Search

Background To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation is often performed. In patients with an extreme diameter hernia, anterior component separation and posterior component separation may be combined. The aim of this study was to assess the additional medialization after simultaneous anterior component separation and posterior component separation. Methods Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Medialization was measured at 3 reference points. Results Anterior component separation provided most medialization for the anterior rectus sheath, posterior component separation provided most medialization for the posterior rectus sheath. After combined component separation techniques total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional posterior component separation after anterior component separation provided 15% to 16%, and additional anterior component separation after posterior component separation provided 32% to 38% of the total medialization after combined component separation techniques. For the posterior rectus sheath, additional posterior component separation after anterior component separation provided 50% to 59%, and additional anterior component separation after posterior component separation provided 11% to 17% of the total medialization after combined component separation techniques. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization. Conclusion Anterior component separation provided most medialization of the anterior rectus sheath and posterior component separation provided most medialization of the posterior rectus sheath. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks.

The enhanced-view totally extraperitoneal (eTEP) approach fulfills all modern principles for the repair of ventral hernias. In the hands of well-trained hernia surgeons, the approach is safe and effective and improves the patient’s quality of life, as demonstrated in more than 30 publications in the last 2 years. However, the eTEP approach is a complex operation that requires in-depth understanding of the extraperitoneal abdominal wall anatomy, including its neurovascular structures and natural boundaries. Formal training is necessary, ideally including cadaver dissection and a mentor.

Background. Rives repair has been traditionally used for large abdominal wall defects with good results on terms of recurrence. However, it is limited by the lateral border of the posterior rectus sheath. The objective of our study was to evaluate recurrence rate, midline closure and mesh overlap in patients operated on elective midline incisional hernia by open Rives retromuscular repair. Methods. This is a prospective observational study of 83 patients who underwent elective open Rives technique between January 2014 and December 2018. Main inclusion criteria were adults with a midline incisional hernia. Recurrence, midline closure and mesh overlap were determined. Results. At a median postoperative follow-up of 32 (5-59) months, 8 cases of recurrence were reported. Patients with recurrence had wider hernia defects (101 ± 52 mm vs 66 ± 36 mm, P = .014) and were repaired with wider meshes (191 ± 93 mm vs 137 ± 68 mm, P = .042). However, although it was not statistically significant, midline closure was lower (38% vs 59%), as well as the overlapping relationship between mesh area and hernia defect area (2.937:1 vs 3.732:1) on patients that developed a recurrence. Conclusions. Rives technique provides good mid-term results in a midline incisional hernia (10% of recurrence at 36 months), including wider hernias in the recurrent cohort. The authors believe that other techniques which allow midline closure and placement of bigger meshes should be considered, especially in those hernias classified as W3 on EuraHS classification (more than 10 cm on width size).

Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures. We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)—Top–down technique; (4) transversus abdominis release (TAR)—bottom–up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains. Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Extraperitoneal colostomy is a widely used technique during abdominoperineal resection (APR) operation for lower rectal cancer. This technique has been reported to be effective to prevent the postoperative parastomal hernia in some retrospective studies, however, there is still a certain incidence of parastomal hernia. A modification of the extraperitoneal colostomy technique is described in this paper that keeps posterior rectal sheath intact instead of having a conventional incision, to further reduce the risk of parastomal hernia. Until now, this modified technique has been performed in 15 patients, no occurrence of parastomal hernia was observed.

Background: Chevrel’s technique provides tensionfree repair of midline incisional hernia, but wide skin and subcutaneous dissection increases rate of complications. Here, we evaluate the double mesh modification of Chevrel’s technique in midline incisional hernia repair. Methods: 22 patients with midline incisional hernia underwent double mesh modification of Chevrel’s technique. After excision of hernial sac with minimal dissection of the skin and subcutaneous tissue, the anterior rectus sheath is incised on both sides to create medial flaps that are sutured toeach other. Both recti abdominis muscles were dissected off the posterior rectus sheath, opening the retrorectus space. Prolene mesh was fixed in the retrorectus space with prolene sutures, and tailored to cover the bare area of anterior surface of both recti muscles and fixed to the lateral flaps of the anterior rectus sheath with interrupted prolene sutures. Results: We observed no recurrences, no skin necrosis, two cases of seroma, one case of superficial wound infection and one case of temporarychronic pain. Conclusion: Double mesh modification of Chevrel technique is an efficient method for treatment of midline incisional hernia, with minimal surgical site occurrences. Keywords: Chevrel technique, Double mesh technique, Midline incisional hernia

Background Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space). Methods Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall. Results All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85–145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1–3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10–27 months). Conclusion In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

Summary:. Some techniques to reconstruct the abdominal wall have been published, including the component separation procedure. The contribution of the rectus abdominis flap in the reconstruction of a giant incisional hernia is reported. The authors report three clinical cases in which the component separation technique was insufficient to reconstruct a giant midline incisional hernia. As a salvage technique, the rectus abdominis flap was dissected in the form of a hinge. The postoperative period was successful in all patients, combining both techniques. The rectus abdominis hinge flap could be used as a complementary technique to component separation to reconstruct a giant midline incisional hernia. There are several options to reconstruct the abdominal wall, such as anterior transposition of the posterior rectus sheath,1 or rotation of the anterior sheath toward the midline. This strategy is known as open book.2 The rectus turnover flap is also used.3 The anterior component separation technique closes defects less than 20 cm width.4 If it is wider, the reconstruction is more difficult. When the operative plan fails in the operating room, an additional technique should be considered. We report on the cases in which we use the rectus abdominis hinge flap.

