Fibroblast matrix implants-a better alternative for incisional hernia repair?

The standard surgical procedure for abdominal hernia repair with conventional prosthetic mesh still results in a high recurrence rate. In the present study, we propose a fibroblast matrix implant (FMI), which is a three-dimensional (3D) poly-L-lactic acid scaffold coated with collagen (matrix) and seeded with fibroblasts, as an alternative mesh for hernia repair. The matrix was seeded with fibroblasts (cellularized) and treated with a conditioned medium (CM) of human Umbilical Cord Mesenchymal Stem Cells (hUC-MSC). Fibroblast proliferation and function were assessed and compared between treated with CM hUC-MSC and untreated group, 24 h after seeding onto the matrix (n= 3). To study the matricesin vivo,the hernia was surgically created on male Sprague Dawley rats and repaired with four different grafts (n= 3), including a commercial mesh (mesh group), a matrix without cells (cell-free group), a matrix seeded with fibroblasts (FMI group), and a matrix seeded with fibroblasts and cultured in medium treated with 1% CM hUC-MSC (FMI-CM group).In vitroexamination showed that the fibroblasts' proliferation on the matrices (treated group) did not differ significantly compared to the untreated group. CM hUC-MSC was able to promote the collagen synthesis of the fibroblasts, resulting in a higher collagen concentration compared to the untreated group. Furthermore, thein vivostudy showed that the matrices allowed fibroblast growth and supported cell functionality for at least 1 month after implantation. The highest number of fibroblasts was observed in the FMI group at the 14 d endpoint, but at the 28 d endpoint, the FMI-CM group had the highest. Collagen deposition area and neovascularization at the implantation site were observed in all groups without any significant difference between the groups. FMI combined with CM hUC-MSC may serve as a better option for hernia repair, providing additional reinforcement which in turn should reduce hernia recurrence.

"Slim-Mesh" Technique for Diastasis Recti Abdominis, Including Obesity-Related Cases.

Background and Objective: We operated on a series of mostly obese patients with diastasis recti abdominis using the "Slim-Mesh" technique to repair/reinforce the diastasis and linea alba/recti muscles without plicating and traumatizing them. Additional objectives were to decrease operation time and intra- and postoperative complications. Methods: We considered T1 cases diastasis after pregnancy and T2 cases obesity (BMI ≥ 30 mg/kg2); D1, D2, and D3 when the diastasis measured 2-3, 3-5, and ≥ 5 cm, respectively; H0 and H1 without and concomitant umbilical and/or epigastric hernia, respectively. At our Department, between May 2010 and November 2022, 47 patients with diastasis recti were operated on with the "Slim-Mesh" technique to reinforce/repair the traumatized linea alba/recti muscles, without plicating them. This was a prospective (83%)-retrospective study. Results: We studied 23 males and 24 females. Mean age and BMI was 58 years and 29 kg/m2, respectively. Groups D1, D2, and D3 comprised 6, 23 and 18 patients, respectively; groups T1, T2, H0 and H1 comprised 22, 25, 13 and 34 patients, respectively. Mean operation time for all cases was 100 minutes. Mean length of hospital stay was 2.3 days and follow-up time was 5 years. We had 6 late postoperative complications: 3 hernia recurrences and 3 trocar site hernias. Conclusion: Considering the lack of agreement on the best surgery for diastasis recti abdominis repair, in our experience the "Slim-Mesh" technique is a valid, safe and easy-to-reproduce way to save, repair and reinforce linea alba/recti muscles in diastasis recti patients, including the obese population (53%).

A Rare Case of Small Bowel Obstruction in a 15-Year-Old Girl: Internal Hernia Associated with Meckel's Diverticulum.

