Assessment of myofascial medialization following posterior component separation via transversus abdominis muscle release in a cadaveric model.

PURPOSE: Posterior component separation (PCS) via the transversus abdominis release (TAR) procedure continues to gain popularity. However, neither the physiologic basis nor the extent of myofascial medialization after TAR is established. We aimed to assess both anterior and posterior rectus fascia (AF and PF) medialization following each step of the TAR procedure. METHODS: Ten fresh cadavers underwent PCS via TAR. Steps included midline laparotomy (MLL), retrorectus dissection (RRD), incision of the posterior rectus sheath (IPL), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Medial advancement of AF and PF was measured following application of 2.5, 5.0 lb, and maximal tension to the fascial edge. Values are represented as mean advancement past midline in centimeters. RESULTS: MLL allowed advancement of 2.5, 3.7, and 4.9 cm. RRD provided advancement of 4.1, 5.9, and 7.6 cm for AF and 4.4, 6.2, and 7.5 cm for PF. IPL provided advancement of 4.2, 6.1, and 8.0 cm for AF and 4.6, 6.6, and 8.3 cm for PF. TAD provided advancement of 4.5, 6.6, and 8.6 cm for AF and 5.3, 7.5, and 9.5 cm for PF. RMD provided advancement of 5.5, 7.9, and 9.9 cm for AF and 6.9, 9.6, and 11.2 cm for PF. Overall, the complete TAR procedure provided AF advancement of 102% and PF advancement of 129%, over baseline. CONCLUSIONS: The TAR procedure provides for substantial medial advancement of both anterior and posterior myofascial components of the abdominal wall. Retromuscular dissection deep to the divided transversus abdominis muscle appears to be the key step of the procedure, allowing for effective reconstruction of very wide (≈ 20 cm) defects.

The effects of Losartan on abdominal wall fascial healing.

PURPOSE: Losartan, a commonly used angiotensin II receptor blocker (ARB) for blood pressure control, also impairs cutaneous wound healing. Our current study will analyze how Losartan affects wound healing in the muscle and fascia from both biomechanical and histological aspects. METHODS: A total of 26 Sprague-Dawley rats were separated into one control group (NS, N = 13) and one experimental group (LG, N = 13) to receive normal saline and 40 mg/kg of Losartan by way of gastric lavage, respectively. 7 days later, all animals were subjected to a 5 cm midline laparotomy. The fascia and skin were then closed with 4-0 prolene and 5-0 vicryl. 15 days postoperatively, the animals were sacrificed and the abdominal wall harvested for wound tensiometric test and histological analysis. RESULTS: All 26 rats survived to the time of necropsy. Tensiometry detected significantly higher wound tensile strength in the NS group (1.6 ± 0.31 N/mm) than in the LG (1.3 ± 0.28 N/mm) group (p = 0.016). Transection histology with trichrome staining demonstrated higher degree of immature fibroplasia inside the wound in the LG group than in the NS group (p = <0.0001). The LG group also had larger incisional gaps than the NG group. CONCLUSION: The antihypertensive drug, Losartan, retards wound healing in the abdominal fascia and reduces wound tensile strength in our rat model. Attention should be paid to the potential effects of various medications on fascial wound healing to guarantee optimal surgical outcomes.

Benefits of immediate dermoglandular preserving reconstruction following giant fibroadenoma excision in two patients.

Giant fibroadenoma is a rare, benign stromal tumor that typically occurs in adolescent women. This rapidly-growing tumor can result in a significant aesthetic and psychosocial morbidity due to gross asymmetry changes in the overlying skin envelope and concerns about malignancy. On initial work-up this lesion must be differentiated from other rare primary breast tumors, including phyllodes tumor, or metastatic disease. Appropriate treatment of giant fibroadenoma requires surgical excision; however, many surgeons are reluctant to perform a concomitant mastopexy or reconstruction at the time of tumor extirpation. This conservative approach results in a loose, ptotic, aesthetically displeasing breast postoperatively. While some degree of skin retraction is expected, patients may have to wait for up to a year to see final results, and further surgical correction may still be required. It is unknown whether these surgeons are not familiar with these techniques or hesitate to increase the amount of scarring on the breast mound of a young female. Using an immediate dermoglandular preserving mastopexy after giant fibroadenoma excision, we have decreased postoperative breast ptosis, removed much of the lax, poor-quality skin and achieved stable, long-term results in two patients. This technique improves the immediate aesthetic outcome, reduces the psychosocial comorbidity associated with waiting for skin retraction and decreases the likelihood of a second surgery.

Hybrid myocardial revascularization after previous left pneumonectomy.

Previous intrapericardial left pneumonectomy and irradiation necessitated an unorthodox, staged approach to myocardial revascularization in a patient with unstable angina pectoris, left main artery, and three-vessel coronary artery disease. A saphenous vein bypass graft was constructed from the descending thoracic aorta to the left anterior descending coronary artery via left thoracotomy, without cardiopulmonary bypass. Two days later the patient underwent stenting of the left main and circumflex coronary arteries. Recovery was uneventful.

Improving coded data entry by an electronic patient record system.

Data are presented on the use of a browsing and encoding utility to improve coded data entry for an electronic patient record system. Traditional and computerized discharge summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no coding; phase II, manual coding, and phase III, computerized semiautomatic coding. Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded manually; (2) using a computerized browsing and encoding utility this percentage may increase by 64%; (3) when forced to encode manually, users may "shift" as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby "bypassing" the need to encode, this was reduced by up to 41% with the computerized approach, and (4) computerized encoding can improve completeness of data encoding, from 46 to 100%. We conclude that the use of a computerized browsing and encoding tool can increase data quality and the percentage of documented data. Mechanisms bypassing the need to code can be avoided.

Improving clinician's coded data entry through the use of an electronic patient record system: 3.5 years experience with a semiautomatic browsing and encoding tool in clinical routine.

This report presents data on clinicians' use of a browsing and encoding utility. Traditional and computerized discharge summaries during three phases of coding ICD-9 diagnoses were compared: phase I (no coding), phase II (manual coding), and phase III (computerized semiautomatic coding). Our data indicate that only 50% of all diagnoses in a discharge summary are encoded manually; using a computerized browsing and encoding utility this rate may increase by 64%; when forced to encode diagnoses manually users may "shift" as much as 84% of relevant diagnoses from the appropriate section to other sections, thereby "bypassing" the need to encode. This effect can be partially reversed by up to 41% with the computerized approach. Using a computerized encoding help can ensure completeness of encoding data (from 46 to 100%). We conclude that the use of a computerized browsing and encoding tool by clinicians can increase data quality and the volume of documented data. Mechanisms bypassing the need to code can be reversed.

Positive efficiency findings using computer assisted ICD-encoding: 3.5 years of experience with the computerized patient record system PADS (Patient Archiving & Documentation System).

In daily routine there is a major discrepancy between what physicians do and what they document. From a medical information processing point of view amongst the more important functions physicians perform in their daily routine is the encoding of diagnoses using a standard vocabulary such as ICD-9. This paper presents evidence that through the use of the ICD-encoding module of a computerized patient record system (PADS, Patient Archiving and Documentation System) user compliance can be improved. "Bypassing" mechanisms can be partly reversed (up to 43%), more coded diagnoses are documented (by 51%) and those diagnoses documented are more complete (increase by 57%).