Objectives Posterior rectus canal assumed immense importance with newer laparoscopic technique of total extra-peritoneal pre-peritoneal (TEPP/TEP) hernioplasty for inguinal hernia. However, scientific study of live surgical anatomy of posterior rectus canal is almost totally lacking in the English literature, and hence the present study was conducted. Material and methods 3-midline-port technique through posterior rectus sheath approach; Initial telescopic dissection under direct CO2 insufflation followed by instrument dissection. Results 68 TEPP hernioplasties were successful in 60 patients with mean age of 50.1 ± 17.2 years (range 18-80) and mean BMI of 22.6 ± 2.0 kg/m2 (range 19.5-31.2). Rectusial fascia was a definite anatomical entity, dividing traditional posterior rectus canal into two channels, namely, true retromuscular space and true posterior rectus canal (T-PRC). Rectusial fascia was variable, i.e., thick diaphanous (n= 47), thick membranous (n= 13), thin membranous (n= 3) and thin flimsy (n= 5). Posterior rectus sheath (PRS) was also variable, incomplete (n= 54) and complete (n= 14). Incomplete PRS showed seven variations in both extent and/or morphology. Complete PRS show five morphological variations. Transversalis fascia demonstrated three morphological variations, namely, single diaphanous (n= 41), single membranous (= 10) and thin flimsy (n= 3). TEPP hernioplasty was readily feasible through avascular true posterior rectus canal. Conclusion Posterior rectus canal is divided by 'rectusial fascia' into two channels, namely, true retromuscular space and true posterior rectus canal, latter being proper avascular plane of dissection for TEPP hernioplasty. Rectusial fascia, posterior rectus sheath and transversalis fascia showed morphological variations. Timely recognition of variable real-time anatomy is recommended to perform adequate proper surgical dissection for seamless TEPP hernioplasty with ease, rapidity and safety.

Introduction Complex and recurrent paraesophageal hernia repairs are a challenge for surgeons due to their high recurrence rates despite the use of various prosthetic and suturing techniques. Methods Here we describe the use of vascularized fascia harvested from the posterior rectus sheath with peritoneum during robotic hiatal hernia repair in two patients with large complex diaphragmatic defects. Results Successful harvesting and onlay of the right posterior rectus sheath based on a falciform vascular pedicle was achieved robotically by rotating and securing the flap to the diaphragmatic hiatus as an onlay flap following cruroplasty of the hiatal defect. Conclusions In patients with difficult to repair large paraesophageal hernias, we demonstrate a promising new technique to restore the dynamic hiatal complex with the tensile strength of autologous vascularized fascia and peritoneum.

Hernias of the posterior rectus sheath are a rarer type of interparietal hernia with only few cases reported up to date. Majority are postsurgical and posttraumatic. Clinical diagnosis may be challenging and imaging is often utilized for diagnosis. Computed tomography (CT) is the preferred imaging technique as it maps out the type, extent, contents, and associated complications. We report a case of posterior rectus sheath hernia with small bowel obstruction diagnosed on CT and managed successfully using laparoscopic primary repair.

Background: The best technique for incisional hernioplasty has not been established yet. One of the difficulties to compare these techniques is heterogeneity in the profile of the patients evaluated. Aim: To analyze the results of three techniques for incisional hernioplasty after open bariatric surgery. Method: Patients who underwent incisional hernioplasty were divided into three groups: onlay technique, simple suture and retromuscular technique. Results and quality of life after repair using Carolina’s Comfort Scale were evaluated through analysis of medical records, telephone contact and elective appointments. Results: 363 surgical reports were analyzed and 263 were included: onlay technique (n=89), simple suture (n=100), retromuscular technique (n=74). The epidemiological profile of patients was similar between groups. The onlay technique showed higher seroma rates (28.89%) and used a surgical drain more frequently (55.56%). The simple suture technique required longer hospital stay (2.86 days). The quality of life score was worse for the retromuscular technique (8.43) in relation to the onlay technique (4.7) and the simple suture (2.34), especially because of complaints of chronic pain. There was no difference in short-term recurrence. Conclusion: The retromuscular technique showed a worse quality of life than the other techniques in a homogeneous group of patients. The three groups showed no difference in terms of short-term hernia recurrence., Graphical Abstract Rives-Stoppa retromuscular technique: A) polypropylene mesh fixed on the posterior rectus sheath; B) rectus abdominal muscle; C) anterior rectus sheath being sutured

Tension-free repairs have revolutionized the way we repair hernias. To help reduce undue tension when performing ventral hernia repair, multiple different techniques of myofascial releases have been described. The purpose of this project is to evaluate tension measurements for commonly performed myofascial releases in abdominal wall hernia repair. Patients undergoing myofascial release techniques for their ventral hernias were enrolled in a prospective Institutional Review Board-approved protocol to measure abdominal wall tension from June 1, 2011 to August 1, 2019. Abdominal wall tensions were measured using tensiometers before and after myofascial release techniques. Descriptive statistics were performed and data were analyzed. Thirty patients had tension measurements (5 anterior myofascial separation, 25 posterior myofascial separation with transversus abdominis release [TAR]). Average age was 60.1 years (range 29-81), 83% Caucasian, 53% female, and 42% recurrent hernias. The average hernia defect in patients undergoing anterior myofascial release was 117.3 cm2, and the average mesh size was 650 cm2. The reduction in tension after anterior release was 4.7 lbs (2.7 lbs vs 7.4 lbs). The average hernia defect in patients undergoing posterior myofascial release (TAR) was 183 cm2, and the average mesh size was 761.36 cm2. The reduction in tension after bilateral posterior rectus sheath incision was 2.55 lbs (5.01 lbs vs 7.56 lbs) with 0.66 lbs further reduction in tension after TAR (4.35 lbs vs 5.01). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair. Preliminary data show tension reductions associated with the different myofascial release techniques and, with further study, may be a useful intraoperative adjunct for decision making in hernia repair.