BACKGROUND Meckel's diverticulum is a congenital remnant of the omphalomesenteric duct and is the most common congenital gastrointestinal malformation. Most patients are asymptomatic, but a rare presentation is with subacute small bowel obstruction (SBO) due to herniation of bowel loops through an internal hernia formed by the Meckel's diverticulum and adjacent mesentery that forms an internal hernia. This report is of a 15-year-old girl presenting as an emergency with vomiting and small bowel obstruction due to an internal hernia associated with Meckel's diverticulum. CASE REPORT We present a case of a 15-year-old girl who presented to the Children's Emergency (CE) department with persistent vomiting and abdominal distension and tenderness. X-rays demonstrated dilated small bowel loops, prompting admission under Pediatric Surgery (PAS). A subsequent computed tomography (CT) scan was performed, which demonstrated multiple dilated small bowel loops, confirming SBO, and a blind-ending "C-shaped" bowel loop at the region of the terminal ileum. A diagnostic laparotomy was performed, which confirmed the presence of a Meckel's diverticulum. The tip of the Meckel's diverticulum was adherent to part of the small bowel mesentery, forming an internal hernia defect through which a loop of proximal ileum had herniated, resulting in SBO. She then underwent a laparoscopy-assisted transumbilical Meckel's diverticulectomy (LATUM). The patient recovered uneventfully and was discharged on the 4th postoperative day. CONCLUSIONS In children presenting with SBO, the possibility of Meckel's diverticulum as an etiology should be considered as a differential diagnosis. Early diagnosis and prompt intervention will improve clinical outcomes and avoid complications.

[A case of abdominal internal hernia through the foramen of Winslow in a pediatric emergency department].

Abdominal internal hernia is a rare cause of intestinal obstruction in pediatric emergency departments, being the herniation through the foramen of Winslow an exceptional entity (less than 0.5% of the herniae). We report the case of a 15-year-old adolescent male without previous surgical interventions who presented with abdominal pain and vomiting; computed tomography scans showed intestinal obstruction due to an internal hernia through the foramen of Winslow. To reduce the herniated ileum, the patient required surgical intervention with diagnostic laparoscopy, which, due to bad visualization, was changed to supraumbilical midline laparotomy. There was no need to resect the affected ileum as it appeared healthy. We did not perform a preventive technique to reduce the risk of recurrence. Postoperative pelvic collection was conservatively managed with antibiotics. The patient undergoes regular follow-up in the pediatric surgery department.

Siguiendo la trayectoria de la abdominoplastia TULUA ­ Revelación de su evolución e impacto global / Tracing the Trajectory of TULUA Abdominoplasty ­ Unveiling its Evolution and Global Impact

La técnica de abdominoplastia TULUA, fue concebida por el Dr. Francisco Villegas en Colombia, su acrónimo en inglés refleja sus principios fundamentales: plicatura Transversal, Sin despegamiento, Liposucción sin restricción que incluye la línea media y flancos, Neo umbilicoplastia, ubicación baja de cicatriz y libre posición del ombligo. A lo largo de los últimos 12 años, la técnica TULUA ha ganado espacio en América Latina, Norteamérica, la zona árabe e India. Destacando su relevancia, se ha propuesto la publicación de un libro monográfico, programado para 2024, que abarcará desde los principios fundamentales hasta las experiencias internacionales con la técnica. Las indicaciones de la abdominoplastia TULUA han evolucionado, incluyendo casos estéticos, secundarios, hernias, cicatrices previas, pérdida masiva de peso, alta definición, aumento muscular y combinaciones con otras plicaturas. Ha sido aplicada con éxito en cierre del abdomen donante de reconstrucción mamaria. A través de investigaciones especializadas y revisiones de pares, la TULUA ha sido reconocida por su aplicabilidad y beneficios, especialmente en la realización segura de liposucción en abdominoplastias. Se sugieren estudios adicionales para evaluar los resultados y posibles complicaciones, abriendo oportunidades para una mayor comprensión y refinamiento. El futuro de la abdominoplastia TULUA parece prometedor, anticipando trabajos prospectivos, indicaciones adicionales y un enfoque gradual para cirujanos en formación. En última instancia, la técnica se presenta como una adición al repertorio de procedimientos estéticos abdominales, contribuyendo al avance de la cirugía abdominal estética.

The TULUA abdominoplasty technique, conceived by Dr. Francisco Villegas in Colombia, its acronym in English reflects its fundamental principles: Transverse plication, no Undermined flap above the umbilicus, Liposuction without restrictions including midline and flanks, Neo umbilicoplasty, low scar placement, and free umbilical positioning. Over the past 12 years, the TULUA technique has gained acceptance in Latin America, North America, the Arab region, and India. Highlighting its relevance, the publication of a monographic book has been proposed, its launch is scheduled for 2024, covering from fundamental principles to international experiences with the technique. Indications for TULUA abdominoplasty have evolved, including aesthetic cases, secondary cases, hernias, previous scars, massive weight loss, high definition, muscle augmentation, and combinations with other plications. It has been successfully applied in closing the donor abdomen for breast reconstruction. Through specialized research and peer reviews, TULUA has been recognized for its applicability and benefits, especially in safely performing liposuction during abdominoplasties. Additional studies are suggested to evaluate results and potential complications, opening opportunities for greater understanding and refinement. The future of TULUA abdominoplasty appears promising, anticipating prospective works, additional indications, and a gradual approach for surgeons in training. Ultimately, the technique presents itself as an addition to the repertoire of abdominal aesthetic procedures, contributing to the advancement of aesthetic abdominal surgery.

