Name: a case series of successful abdominal closure utilizing a novel technique combining a mechanical closure system with a biologic xenograft that accelerates wound healing
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Description: Watch this Scientific Journal Video about A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wou

The authors have no acknowledgements.

1. Installation of Dynamic Tissue System
<ol>
	<li>Exclude if there is hemodynamic instability, a need for further abdominal washouts, or a concern for intraabdominal sepsis.
	<ol>
		<li>If an ostomy exists, trim the ostomy wafer to make as narrow as possible and outline on abdominal skin. Cover ostomy with 4x4 and secure in place with adhesive transparent film dressing.</li>
		<li>Apply antimicrobial betadine impregnated adhesive drape to the skin of the abdomen widely, covering the operating field.</li>
		<li>Wash the abdomen out with at least 2 L of 40.5&#176; C normal saline.</li>
		<li>Measure and record the myofascial gap (MFG), visceral extrusion (VE), and the length of incision in centimeters for documentation of progress on the operative note.</li>
		<li>Mark the skin of the anterior abdominal wall 5 cm laterally from medial fascial edge to create an ellipse around the midline wound.</li>
		<li>Place the elastomer buttons side by side on the ellipse created in step 1.1.5. with the &#8220;U&#8221; of the elastomer at the 5 cm ellipse demarcation around the midline wound. This will assure 3 cm spacing as recommended.</li>
		<li>Create superficial thickness dermotomies with an 11 blade.</li>
		<li>Pull the elastomer through the abdominal wall using the cannulator.</li>
		<li>Repeat the same steps on the opposite side. This time pull the elastomer across the myofascial gap and secure both ends with a hemostat.</li>
		<li>Loosely attach the elastomer bands to the elastomer buttons. Do not tighten elastomer bands.</li>
		<li>Attach elastomer adhesion stickers on the button tails.</li>
		<li>Perform osteopathic maneuvers throughout installation. This is performed with two people standing on either side of the patient. Apply bimanual forces in the flank area, gently massaging towards the midline and create circular motions synchronized with the other operator first towards the head and then creating circular motions towards the feet.</li>
	</ol>
	</li>
</ol>
2. Silicone Visceral Protector Inserted
<ol>
	<li>Insert silicone visceral protector midline over abdominal viscera, taking care to protect any ostomies (Figure 3).</li>
	<li>Envelop the abdominal viscera with silicone visceral protector down to each paracolic gutter.</li>
	<li>Create necessary cut outs in the visceral protector with scissors to protect the ostomies.</li>
	<li>Place elastomer retainer in the midline on top of visceral protector and evenly space elastomer bands into the retainer (trim to size).</li>
	<li>Adjust elastomer bands slowly in between osteopathic maneuvers.</li>
	<li>Stop elastomer adjustments when tension hashmarks across the MFG is 1.5 &#8211; 2x stretch.</li>
	<li>Record the MFG and VE with a ruler in centimeters at the start, install, and completion (Figure 4).</li>
</ol>
3. Installation of Negative Pressure Wound Therapy Device
<ol>
	<li>Make NPWT device sponge as thing as possible and place in the midline above the elastomer retainer (Figure 5).</li>
	<li>Cover with vacuum drape tape and apply the negative pressure device with continuous suction at -100 mmHg.</li>
	<li>Perform osteopathic maneuver a few more times.</li>
</ol>
4. Elastomer Adjustment
<ol>
	<li>Bring the patient back to operating room, or if your facility has the capability to perform in ICU, periodically. First elastomer adjustment can be 2 &#8211; 5 days after installation.</li>
	<li>Remove the NPWT device overlying the midline wound with scissors, taking care to leave the adhesive iodine drape on the skin intact.</li>
	<li>Prep the abdomen widely including the elastomers in place with 4% chlorhexidine gluconate.</li>
	<li>Perform osteopathic maneuvers intermittently throughout procedure. See step 1.1.12. for details.</li>
	<li>Record the MFG and myofascial apposition (Figure 6).</li>
	<li>Irrigate the midline wound with at least 2 L of 40.5&#176; C normal saline, taking care not to spill water on the DTS or the antimicrobial iodine impregnated adhesive drape.</li>
	<li>Adjust elastomers by releasing the elastomer from the anchor and pulling each elastomer laterally, away from the midline.</li>
	<li>Reapply the black sponge NPWT device.</li>
</ol>
5. Fascial Closure
<ol>
	<li>Bring the patient back to the operating room. Prep widely.</li>
	<li>Remove the elastomer retainer.</li>
	<li>Remove the visceral protector and irrigate the abdominal cavity with at least 2 L of normal saline.</li>
	<li>Close the fascia in a bi-directional fashion utilizing a Smead-Jones technique and a #2 vicryl suture on a TP1 needle.</li>
	<li>Irrigate and dry the midline wound.</li>
	<li>Apply PUBM micromatrix powder to the midline wound and evenly distribute the powder so that the newly created linea alba is covered in PUBM micromatrix.</li>
	<li>Hydrate a two-layer, 10x15 cm, PUBM wound sheet and delaminate so there are 2 single sheets. Apply the sheets on top of the powder to cover the entire midline wound surface (Figure 7).</li>
	<li>Appose skin edge with strips of vac drape tape (Figure 8).</li>
</ol>