Background Large incisional hernias require medialization of the rectus abdominis muscles to facilitate tension-free closure. Medialization may be achieved by Rives-Stoppa, anterior component separation, or posterior component separation. This study aims to compare medialization achieved by these techniques in postmortem human specimens. Methods First, the Rives-Stoppa procedure was performed. Subsequently, anterior and posterior component separation were performed on one side in each specimen, with each specimen functioning as its own control. Medialization was measured at three levels of the linea alba with three 1-kg weights. Both medialization obtained in addition to initial medialization after opening the linea alba and total medialization were measured. Results are presented as median and interquartile range. Results A total of 13 postmortem human specimens were included (Rives-Stoppa n = 13, component separation n = 10). Additional medialization after Rives-Stoppa was 1.2 cm (IQR: 0.3–2.2) for the anterior rectus sheath and 2.2 cm (IQR: 1.6–3.0) for the posterior rectus sheath (total medialization: 3.9 and 4.5 cm). For the anterior rectus sheath, additional medialization was 2.6 cm (IQR: 1.2–3.6) after anterior component separation and 1.9 cm (IQR: 0.4–3.4) after posterior component separation (P = .125, total medialization: 6.5 and 5.7 cm). For the posterior rectus sheath, additional medialization was 3.0 cm (IQR: 2.2–3.7) after anterior component separation and 5.2 cm (IQR: 4.2–5.9) after posterior component separation (P Conclusion Posterior component separation yielded significantly more medialization of the posterior rectus sheath compared with Rives-Stoppa and anterior component separation. Anterior component separation may provide marginally more medialization of the anterior rectus sheath.

Retromuscular repair of large postoperative ventral hernias and diastasis rectus abdominis may improve the results of these procedures compared to IPOM, and therefore becomes more and more popular last time. A 33-year-old woman with a postpartum 6 cm wide diastasis was operated. Six trocars were used: four 5-mm, and two 10-mm, symmetrically placed at the both flanks. After separation of posterior rectus sheath from rectus muscles on the both sides, the diastasis and the incision of the sheath was sewn. In the retromuscular space, Parietene Progrip Mesh (Covidien, USA) was fixated to the rectus muscles. The operation time was 5 hours. There were no postoperative complications, including confirmed by postoperative ultrasound. The patient was discharged on the 4th postoperative day. Laparoscopic retro-muscular repair allows to mobilize the rectus abdominis muscles, and placement of self-tacking mesh eliminates the need for transfascial sutures and tackers. These principles reduce the risk of recurrence and development of chronic pain., В последнее время все более популярной становится ретромускулярная пластика, результаты которой при больших послеоперационных грыжах и диастазе лучше, чем методики IPOM. Операция выполнена пациентке в возрасте 33 года с послеродовым диастазом прямых мышц живота шириной 6 см. Использовали 6 троакаров (четыре 5-миллиметровых и два 10-миллиметровых), расположенных симметрично по обоим фланкам. После отсепаровки заднего влагалища от прямых мышц с обеих сторон ушили диастаз и разрез заднего влагалища. В ретромускулярном пространстве к мышцам была зафиксирована сетка Parietene Progrip Mesh (Covidien, США). Длительность операции — 5 ч. Послеоперационных осложнений не было, что было подтверждено при ультразвуковом исследовании. Больная выписана на 4-е сутки послеоперационного периода. Лапароскопическая ретромускулярная пластика позволяет мобилизовать прямые мышцы живота. При установке самофиксирующегося сетчатого имплантата отпадает необходимость в трансфасциальных швах и такерах, что уменьшает риск рецидива и развития хронического болевого синдрома., Останнім часом набуває популярності ретромускулярна пластика, результати якої при великих післяопераційних грижах і діастазі кращі, ніж методики IPOM. Операцію виконано пацієнтці віком 33 роки з післяродовим діастазом прямих м’язів живота завширшки 6 см. Використовували 6 троакарів (чотири 5-міліметрових та два 10-міліметрових), розташованих симетрично по обох фланках. Після відсепарування задньої піхви від прямих м’язів з обох боків зашили діастаз і розріз задньої піхви. У ретромускулярному просторі до м’язів було зафіксовано сітку Parietene Progrip Mesh (Covidien, США). Тривалість операції — 5 год. Післяопераційних ускладнень не було, що підтверджено при ультразвуковому дослідженні. Хвору виписано на 4-ту добу післяопераційного періоду. Лапароскопічна ретромускулярна пластика дає змогу мобілізувати прямі м’язи живота. При встановленні сітчастого імплантата, який самофіксується, немає необхідності в трансфасціальних швах і такерах, що зменшує ризик рецидиву та розвитку хронічного больового синдрому.

Ventral hernia repairs are typically repaired with the use of mesh and subsequently restoration of the anatomical midline. While the mesh can be placed in any layer of the abdominal wall, a retrorectus position offers the advantages of being isolated from the rest of the abdominal wall and the peritoneal cavity. The posterior rectus sheath and the rectus abdominis muscle border the retrorectus space. This chapter discusses a retrorectus mesh ventral hernia repair, also known as the Rives-Stoppa repair.

Spontaneous posterior rectus sheath hernia is perhaps one of the rarest hernias described only in a few published cases. We present the case of a small bowel herniation through the posterior rectus sheath in a woman without previous abdominal surgical history, resulting in acute small bowel obstruction who was successfully treated by laparoscopy. This is the first case report of this kind of hernia managed with laparoscopic technique. Although the laparoscopic approach is not considered standard treatment for strangulated hernias, in selected cases, it allows the identification and repair of the defect.

Background Component separation technique involves incision of abdominal muscle and its aponeurosis, which generates a myofascial advancement flap to assist with fascial closure in abdominal wall reconstructions. This tissue mobilization allows for musculo-fascial approximation of much larger abdominal wall defects than would otherwise be possible. With extensive tissue mobilization, however, there is concern for significant wound and systemic complications. Methods A prospective, single institution hernia database was queried for patients undergoing component separation from January 2006 to May 2018. Emergency operations were excluded. Anterior component separation (external oblique release with posterior rectus sheath release) and posterior component separation (transversus abdominus release and posterior rectus sheath release) were examined. Results Of the 775 component separation, 33.4% included anterior component separation and 66.6% posterior component separation. Mean age was 58.8 ± 11.5 years, mean body mass index was 33.6 ± 7.1 (kg/m2), and 27.9% of patients were diabetic. Hernias were large (280.0 ± 220.9 cm2) and often complex (recurrent: 62.6%, incarcerated: 41.5%, concomitant panniculectomy: 39.1%, and contaminated: 37.0%). Defect size was larger in anterior component separation group compared with posterior component separation (379.5 ± 265.2 vs 230.0 ± 175.0 cm2, P Conclusion Both anterior component separation and posterior component separation are associated with low recurrence rates, but anterior component separation is associated with higher wound complications. Prehabilitation and operative techniques improve outcomes of component separation.