Smoking Is Correlated to Internal Hernia After Gastric Bypass Surgery: a Post hoc Analysis of Data from a Randomized Clinical Trial.

PURPOSE: Internal herniation is a well-known complication of laparoscopic Roux-en-Y gastric bypass (L-RYGB). The aim of this study was to evaluate smoking as an independent risk factor for internal herniation after L-RYGB. MATERIALS AND METHODS: This study was performed as an exploratory post hoc analysis of data from a previous published randomized controlled trial (RCT) designed to compare closure and non-closure of mesenteric defects in patients undergoing L-RYGB. The primary outcome of this study was to assess the significance of smoking as a risk factor for internal herniation after L-RYGB. Secondary outcome was early postoperative complications defined as Clavien-Dindo grade ≥ 2. RESULTS: Four hundred one patients were available for post hoc analysis. The risk of internal herniation was significantly higher among patients who were smoking preoperatively (hazard ratio (HR) 2.4, 95% confidence interval (c.i.) 1.3 to 4.5; p = 0.005). This result persisted after adjusting for other patient characteristics (HR 2.2, 1.2 to 4.2; p = 0.016). 6.0% of the patients had postoperative complications within the first 30 days. 4.9% of these patients were smoking and 6.3% were not smoking, p = 0.657. 11.0% of the patients underwent surgery due to internal herniation by 5 years after the primary procedure. CONCLUSION: Smoking is a significant risk factor for internal herniation but did not increase risk for 30 days postoperative complications.

[An abdominal wall bulging: consider a neurological cause]. / Een uitstulping van de buik.

A patient with a swelling of the abdominal wall is a regular occurrence in general practice and hospital. The diagnosis can often be made with a thorough history and physical examination. An abdominal wall hernia is characterized by an increase in swelling on standing physical examination and Valsalva maneuver, which is often reducible, and a hernia defect is palpable. If no interruption of the abdominal wall is palpable and there is hypoesthesia, there may be an abdominal wall paresis because of thoracic paramedian hernia nuclei pulposi (HNP). Where an abdominal wall hernia is treated surgically in case of symptoms, this is conservatively treated with an HNP.

Laparoscopic repair of perineal hernia and unilateral inguinal hernia after rectal cancer surgery: A case report.

INTRODUCTION: Perineal hernia (PH) is a rare complication that can occur after abdominoperineal resection for rectal cancer. Laparoscopic repair of PHs has gained increasing popularity compared to open approaches due to advantages such as superior visualization, decreased invasiveness, and faster recovery. This case report highlights the successful use of laparoscopic tension-free mesh repair for concurrent perineal and inguinal hernias after rectal cancer surgery. CASE DESCRIPTION: A 51-year-old man underwent laparoscopic-assisted abdominoperineal resection for rectal cancer. About 2 months postoperatively, he developed reducible masses in the perineal and left groin regions, associated with urinary symptoms and sensation of prolapse. Physical exam revealed protruding masses that enlarged with Valsalva. Pelvic CT confirmed PH and left inguinal hernia. INTERVENTIONS: Laparoscopic tension-free repair of the PH and inguinal hernia was performed on this patient. The repair was completed by the steps of adhesion separation, mesh placement, and fixation. OUTCOMES: The 98-minute surgery was successful without complications. The patient recovered well, ambulating on postoperative day 2 and getting discharged on day 6. CONCLUSION: This case demonstrates that laparoscopic tension-free repair with mesh is an effective approach for treating PH and concurrent inguinal hernia following rectal cancer surgery, resulting in successful outcomes and low recurrence rates. The laparoscopic technique provides benefits of minimal invasiveness and rapid recovery.

The significance of initial lactate levels in emergency department presentations of abdominal wall hernia.

