Abdominal weakness, bulge, or hernia after DIEP flaps: An algorithm of management, prevention, and surgical repair with classification.

BACKGROUND: This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Abdominal wall morbidities are categorized, and an algorithm for management is provided. METHODS: A retrospective review of 644 patients who underwent abdominal based flap breast reconstruction between 2009 and 2018 and met selection criteria was performed. Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. The incidence of abdominal weakness was evaluated by BREAST-Q™ data. Risk factors were analyzed. RESULTS: Of the 644 patients, 23 (3.6%) had a clinically significant bulge or hernia on exam postoperatively. Developing an abdominal wound postoperatively and sacrificing nerves both correlated with an increased incidence of bulge or hernia (p < 0.05). The use of lateral row perforators, keeping the umbilicus, higher BMI, and the use of biological mesh in the initial abdominal wall repair trended toward an increased incidence of bulge or hernia; however, these data were not statistically significant. Seven percent of patients who answered the BREAST-Q™ reported abdominal weakness. Patients in the umbilicus sacrificing cohort had an increased incidence of weakness (p < 0.05). Abdominal wounds, nerve sacrificing procedures and obesity correlated with an increased incidence of weakness; these data were not statistically significant. CONCLUSIONS: A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. Abdominal wall morbidity is classified as: type 1 - abdominal weakness; type 2 - smaller, unilateral abdominal bulge; and type 3 - true abdominal hernia or large bilateral bulge. An algorithm of treatment is presented, which includes physical therapy and surgical repair recommendations.

Dicas em Saúde: Hérnia Abdominal

Hérnia abdominal é o escape (protusão) parcial ou total de um ou mais órgãos por um orifício que se abre, por má formação ou por enfraquecimento nas camadas de tecido protetoras dos órgãos internos do abdômen.

Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review.

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes.

[A woman with a lumbar swelling]. / Een vrouw met een lumbale zwelling.

We present the case of a 57-year-old woman with a large (7 x 5 cm), asymptomatic lumbar swelling. A lumbar MRI scan revealed a hernia of the superior lumbar triangle (Grynfeltt-Lesshaft hernia). Thus far, 300 cases have been described in the literature. Therapeutic options include surgical and conservative treatment.

Diagnosis and treatment of chronic abdominal pain 5 years after Roux-en-Y gastric bypass.

BACKGROUND: Knowledge of optimal diagnostic workup, etiology, and response to treatment of chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) is limited. OBJECTIVE: To define the etiology of chronic abdominal pain presenting at the 5-year follow-up after RYGB and to evaluate response to treatment. SETTING: Oslo University Hospital (tertiary referral center for obesity surgery). METHODS: Of 234 patients operated during a randomly selected 12-month period, 165 (71%) returned for 5-year follow-up, and 160 responded to study questionnaires. Of these, 54 (34%) reported chronic abdominal pain and were invited to participate in a structured diagnostic and treatment algorithm. These patients were contacted for the evaluation of their response to treatment. RESULTS: Fifty-one of 54 patients (94%) reporting chronic abdominal pain at the 5-year follow-up were included in the study. Of the 45 patients with onset of symptoms post-RYGB, 28 (62%) underwent one or more radiologic evaluations, 10 (22%) underwent endoscopy, and 13 (29%) underwent laparoscopy. Diagnosis and treatment were established for 34 patients (76%), whereas 11 (24%) had abdominal pain of unknown cause. The most common etiology was internal herniation (n = 6), dumping (n = 6), food intolerance (n = 6), gallstones (n = 5), and irritable bowel syndrome (n = 4). After a median follow-up of 13.0 months (standard deviation, 11.5), 37 (82%) patients reported remission or improvement of symptoms, 6 had unchanged symptoms, and 2 patients were lost to follow-up. CONCLUSIONS: The etiology of long-term chronic abdominal pain post-RYGB is diverse. A multidisciplinary team can help most patients with dedicated follow-up, but a subset of patients has symptoms of unknown etiology.

Fibrin glue mesh fixation combined with mesenchymal stem cells or exosomes modulates the inflammatory reaction in a murine model of incisional hernia.