Posterior rectus sheath hernias are a rare type of interparietal hernia previously described in a limited number of case reports. There has only been one published case report of a laparoscopic mesh repair. We present a case series of two posterior rectus sheath hernias diagnosed at laparoscopy. A preperitoneal mesh herniorrhaphy was performed to repair the defects. To our knowledge this is the first time such a repair has been performed for this type of hernia. Both hernia necks were infra-umbilical in position. In all previously reported case reports the hernial necks were supraumbilical in position.This is the first case series to be published of this exceedingly rare type of interparietal hernia.

Approximately 4–5 million laparotomies are performed each year in the United States, 2–20% of which are complicated by incisional hernia (IH) [1]. IH is the most common complication of laparotomy requiring reoperation at a ratio beyond bowel obstruction of 3:1 [2]. The vast majority of hernias develop 6 months to 3 years after laparotomy and are associated with wound infection, obesity, tobacco abuse, immune suppression, and suture closure technique [3, 4]. As such, roughly 200,000 incisional hernia repairs are performed annually with a recurrence rate of 45–50% inclusive of all techniques and 20–30% with mesh repair in all-comers [1, 5, 6]. Factors impacting the success of operative repair include management and optimization of medical comorbidities (i.e., obesity, diabetes, smoking, pulmonary function, MRSA colonization) [2]. Tension-free mesh repair is currently the accepted standard of care given prohibitively high recurrence with suture repair alone [1, 6]. However, despite the groundbreaking work of many herniorrhapists over decades of research, the gold standard of mesh herniorrhaphy remains subject to debate [2].

Background: Ultrasound guided rectus sheath block can block the ventral rami of the 7th to 12th thoracolumbar nerves by injection of local anesthetic into the space between the rectus muscle and posterior rectus sheath. The aim of this randomized double-blind study was to evaluate the analgesic effect of the bilateral ultrasound guided rectus sheath block as supplement of general anesthesia on patents undergoing elective umbilical hernia repair. Methods: After the hospital ethics committee approval, 60 (ASA I–II) adult patients scheduled for umbilical hernia repair were included in this study. The group I (n=30) patents received only general anesthesia. In the group II (n = 30) patents after induction of general anesthesia received a bilateral ultrasound guided rectus sheath block with 40 ml of 0.25% bupivacaine. In this study we assessed demographic and clinical characteristics, pain score - VAS at rest at 2, 4, 6, 12 and 24 hours after operation and total analgesic consumption of morphine dose over 24-hours. Results: There were statistically significant differences in VAS scores between the groups I and II at all postoperative time points - 2hr, 4 hr, 6 hr, 12 hr and 24 hr. (P < 0.00001). The cumulative 24 hours morphine consumption after the operation was significantly lower in the group II (mean = 3.73 ± 1. 41) than the group I (mean = 8.76 ± 2.41). This difference was statistically significant (p = 0.00076). Conclusion: The ultrasound guided rectus sheath block used for umbilical hernia repair could reduce postoperative pain scores and the amount of morphine consumption in 24 hours postoperative period.

Background Bilateral rectus sheath blocks have proven to be superior to local anesthetic infiltration for umbilical incisions and have been gaining popularity for the treatment of perioperative pain in children. We aim to develop a technique of surgeon performed rectus sheath blocks under laparoscopic-guidance alone. Methods In phase I, we observed the laparoscopic appearance of a rectus sheath block. The pain management team performed an ultrasound-guided rectus sheath nerve block as we visualized the posterior rectus sheath with the laparoscope. In phase II, after completion of the laparoscopic procedure, we performed a rectus sheath nerve block. Ultrasound was used to identify where the local anesthetic had been injected. Results Nineteen patients were included in this study, accounting for 38 rectus sheath blocks. In phase I, we observed with the laparoscope the delivery of ten ultrasound-guided rectus sheath blocks. In phase II, 28 laparoscopic-guided rectus sheath blocks were completed with immediate ultrasound confirmation of correct placement. Conclusions We have demonstrated that the rectus sheath nerve block can be performed reliably under laparoscopic-guidance alone. The efficacy of the laparoscopic-guided nerve block compared to the ultrasound-guided approach will need further study in a prospective, randomized trial. Type of study Retrospective review. Level of evidence 3.

Prospective randomized controlled study was conducted between 2005 and 2007 which compares midline incision and paramedian incision. A total of 165 cases were randomized in to two groups 85 and 80 cases. Only cases having midline scar were excluded from the present study. 6 cases (7.5%) of incisional hernia were reported in case of midline incision as compared to one case (1.25%) in paramedian incision. One case (1.25%) of burst abdomen was reported in paramedian incision. Time taken for midline incision opening and closing was less 12.9min as compared to paramedian incision is 23.0min.This is attributed for longer incision is required in case of paramedian incision and closure is required in layered manner, anterior and posterior rectus sheath.

Complex abdominal wall reconstruction may be accomplished utilizing anterior component separation techniques. These techniques involve both division of the posterior rectus sheath and the external oblique aponeurosis to facilitate advancement of the rectus abdominis muscle along with the internal oblique and transversus abdominis muscle. Significant advancement of the abdominal wall may be obtained resulting in closure of defects spanning nearly 20 cm in width. While traditional techniques involved the creation of undermining skin flaps with resultant wound morbidity, evolutionary techniques including the perforator preserving technique and endoscopic component separation technique allow for similar abdominal advancement while minimizing wound complications.