INTRODUCTION: Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias. MATERIALS AND METHODS: Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound. RESULTS: We enrolled 493 patients meeting the criteria. Median age was 65 years, with 54% (n = 266) being male. Regarding outcomes, 40.5% (n = 200) were hospitalized, 27.7% (n = 137) underwent surgery, and 7.9% (n = 39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n = 3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p < 0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p < 0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p < 0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96 mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p < 0.05). CONCLUSION: Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

Post-appendicectomy small bowel obstruction due to internal hernia involving Meckel's diverticulum.

Meckel's diverticulum is the most common congenital abnormality of the small bowel, present in about 2% of the population. A man in his 20s underwent a laparoscopic appendicectomy for acute appendicitis and recovered uneventfully. He presented to the emergency department 1 month later with features of acute small bowel obstruction. Emergency diagnostic laparoscopy revealed a band adhesion between the apex of a Meckel's diverticulum to the appendicectomy stump. Internal herniation of ileum under this band adhesion resulted in small bowel obstruction and ischaemic necrosis of the Meckel's diverticulum. The band adhesion was divided, and the Meckel's diverticulum was resected at the base with a linear cutting stapler. This complication has not been reported previously. A Meckel's diverticulum is an important differential diagnosis of acute appendicitis and should routinely be searched for among other pathologies. It can rarely cause a postoperative complication of internal hernia.

Global, regional, and national burden of inguinal, femoral, and abdominal hernias: a systematic analysis of prevalence, incidence, deaths, and DALYs with projections to 2030.

BACKGROUND: Hernias, particularly inguinal, femoral, and abdominal, present a global health challenge. While the global burden of disease (GBD) study offers insights, systematic analyses of hernias remain limited. This research utilizes the GBD dataset to explore hernia implications, combining current statistics with 2030 projections and frontier analysis. METHODS: We analyzed data from the 2019 GBD Study, focusing on hernia-related metrics: prevalence, incidence, deaths, and disability-adjusted life years (DALYs) across 204 countries and territories, grouped into 21 GBD regions by the socio-demographic index (SDI). Data analysis encompassed relative change calculations, as well as annual percentage change (APC) and average annual percentage change (AAPC), both of which are based on joinpoint regression analysis. The study additionally employed frontier analysis and utilized the Bayesian age-period-cohort model for predicting trends up to 2030. Analyses utilized R version 4.2.3. RESULTS: From 1990 to 2019, the global prevalence of hernia cases surged by 36%, reaching over 32.5 million, even as age-standardized rates declined. A similar pattern was seen in mortality and DALYs, with absolute figures rising but age-standardized rates decreasing. Gender data between 1990 and 2019 showed consistent male dominance in hernia prevalence, even as rates for both genders fell. Regionally, Andean Latin America had the highest prevalence, with Central Sub-Saharan Africa and South Asia noting significant increases and decreases, respectively. Frontier analyses across 204 countries and territories linked higher SDIs with reduced hernia prevalence. Yet, some high SDI countries, like Japan and Lithuania, deviated unexpectedly. Predictions up to 2030 anticipate increasing hernia prevalence, predominantly in males, while age-standardized death rates and age-standardized DALY rates are expected to decline. CONCLUSIONS: Our analysis reveals a complex interplay between socio-demographic factors and hernia trends, emphasizing the need for targeted healthcare interventions. Despite advancements, vigilance and continuous research are essential for optimal hernia management globally.

Comparison between the mesenteric fixation method (MEFIX) and conventional methods at preventing the occurrence of Petersen's hernia: a study protocol for a multicenter randomized controlled trial.

BACKGROUND: Petersen's hernia, which occurs after Billroth-II (B-II) or Roux-en-Y (REY) anastomosis, can be reduced by defect closure. This study aims to compare the incidence of bowel obstruction above Clavien-Dindo classification grade III due to Petersen's hernia between the mesenteric fixation method and the conventional methods after laparoscopic or robotic gastrectomy. METHODS: This study was designed as prospective, single-blind, non-inferiority randomized controlled multicenter trial in Korea. Patients with histologically diagnosed gastric cancer of clinical stages I, II, or III who underwent B-II or REY anastomosis after laparoscopic or robotic gastrectomy are enrolled in this study. Participants who meet the inclusion criteria are randomly assigned to two groups: a CLOSURE group that underwent conventional Petersen's defect closure method and a MEFIX group that underwent the mesenteric fixation method. The primary endpoint is the number of patients who underwent surgery for bowel obstruction caused by Petersen's hernia within 3 years after laparoscopic or robotic gastrectomy. DISCUSSION: This trial is expected to provide high-level evidence showing that the MEFIX method can quickly and easily close Petersen's defect without increased postoperative complications compared to the conventional method. TRIAL REGISTRATION: ClinicalTrials.gov NCT05105360. Registered on November 3, 2021.