<ol>
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A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Open+abdomen+in+gastrointestinal+surgery:+Which+technique+is+the+best+for+temporary+closure+during+damage+control?.">Open abdomen in gastrointestinal surgery: Which technique is the best for temporary closure during damage control?.</a> World Journal of Gastrointestinal Surgery. 8 (8), 590-597 (2016).</li><li>Karakose, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bogota+Bag+Use+in+Planned+Re-Laparotomies.">Bogota Bag Use in Planned Re-Laparotomies.</a> Medical Science Monitor. 22, 2900-2904 (2016).</li><li>Lassalle, S., Chechin, C., de la Forge, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+cleansing+technique+for+complex+wounds.">A new cleansing technique for complex wounds.</a> Soins. 62 (814), 12-15 (2017).</li><li>Strang, S. G., Van Lieshout, E. M., Van Waes, O. J., Verhofstad, M. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+and+mortality+of+abdominal+compartment+syndrome+in+severely+injured+patients:+A+systematic+review.">Prevalence and mortality of abdominal compartment syndrome in severely injured patients: A systematic review.</a> The Journal of Trauma and Acute Care Surgery. 81 (3), 585-592 (2016).</li><li>Bressan, A. K., Ball, C. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intra-abdominal+hypertension+and+abdominal+compartment+syndrome+in+acute+pancreatitis,+hepato-pancreato-biliary+operations+and+liver+transplantation.">Intra-abdominal hypertension and abdominal compartment syndrome in acute pancreatitis, hepato-pancreato-biliary operations and liver transplantation.</a> Anaesthesiology Intensive Therapy. 49 (2), 159-166 (2017).</li><li>Muresan, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+much+does+decompressive+laparotomy+reduce+the+mortality+rate+in+primary+abdominal+compartment+syndrome?:+A+single-center+prospective+study+on+66+patients.">How much does decompressive laparotomy reduce the mortality rate in primary abdominal compartment syndrome?: A single-center prospective study on 66 patients.</a> Medicine (Baltimore). 96 (5), e6006 (2017).</li><li>Coccolini, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=IROA:+International+Register+of+Open+Abdomen,+preliminary+results.">IROA: International Register of Open Abdomen, preliminary results.</a> World Journal of Emergency Surgery. 12, 8 (2017).</li><li>Lecheminant, J., Field, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Porcine+urinary+bladder+matrix:+a+retrospective+study+and+establishment+of+protocol.">Porcine urinary bladder matrix: a retrospective study and establishment of protocol.</a> Journal of Wound Care. 21 (10), 482 (2012).</li><li>Coccolini, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=IROA:+International+Register+of+Open+Abdomen,+preliminary+results.">IROA: International Register of Open Abdomen, preliminary results.</a> World Journal of Emergency Surgery. 12, 8 (2017).</li><li>Muturi, A., Ndaguatha, P., Ojuka, D., Kibet, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+and+predictors+of+intra-abdominal+hypertension+and+compartment+syndrome+in+surgical+patients+in+critical+care+units+at+Kenyatta+National+Hospital.">Prevalence and predictors of intra-abdominal hypertension and compartment syndrome in surgical patients in critical care units at Kenyatta National Hospital.</a> BMC Emergency Medicine. 17 (1), (2017).</li><li>Okullo, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Abdominal+Reapproximation+Anchor+Device.">The Abdominal Reapproximation Anchor Device.</a> Surgical Innovation. 24 (1), 49-54 (2017).</li><li>Yetisir, F., Sarer, A. E., Acar, H. Z., Aygar, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Delayed+Closure+of+61+Open+Abdomen+Patients+Based+on+an+Algorithm.">Delayed Closure of 61 Open Abdomen Patients Based on an Algorithm.</a> Indian Journal of Surgery. 79 (1), 38-44 (2017).</li><li>Chaudhry, H., Bukiet, B., Zhiming, J., Stecco, A., Findley, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Deformations+experienced+in+the+human+skin,+adipose+tissue,+and+fascia+in+osteopathic+manipulative+medicine.">Deformations experienced in the human skin, adipose tissue, and fascia in osteopathic manipulative medicine.</a> The Journal of the American Osteopathic Association. 114 (1), 780-787 (2017).</li></ol>