Background: Early treatment of hernia is very important to reduce the risk of obstruction and or strangulation. Ventral hernias include umbilical, epigastric, and incisional hernias and represent 10-15% of all primary hernias. Conventionally, theses hernias are treated by suture repair with a substantial rate of recurrence and this increase the demand for a better technique of repair. There is no exact protocol or consensus on how the repair should be carried out. Aim of work: To present a new surgical technique for ventral hernia repair with least recurrence rate. Material and methods: This study was performed at a tertiary hospital and included 100 patients with uncomplicated ventral hernias and fit for surgery. Partial pre-peritoneal and partial subrectal insertion of prolene mesh was the new surgical technique done. Results: The study included 58 females and 42 males. The mean BMI was 28.6. The mean defect size was 30.3 cm (range 9-64). The mean operative time was 47.5 minutes (range 35- 62). The mean hospital stay was 2 days (range 2-4). Postoperative complications including wound infection (3 cases), seroma (7 cases) and hematoma (2 cases). Recurrence occurred in one case after 1 year. The efficacy rate was 98.75%. Conclusions: Pre-peritoneal and pre- posterior rectus sheath insertion of prolene mesh is a new surgical technique for ventral hernia repair with high efficacy and low recurrence rate.

The authors brought to light a very important aspect of abdominoplasty, which is the functional improvement that this operation may offer.1 Abdominoplasty is one of the most frequent plastic surgeries involved on medical legal disputes in Brazil,2 therefore, any technique that can improve the outcome of this operation is very welcome. Toranto3 called the attention to this aspect in 1990 when he developed a very well designed study using MRI to demonstrate the effectiveness of the so called wide rectus abdominis plication. In this operation he made a plication in the lateral aspect of the recti muscles with a consequent repositioning of the recti muscles on a 90 degree angle to the inside of the abdominal cavity. The idea behind this was to shorten the posterior rectus sheath by making this wide vertical plication. The posterior rectus sheath is the extension of the transverse muscle fascia. The transverse muscle originates in the fascia lumbodorsalis. The traction applied on this muscle will force the fascia lumbodorsalis laterally, thus repositioning the vertebral bones, with a consequent decrease of the low back pain. This was demonstrated also by the excellent results obtained by this author and, more recently by Oneal et al,4 who developed a long-term follow-up study. The problem of this technique, besides the excessive traction of the umbilicus after the wide plication, is the possible increase of the intra-abdominal pressure (IAP) and its consequences. To prevent the increase of the IAP, an alternative technique has been proposed by making the plication directly on the posterior rectus sheath and releasing the lateral recess of the rectus muscle. This is done in order to increase the width of the aponeurotic sheath to allow more space for the rectus muscle.5 The increase of the IAP may lead to a …

Restoring abdominal wall cover and contour in children undergoing bowel and multivisceral transplantation is often challenging due to discrepancy in size between donor and recipient, poor musculature related to birth defects and loss of abdominal wall integrity from multiple surgeries. A recent innovation is the use of vascularized posterior rectus sheath to enable closure of abdomen. We describe the application of this technique in two pediatric multivisceral transplant recipients--one to buttress a lax abdominal wall in a 22-month-old child with megacystis microcolon intestinal hypoperistalsis syndrome and another to accommodate transplanted viscera in a 10-month child with short bowel secondary to gastoschisis and loss of domain. This is the first successful report of this procedure with long-term survival. The procedure has potential application to facilitate difficult abdominal closure in both adults and pediatric liver and multivisceral transplantation.

Suprapubic hernias are considered difficult to repair laparoscopically due to deficient posterior rectus sheath and proximity to important neurovascular structures and the urinary bladder. We retrospectively reviewed 72 patients (18 males, 54 females) who, between 1998 and 2008, had undergone laparoscopic repair for suprapubic hernial defects located less than 5 cm from the pubic arch. Five patients (6.9%) had recurrent hernias. A peritoneal flap was dissected distally to facilitate a mesh overlap of at least 5 cm from the hernial defect. The lower margin of the mesh was fixed under direct vision to Cooper’s ligaments bilaterally. The raised peritoneal flap was reattached to the anterior abdominal wall thereby partially extraperitonealizing the mesh. Mean diameter of the hernial defect was 5.2 cm (range = 3.1–7.3 cm) as measured intraperitoneally. Mean size of the mesh used was 328.8 cm2 (range = 225–506 cm2). Mean operating time was 116 min (range = 64–170 min). Overall complication rate was 27.8%. There were no conversions. No recurrences were observed at a mean follow-up of 4.8 years (range = 1.2–6.9 years) and a follow-up rate of 84.7% A mesh overlap of at least 5 cm and fixation of the lower margin of the mesh under direct vision to Cooper’s ligaments appears to confer increased strength and durability and contribute to low hernia recurrence rates in patients with suprapubic hernias.

Material & methods: This is a 81 years old lady with hypothyroidism who was operated 3 years ago. In the previous surgery an onlay mesh placement was performed. The patient developed a symptomatic recurrent incisional hernia that impaired her quality of life. The patient was operated under general anesthesia. A Rives procedure was planned. The main goals of the retromuscular repair were achieved and are explained during the video: dissection of the sac delimiting the borders of the defect, removal of the previous onlay mesh that was completely integrated in the scar, dissection of the retromuscular space leaving the posterior sheath attached to the sac, closure of the posterior rectus sheath, dissection of the "fatty triangle" of Conze extending it more than 8 cm from the defect and dissecting the retropubic preperiotoneal space beyond the arquate line. In this case, a large-pore 30 x 20 cm self-gripping mesh made of polyester and polylacti acid was used as tissue reinforcement. The anterior aponeourosis was completely close in the midline without tension. No drains were used.