Surgical meshes are effective and frequently used to reinforce soft tissues. Fibrin glue (FG) has been widely used for mesh fixation and is also considered an optimal vehicle for stem cell delivery. The aim of this preclinical study was to evaluate the therapeutic effect of MSCs and their exosomes combined with FG for the treatment of incisional hernia. A murine incisional hernia model was used to implant surgical meshes and different treatments with FG, MSCs and exo-MSCs were applied. The implanted meshes were evaluated at day 7 by anatomopathology, cellular analysis of infiltrating leukocytes and gene expression analysis of TH1/TH2 cytokines, MMPs, TIMPs and collagens. Our results demonstrated a significant increase of anti-inflammatory M2 macrophages and TH2 cytokines when MSCs or exo-MSCs were used. Moreover, the analysis of MMPs, TIMPs and collagen exerted significant differences in the extracellular matrix and in the remodeling process. Our in vivo study suggests that the fixation of surgical meshes with FG and MSCs or exo-MSCs will have a beneficial effect for the treatment of incisional hernia in terms of improved outcomes of damaged tissue, and especially, in the modulation of inflammatory responses towards a less aggressive and pro-regenerative profile. STATEMENT OF SIGNIFICANCE: The implantation of surgical meshes is the standard procedure to reinforce tissue defects such as hernias. However, an exacerbated and persistent inflammatory response secondary to this implantation is frequently observed, leading to a strong discomfort and chronic pain in the patients. In many cases, an additional surgical intervention is needed to remove the mesh. This study shows that mesenchymal stem cells and their exosomes, combined with a fibrin sealant, can be used for the successful fixation of these meshes. This new therapeutic approach, assayed in a murine model of incisional hernia, favors the modulation of the inflammatory response towards a less aggressive and pro-regenerative profile.

Non-operative treatment as a strategy for patients with parastomal hernia: a multicentre, retrospective cohort study.

AIM: Parastomal hernia is the most common complication following stoma construction. Surgical treatment is usually chosen over non-operative treatment, but a clear rationale for the choice of management is often lacking. This study aims to investigate the reasons for non-operative treatment, cross-over rates and postoperative complications. METHOD: A multicentre, retrospective cohort study was conducted. Patients diagnosed with a parastomal hernia between January 2007 and December 2012 were included. Data on baseline characteristics, primary surgery and hernias were collected. For non-operative treatment, reasons for this treatment and cross-over rates were evaluated. For all patients undergoing surgery (surgical treatment and cross-overs), complication and recurrence rates were analysed. RESULTS: Of the 80 patients included, 42 (53%) were in the surgical treatment group and 38 (48%) in the non-operative treatment group. Median follow-up was 46 months (interquartile range 24-72). The reasons for non-operative treatment were absence of symptoms in 12 patients (32%), comorbidities in nine (24%) and patient preference in three (7.9%). In 14 patients (37%) reasons were not documented. Eight patients (21%) crossed over from non-operative treatment to surgical treatment, of whom one needed emergency surgery. In 23 patients (55%), parastomal hernia recurred after the original surgical treatment, of whom 21 (91%) underwent additional repair. CONCLUSION: Parastomal hernia repair is associated with high recurrence and additional repair rates. Non-operative treatment has a relatively low cross-over and emergency surgery rate. Given these data, non-operative treatment might be a better choice for patients without complaints or with comorbidities.

Hernia obturatriz complicada. Conducta diagnóstica y terapéutica / COMPLICATED OBTURATOR HERNIA. DIAGNOSIS AND THERAPEUTIC MANAGEMENT

La hernia obturatriz tiene una baja incidencia, predomina en mujeres ancianas desnutridas, habitualmente con signos y síntomas poco específicos, situación que requiere resolución quirúrgica precoz para disminuir la morbi-mortalidad. Materiales y métodos: Análisis retrospectivo observacional sobre tres casos de oclusión intestinal por hernia obturatriz en el servicio de Cirugía General del Hospital Italiano de Córdoba entre el período comprendido desde enero de 2013 a diciembre de 2015. Resultados: Los tres pacientes fueron diagnosticados por TC en el preoperatorio, en dos se debió realizar resección intestinal y entero-entero anastomosis. Conclusión: la cirugía de urgencia es el tratamiento ideal

Obturator hernia is a rare type of hernia. Because of its low incidence, predominantly in elderly malnourished women, usually with non- specific signs and symptoms, diagnosis and treatment are often delayed. This situation requires early surgical treatment to prevent serious morbidity and mortality associated with this entity. Methods: Retrospective observational analysis of 3 cases of intestinal occlusion due to complicated obturator hernia at the Department of General Surgery, Hospital Italiano Córdoba, Argentina, between January 2013 to December 2015. Results: All three cases were diagnosed preoperatively by CT , but in two of the three cases it was due to perform an intestinal resection with anastomosis. Conclusion: The surgery performed early after admission, is the treatment of choice.

