Rectus Abdominis

We report on a new method of incisional hernia repair applicable to any size of hernia and the long-term results of this method. Musculus rectus abdominis is bandaged or partially bandaged in a loose way with a 2-cm-wide band of polypropylene (Prolene) on both sides at a distance of 2 cm, depending on the size of the hernial opening. The aims of this technique, which were defined in 1999 when we started using the method, were to find a simple method for surgeons, a safe mesh fixation and the prevention of a postoperative stiff abdomen. Another aim was to find a method for optimal patient care at reasonable costs. Two hundred and seventeen patients underwent an operation according to this method in our department from June 1999 until December 2007. The first 75 patients of this cohort were treated using a technique in which the musculus rectus abdominis was bandaged in a loose way. One hundred and forty-two patients (since October 2001) were treated using a technique in which the mus...

Diastasis is a separation of the two recti due to various reasons, and can be measured as the 'inter-recti distance' (IRD). Surgery for diastasis is controversial, while laparoscopic repair has rarely been reported. We describe our method of laparoscopic plication-the 'Venetian blinds' technique combined with mesh reinforcement for patients with diastasis of the recti. A total of 18 patients out of 35 that presented to us were operated. The common indications were cosmesis and discomfort while performing normal activities. Laparoscopic plication with the 'Venetian blinds' technique of the diastasis with prosthetic reinforcement was performed for all cases. The mean body mass index (BMI) was 28.6 kg/m(2) (range 25-32.2) and obese patients had a larger IRD. The mean operating time was 113 min (range 72-154). Minor complications were present in five (27.77%) patients. The recurrence rate after 6-48 months follow up was 0% in this series. Even though surgery for ...

The comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes. Utilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups. Of 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue e...

The aim of this study was to characterize and compare the morphological and histomorphometric characteristics of the pectoral fascia, fascia lata and ventral rectus sheath. Twenty cadaveric samples of these fascias were analyzed and stained with hematoxylin and eosin, orcein, Van Gieson, Masson's trichrome and Verhoeff¨s stain (1200 slides in total). Morphological evaluation, semiquantitative, morphometric and microdensitometric analysis of elastic fibers present in each of the tissues and a morphometrical analysis of tissue thickness were performed. The mean value of the pectoral fascia thickness was 612±68.13 μm; 84±246 μm for the fascia lata and 584±92 μm for the ventral rectus sheath. The area occupied by the elastic fibers in the pectoral fascia was 12.24±5.84%; 6,54±3.85% for the fascia lata and 11.11±5.26% for the ventral rectus sheath. There were no statistically significant differences when comparing the mean values between the pectoral fascia and the ventral rectus she...

Substantial fluctuations in body weight can result in diastasis recti and weakening of the connections between the lateral abdominal muscles and the rectus sheath. The authors sought to determine the postural and psychological effects of abdominoplasty with vertical rectus plication. Forty women with substantial back and lumbar pain owing to abdominal lipodystrophy were evaluated in a prospective study. Preoperatively and 6 months postoperatively, patients underwent bidirectional radiography of the thoracic and lumbar regions. A visual analog scale (VAS), the Beck Depression Inventory (BDI), and the Nottingham Health Profile (NHP) were applied to assess physical, psychological, and quality-of-life changes following surgery. Significant improvements in posture, assessed in terms of lumbar lordosis, thoracic kyphosis, and the lumbosacral angle, were observed 6 months after abdominoplasty with rectus plication. Results of the VAS and BDI indicated significant improvements in pain and q...

The objective of this study was to investigate the sex-dependent regulation of skeletal muscle uncoupling protein (UCP)3 mRNA expression in response to overweight and its relationship with serum levels of free fatty acids, leptin, and insulin. Two obesity models were used: rats made obese by feeding them with a cafeteria diet for 14 wk, and postcafeteria overweight rats fed a chow diet for 10 wk after consuming the cafeteria diet for 14 wk. The effects of 24-h fasting were studied in postcafeteria rats and their age-matched controls. The cafeteria rats ate a high-fat diet and attained an excess body weight that was higher in females (+59%) than in males (+39%). A trend to higher induction of abdominal muscle UCP3 mRNA in male rats than in females after cafeteria diet was apparent (+116% increase vs. +26% increase). Postcafeteria male but not female rats still showed the tendency to have increased UCP3 mRNA levels relative to their age-matched controls. A linear regression analysis s...