Dr. Catherine Ronaghan is an ACell&#160;cadaver lab proctor and speaker. The rest of the authors have nothing to disclose.

The most critical step of the protocol for closing a complex abdominal wound is performing osteopathic maneuvers before elastomer placement, after elastomer placement, and before and after elastomer adjustments. In addition, we perform osteopathic maneuvers on these patients after surgery three times a day, for at least five days. Our approach describes the use of osteopathic maneuver prior and after elastomer adjustments. The anecdotal observation has been that these maneuvers aid in fascial approximation, by facilitati...

The increasing prevalence of abdominal compartment syndrome (ACS) has led to an emergence of various temporary abdominal closure (TAC) techniques1. TAC is performed to prevent evisceration, assist in the removal of unwanted intraperitoneal fluid, minimize intra-abdominal complications, and expedite the closure of the abdominal cavity2. Closure of an open abdomen facilitates restoration of normal physiology in the patient3. Prolonged duration of an open abdomen results in complications&#160;such as fistula formation and an inability to close the abdomen4. There are several methods to achieve final closure of an open abdomen.
The simplest way to temporarily close an abdomen is by using towel clips to close the skin5. One of the most commonly used and studied abdominal closure techniques is negative pressure wound therapy (NPWT)5. For the NPWT, a nonadherent barrier to protect the intraabdominal contents is applied followed by a moisture-absorbing sponge-like material,&#160;an outermost adhesive layer to sure the dressing in place, and a negative pressure mechanism6. A Bogota bag can also be used for temporary closure of an open abdomen. A Bogota bag is an empty intravenous fluid bag cut in half and sutured to&#160;skin edges7. NPWT and the Bogota bag closure are two temporizing measures that facilitate delayed primary closure of the abdominal cavity7.
Once the abdomen is deemed ready for closure, different closure methods can be utilized. The simplest way is to apply a split-thickness graft over the omentum once it has formed healthy granulation tissue. If the wound is not contaminated, a nonabsorbable synthetic sheet may be used to bridge the fascial edges8. If the fascial gap is less than 14-20 cm in maximal diameter, component separation of the rectus sheath can be performed9.
Some abdominal closure techniques allow for gradual reapproximation of the fascial edges and eventual primary closure10. A Wittmann patch consists of two opposing Velcro sheets that are sutured to each fascial edge11. The opposing sheets are then fastened together in the midline. This mechanism allows easy re-entry into the abdomen and adjustment for abdominal compartment pressures. Additionally, this can&#160;provide midline traction on the fascial edges that can prevent retraction of the fascial edges and also facilitate primary closure of the fascia.
Alternatively, a DTS is available and is part of the technique described in this paper. The described DTS is composed to a silicone viscera protector that is applied over abdominal contents to prevent adhesions and adherence of viscera to the abdominal wall. Adjustable elastomers then penetrate the full abdominal wall thickness on each side and provide medializing dynamic tension, allowing relaxation of the flat muscles (obliques and transversus abdominus). This allows medialization of the rectus myofascial units (Figure 1). A product composed of porcine urinary bladder extracellular matrix can be placed in the subcutaneous space once primary myofascial closure is achieved (Figure 2). Porcine xenograft placement in the subcutaneous space augments and expedites wound healing through angiogenesis, innervation, modulation of the inflammatory response, and resistance to infection12.
In this study, we describe a novel technique of primary abdominal closure following abdominal compartment syndrome utilizing a dynamic closure system and a biologic xenograft. At our level 1&#160;trauma and acute care center, abdominal compartment syndrome is a common diagnosis. Prior to utilization of this novel method, most catastrophic open abdomens were not amenable to primary closure and a skin graft was placed over the viscera or bridging&#160;mesh. Since the adoption of this method in May of 2016, we have closed 100% of open abdomens due to abdominal compartment syndrome in a high-risk&#160;population (average BMI 40.45, SD 9.83) (Table 1).