Background Traditional retrorectus techniques for ventral hernia repair often produce abdominal wall pain related to transfascial suture placement. This report details results of a retrorectus mesh herniorrhaphy technique avoiding transfascial suture fixation. Methods A retrospective review of 90 patients who underwent retrorectus ventral hernia repair between 2009 and 2015 was performed. All were treated with primary posterior rectus fascial closure and retrorectus mesh placement. Standard weight polypropylene mesh was used with polypropylene tacking sutures to the posterior rectus sheath with medialization of the rectus muscles and primary closure of the anterior rectus sheath over the mesh repair. Results The overall complication rate was 19.6%. Hernia recurrence occurred in 2 patients (2.2%) with mean follow-up of 3.0 years. There were 4 cases of superficial infection (4.3%). Two patients (2.2%) developed hematomas and 2 patients developed seromas (2.2%). Late abdominal pain occurred in 6 (6.5%) patients, eventually resolving in all but 2. Conclusions Retrorectus ventral hernia repair avoiding transfascial suture placement produces a functional repair with minimal chronic pain and a low rate of complications.

Introduction Cutaneous ureterostomy is the simplest and safest method of all permanent urinary diversions. However, the procedure does carry a risk of stomal stenosis. We describe a simple technique for improving tubeless cutaneous ureterostomy. Technical Considerations Between June 1991 and June 2003, the Toyoda cutaneous ureterostomy was performed in 54 patients (102 renal units) with a minimum of 6 months of follow-up. Since 1998, we introduced a new technique, consisting of fixation between the anterior and posterior rectus sheath by four interrupted sutures to maintain the stability of the abdominal wall tunnel for the ureters. The ureteral patency rate was reviewed. Of the 79 renal units (77.5%) that achieved a tubeless condition, 70 (68.6%) had no hydronephrosis. The catheter-free rate improved from 60.5% (26 of 43 renal units) to 89.8% (53 of 59 renal units) with the introduction of the new surgical stabilization step for the abdominal wall tunnel. Conclusions This surgical modification is an effective and simple procedure that improves tubeless cutaneous ureterostomy performed with the Toyoda method.

Background: The Roux-en-Y gastric bypass (RYGBP) is now performed laparoscopically widely with low morbidity and mortality. However, in some cases long-term adequate weight loss is not satisfied because of dilatation of the gastrojejunostomy. Therefore, a prosthetic material and bio-membranes have been used to prevent dilatation. In this study, we used posterior rectus sheath by laparoscopy, to evaluate feasibility and safety of the procedure. Methods: 20 Yorkshire pigs, under general anesthesia, had a standard laparoscopic RYGBP. In addition, 10 had their gastrojejunostomy anastomosis wrapped with 2x10 cm posterior rectus sheath. Clinical and operative outcome after operation were compared with the control group of laparoscopic RYGBP cases. Results: The median weight of the pigs was 46.1 kg (range 42-51) in the posterior rectus sheath-applied group and 45.2 kg (range 42-49) in the control group. All gastrojejunostomies in the posterior rectus sheath-applied group were successfully reinforced laparoscopically. Both groups loss weight compared with their normal growth weight, but there was no significant difference in the median weight loss between the two groups. Two pigs in the posterior rectus sheath-applied group developed a stenosis at the gastrojejunostomy anastomosis following RYGBP. All pigs in the posterior rectus sheath-applied group were found to develop hypertrophic smooth muscle and connective tissue scarring at the gastrojejunostomy on histologic examination. Conclusion: Laparoscopic application of posterior rectus sheath around the gastrojejunostomy in laparoscopic RYGBP is feasible and safe. The sheath-applied group developed stenosis and connective tissue scarring. Additional research is needed to evaluate effectiveness in preventing dilation of the anastomosis.

Background: Laparoscopic hernia surgeon needs accurate knowledge of not only of target inguinal region but also of adjacent access areas, but he/she is severely constrained by absence of research work on laparoscopic live surgical anatomy in literature. Methods: Prospective study in patients who underwent laparoscopic total extra-peritoneal preperitoneal (TEPP) inguinal hernioplasty through 3-midline-port technique at Jawaharlal Nehru Medical College Hospital, Aligarh between 2010 and 2015. Results: Sixty-eight TEPP repairs were performed in 60 adult patients. Overall incidence of conversion to Open/TAPP hernioplasty was 4% of all cases, but conversion secondary to the anatomic variation of short PRS was seen in only 1.4% of all cases. The endvision and ease of procedure (EOP) were 8.20±1.33 and 7.27±2.05 visual analog score respectively, and both of them were adversely affected in presence of variant PRS anatomy. Average operation time (OT) for unilateral TEPP hernioplasty was 1.9 hours and it was adversely affected in presence of variant PRS anatomy. Overall incidence of surgical emphysema was 16%, and its development was significantly more in presence of variant PRS anatomy. Overall incidence of peritoneal injury, postoperative seroma, infection and chronic pain was 28%, 10%, 6.7% and 1.5% respectively, but they were not affected by variant PRS anatomy. Conclusions: Posterior Rectus Sheath Variations had significant impact on the intra-operative working but did not affect post-operative clinical outcome. Keen observation, timely recognition of anatomic variations and judicious dissection are essential keys for smooth conduct of the well-organized TEPP hernioplasty with ease, safety, rapidity and better results.

A posterior rectus sheath hernia is an abdominal wall hernia that is rarely encountered. Owing to its rarity, it can be easily overlooked in the setting of a patient presenting with abdominal pain. We report a case of a posterior rectus sheath hernia that caused intermittent small bowel obstruction. The unusual aspects of this case are that the defect was large, measuring 6 cm in the transverse diameter, and that it contained small bowel within a large portion of the rectus sheath. Because the defect was large and affected nearly the entire posterior rectus sheath, it was difficult to discern on computed tomography until a small bowel obstruction developed. In this case, a limited awareness of this clinical entity contributed to the delay in diagnosis.