Large duodenal defects/fistulae are difficult to repair, due to complex duodenal anatomy. Musculo-epithelial flaps are conventionally used for reconstruction of large soft tissue defects. We report the clinical use of rectus abdominis musculo-peritoneal (RAMP) flap for repair of duodenal fistulae. Eight patients with duodenal fistulae underwent repair using right RAMP flap, based on the position of the superior epigastric artery. Feeding jejunostomy was done routinely to start early enteral feeding. Duodenal fistulae healed within 3-5 days in all the cases except one, in whom bile continued to leak for 30 days. One patient died within 12 hours of second surgery. Superficial wound infection was a common (n=3) cause of morbidity. RAMP flap for closure of duodenal defect is a simple, technically easy and dependable procedure, which can be performed quickly in critically ill patients. It can be used for repair of large duodenal defects with friable edges when omentum is not available or...

The aim of this study was to incorporate a segment of pubic bone to rectus abdominis muscle (RAM). Eight RAM flaps from four fresh cadavers were used. During surgical dissection, utmost care was paid to enclose the areolar tissue between the main deep inferior epigastric (DIE) vessels and the pubic bone. A bone segment, 1.5 x 5 cm in dimension with an intact periosteum, was included with the RAM. Surgical dissections revealed two major vascular branches. The first branch arising from the DIE artery (DIEA) at a distance of 5.2 +/- 1.4 cm from the origin gave rise to two consistent subbranches. The second major branch originated from the DIEA at a distance of 8.4 +/- 1.8 cm from the origin. The first branch gave off two subbranches. The second subbranch coursed anteromedially and nourished the periosteum of the pubic bone. Microangiography showed a similar branching pattern of the vessels that create two significant networks. The X-rays confirmed a rich vascular network around the periosteum of the pubic bone. This wealthy nourishment of the pubic periosteum comes mainly from the perpendicular descending branches. In conclusion, a vascularized part of pubic bone can be incorporated to the RAM flap by preserving the delicate vascular network between the DIE vessels and the pubic periosteum.

Reconstructive procedures are being performed with increasing frequency in conjunction with pelvic exenterations and other radical gynecologic surgeries. The most common reconstructive procedures include continent urinary diversion, rectosigmoid ...

Large duodenal defects/fistulae are difficult to repair, due to complex duodenal anatomy. Musculo-epithelial flaps are conventionally used for reconstruction of large soft tissue defects. We report the clinical use of rectus abdominis musculo-peritoneal (RAMP) flap for repair of duodenal fistulae. Eight patients with duodenal fistulae underwent repair using right RAMP flap, based on the position of the superior epigastric artery. Feeding jejunostomy was done routinely to start early enteral feeding. Duodenal fistulae healed within 3-5 days in all the cases except one, in whom bile continued to leak for 30 days. One patient died within 12 hours of second surgery. Superficial wound infection was a common (n=3) cause of morbidity. RAMP flap for closure of duodenal defect is a simple, technically easy and dependable procedure, which can be performed quickly in critically ill patients. It can be used for repair of large duodenal defects with friable edges when omentum is not available or...

Prior imaging studies of torso muscle moment arms for use as inputs into biomechanical models have been derived from subjects lying supine. Recent research suggests moment arms of the rectus abdominis are larger when standing versus lying supine. Axial MRI images, through and parallel to the intervertebral discs were obtained from five females in a standing upright neutral posture. Digitizing software was utilized to quantify the distance in the sagittal plane between the centroids of the intervertebral disc and the rectus abdominis muscle, and converted to the transverse plane to allow comparisons with studies with subjects in a supine posture. The mean sagittal plane moment arms in the transverse plane were 9.7, 9.1, 8.5, 8.5 and 9.8 cm at the L(1)/L(2), L(2)/L(3), L(3)/L(4), L(4)/L(5) and L(5)/S(1) intervertebral levels, respectively. Compared with a study on females of a similar age group, the moment arms from this study were larger at each level, increasing from 7.3% larger at L(1)/L(2) to 43.7% larger at L(5)/S(1). Accurate anatomical geometrical representation in biomechanical models is necessary for valid estimates of internal loading. Sagittal plane rectus abdominis moment arms were larger from the upright neutral torso posture in this study compared to studies with subjects lying supine. This suggests the torso internal moment generating capability would be represented differently in biomechanical models that use data from studies where subjects were upright, which is more reflective of the postures biomechanical models are utilized for, than when using anatomical geometry derived from supine postures.

There is a controversy regarding the efficacy of rectus sheath block (RSB). The aim of the present study was to evaluate analgesic efficacy and safety of three different methods of RSB in postoperative pain management after midline laparotomy. A prospective, randomized, controlled, open-label clinical trial with 4 parallel groups was conducted in a tertiary care hospital in Finland. A total of 57 patients undergoing midline laparotomy were randomized to the control group (n = 12) or to 1 of the 3 active RSB analgesia groups: single-dose (n = 16), repeated-doses (n = 12), or continuous infusion (n = 17). Opioid consumption with iv-patient-controlled analgesia pump was recorded, and pain scores and patients' satisfaction were surveyed on an 11-point numeric rating scale for the first 48 postoperative h. Plasma concentrations of oxycodone and levobupivacaine were analyzed. All adverse events during the hospital stay were recorded. Oxycodone consumption was less during the first 12 ...