<table><tbody><tr><td>ABRA Abdominal Wall Closure Set</td><td>Southmedic</td><td>CWK08 Abdominal</td><td></td></tr><tr><td>3M Ioban 2 Antimicrobial Incise Drape</td><td>3M</td><td>6651EZ</td><td></td></tr><tr><td>MicroMatrix Micronized Particles 200 mg</td><td>ACell</td><td>MM0200</td><td></td></tr><tr><td>Cytal Wound Matrix 2-Layer 10 x 15 cm</td><td>ACell</td><td>WSM1015</td><td></td></tr><tr><td>Negative Pressure Therapy System</td><td>KCI</td><td>09-03-193.ABT.IE</td><td></td></tr></tbody></table>

a case series of successful abdominal closure utilizing a novel technique combining a mechanical closure system with a biologic xenograft that accelerates wound healing

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. The short and long-term consequences of living with a chronically open abdominal compartment include pulmonary, musculoskeletal, gastrointestinal, and emotional disability. The closure of catastrophic open abdomens presents a challenge to the surgeon. We present a technique utilizing a mechanical abdominal closure device in conjunction with biologic xenograft in closing complex open abdomens. This technique offers another option for definitive fascial closure and accelerated wound healing in this difficult patient population. The dynamic tissue system (DTS) is installed after control of original intraabdominal pathology. A porcine urinary bladder matrix (PUBM) is then placed in the subcutaneous space once fascial closure is achieved. Overall, primary myofascial closure was achieved in 100% of patients at a mean of 9.36 days.

We have analyzed a total of 11 patients so far with catastrophic open abdomens. Primary myofascial closure was achieved at a mean of 9.36 days. We had 0% surgical site infections (SSI) and achieved 100% primary myofascial closure. No enteroatmospheric fistula resulted in this technique, unless present prior to this DTS and xenograft approach. Since May 2016, zero open abdomens were left open or covered with a skin graft (Figure 9).
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Watch this Scientific Journal Video about A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wou

A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing

Closure of catastrophic open abdominal wounds presents a challenge to the surgeon. We present a surgical technique utilizing a combination of mechanical and biologic xenograft closure systems in closing complex open abdominal wounds. This technique offers another option to the surgeon for definitive fascial closure and accelerated wound healing.

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. ...

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Research

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Medicine

51.1K Views.  Texas Tech University Health Sciences Center. Closure of catastrophic open abdominal wounds presents a challenge to the surgeon. We present a surgical technique utilizing a combination of mechanical and biologic xenograft closure systems in closing complex open abdominal wounds. This technique offers another option to the surgeon for definitive fascial closure and accelerated wound healing.