Contribution of Computed Tomographic Imaging to the Management of Acute Abdominal Pain after Gastric Bypass: Correlation Between Radiological and Surgical Findings.

BACKGROUND: We evaluated the diagnostic accuracy of first interpretations of computed tomographic (CT) images and blind interpretation using predefined CT signs in patients with previous Roux-en-Y gastric bypass (RYGBP) and acute abdominal pain. METHODS: We performed a retrospective chart review of patients with RYGBP who underwent surgical exploration from January 2009 to December 2014 for acute abdominal pain in our university institution, excluding patients without CT scan and comparing initial CT imaging interpretation with surgical findings. Two blinded radiologist specialists in bariatric imaging evaluated the CT images for seven previously reported CT signs. We then calculated the sensitivity and specificity of these signs and Cohen's kappa inter-observer agreement for diagnosing internal hernia. RESULTS: Sixty-four patients had a recorded CT scan. The original CT interpretation showed that 26/64 (40%) patients had an accurate diagnosis. Cohen's kappa coefficient for concordance between surgical exploration and first interpretation was 0.26. The image review showed an accurate diagnosis was obtained in 51/64 patients (79.6%) and 48/64 (75%) patients for the first and second reader, respectively (Cohen's kappa coefficient = 0.67; 95% confidence interval = 0.52-0.76). The most prevalent sign indicating internal hernia was whirling of the mesentery (sensitivity = 82-91%; specificity = 79-93.1%). CONCLUSIONS: CT is an important diagnostic tool for skilled readers for managing acute abdominal pain in patients with previous RYGBP. Experience in the abdominal and bariatric imaging and the use of predetermined CT image signs provided a high degree of accuracy and confidence. A low threshold for surgical exploration remains the gold standard of appropriate treatment.

Hernia lumbar bilateral de Grynfelt Lesshaft: un nuevo reporte / Bilateral lumbar Grynfelt Lesshaft hernia: a new report

Fundamento: de las hernias lumbares, la congénita es la menos frecuente y representa menos del 20 porciento, entre las adquiridas la menos observada es la espontánea o primaria. Se expone la anatomía de la pared abdominal posterior con sus dos triángulos, inferior de Petit y superior de Grynfelt Lesshaft que dan lugar a hernias lumbares de igual nombre. La hernia lumbar superior es más frecuente que la inferior y se origina en el triángulo superior, es inusual la presencia de hernia bilateral; se actualiza la clasificación, diagnóstico y tratamiento.Objetivo: exponer lo infrecuente de la hernia Grynfelt Lesshaft, al ser bilateral y tratada por cirugía ambulatoria con anestesia local.Caso clínico: se reporta el caso de una paciente diagnosticada con hernia primaria espontánea de Grynfelt Lesshaft bilateral y tratada por cirugía ambulatoria con anestesia local.Conclusiones: debe conocerse la anatomía de esta región y aplicar el tratamiento adecuado, con las distintas variantes técnicas que permitan lograr el éxito terapéutico en esta variedad de hernia.(AU)

Background: among lumbar hernias, congenital one is the less frequent and represents less than 20 percent. From the acquired ones, the less observed is the spontaneous or primary. The anatomy of the posterior abdominal wall with its two triangles, inferior of Petit and superior of Grynfelt Lesshaft is presented. Lumbar hernias are named after them. Superior lumbar hernia is more common than the inferior and it originates in the superior triangle. The presence of bilateral hernia is unusual. Classification, diagnosis and treatment are updated.Objective: to show how infrequent is Grynfelt Lesshaft hernia since it is bilateral and treated with ambulatory surgery with local anaesthesia.Clinical case: the case of a patient diagnosed with spontaneous primary Grynfelt Lesshaft bilateral hernia is reported and treated with local anaesthesia in ambulatory surgery.Conclusions: anatomy of this region should be known and the effective treatment with different technical variants that permit to achieve therapeutic success in this type of hernia.(AU)

[PROPHYLAXIS OF INFILTRATIVE-INFLAMMATORY COMPLICATIONS OF THE WOUNDS HEALING IN PATIENTS, OPERATED ON FOR NONCOMPLICATED HERNIA OF ANTERIOR ABDOMINAL WALL].