Incisional hernias are common. Those involving large fascial defects are usually repaired using a synthetic mesh. Complications of such repairs involving mesh pose particular problems in management. This paper describes a new technique for repairing large ventral incisional hernias which does not involve the use of a mesh. Our repair is anatomical in first reconstructing the posterior rectus sheath and then using a darn to approximate the recti. We have used this technique successfully in three cases of massive incisional hernias measuring 20 cm or more in diameter and have not experienced any complications. In particular, no recurrences of the hernias have occurred. The technique described can be used to repair primary incisional hernias as well as salvage cases when previous repairs have failed.

Hernias are often associated with congenital defects or incisional breakdown. We present a rare case of a spontaneous posterior rectus sheath herniation with associated incarcerated small bowel in a woman with no previous abdominal surgery. This is accompanied with a review of the literature and the suggestion that spontaneous posterior rectus sheath herniation is possibly a separate clinical entity.

Leiomyoma is the commonest benign tumour of the reproductive tract and are found in 20% of women of reproductive age [1]. Extrauterine leiomyomas are uncommon, generally benign and occasionally cause diagnostic dilemmas as they can mimic malignancy. Anterior abdominal wall leiomyomas are a rare finding and there are very few reported cases of primary abdominal wall leiomyoma without previous uterine surgeries or concomitant presence of uterine fibroids [2]. We present an interesting case of primary solitary leiomyoma of the anterior abdominal wall in a patient with no previous history of any uterine surgery. A 32-year-female patient presented with a lump in right lower abdomen noticed eight months ago which was progressively increasing in size. Initially, it was painless but for the last two months there was dull aching pain in the lump, not related to menstrual cycles. In the past history, she had undergone laparoscopic tubal ligation ten years back. She had three living children through normal vaginal delivery. There was no history of contraceptive use in the past. General physical and chest examination were normal. Local examination revealed a lump of size 8 x 6 cm to the right of the umbilicus below the rectus sheath. It was non tender, oval shaped, firm in consistency, smooth with well defined margins and mobile in all directions. Her haematological and routine biochemistry investigations were within normal limits. Contrast enhanced computed tomography (CECT) scan of the whole abdomen showed a well-defined mass measuring 8.8 x 8.2 x 5.2 cm in the right lower abdomen showing heterogenous enhancement on contrast. It was closely abutting the anterior abdominal wall muscles with loss of intervening fat planes suggesting probable origin from the rectus muscle sheath [Table/Fig-1]. Fine needle aspiration cytology (FNAC) of the lump suggested spindle cell tumour with unknown malignant potential. [Table/Fig-1]: Contrast enhanced computed tomography (CECT) of the abdomen showing a well circumscribed mass lesion (marked as A) arising from the anterior abdominal wall The patient was taken up for exploratory laparotomy via right lower paramedian incision. A 8 x 8 x 6 cm size firm, well-circumscribed, pedunculated mass was found between the rectus muscle and the posterior rectus sheath [Table/Fig-2] with its pedicle attached to the posterior rectus sheath near the arcuate line. The mass was completely excised [Table/Fig-3]. Other intra abdominal organs along with the uterus and adnexa were normal on exploration. Cut section of the specimen demonstrated grayish-white, firm showing whorled trabeculated pattern [Table/Fig-4]. [Table/Fig-2]: Intraoperative photograph after tumour removal showing the site on the posterior rectus sheath from where the tumour arose [Table/Fig-3]: Gross pathological photograph of the resected tumour showing a well circumscribed mass lesion [Table/Fig-4]: Cut section of the excised mass lesion showing smooth and firm greyish white whorl trabeculated pattern Histopathology report showed spindle-shaped smooth muscle cells in interlacing bundles and whorls. No areas of necrosis or atypia were seen. These features were suggestive of leiomyoma [Table/Fig-5]. Patient’s post operative period was uneventful. She was doing well at three months follow up. [Table/Fig-5]: Hematoxylin & Eosin stained section (400X) showing spindle shaped smooth muscle cells in interlacing fascicles. Cells have indistinct borders, fibrillary cytoplasm, elongated nuclei, fine chromatin with inconspicuous nucleoli The commonest primary diseases of the rectus muscle sheath, which are encountered in the clinical setting, are desmoid tumour and rectus sheath hematoma. Other disorder of the rectus muscle sheath can be abscesses from diverticulitis, perforated sigmoid carcinoma, gallbladder empyema, and disseminated actinomycosis [3] and rarely leiomyoma. Abdominal wall leiomyoma can be primary or parasitic. Parasitic leiomyomas have been reported in the retro- or pre-peritoneum. It has been proposed that the uterine leiomyoma becomes adherent to these structures, developes its own blood supply from the surrounding structures and gradually over the time it loses its attachment with the uterus, thus developing as a parasite at the new location [4]. This entity occurs more commonly after laparoscopic uterine surgery than laparotomy [5]. Abdominal wall leiomyomas are a rare finding and are thought to follow seeding of tumour cells following surgical resection of uterine fibroid [2,5]. However, the exact cause of the origin of primary leiomyoma from the anterior abdominal wall is not clear. It has been postulated that the transformation of the cells of the vessel wall in the anterior abdominal layer to leiomyoma occurs probably due to somatic mutations and interplay of hormonal and growth factors [6]. Somatic soft tissue leiomyomas commonly present late in their course as large localized masses. Macroscopically, they present as well circumscribed mass and usually surrounded by a fibrous pseudo-capsule. Histologically, they lack atypia, necrosis and are mitotically inactive (

Until the relatively recent interest in laparoscopic preperitoneal hernia repairs, most Surgeons in the United States and in many other countries performed open anterior repairs. There was little reason to study the preperitoneal anatomy. Surgeons involved with laparoscopic and open preperitoneal hernia repairs work in the preperitoneal fascial planes and transversalis fascia that has not been well described in the current English literature. We have carefuly studied the preperitoneal fasciae and posterior rectus sheath using the excellent perspective, lighting and magnification afforded by the laparoscopic approach. The preperitoneal fascias are distinct from the transversalis fascia with a separate blood supply. The transversalis fascia in the inguinal space is likely related to the posterior rectus fascia. We attempt to clarify the anatomy of the fasciae in this area with laparoscopic photographs and validate our observations with review of the literature and selected illustrations taken from anatomical texts.