Video: A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing

The C-seal: A Biofragmentable Drain Protecting the Stapled Colorectal Anastomosis from Leakage

Colorectal anastomotic leakage (AL) is a serious complication in colorectal surgery leading to high morbidity and mortality rates1. The incidence of AL varies between 2.5 and 20% 2-5. Over the years, many strategies aimed at lowering the incidence of anastomotic leakage have been examined6, 7. 
The cause of AL is probably multifactorial. Etiological factors include insufficient arterial blood supply, tension on the anastomosis, hematoma and/or infection at the anastomotic site, and co-morbid factors of the patient as diabetes and atherosclerosis8. Furthermore, some anastomoses may be insufficient from the start due to technical failure.
Currently a new device is developed in our institute aimed at protecting the colorectal anastomosis and lowering the incidence of AL. This so called C-seal is a biofragmentable drain, which is stapled to the anastomosis with the circular stapler. It covers the luminal side of the colorectal anastomosis thereby preventing leakage.
The C-seal is a thin-walled tube-like drain, with an approximate diameter of 4 cm and an approximate length of 25 cm (figure 1). It is a tubular device composed of biodegradable polyurethane. Two flaps with adhesive tape are found at one end of the tube. These flaps are used to attach the C-seal to the anvil of the circular stapler, so that after the anastomosis is made the C-seal can be pulled through the anus. The C-seal remains in situ for at least 10 days. Thereafter it will lose strength and will degrade to be secreted from the body together with the gastrointestinal natural contents.
The C-seal does not prevent the formation of dehiscences. However, it prevents extravasation of faeces into the peritoneal cavity. This means that a gap at the anastomotic site does not lead to leakage.
Currently, a phase II study testing the C-seal in 35 patients undergoing (colo-)rectal resection with stapled anastomosis is recruiting. The C-seal can be used in both open procedures as well as laparoscopic procedures. The C-seal is only applied in stapled anastomoses within 15cm from the anal verge. In the video, application of the C-seal is shown in an open extended sigmoid resection in a patient suffering from diverticular disease with a stenotic colon.

The C-seal is a biofragmentable drain protecting the stapled colorectal anastomosis. In this video, details of the manufacturing, deployment and use are shown.

Colorectal anastomotic leakage (AL) is a serious complication in colorectal surgery leading to high morbidity and mortality rates1. The incidence of AL ...

Use of a Rat Model to Study Ventral Abdominal Hernia Repair

Ventral abdominal hernia is a relatively common clinical condition that sometimes requires herniorraphy (surgical repair). The repair of ventral abdominal hernia typically requires implantation of a material to serve as a mechanical bridge across the defect in the abdominal wall. Biomaterials, such as porcine small intestinal submucosa (SIS), also serve as a lattice for cell growth into the implant and can naturally incorporate into the host tissue. Development of such repair materials benefits from use of animal models in which experimental abdominal wall defects are easily created and are amenable to repair in a reproducible fashion. The method offered here describes surgical creation and repair of ventral abdominal hernia in a rat model. When SIS is used to repair an experimental ventral abdominal hernia in this model, it is rapidly incorporated into host tissue within 28 days of implantation. Histologically, incorporation of their implanted material into host tissue is characterized by a robust fibrovascular response. Future refinements and applications of the rat abdominal hernia model may likely involve diabetic and/or obese animals as a means to more closely mimic common co-morbidities of man.

This manuscript describes methods associated with creation and repair of a ventral abdominal wall defect (hernia). This model can be used to study repair strategies such as those that use implanted materials. In this manuscript, repair of the experimental hernia with porcine small intestinal submucosa is presented as an example.

Ventral abdominal hernia is a relatively common clinical condition that sometimes requires herniorraphy (surgical repair). The repair of ventral abdominal ...

Bioengineering

Creation of Abdominal Adhesions in Mice

Abdominal adhesions consist of fibrotic tissue that forms in the peritoneal space in response to an inflammatory insult, typically surgery or intraabdominal infection. The precise mechanisms underlying adhesion formation are poorly understood. Many compounds and physical barriers have been tested for their ability to prevent adhesions after surgery with varying levels of success. The mouse and rat are important models for the study of abdominal adhesions. Several different techniques for the creation of adhesions in the mouse and rat exist in the literature. Here we describe a protocol utilizing abrasion of the cecum with sandpaper and sutures placed in the right abdominal sidewall. The mouse is anesthetized and the abdomen is prepped. A midline laparotomy is created and the cecum is identified. Sandpaper is used to gently abrade the surface of the cecum. Next, several figure-of-eight sutures are placed into the peritoneum of the right abdominal sidewall. The abdominal cavity is irrigated, a small amount of starch is applied, and the incision is closed. We have found that this technique produces the most consistent adhesions with the lowest mortality rate.

