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Background Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. Methods The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). Results From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. Conclusion The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be “lost arts” in modern trauma care.

PURPOSE The purpose of this study was to compare clinical outcomes of incisional hernia repair in solid organ transplant patients using non-cross-linked porcine acellular dermal matrix (PADM), human derived acellular dermal matrix (HADM) and synthetic mesh. METHODS A retrospective review of patients who underwent hernia repair with PADM after pancreas and/or renal transplant at the University of Maryland Medical Center from 2008 to 2012 was conducted. Repair type, postoperative infection, hernia recurrence, mesh removal, and length of follow-up were recorded. Results were compared with our previously published data evaluating HADM and synthetic mesh used in transplant patients between 2000 and 2005. RESULTS Twenty-seven patients underwent ventral hernia repair with PADM, 34 patients were repaired with HADM and 26 were repaired with synthetic mesh. The rate of wound infection in those repaired with PADM, HADM, and synthetic mesh were 14.8%, 14.7%, and 65.4%, respectively. Rates of recurrence were 13.3%, 23.5%, and 76.9%, respectively. Rate of mesh removal was found to be 7.4%, 11.8%, and 69.2%, respectively. These complication rates were significantly lower in patients who received HADM or PADM compared with patients repaired with synthetic mesh (P < 0.001). There was no statistically significant difference in the outcomes between the groups repaired with HADM or PADM. CONCLUSIONS The use of PADM for incisional hernia repair after kidney and/or pancreas transplant significantly reduces the incidence of hernia recurrence, wound infection, and need for mesh removal compared to synthetic mesh. No difference in morbidity between HADM and PADM was observed in the study population; however, longer follow-up in the PADM group is warranted.

Objective: Applications for Abdominal Wall Vascularized Composite Allotransplantation may expand if a functional graft with decreased immunosuppressive requirements can be designed. We hypothesize that it is anatomically feasible to prepare a functional, innervated, and vascularized abdominal composite graft using a multilayered component separation technique. Including vascularized bone in the graft design may decrease the immunosuppressive requirements by inducing immunologic chimerism. Methods: Two cadaver torsos were used. Adipocutaneous flaps were elevated from the midaxillary lines, preserving deep inferior epigastric artery perforators. A 2-layered component separation through the external and internal oblique fasciae was carried out, exposing segmental intercostal thoracolumbar nerves. Superiorly directed muscle release over the subcostal margin provided for a 3-rib segment with attached rectus abdominis muscle. The remainder of the full-thickness allograft was harvested with its vasculature. Flap inset into the recipient cadaver abdomen, with osteosynthesis fixation between donor and recipient ribs, was achieved. Results: The harvested grafts had an average size of 845 ± 205 cm2 with a total procurement time of 110 minutes. On one cadaver, 4 thoracolumbar nerves were isolated bilaterally, while the other cadaver yielded 3 nerves. The nerves were transected with an average length of 5.7 ± 1.2 cm. The graft vasculature was transected with a length of 4.40 ± 0.10 cm. Conclusion: Using the principles of component separation technique, we demonstrated a novel approach to harvest and transfer a neurotized osteomyofasciocutaneous abdominal wall allotransplant as a multipedicled, single functional unit.

Surgical manipulation of the groin can lead to persistent lymphorrhea or lymphoceles with a reported incidence of 1.8%–18.9%.1 The wound complications associated with such leaks lymphatic leak can lead to prolonged hospital stays, additional operations, and increased healthcare costs for the patient and society.2 Initial management with pressure dressings and immobilization can progress to include aspiration, drain placement, sclerosant, radiotherapy, negative pressure wound therapy, lymphovenous anastomosis, surgical tissue transfer, and exploration with lymphatic ligation.2–5 Up to half of all patients with lymphatic leak develop an associated infection which can be catastrophic in the setting of a vascular graft.4 Vital dyes, such as isosulfan blue (Lymphazurin, Tyco Healthcare, Norwalk, Conn.), are commonly used for intraoperative identification of lymphatic leaks, thereby reducing time to resolution, complications, and need for reoperation.6 Indocyanine green (ICG) imaging is an emerging modality for lymphatic vessel visualization. We report the utility of laser-assisted ICG lymphography for intraoperative identification of lymphatic leaks presenting after surgical groin manipulation.

RESULTS: Patient characteristics indicate that age, race, diagnosis, and severity of illness are significantly associated with the development of BCs. 14.6% of LT recipients developed an in-hospital BC; these events have substantial implications for peri-operative outcomes, including hospital and ICU LOS (27.9 vs 19.6 days, p

Crossed fused renal ectopia in the presence of abdominal aortic aneurysms (AAAs) is a rare challenge to therapy. A 68-year-old man had a 6.9-cm AAA, a 6.6-cm left common iliac aneurysm, and a 3.2-cm right internal iliac aneurysm. He had multiple comorbidities and a right-sided crossed fused kidney supplied by two small renal arteries arising from the AAA. Aortorenal bypass with staged endovascular aneurysm repair was used to treat the aneurysmal disease. Two-stage open aortorenal bypass followed by endovascular repair for complex aneurysms is feasible in the rare patient with such a congenital anomaly.