Introduction Parastomal herniation is not uncommon and numerous surgical approaches to the problem have been employed including mesh reinforcement. Bowel wall erosion is a worrying potential complication of placing an edge of mesh around bowel. To reduce this possibility a simple modification is suggested. Method The polyproylene mesh repair is fashioned on the posterior rectus sheath. The required aperture for the bowel is marked appropriately on the mesh. Instead of simple removal of the marked circle, the aperture is fashioned by folding back and stitching in place the triangular flaps from the middle to form a rolled rather than sharp edge. Non-absorbable monofilament stitches reconstitute the mesh encirclement, and attach it laterally and medially to the aponeurotic tissue. A review of the case notes was conducted and each patient was contacted by a postal questionnaire. Results This technique has been used in 10 patients (7 end colostomies, 2 end ileostomies and 1 loop ileostomy) since 2000. Over a median follow-up period of 30 months (range 2 to 40 months) there have been no hernia recurrences, no infected meshes, no bowel damage attributable to the mesh and no troubles with stoma. The only complication encountered has been a segment of superficial wound breakdown in one patient. Conclusions This technique appears to offer a safe and reliable modification for mesh repair of parastomal herniation, in being designed to obviate the possibility of erosion of the stomal bowel wall by a sharp mesh edge but at the same time providing a sound herniorrhaphy by complete encirclement.

We report a case of an emergent pacemaker implantation in a 1,502 g preterm neonate immediately after birth due to congenital complete atrioventricular block. At a gestational age of 29 weeks the patient was delivered by cesarean section followed by unsuccessful drug treatment of the atrioventricular block. Sixty-five minutes after birth the patient underwent permanent pacemaker implantation. Through a subxyphoid approach, a lead was fixed to the epicardium of the right ventricle, and connected to a pulse generator inserted between the rectus abdominus muscle and posterior rectus sheath. The patient is alive and well 16 months after the operation without pacemaker failure.

The abdomen of a neonate, infant or young child is more square than rectangular. Accordingly, the transverse supraumbilical incision affords optimal access to all areas of the abdominal cavity. As a child grows, the abdomen becomes more rectangular, and a midline incision becomes the approach of choice for laparotomy (see Chap. A9).

The rectus sheath has been extensively described in gross anatomic studies but there is very little information available regarding the arcuate line (AL). The aim of the present study therefore was to explore and delineate the morphology, topography and morphometry of the arcuate line and provide a comprehensive picture of its anatomy across a broad range of specimens. The AL was present in all specimens examined. In addition, the AL was found to be located at a mean of 70.2% (67.3-75.2%) of the distance between the pubic symphysis and the umbilicus, and at 33.9% (30.2-35.4%) of the distance between the pubic symphysis and the xiphoid process. This location was found to be at a mean of 2.1 +/- 2.3 cm superior to the level of the anterior superior iliac spines. Furthermore, there were three distinct types of AL morphology. In type I (65%), the fibers of the posterior rectus sheath (PRS) gradually disappeared over the transversalis fascia, creating an incomplete demarcation of the actual location of the AL. In type II (25%) the termination of the fibers of the PRS was acutely demarcated over the transversalis fascia, creating a clear border with the AL. In type III (10%) the fibers of the PRS created a double and thickened aponeurotic line. In these cases a double AL was observed. Better preoperative knowledge of the location of the AL may, in some cases, help preoperative planning to facilitate primary fascial repair, which can then be supported with on-lay mesh, depending on the clinical situation.

Background: Laparoscopic gastrostomy is the best option for long-term gastric intubation when percutaneous endoscopic gastrostomy is not possible. The ideal technique is yet to be defined. Methods: A technique of suturing the gastric wall to the posterior rectus sheath under direct vision has been developed. The method is simple and avoids the difficulties and potential complications described with other techniques. Results: The technique has been used in three cases with excellent results and no complications. Conclusion: The described technique is a further advance in defining the ‘ideal’ technique of laparoscopic gastrostomy.

Recurrent rectus diastasis is a troublesome complication because its correction requires an extensive procedure. Two patients with recurrent rectus diastasis secondary to abdominoplasty corrected by plication of the anterior rectus sheath are presented. These patients had lateral insertion of the rectus muscles. They were treated by the advancement of the rectus muscles after undermining of the posterior rectus sheath and a two-layer closure to correct the rectus diastasis. Good cosmetic results and postoperative pain control were achieved in both cases. The causes, prevention, and treatment for this type of rectus diastasis are described. The main reason for recurrence of this deformity in these patients was lateral insertion of the rectus muscles on the costal margins. On the basis principle, an efficient technique to correct this deformity is described. A postoperative compute tomography scan with slices made at the same bony level as the preoperative control examination demonstrated total correction of rectus diastasis over a long-term follow-up evaluation. Advancement of the recti muscles seems to be a reliable method for correcting recurrent rectus diastasis in patients with lateral insertion of the recti muscles.

Contains fulltext : 58140.pdf (Publisher’s version ) (Closed access) Closure of large incisional hernias with the Components Separation Method (CSM) could be explained by medial-caudal rotation of the internal and transverse oblique muscles around their centres of origin. In eight human cadavers, the CSM was performed, and translation of the rectus abdominis muscle was measured. Mean unilateral translation of the rectus abdominis in the lateral-medial direction measured 2.2, 3.7, and 3.5 cm. This was 2.7, 4.5, and 4.0 cm after release of the posterior rectus sheath. Mean translation in a caudal direction was 0.5 cm, but seven cadavers showed a mean translation of 1 cm of the uppermost measuring point in a cranial direction. The hypothesis that rotation of separate tissue layers of the abdominal wall largely accounts for the translation effect of the CSM must be rejected. Release of the external oblique muscle produces more benefit to abdominal wall closure than release of the posterior rectus sheath.