Switching from robotic-assisted extended transabdominal preperitoneal (eTAPP) to totally extraperitoneal (eTEP) hernia repair for umbilical and epigastric hernias.

Our study aimed to assess the safety and effectiveness of the robotic-assisted extended totally extraperitoneal (eTEP) repair compared to transabdominal preperitoneal (eTAPP) repair with a suprapubic trocar insertion to treat umbilical and epigastric hernias. On a prospectively maintained database, we identified patients who underwent either eTEP or eTAPP for treating umbilical and epigastric hernias. During the study period, 53 patients were included, 32 in the eTEP group and 21 in the eTAPP group. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male, and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). The operative time for eTEP was slightly shorter than for eTAPP (106 ± 43 min vs. 126 ± 74 min, p = 0.232). Postoperatively, only one case of bleeding and one seroma were recorded. No complication occurred during a mean follow-up of 11.3 ± 6.4 months in the eTEP group and 20.5 ± 9.7 months in the eTAPP group. In conclusion, our study showed that the eTEP with suprapubic approach was safe and feasible in the treatment of epigastric and umbilical hernias. According to our experience, shorter operative time, integrity of the posterior layers and increased overlap size are the main surgical reasons of switching from eTAPP to eTEP.

Soft, Long-Lived, Bioresorbable Electronic Surgical Mesh with Wireless Pressure Monitor and On-Demand Drug Delivery.

Current research in the area of surgical mesh implants is somewhat limited to traditional designs and synthesis of various mesh materials, whereas meshes with multiple functions may be an effective approach to address long-standing challenges including postoperative complications. Herein, a bioresorbable electronic surgical mesh is presented that offers high mechanical strength over extended timeframes, wireless post-operative pressure monitoring, and on-demand drug delivery for the restoration of tissue structure and function. The study of materials and mesh layouts provides a wide range of tunability of mechanical and biochemical properties. Dissolvable dielectric composite with porous structure in a pyramidal shape enhances sensitivity of a wireless capacitive pressure sensor, and resistive microheaters integrated with inductive coils provide thermo-responsive drug delivery system for an antibacterial agent. In vivo evaluations demonstrate reliable, long-lived operation, and effective treatment for abdominal hernia defects, by clear evidence of suppressed complications such as adhesion formation and infections.

Traumatic lumbar hernia: A systematic review of the literature.

PURPOSE: Traumatic lumbar hernia (TLH) constitutes a protrusion of content through a defect in the posterior abdominal wall, as a result of injury. This rare entity has been described in limited number of cases. METHODS: A systematic review of the literature was performed according to the meta-analysis of observational studies in epidemiology guidelines. The English literature from 1990 until 2021 was reviewed, using PubMed, EMBASE and Google Scholar bibliographic databases, to identify case reports and case series with patients that were diagnosed with TLH. For each eligible study, demographics, clinical presentation, hernia characteristics, preoperative imaging investigations, operation details, and postoperative data were extracted for assessment. Statistical analysis was performed on SPSS, version 20.0. RESULTS: A total of 62 studies were included for review, with 164 patients with TLH. Mean age was (42.6 ± 14.3) years (47.6% males, 31.1% females, gender not specified in 35 cases). Mean diameter of hernia neck was (6.3 ± 3.1) cm, while the triangles of Petit and Grynfeltt were affected in 74.5% and 14.6%, respectively. Patients diagnosed in the emergency setting account for 54.2%, with CT scan establishing diagnosis in all but one case (97.7%). A delayed diagnosis was made in 45.8%, at a mean 1 year following trauma. Flank bulging (82.8%) and chronic back pain (34.3%) were the most frequent symptoms. In both delayed and acute group, open surgery (63.6% and 92.3%, respectively) was the preferred surgical approach. Postoperative complications were reported in 11.4% of acute and 15.0% of delayed patients. Hernia recurrence was 7%. CONCLUSIONS: TLH is uncommon with 164 cases described since 1990. CT scan is the gold standard in diagnosis. Open surgery is generally the preferred approach, particularly in the emergency setting. Acute TLH can be treated either by primary suture repair or mesh, depending on the local conditions, whereas delayed cases usually require a mesh.