee is infrequent and it was not found any case like this in the reviewed literature; therefore we decided to present the case. The main objective of our work was describing it, showing the procedure and efficacy of the surgical that gave a satisfactory result (AU).

Hematoma de Morel Lavallée gigante en la rodilla derecha: reporte de un caso / Giant Morel Lavallée hematoma in the right knee: case report

RESUMEN Se presenta el caso del paciente de 36 años de edad, con antecedentes de acondroplasia que desde hace 7 meses sufrió una lesión traumática no de gravedad en la rodilla derecha. La cual comienza a aumentar de volumen con contenido líquido fluctuante. Fue puncionado en dos ocasiones obteniéndose líquido serohemático; al no resolver y continuar aumentando de tamaño, se le plantea que es portador de un hematoma seroso de Morel Lavallée, que se produce por la fricción entre el tejido celular subcutáneo y la fascia. Su localización es infrecuente en la rodilla por lo que se decide presentar el caso ya que en la literatura revisada; no aparece ningún caso descrito. Por lo que constituye el objetivo principal de este trabajo, describir su proceder y la eficacia del tratamiento quirúrgico, con el que se obtuvo resultado satisfactorio (AU).

ABSTRACT We present the case of a patient aged 36 years, with antecedents of achondroplasia who 7 months ago suffered a non serious traumatic lesion in the right knee. The volume of the lesion began to increase with a fluctuant fluid contain. It was punctured twice draining serohematic fluid; it did not solve and the size increased more and more, so the patient was said that he had a serous Morel Lavallée hematoma, produced by the friction between the subcutaneous cell tissue and fascia. Its location in the knee is infrequent and it was not found any case like this in the reviewed literature; therefore we decided to present the case. The main objective of our work was describing it, showing the procedure and efficacy of the surgical that gave a satisfactory result (AU).

Use of composite mesh in gastroschisis: A unique approach.

Gastroschisis is a congenital defect of the abdominal wall involving evisceration of abdominal contents. Initial surgical treatment of this condition depends on the size of the defect, size of the abdominal cavity and amount of bowel exposed. Various techniques described are primary closure, use of the skin flap and silo bag application, followed by fascial closure. Here we present a case wherein even after 7 days of silo bag application, fascial closure was not possible, and a composite mesh was used to cover the bowel until further repair could be attempted.

Denonvilliers' fascia revisited.

Although several studies have reported that the peritoneum does not contribute to the formation of a fascia between the urogenital organs and rectum, Denonvilliers' fascia (DF), a fascia between the mesorectum and prostate (or vagina) in adults, is believed to be a remnant of the peritoneum. Remnants of the peritoneum, however, were reportedly difficult to detect in other fusion fasciae of the abdominopelvic region in mid-term fetuses. To examine morphological changes of the pelvic cul-de-sac of the peritoneum, we examined 18 male and 6 female embryos and fetuses. A typical cul-de-sac was observed only at 7 weeks, whereas, at later stages, the peritoneal cavity did not extend inferiorly to the level of the prostatic colliculus or the corresponding structure in females. The cul-de-sac had completely disappeared in front of the rectum at 8 weeks and homogeneous and loose mesenchymal tissue was present in front of the rectum at the level of the colliculus at 12-16 weeks. We found no evidence that linearly arranged mesenchymal cells developed into a definite fascia. Therefore, the development of the DF in later stages of fetal development may result from the mechanical stress on the increased volumes of the mesorectum, seminal vesicle, prostate and vagina and/or enlarged rectum. Therefore, we considered the DF as a tension-induced structure rather than a fusion fascia. Fasciae around the viscera seemed to be classified into (1) a fusion fascia, (2) a migration fascia and (3) a tension-induced fascia although the second and third types are likely to be overlapped.

Undescended testis accompanying congenital Spigelian hernia: is it a reason, a result, or a new syndrome?

