1The surgical treatment for the recurrent groin herniasEver since the advent of elective surgical intervention for inguinal hernia recurrences have been observed. Indeed, many of the modern surgical techniques for herniorrhaphy were devised specifically to minimize recurrence rates. For many reasons it has been difficult to actually quantify a true recurrence rate for inguinal hernia repair. Surgeons use a variety of anatomic and “tension free” mesh repairs when fixing a symptomatic groin heria. In general the recurrence rates for each type of repair have been reported and vary from 0.5% to 10% in the current literature. One factor contributing to the broad range of recurrence is the duration 0 follow up. While most recurrences are noted within 2 to 5 years of the original repair, patients often do not seek repair of the recurrence for some 10 to 15 years following the original operation. Longterm follow up is necessary to appreciate the outcome of hernia repair.In the early 1970’s Dr L M Nyhus taught me the preperitoneal approach to the repair of groin hernia. Introduced it into my practice at the time initially restriction its use to to the repair of recurrent groin hernia but eventually enlarged the indications to include high risk patients, patients with incarcerated hernia, femoral hernia and when I felt the surgical resident needed instruction in the anatomy of the groin. I have used the preperitoneal approach for the repair of groin hernia over 3 000 times in general and specifically for the repair of recurrent groin hernia in over 750 patients. The results have been most ratifying. For first time recurrent groin hernia repair the recurrence rate for over 90% of patients followed five years was 1.6%.
OBJECTIVE: To explore an effective method to repair the abdominal wall defect. METHODS: From July 1996 to December 2000, 7 cases with abdominal wall defect were repaired by pedicle graft of intestine seromuscular layer and skin graft, among them, intestinal fistula caused by previous injury during operation in 4 cases, abdominal wall defect caused by infection after primary fistulization of colon tumor in 2 cases, abdominal wall invaded by intestinal tumor in 1 case. Exploratory laparotomy was performed under general anesthesia, the infective and edematous tissue around abdominal wall defect was gotten rid off, and the pathologic intestine was removed. A segment of intestine with mesentery was intercepted, and the intestine along the longitudinal axis offside mesentery was cutted, the mucous layer of intestine was scraped. The intestine seromuscular layer was sutured to the margin of abdominal wall defect, and grafted by intermediate split thickness skin. RESULTS: The abdominal wall wound in 6 cases were healed by first intention, but part of grafted skin was necrosed, and it was healed by second skin graft. No intestinal anastomotic leakage was observed in all cases. Followed up 1 to 2 years, there were no abdominal hernia or abdominal internal hernia. All the cases could normally defecate. The nutriture of all cases were improved remarkably. CONCLUSION: Pedicle graft of intestine seromuscular layer is a reliable method to repair abdominal wall defect with low regional tension, abundant blood supply and high successful rate.
Objective To investigate the reconstructive methods and effectiveness of modified pedicled anterolateral thigh (ALT) myocutaneous flap for large full-thickness abdominal defect reconstruction. Methods Between January 2016 and June 2018, 5 patients of large full-thickness abdominal defects were reconstructed with modified pedicled ALT myocutaneous flaps. There were 3 males and 2 females with an average age of 43.7 years (range, 32-65 years). Histologic diagnosis included desmoid tumor in 3 cases and sarcoma in 2 cases. The size of abdominal wall defect ranged from 20 cm×12 cm to 23 cm×16 cm. Peritoneum continuity was reconstructed with mesh; lateral vastus muscular flap was used to fill the dead space and rebuild the abdominal wall strength; skin grafting was applied on the muscular flap, the rest abdominal wall soft tissue defects were repaired with pedicled ALT flap. The size of lateral vastus muscular flap ranged from 20 cm×12 cm to 23 cm×16 cm, the size of ALT flap ranged from 20 cm×8 cm to 23 cm×10 cm. The donor site was closed directly. Results All flaps and skin grafts survived totally, and incisions healed by first intention. All patients were followed up 6-36 months (mean, 14.7 months). No tumor recurrence occurred, and abdominal function and appearance were satisfying. No abdominal hernia was noted. Only linear scar left in the donor sites, and the function and appearance were satisfying. Conclusion Modified pedicled ALT myocutaneous flap is efficient for large full-thickness abdominal defect reconstruction, decrease the donor site morbidity, and improve the donor site and recipient site appearance.