Abdominal adhesions that form after surgery are a major cause of pain, infertility, and hospitalization and reoperation for small bowel obstruction. Our surgical procedure for creating abdominal adhesions in mice is a reliable tool to study the mechanisms underlying the formation of adhesions.

Abdominal adhesions consist of fibrotic tissue that forms in the peritoneal space in response to an inflammatory insult, typically surgery or ...

Techniques of Sleeve Gastrectomy and Modified Roux-en-Y Gastric Bypass in Mice

Obesity is a major public health issue, with a prevalence of 4 to 28% for men and 6.2 to 36.5% for women in Europe (from 2003 to 2008). Morbid obesity is frequently associated with metabolic complications, such as type 2 diabetes, hypertension, and dyslipidemia, reducing life expectancy and quality. In the absence of any effective noninvasive treatments, bariatric surgery is a valuable therapeutic option for patients with morbid obesity (body mass index (BMI) &#62;40 kg/m2), leading to long-term, sustained weight loss and improvements in metabolic complications. However, the underlying cellular and molecular mechanisms sustaining the beneficial effects of bariatric surgery are not yet fully understood. Due to the numerous genetically-modified strains available, the mouse model is the most convenient animal model to explore the molecular mechanisms behind the pleiotropic beneficial effects of bariatric surgeries. Here, we detailed the optimized healthcare methods and surgical protocols in mice for the two most widely-used bariatric surgeries: the sleeve gastrectomy and the modified Roux-en-Y gastric bypass. Deciphering the molecular mechanisms underlying the therapeutic effects of bariatric surgeries offers the promise of identifying new therapeutics targets.

Bariatric surgery is the most efficient way to reduce body weight and the deadly metabolic complications (diabetes, obesity, and dyslipidemia) frequently associated with morbid obesity. Mouse models of bariatric surgery represent a unique asset for deciphering molecular mechanisms behind the beneficial effects of these surgeries on diabetes, hypertension, and dyslipidemia.

Obesity is a major public health issue, with a prevalence of 4 to 28% for men and 6.2 to 36.5% for women in Europe (from 2003 to 2008). Morbid obesity is ...

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

Robotic Radical Cystectomy, Pelvic Lymph Node Dissection, and Intracorporeal Ileal Conduit Urinary Diversion

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower surgical blood loss, its potential association with shorter hospital stay after surgery. These factors suggest that the robotic approach to radical cystectomy may be an important component of enhanced recovery programs aimed at reducing surgical morbidity. This paper describes the importance of the cranial placement of robotic trocars, the use of Cadiere forceps for atraumatic bowel grasping, pelvic lymph node dissection (PLND), and utero-enteric anastomoses. Also discussed are steps that are critical for the successful outcome of RARC. In spite of the increased operating times and associated costs and the costs of robotic surgical platforms and equipment, adoption of the robotic technique by bladder cancer surgeons has increased. This paper describes a systematic and reproducible method that details robotic extended pelvic lymph node dissection, cystectomy/cystoprostatectomy, and intracorporeal ileal conduit urinary diversion.

This paper describes robotic radical cystectomy, pelvic lymph node dissection, and intracorporeal ileal conduit urinary diversion.

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower ...