INTRODUCTION: Frequent reporting of cases of the coexistence of a Spigelian hernia (SH) with an undescended testis (UT) suggests that this phenomenon may be a syndrome. In this article, four pediatric cases in which an UT accompanies a congenital SH have been discussed in light of the literature. METHODS: In this study, four cases aged between 6 months and 5 years who had a SH accompanied by an UT were evaluated and underwent surgery. RESULT: The patient's ages were 6 months, 1 year, 2 years, and 5 years old. The testis was observed in the opened hernia sac. The patients did not have a gubernaculum or an inguinal canal on the side of the hernia. CONCLUSIONS: Neither the theories suggesting that SH leads to an UT nor those suggesting that an UT leads to a SH are satisfactory. We believe that this coexistence may be the congenital Spigelian-cryptorchidism syndrome seen in boys. As in the four cases presented here, elements of this syndrome are defects in the Spigelian fascia and the hernia sac enveloping the testis and an absence of the gubernaculum and the inguinal canal.

Anatomical relationship of Roos' type 3 band and the T1 nerve root.

BACKGROUND: The most common clinical presentation of thoracic outlet syndrome stems from compression of the lower trunk of the brachial plexus or ulnar nerve. A plethora of anatomical variations have been implicated in the cause of thoracic outlet syndrome. Roos' identification and classification of scalene muscle and fibrous bands have added an additional dimension to understanding its cause and subsequent treatment. Understanding the anatomy and relationship of this band with the lower trunk of the brachial plexus is of paramount importance. METHODS: As part of the authors' long-term study of the type 3 band in relation to the brachial plexus, 70 embalmed cadavers were dissected to yield 100 first thoracic ribs. Fibrous bands, when present, were studied in relation to the brachial plexus. RESULTS: A fibrous band consistent with Roos' type 3 was identified and found to occur in 35 percent of first ribs and 41 percent of cadavers. The mean size was 3.45 × 0.27 cm. Origins and insertions are described. Contrary to Roos' own description, however, the authors observed that Roos' type 3 band was anterior to the T1 nerve root, creating a tunnel through which the T1 nerve root must pass before joining the C8 nerve root. CONCLUSIONS: The authors believe that the type 3 band, when present, can create a tunnel that compresses the T1 nerve root against the first rib, potentially predisposing susceptible individuals to thoracic outlet syndrome. Clinical studies are needed to determine whether correlations between type 3 bands and thoracic outlet syndrome exist.

Repair of the midline fascial defect in abdominoplasty with long-acting barbed and smooth absorbable sutures.

BACKGROUND: Traditionally, repair of the midline fascial defect has been performed with interrupted or running permanent sutures during abdominoplasty. Barbed suture devices, however, eliminate the need for knot tying and potentially are equally effective at maintaining the repair while allowing for faster deployment and elimination of a potential nidus for infection. OBJECTIVE: The authors report their experience with long-acting absorbable barbed and smooth sutures. METHODS: A retrospective chart review was conducted on 34 consecutive patients who underwent abdominoplasty, alone or in conjunction with other procedures, between August 2006 and December 2009. Seventeen patients had repair of the midline abdominal wall rectus diastasis performed with a smooth running absorbable polydioxanone suture, and 17 underwent repair with a barbed suture. RESULTS: All 34 patients were women; their mean age was 43.6 years, and their mean body mass index was 23.0 kg/m(2). Sixty-eight percent of the patients elected to undergo concurrent procedures. Patients were followed for a mean of 34 months (27 months barbed; 42 months smooth). No cases of recurrent diastasis were observed. Complications included minor seroma (two cases in the barbed suture group, one in the smooth group) and infected hematoma (one in the barbed suture group). CONCLUSIONS: Based on the data from this series of patients, long-acting absorbable barbed or smooth sutures appear to be equally effective in maintaining rectus diastasis repair. Barbed sutures therefore hold promise as a useful alternative to permanent sutures for the plication of the rectus fascia during abdominoplasty.