ObjectiveTo summarize the research progress of surgical technique and immunosuppressive regimen of abdominal wall vascularized composite allograft transplantation in animals and clinical practice. MethodsThe literature on abdominal wall transplantation at home and abroad in recent years was extensively reviewed and analyzed. ResultsThis review includes animal and clinical studies. In animal studies, partial or total full-thickness abdominal wall transplantation models have been successfully established by researchers. Also, the use of thoracolumbar nerves has been described as an important method for functional reconstruction and prevention of long-term muscle atrophy in allogeneic abdominal wall transplantation. In clinical studies, researchers have utilized four revascularization techniques to perform abdominal wall transplantation, which has a high survival rate and a low incidence of complications. ConclusionAbdominal wall allotransplantation is a critical reconstructive option for the difficulty closure of complex abdominal wall defects. Realizing the recanalization of the nerve in transplanted abdominal wall to the recipient is very important for the functional recovery of the allograft. The developments of similar research are beneficial for the progress of abdominal wall allotransplantation.
Objective To compare the effect of small intestinal submucosa(SIS)and polypropylene mesh(PPM) on repairing abdominal wall defects in rats, and toprobe into the feasibility of using SIS to repair the abdominal wall defects. Methods 100 SD rats(50 males and 50 females)were randomly divided into 2 groups(n=50). Their weight ranged from 200 to 250 g.Full thickness abdominal wall defects (2 cm×2 cm) were created by surgery and were repaired with SIS and PPM respectively. At different postoperative time (1st, 2nd, 4th, 8th and 12th week), animals were sacrificed to make histological observation. The tensile strengthand the development of adhesions were measured and observed. Results 95 animals survived and were healthy after surgery. No inflammatory response and obvious immunoreaction were observed in both groups. One week after operation, the tensile strengthof abdominal wall in SIS group (204.30±5.13 mmHg) was lower than that in PPMgroup(240.0±10.0 mmHg) at 1st week(P＜0.05),and there were no difference at 4th, 8th, 12th week. Adhesions were more marked in PPM group thanthat in SIS group(P＜0.05). Conclusion Both SIS and PPM are histologically compatible when used in rats and can maintain sufficient tensile strength. SIS is superior to PPM in regards to tissue compatibility and adhesion formation.
Objective To research the effect of porcine acellular dermal matrix in the reconstruction of abdominal wall defects in rabbits, and to investigate the appl ication feasibil ity of xeno-transplantation of acellular dermal matrix. Methods The porcine acellular dermal matrix was prepared from a health white pig. Twenty-six Japanese white rabbits (weighing 2.2-2.3 kg, female or male) were randomly assigned to 2 groups: the control group (n=6) and the experimental group (n=20). In the control group, the full-thickness abdominal wall defect of 5.0 cm × 0.5 cm was made, and the defect wassutured directly; in the experimental group, the full-thickness abdominal wall defect of 5.0 cm × 2.5 cm was made, and the defect was repaired with porcine acellular dermal matrix patch at the same size as the defect. At 5 weeks after surgery, the incidence of hernia and the intra-abdominal adhesions were observed and the wound breaking strength was compared between the patchfascia interface and the fascia-fascia interface. The graft vascularization was evaluated through histological analysis at 6 months after surgery in the experimental group. Results No hernia occurred in all rabbits of 2 groups. At 5 weeks after surgery, heal ing was observed between patch and the muscularfascia; the vascularization was seen in the porcine acellular dermal matrix patch. There was no significant difference in the adhesion grade (Z= —0.798, P=0.425) between the experimental group (grade 2 in 1 rabbit, grade 1 in 5, and grade 0 in 12) and the control group (grade 1 in 1 and grade 0 in 5). No significant difference was found (t= —0.410, P=0.683) in the breaking strength between the patch-fascia interface in the experimental group [(13.0 ± 5.5) N] and the fascia-fascia interface in control group [(13.6 ± 4.0) N]. In the experimental group, the small vessels and the infiltration of inflammatory cells were observed in the porcine acellular dermal matrix patch after 5 weeks through histological observations. The junctions of the patch-fascia interface healed with fibrous connective tissue. At 6 months after surgery, the inflammation was subsided and the collagen fiber of the patch was reconstructed. Conclusion The porcine acellular dermal matrix patchhas good results in repairing full-thickness abdominal wall defect. The patch-fascia interface has siml iar breaking strength to the fascia-fascia interface. The collagen fibers of the patch are reconstructed.