The results of investigation of the inflammatory processes dynamics in operative wounds in 238 patients after surgical intervention, performed for noncomplicated hernias of anterior abdominal wall of various localization, as well as the impact of polarized light on correction of the vegetative nervous system disorders, for prophylaxis of infiltrative-purulent complications were analyzed.

Treatment of Abdominal Segmental Hernia, Constipation, and Pain Following Herpes Zoster with Paravertebral Block.

Herpes zoster (HZ) most commonly occurs in elderly patients and involves sensory neurons resulting in pain and sensory changes. Clinically significant motor deficits and visceral neuropathies are thought to be relatively rare. A 72-year-old man presented with abdominal segmental hernia, constipation, and pain following HZ in the left T9-10 dermatome. Sixteen days before presentation, he had developed a painful herpetic rash in the left upper abdominal quadrant. Approximately 10 days after the onset of the rash, constipation occurred and was managed with daily oral medication with bisacodyl 5 mg. In addition, 14 days after the onset of HZ, the patient noticed a protrusion of the left upper abdominal wall. Abdominal x-ray, ultrasound of the abdomen, and electrolyte analysis showed no abnormalities. General physical examination revealed a reducible bulge in his left upper quadrant and superficial abdominal reflexes were diminished in the affected region. Electromyographic testing revealed denervational changes limited to the left thoracic paraspinal muscles and supraumbilical muscles, corresponding to the affected dermatomes. He was prescribed with 500 mg of famciclovir 3 times a day for 7 days, and pregabalin 75 mg twice a day and acetaminophen 650 mg 3 times a day for 14 days. However, his pain was rated at an intensity of 5 on the numerical analogue scale from 0 (no pain) to 10 (worst pain imaginable). A paravertebral block was performed at T9-10 with a mixture of 0.5% lidocaine 3 mL and triamcinolone 40 mg. One day after the procedure, the abdominal pain disappeared. In addition, 5 days after the intervention, the abdominal protrusion and constipation were resolved. He currently remains symptom free at a 6 month follow-up.

Laparoscopic-assisted management of traumatic abdominal wall hernias in children: case series and a review of the literature.

BACKGROUND: Traumatic abdominal wall hernia (TAWH) is defined as herniation through a disrupted portion of musculature/fascia without skin penetration or history of prior hernia. In children, TAWH is a rare injury. OBJECTIVE: The objectives of this study were to report our experience with different management strategies of TAWH in children and to determine the utility of laparoscopy. DESIGN/METHOD: A retrospective chart review of all children treated by pediatric surgery at our institution for TAWH in a 5year interval was performed. Data were collected on mechanism of injury, initial patient presentation, surgical management, and outcomes. RESULTS: We present 5 cases of traumatic abdominal wall hernia; 3 were managed using laparoscopic assistance. One patient was managed nonoperatively. All patients recovered without complications and were asymptomatic on follow up. CONCLUSION: Traumatic abdominal wall hernias require a high index of suspicion in the cases of blunt abdominal trauma. Laparoscopy is useful mainly as a diagnostic modality, both to evaluate the hernia and associated injuries to intraabdominal structures. Its use may facilitate repair through a smaller incision. Conservative management of TAWH may be appropriate in select cases where there is a low risk of bowel strangulation.

Watchful waiting in incisional hernia: is it safe?

BACKGROUND: Incisional hernia (IH) is among the most common postoperative complications after abdominal surgery. Operative treatment (OT) using mesh is the treatment of choice. A strategy of watchful waiting (WW) might be a considered in some patients. This retrospective study compares the outcomes of WW and OT. METHODS: All patients presenting with IH in an academic surgery department between January 2004 and December 2009 were analyzed according to whether they were treated by WW or OT. Crossovers between both groups were also analyzed. Patient characteristics, information about the initial abdominal operative procedure, symptoms at presentation, and characteristics of the hernia were collected retrospectively. In case of OT, postoperative complications were analyzed. RESULT: In total, 255 patients were included; 151 (59%) in the OT group and 104 (41%) in WW group. The median follow-up was 68 months (interquartile range [IQR], 52-93). The reasons for WW were the absence of symptoms in 34 patients (33%), comorbidities in 24 (23%), and obesity in 23 (22%). During follow-up, 34 patients (33%) crossed over from WW to OT. Eight of the crossovers (24%) were emergency repairs owing to incarceration at a median of 1 month (IQR, 1-5) after the start of WW. The incidence of unexpected intraoperative intestinal perforation was greater in the crossover group (13%) compared with the OT group (2%; P = .002). Postoperative fistulas were seen in 7% of patients who crossed over from WW to OT versus 0% in primary OT (P = .002). Postoperatively, 3 patients died, 2 of whom were treated operatively after belonging initially to the WW group. CONCLUSION: WW for IH leads to high crossover rates with significantly greater incidence of intraoperative perforations, fistulas, and mortality, than in the OT group, particularly in patients who require emergency repair of IH owing to incarceration.