Tratamientos del Neuroma de Morton / Treatment of Monton´s neuroma

Este artículo está basado en una exhaustiva revisión bibliográfica. Pretende dar a conocer los posibles tratamientos del Neuroma de Morton, que están al alcance del profesional, para escoger el más optimo para la resolución de la patología. La revisión bibliográfica se realizó consultando artículos publicados en revistas especializadas, libros y diferentes páginas de internet. La conclusión obtenida es que el diagnóstico correcto, mediante los test de exploración, es básico para erradicar la patología. El apoyo de las técnicas de diagnóstico complementario es necesario debido a las diferentes patologías que presentan una sintomatología similar. Por último, destacar que, concretar la etiología compresiva o degenerativa del nervio, nos facilita la elección del tratamiento más adecuado, ya sea incruento o quirúrgico (AU)

This article is based on an extensive literature review. It aims to show professionals the available treatments that are possible for Morton’s neuroma, in order for them to choose the best one to cure this condition. The literature review was carried out by consulting published papers in journals, books and several websites. The conclusion is that a correct diagnosis, through clinical examination, is essential to eradicate this condition. Complementary diagnostic techniques are necessary because there are different diseases that have similar symptoms. Finally, it is worth highlighting that, defining the degenerative or compression etiology of the nerve, makes it easier to choose the most appropriate treatment, whether it is non-invasive or surgical (AU)

Preservação e suspensão da fáscia de Scarpa na abdominoplastia / The preservation and suspension of Scarpa’s fascia in abdominoplasty

Introdução: Muitos estudos já foram feitos para buscar uma abdominoplastia mais atrativa, segura e com menos riscos. Enquanto as táticas e técnicas variam, pouco se fala sobre a preservação e suspensão da fáscia de Scarpa. Método: Os autores realizaram um estudo retrospectivo, demonstrando sua experiência com a lipoabdominoplastia clássica com a preservação e suspensão da fáscia de Scarpa, em 235 pacientes, nos últimos 5 anos. A maioria dos pacientes teve grande perda de peso e foi submetida a vários procedimentos de contorno corporal. Resultados: A incidência de complicações relacionada à abdominoplastia com suspensão da fáscia de Scarpa foi baixa (5,9%) e a técnica promoveu bons resultados estéticos. Complicações e contorno corporal favorável pós-cirúrgico são detalhados neste estudo. Conclusões: Procedimentos de contorno corporal com suspensão da fáscia de Scarpa promovem boa silhueta, adequado acomodamento do retalho abdominal e relaxam a tensão da área próxima da virilha.

Background: Many studies have been done in the quest for a safer, lower risk and more attractive abdominoplasty. Techniques and tactical approach may vary and few are said about preservation and suspension of Scarpa’s fascia. Methods: This retrospective report presents our experience with lipoabdominoplasty along with preservation and suspension of Scarpa’s fascia in 235 cases, over the past five years. Most patients had massive weight loss and were submitted to multiple operations. Results: Complication rate related directly to abdominoplasty with suspension of Scarpa’s fascia was low (5.9%) and the technique resulted in nice and smooth contour. Complications and favorable contour out come are detailed in this study. Conclusion: Abdominal contour procedures with Scarpa’s suspension promotes a nice silhouette, promotes better accommodation for the abdominal flap and takes up tension of the groin region.

Manejo del sulcus vocalis con injerto de fascia temporal / Sulcus vocalis management with fascia temporal graft