Application of Straight-needle, Three-tailed, Knot-free, Peritoneal Sutures in Laparoscopic Transabdominal Preperitoneal Hernia Repair

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is placed, the peritoneum must be resutured to avoid contact with the tissues and organs in the abdominal cavity. If the peritoneal suture time is too long, the operation and anesthesia time will be prolonged, increasing the burden on the patient. Moreover, improper suture methods cause serious consequences, such as intestinal obstruction and mesh infection.
The straight-needle suture method transforms the three-dimensional spatial configuration of the needle holder and the arc needle tip into a two-dimensional planar structure, which greatly reduces the difficulty of suturing. The three-tailed knot can be anchored at the beginning of the suture by its friction and button effect, which has an exact fixation effect. Thus, the suture does not easily slip, and the time to complete the suturing is shortened. Compared with the traditional suture method, the operator can suture the peritoneum more quickly, beginners can pass through the difficult learning curve faster, and skilled operators can also shorten the total operation time of TAPP to a certain extent. Thus, this suture method is extremely amenable to clinical application.

Here, we present a protocol to introduce a new peritoneal suture method. This method is called straight-needle, three-tailed, knot-free suture, and we will outline the manufacturing method and clinical application of this suture in detail.

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Surgical Closure of Equine Abdomen, Prevention, and Management of Incisional Complications

Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may jeopardize return to athletic function. Therefore, many techniques have been developed to reduce their occurrence and expedite their resolution when they occur. Our technique of celiotomy incision closure includes the use of tension sutures (vertical U mattress) of polyglactin 910 on the linea alba, which is then apposed by polyglactin 910 interrupted sutures or a simple continuous pattern suture with a stop midway before routine closure of the superficial layers. The celiotomy incision is protected by an elastic bandage during the immediate postoperative period. This technique has been associated with favorable results: 5.3% confirmed incisional infections after a single celiotomy and 26.7% after repeat celiotomy. The overall incisional complication (serous/sanguineous discharge, hematoma, infection, hernia formation, and complete wound breakdown) occurrence was 9.5% and 33.3% after single and repeat laparotomy, respectively. In cases considered more susceptible to infection (early relaparotomy or laparotomy incisions longer than 30 cm), negative pressure therapy was found easy to apply on closed incisions. No detrimental effects were observed. However, the potential prophylactic benefit of this therapy needs to be confirmed in a larger group. In infected laparotomy wounds requiring drainage, the use of negative pressure therapy seemed to have a positive effect on the formation of granulation tissue. However, there was no control group to allow statistical confirmation. Finally, one case of complete breakdown of the laparotomy incision was managed by stainless steel retention sutures, the application of negative pressure therapy, and a hernia belt. At re-evaluation 15 months post-surgery, several small hernias were detected, but the horse had returned to his previous level of sports performance and had not shown any episode of colic.

This paper describes a method of abdominal wall closure using tension and apposition sutures in horses undergoing ventral midline laparotomies. It also describes methods for prevention and management of postoperative incisional complications, such as bandaging, negative pressure therapy, and in case of wound breakdown, the application of retention sutures.

Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may ...

Novel and Innovative Hybrid Technique for Type A Aortic Dissection

Acute Stanford type A aortic dissection (TAAD) is a surgical emergency characterized by a high mortality rate and numerous complications. In the treatment of TAAD, the timing of surgery and the choice of surgical procedure are of paramount importance. Open total aortic arch reconstruction remains the gold standard for aortic arch surgery and is one of the most challenging procedures. However, this approach is invasive, relatively lengthy, and associated with substantial bleeding, which necessitates high levels of operator skill and carries the risk of multiple complications, particularly neurological ones. This report describes a novel hybrid procedure named Open Ascending Aorta Replacement Combined with Fenestrated Total Aortic Arch Stenting. A case was selected in which the lesion did not involve the aortic arch, at least on the greater curvature side of the arch. Ascending aortic replacement was performed, followed by arch intervention with self-modified stent grafts to preserve the aortic arch native branches. This approach allows for a rapid simplification of the procedure, avoids deep hypothermia or circulatory arrest associated with conventional open surgery, and mitigates neurological complications.

The protocol describes ascending aortic replacement combined with endovascular coverage of the entire aortic arch with a fenestrated stent graft in a patient with acute type A aortic dissection in the absence of a tear in the aortic arch.

Acute Stanford type A aortic dissection (TAAD) is a surgical emergency characterized by a high mortality rate and numerous complications. In the treatment ...