Abdominal hernias: a clinical review of their assessment and management in the Naval Service.

Hernias are a relatively common occurrence in the armed forces community and may affect an individual's fitness for duty and impact on operational capability, particularly in specialist occupations. Their early identification and management will allow appropriate treatment and minimise any impact on operational capability. This article aims to summarise the assessment and management of simple hernias and considers occupational considerations in their management for personnel serving in the Royal Navy and Royal Marines.

Investigating muscle regeneration with a dermis/small intestinal submucosa scaffold in a rat full-thickness abdominal wall defect model.

Repair of large complex ventral wall hernias is challenging and outcomes are often poor due to hernia recurrence and compromised abdominal wall function. Currently, biological grafts are used to assist in repairing these complex hernias. Dermis grafts are often chosen because of their mechanical characteristics; however, dermis does not have the ability to promote the muscle regeneration needed to regain abdominal wall function. In contrast, small intestinal submucosa (SIS) grafts have been shown to promote muscle generation in volumetric muscle loss (VML) models. Hence, the objective of this study is to investigate the extent to which SIS grafts can be used together with dermis grafts to repair and promote muscle regeneration in a full-thickness abdominal wall defect in a rat model. The dermis layer is intended to mechanically bridge the defect and support constructive tissue remodeling while the SIS is intended to degrade and promote neo-muscle formation. After 16 weeks of implantation, we found only a small amount of vascularized muscle (<10% of the defect area) in the repaired defects. No significant difference in defect muscle area was found between the groups receiving the dermis + SIS scaffolds and the control (dermis alone) group. Our findings indicate that the SIS constructions investigated could not promote appreciable muscle regeneration in this rigorous animal model of VML and incomplete abdominal closure. Future investigation into combination scaffold, cell and molecular therapies would be warranted to address the need for functional muscle regeneration in challenging clinical conditions such as complex abdominal wall repair.

Early intervention, parastomal hernia and quality of life: a research study.

Parastomal hernia continues to be a common and distressing problem for stoma patients. But are they preventable? In 2005 and again in 2007, Thompson and Trainor reported that by introducing a simple prevention programme that advised the wearing of support garments for heavy lifting for 1 year after stoma surgery, they significantly reduced the incidence of parastomal hernias. They also found that most of the hernias occurred in the early months after stoma surgery (their intervention programme started 3 months after surgery). The current study builds on Thompson and Trainor's work by introducing an intervention programme at a much earlier stage, with specific advice to wear a lightweight support garment on discharge from hospital in place of normal underwear. Advice was also given about lifting and participants were started on an abdominal exercise programme. Quality of life was monitored at discharge, 3 months, 6 months and 1 year. The results show reduced hernia rates and an increased quality of life for these patients. The aim was to improve on the results of Thompson and Trainor in reducing parastomal hernias, improving quality of life and reducing costs to the NHS through fewer complications associated with hernias, and wasted prescriptions for unused, inappropriate or ill-fitting support wear.

Understanding noninguinal abdominal hernias in the athlete.

Abdominal hernias are common with over 20 million hernia repairs performed worldwide. Inguinal hernias are the most common type of hernia. Inguinal and sports hernia have been discussed at length in recent literature, and therefore, they will not be addressed in this article. The noninguinal hernias are much less common but do occur, and knowledge of these hernias is important when assessing the athlete with abdominal pain. Approximately 25% of abdominal wall hernias are noninguinal, and new data show the order of frequency as umbilical, epigastric, incisional, femoral, and all others (i.e., Spigelian, obturator, traumatic). Return-to-play guidelines need to be tailored to the athlete and the needs of their sport. Using guidelines similar to abdominal strain injuries can be a starting point for the treatment plan. Laparoscopic repair is becoming more popular because of safety and efficacy, and it may lead to a more rapid return to play.