El sulcus vocalis es una lesión en la cual el epitelio del pliegue vocal tiende a invaginarse y adherirse al ligamento y/o músculo resultando en disfonía. Existen múltiples tratamientos descritos ninguno con resultados ideales. Este es un estudio descriptivo-prospectivo en el Hospital Militar Central en pacientes operados por sulcus vocalis tipos II y III e implantados con fascia autóloga entre junio de 2006 y diciembre de 2008. De 17 pacientes operados cumplieron los criterios de inclusión 11. Edad promedio 32 años. 9 presentaron mejoría del análisis acústico de la voz con una tendencia a la mejoría en todas las variables, particularmente en el Shimmer y la frecuencia fundamental. En la estroboscopia, 10 pacientes presentaron recuperación de la onda mucosa y en 5 del cierre glótico. Ningún paciente presentó reacciones adversas al procedimiento. Del presente estudio se puede considerar que el manejo del sulcus vocalis con injerto autólogo de fascia temporal es un procedimiento seguro que en la mayoría de los casos representa una mejoría subjetiva y objetiva de la calidad de voz. Es necesario aumentar el tamaño de la muestra para obtener resultados de mayor poder estadístico y definir los criterios de éxito.

Sulcus vocalis is an injury in which the epithelium of the vocal fold tends to invaginate and attach to the ligament and / or muscle resulting in dysphonia. There are multiple treatments as described but none has ideal results. This is a descriptive – prospective study carried out at the Hospital Militar Central in patients that had been operated on due to sulcus vocalis of the type II and III and who have been given implants with autologous fascia between June, 2006 and December, 2008. Out of 17 patients that were operated on, 11 complied with the inclusion criteria. The average age was 32 years old. 9 of them exhibited an improvement on the acoustic analysis of the voice with a tendency to improvement in all variables, especially in Shimmer and the basic frequency. 10 patients exhibited a recovery of the mucous wave in the stroboscope analysis and 5 in the glottal closure. Not one patient showed adverse reactions to the procedure. It can be considered from this study that managing sulcus vocalis with a temporalis fascia autologous graft is a safe procedure that represents a subjective and an objective improvement of the quality of the voice. It is necessary to increase the size of the simple in order to obtain results with a greater statistical power and be able to define the criteria for success.

Falla de coalescencia Toldt II con hernia interna mesocolica derecha en el adulto

Se presenta un caso de abdomen agudo oclusivo en el adulto, en donde se diagnosticó como etiología a una hernia interna mesocólica derecha atascada por falta de coalescencia de la fascia de Toldt II que formaba el saco, con su anillo ubicado por detrás de los vasos mesentéricos. Se efectuó una búsqueda bibliográfica nacional e internacional.

The analyzed case regards an acute small bowel obstruction in an adult, which etiology was an internal mesocolic right hernia, complicating a lack of coalescense of “Toldt´s fascia II” that formed the sack, with its ring located behind the mesenteric artery. A research was performed in both national and international bibliography.

Falla de coalescencia Toldt II con hernia interna mesocolica derecha en el adulto

Se presenta un caso de abdomen agudo oclusivo en el adulto, en donde se diagnosticó como etiología a una hernia interna mesocólica derecha atascada por falta de coalescencia de la fascia de Toldt II que formaba el saco, con su anillo ubicado por detrás de los vasos mesentéricos. Se efectuó una búsqueda bibliográfica nacional e internacional.(AU)

The analyzed case regards an acute small bowel obstruction in an adult, which etiology was an internal mesocolic right hernia, complicating a lack of coalescense of ¶Toldt´s fascia II÷ that formed the sack, with its ring located behind the mesenteric artery. A research was performed in both national and international bibliography.(AU)

Axillary arch: a rare variation

The axillary arch is a muscle slip varying from7 to 10 cm in length and 5 to 15 mm inbreadth. It occasionally arises from the edge ofthe latissimus dorsi, at about the middle ofthe posterior fold of the axilla and crosses theaxilla in front of the axillary vessels and nervesto join the under-surface of the tendon of thepectoralis major, the coracobrachialis, or thefascia over the biceps. During the dissection ofa human cadaver, an unusual muscle band wasencountered and identified as an axillary archon the right side of a 60-year old male cadaver.The anomalous muscle band was an extensionfrom the lateral border of the latissimusdorsi muscle. The muscle measured 6 cm inlength, 2 cm wide and 2 mm thick. Since thismuscle may be the cause of different pathologies,we were prompted to discuss the clinicalrelevance of our findings (AU)

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