Objective To analyze the cl inical therapeutic effect of extended Sublay technique via previous incision for repairing flank hernias in comparison with routine Sublay technique. Methods Between May 2004 and May 2009, 41 patients with flank hernia were treated by extended Sublay repair via previous incision (extended Sublay repair group, n=18) and by routine Sublay repair (rountine Sublay repair group, n=23). In extended Sublay repair group, there were 11 males and 7 females with an average age of 45.2 years (range, 32-61 years); flank hernia was cuased by flank incision operation (12 patientswith surgery history of nephrectomy, adrenalectomy, and vascular procedure) and traffic accident (6 patients) with an average disease duration of 14.5 months (range, 8-23 months); and the locations were the left flank region in 11 patients (7 affected superior lumbar triangles and 4 affected inferior lumbar triangles) and the right flank region in 7 patients (5 affected superior lumbar triangles and 2 affected inferior lumbar triangles). In routine Sublay repair group, there were 14 males and 9 females with an average age of 48.7 years (range, 33-64 years); flank hernia was cuased by flank incision operation (15 patients with surgery history of nephrectomy, adrenalectomy, and vascular procedure), traffic accident (6 patients), and fall ing (2 patients) with an average disease duration of 18.2 months (range, 11-27 months); and the locations were the left flank region in 10 patients (5 affected superior lumbar triangles and 5 affected inferior lumbar triangles) and the right flank region in 13 patients (9 affected superior lumbar triangles and 4 affected inferior lumbar triangles). There was no significant difference in general data between 2 groups (P gt; 0.05). Results The mesh size in extended Sublay repair group was significantly larger than that in routine Sublay repair group [(618.2 ± 40.6) cm2 vs. (512.2 ± 36.5) cm2, P lt; 0.05 ]. There was no significant difference in hernia ring size, operation time, and hospital ization day between 2 groups (P gt; 0.05). In extended Sublay repair group, the patients were followed up 17 to 35 months (26.2 months on average) with an early compl ication incidence of 27.8% (hematomas in 2 cases, seroma in 1 case, and chronic pain in 2 cases within 1 month) and a late compl ication incidence of 0 (no hernia recurrence and abdominalwall bulge during follow-up). In routine Sublay repair group, the patients were followed up 14-35 months (24.5 months onaverage) with an early compl ication incidence of 13.0% (seroma in 1 case and chronic pains in 2 cases within 1 month) and a late compl ication incidence of 30.4% (hernia recurrence in 3 cases and abdominal wall bulge in 4 cases at 1-3 months). There was significant difference in the late compl ication incidence between 2 groups (P lt; 0.05). Conclusion Extended Sublay technique is a safe and effective approach for flank hernia repair. Making clear the anatomy of lumbar region, harvesting adequate space for mesh overlap, and effectively-fixing are critical to ideal cl inical outcomes.
To overcome the disadvantages of the artificial materials, to design pedicled demucosal small intestinal sheet to repair full-thickness abdominal wall defect. Methods The porcine model of full-thickness abdominal wall defect by resecting 10 cm × 7 cm abdominal wall tissue (from skin to peritoneum) in 20 female animals, which were randomizedto jejunum and ileum sheet groups(n=10). Defect of abdominal wall were repaired with pedicled demucosal jejunum/ileum sheet respectively and immediate spl it-thickness free skin grafting. The general condition was observed and the tension strength of the repaired abdominal wall was measured 30 days postoperatively. In another 5 models, defect was repaired with pedicled demucosal small intestinal sheets and immediate spl it-thickness free skin grafting. The histological change and tissue thickness of the pedicled demucosal small intestinal sheet, spl it-thickness free skin graft and the repaired abdominal wall were observed and measured respectively after 30 days of operation. Results The operations were successful and no operative death occurred in all animals. All pedicled demucosal small intestinal sheets primarily healed to the edge of defected abdominal walls. Neither infection nor wound dehiscence occurred. All the spl it-thickness free skin grafting were successful. Regeneration of the intestinal mucosa occurred 4 days to 5 days postoperatively in 3 animals (2 of jejunum sheet group and 1 of ileum sheet group) at the initial stage andwere successfully treated. No postoperative herniation occurred in all animals. The cel iac pressure of herniation of the repaired abdominal wall jejunum/ileum sheet was (24.8 ± 3.4) kPa in jejunum sheet group and (21.3 ± 2.8) kPa in ileum sheet group, and the difference was significant (P lt; 0.01). No rupture of the repaired abdominal wall occurred in jejunum and ileum sheet groups when the cel iac pressure was 40 kPa. Before repairing the abdominal wall defects, there was a l ittle residual mucosal tissue on the surface of all pedicled demucosal small intestinal sheets. At the 30th day after operation, conspicuous hyperplasia and thickening occurred in all parts of tissue of the repaired abdominal walls and the residual mucosal tissue disappeared completely. Conclusion Because of simple operation, satisfactory achievement ratio, good effect, no important compl ication, and no use of expensive prosthetic materials, it is a feasible method to repair the full-thickness abdominal wall defect with pedicled demucosal small intestinal sheet.