Background  Mammary reconstruction by using the transverse myocutaneous flap of the abdominal straight muscle (TRAM) is still an option well accepted in many parts of the world. However, bipedicled TRAM flaps are associated with greater morbidity of the abdominal donor area. The aim of this study was to describe an efficient technique for correcting the delayed defects of the abdominal wall

The internal mammary artery has been well-investigated due to its frequent use in cardiac surgery. However, in reconstructive microsurgery in the thoracic region, the internal mammary vessels have been used rarely as recipient vessels, due to difficulties and lack of knowledge about the internal mammary veins. This study was designed to investigate the anatomy and topography of the veins. Its goal was to gain sufficient information about their availability in free-tissue transfer. Dissection of the vessels was performed in 86 cadavers bilaterally to the sternum. At the level of the fourth rib, which is the most desired access for microvascular anastomosis in reconstructive breast surgery with free flaps, the veins were found to be adequately large (range 0.64 to 4.45 mm). Results were in close agreement with 100 bilateral measurements obtained by color Doppler sonography in 16 patients preoperatively, and additionally in 34 healthy volunteers. Preoperative detection of vessels with the aid of sonography facilitated planning of surgical procedures. According to these findings, the internal mammary veins may be used as suitable recipient veins for free microvascular tissue transfer, especially for established autologous breast reconstruction with the free transverse rectus abdominis myocutaneous flap, or for reconstruction of complex thoracic-wall defects.

Osteogenic proteins of the transforming growth factor-beta superfamily induce periodontal tissue regeneration in animal models, including primates. To our knowledge, no studies have been performed in periodontal regeneration using the transforming growth factor-beta 3 isoform. In the present study, recombinant human transforming growth factor-beta 3 was examined for its ability to induce periodontal tissue regeneration in the nonhuman primate, Papio ursinus. Class II furcation defects were surgically created bilaterally in the maxillary and mandibular molars of four adult baboons. Heterotopic ossicles, for transplantation to selected furcation defects, were induced within the rectus abdominis muscle by recombinant human transforming growth factor-beta 3. Forty days later, the periodontal defects were implanted with recombinant human transforming growth factor-beta 3 in Matrigel as the delivery system, with recombinant human transforming growth factor-beta 3 plus minced muscle tissue in Matrigel, or with the harvested recombinant human transforming growth factor-beta 3-induced ossicles. Sixty days after periodontal implantation, the animals were killed and the specimens harvested. Histological analysis on undecalcified sections measured the area and volume of new alveolar bone and the coronal extension of newly formed alveolar bone and cementum. Morphometric analyses showed pronounced periodontal regeneration in experimental defects compared with controls. Substantial regeneration was observed in defects implanted with fragments of heterotopically induced ossicles and with recombinant human transforming growth factor-beta 3 plus minced muscle tissue. Recombinant human transforming growth factor-beta 3 in Matrigel significantly enhanced periodontal tissue regeneration in the nonhuman primate, P. ursinus.

To obtain a clear surgical margin, abdominoperineal excision (APE) for rectal cancer frequently leaves a large perineal defect surrounded by irradiated tissue. A vertical rectus abdominis myocutaneous (VRAM) flap may facilitate healing of this wound. The current study aims to determine the effect of VRAM flap perineal reconstruction following APE on patient quality of life (QOL). This is a retrospective cohort study from a prospectively collected database. Data on QOL were assessed via telephone questionnaire using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30, EORTC QLQ-C29 and the Cleveland Clinic QOL questionnaires. Twenty-seven patients underwent primary perineal closure, and 12 patients underwent a VRAM flap perineal reconstruction. The mean duration of follow-up was 16.8 months. Overall, there was no significant difference in the Cleveland Clinic QOL score between groups (VRAM vs. no VRAM: 0.7 ± 0.2 vs. 0.7 ± 0.2, p 0.735). Patients in the VRAM group had lower levels of fatigue (5.5 ± 9.9 vs. 23.6 ± 19.2, p 0.004). Patients in the VRAM group had reduced sore skin scores around the stoma site (11.0 ± 16.2 vs. 31.8 ± 31.1, p 0.036). VRAM flap was associated with an increased incidence of abdominal wall hernia (VRAM vs. no VRAM: 25 % vs. 0 %, p 0.024). This study is limited by its non-randomized retrospective design and relatively small sample size. A significant difference in patient QOL was not demonstrated between VRAM flap and primary perineal closure after APE for rectal cancer. Further studies in this area are warranted.