Objective To summarize the therapeutic experiences of abdominal wall bulge repair with compound patch intraperitoneal placement. Methods From October 2005 to October 2008, intraperitoneal onlay mesh with compound patch applied in 7 patients with abdominal wall bulge, whose clinical data were analyzed retrospectively. Results All the procedures were performed successfully, including 5 open operation and 2 laparoscopic repair. The mean operation time was 85 min (ranged 68 to 130 min). After operation, 1 seroma formation and 1 hemorrhage in the thoracic cavity developed and were cured with the conservative therapy. Mean postoperative hospital stay was 9.5 d (ranged 8 to 16 d). There was no recurrence, infection, or prolonged pain during 1－4 years follow-up. Conclusion Abdominal wall bulge is caused by the weakness of abdominal wall muscle, and the intraperitoneal onlay mesh repair with compound patch is an appropriate therapy.
Objective To investigate the improvement effects and mechanisms of composite chitosan (CS) hydrogel on traditional polypropylene (PP) mesh for repairing abdominal wall defects. Methods CS hydrogel was prepared via physical cross-linking and then combined with PP mesh to create a CS hydrogel/PP mesh composite. The internal structure and hydrophilicity of the composite were characterized using macroscopic observation, upright metallographic microscope, scanning electron microscopy, and water contact angle measurements. The performance of the composite (experimental group) in resisting cell adhesion and supporting cell infiltration was assessed through fibroblast (NIH-3T3) infiltration experiments and human umbilical vein endothelial cells (HUVECs) tube formation assays, and simple cells were used as control group. Finally, a bilateral abdominal wall defect model (1.5 cm×1.0 cm) was established in 18 Sprague Dawley rats aged 8-10 weeks, with the composite used on one side (experimental group) and PP mesh on the other side (control group). The effects on promoting wound healing, preventing adhesion, angiogenesis, and anti-inflammation were investigated through macroscopic observation, histological staining (HE and Masson staining), and immunohistochemical staining (CD31, CD68). Results The composite appeared as a pale yellow, transparent solid with a thickness of 2-3 mm, with the PP mesh securely encapsulated within the hydrogel. Scanning electron microscopy revealed that the hydrogel contained interconnected pores measuring 100-300 μm, forming a porous structure. Contact angle measurements indicated that CS hydrogel exhibited good hydrophilicity, while PP mesh was highly hydrophobic. In vitro cell culture experiments showed that DAPI staining indicated fewer positive cells in the experimental group after 1 day of culture, while the cells in control group covered the entire well plate. After 3 days of culture, the cells in experimental group were spherical and displayed uneven fluorescence, suggesting that the material could reduce cell adhesion while supporting cell infiltration. HUVECs tube formation experiments demonstrated an increase in cell numbers in experimental group with a trend towards tube formation, while cells in control group were sparsely distributed and showed no migration. In the rat abdominal wall defect repair experiment, results showed that after 1 week post-surgery, the experimental group had tissue and blood vessels infiltrating, and by 4 weeks, the integrity was well restored with significant regeneration of muscle and blood vessels, while the control group exhibited adhesions and incomplete healing. HE staining results indicated weaker cell infiltration in the experimental group, with cell density significantly higher than that of the control group at 2 and 4 weeks post-surgery (P<0.05). Masson staining revealed that collagen fibers in the experimental group were arranged neatly, with significantly increased collagen content at 2 weeks post-surgery (P<0.05), while collagen content was similar in both groups at 4 weeks (P>0.05). Immunohistochemical staining showed that CD31-positive cells were evenly distributed between muscle layers in the experimental group, whereas the control group exhibited notable defects. At 2 weeks after operation, the CD31-positive cell ratio was significantly higher than that in the control group (P<0.05); at 2 and 4 weeks after operation, the CD68-positive cell ratio in the experimental group was significantly lower than that in the control group (P<0.05). Conclusion CS hydrogel has a positive effect on preventing adhesions and promoting wound healing, exhibiting anti-inflammatory and pro-angiogenic properties during the healing process. This provides a promising strategy to address challenges related to abdominal adhesions and reconstruction.