BACKGROUND: valproic acid (VPA), an epigenetic drug, has potential for the treatment of neoplasms. Its effects on the healing of the peritoneal-musculo-aponeurotic plane (PMA) of the abdominal wall are studied.
METHODS: sixty Wistar rats were allocated into two groups: experimental (VPA) and control (0.9% sodium chloride), treated daily, starting three days before the intervention and until euthanasia. Under anesthesia, a median laparotomy was performed and repaired with two synthetic layers. Assessments took place 3, 7 and 14 days after surgery. The integrity of the wounds, the quality of the inflammatory reaction, the intensity of the leukocyte infiltrate, collagen synthesis, the intensity of angiogenesis and the presence of myofibroblasts were studied.
RESULTS: there was dehiscence of the PMA plane in 11 of the 30 animals (p=0.001) in the experimental group. There was no difference in the quality and intensity of the inflammatory reaction. Immunohistochemistry revealed, in the experimental group, less collagen I (p3=0.003, p7=0.013 and p14=0.001) and more collagen III (p3=0.003, p7=0.013 and p14= 0.001). Collagen evaluated by Sirus Supra Red F3BA showed, in the experimental group, less collagen at all three times (p<0.001) with less collagen I and collagen III (p<0.001). A lower number of vessels was found on the 3rd day (p<0.001) and on the 7th day (p=0.001) and did not affect the number of myofibroblasts.
CONCLUSIONS: VPA showed dehiscence of the PMA plane, with less deposition of total collagen and collagen I, less angiogenic activity, without interfering with the number of myofibroblasts.

OBJECTIVE: Ventral hernias are a common complication of laparotomy, posing challenges particularly when primary fascial closure is unattainable. Although chemical component separation using preoperative botulinum toxin A (BTX) injections has emerged as a promising adjunct, objective evidence of its efficacy remains limited. This study aimed to objectively assess the effect of preoperative BTX on traction force during ventral hernia repair.
METHODS: A prospective, single-blind study was conducted on patients with midline incisional hernias following liver transplantation. BTX was administered unilaterally, and the traction force required to medially advance the anterior rectus sheath was measured intraoperatively. Pre- and post-injection CT scans were analyzed for changes in hernia size and LAW muscle measurements. Statistical analyses were performed to evaluate traction force differences between BTX-injected and uninjected sides.
RESULTS: Ten patients underwent hernia repair with primary fascial closure achieved in all cases. Comparison of pre- and post-injection CT scans showed no significant changes in hernia size. LAW muscle length increased by 1.8 cm, while thickness decreased by 0.2 cm. Intraoperative traction force measurements revealed a significant reduction on the BTX-injected side compared to the uninjected side (p < 0.0001). The traction force ratio on the BTX-injected to the uninjected side averaged 57%, indicating the efficacy of BTX in reducing tension.
CONCLUSIONS: Preoperative BTX significantly reduces traction force during ventral hernia repair, highlighting its potential as an adjunctive therapy in complex cases. While challenges remain in patient selection and outcome assessment, BTX offers a promising avenue for enhancing abdominal wall reconstruction outcomes and reducing surgical complications.

BACKGROUND: The recent guidelines from the European and American Hernia Societies recommend a continuous small-bite suturing technique with slowly absorbable sutures for fascial closure of midline abdominal wall incisions to reduce the incidence of wound complications, especially for incisional hernia. However, this is based on low-certainty evidence. We could not find any recommendations for skin closure. The wound closure technique is an important determinant of the risk of wound complications, and a comprehensive approach to prevent wound complications should be developed.
METHODS: We propose a single-institute, prospective, randomized, blinded-endpoint trial to assess the superiority of the combination of continuous suturing of the fascia without peritoneal closure and continuous suturing of the subcuticular tissue (study group) over that of interrupted suturing of the fascia together with the peritoneum and interrupted suturing of the subcuticular tissue (control group) for reducing the incidence of midline abdominal wall incision wound complications after elective gastroenterological surgery with a clean-contaminated wound. Permuted-block randomization with an allocation ratio of 1:1 and blocking will be used. We hypothesize that the study group will show a 50% reduction in the incidence of wound complications. The target number of cases is set at 284. The primary outcome is the incidence of wound complications, including incisional surgical site infection, hemorrhage, seroma, wound dehiscence within 30 days after surgery, and incisional hernia at approximately 1 year after surgery.
CONCLUSIONS: This trial will provide initial evidence on the ideal combination of fascial and skin closure for midline abdominal wall incision to reduce the incidence of overall postoperative wound complications after gastroenterological surgery with a clean-contaminated wound. This trial is expected to generate high-quality evidence that supports the current guidelines for the closure of abdominal wall incisions from the European and American Hernia Societies and to contribute to their next updates.
BACKGROUND: UMIN-CTR UMIN000048442. Registered on 1 August 2022. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000055205.

BACKGROUND: The current literature supports the closure of trocar sites ≥10-mm for the risk of developing incisional hernias, while there is no need to suture the abdominal fascia when using 5-mm trocars. To date, evidence regarding the closure of 8-mm trocars that are use by new robotic systems is weak. The aim of our study was to investigate the incidence of incisional hernia for 8-mm trocars.
METHODS: We prospectively collected data on all patients undergoing robotic-assisted abdominal wall surgery from 2020 to 2023, in whom the abdominal fascia of all 8-mm trocars was not closed. The enrolled patients underwent a follow-up visit during which we conducted clinical and sonographic evaluations of all 8-mm trocars, in addition to assessing the satisfaction levels of the patients. The primary outcome was the incidence of port-site hernia.
RESULTS: We enrolled 166 patients, 155 men and 11 women, for a total of 513 trocars accessed. Mean age was 61.1 ± 14.0 years, and mean BMI was 27.0 ± 3.9 kg/m2. The follow-up visits were carried out after a median follow-up of 14.5 (9.0-23.2) months. Only one case developed an asymptomatic 1 × 1 cm supra-umbilical hernia that was not treated. Patient reported a satisfaction regarding the 8-mm trocars and skin sutures of 9.8 ± 0.5 out of 10 points.
CONCLUSIONS: The occurrence of a trocar-site hernia after 8-mm robotic access is extremely low. Hence, the fascia closure may not be necessary.

OBJECTIVE: This work aimed to investigate the validity of wearable activity monitors (WAMs) as an objective tool to measure the return toward normal functional mobility following abdominal wall surgery. This was achieved by quantifying and comparing pre- and postoperative physical activity (PA).
METHODS: A multicenter, prospective, observational cohort study was designed. Patients undergoing abdominal wall surgery were assessed for eligibility and consent for study participation was obtained. Participants were asked to wear a WAM (AX3, Axivity) on the wrist of their dominant hand at least 48 hours pre-operatively, for up to 2 weeks postop, and again after 6 months postop for 48 hours.
RESULTS: A cohort of 20 patients were recruited in this validation study with a mean age of 47.3 ± 13.0 years. Postoperation, the percentage median PA (±IQR) dropped to 32.6% (20.1), whereas on day 14, PA had reached 64.6% (22.7) of the preoperative value providing construct validity. Activity levels at >6 months postop increased by 16.4% on an average when compared to baseline preoperative PA (p = 0.046).
CONCLUSIONS: This study demonstrates that WAMs are valid markers of postoperative recovery following abdominal wall surgery. This was achieved by quantifying the reduction in PA postoperation, which has not been previously shown. In addition, this study suggests that abdominal wall surgery may improve the patient\'s quality of life via increased functional mobility at 6 months postop. In the future, this technology could be used to identify the patient and surgical factors that are predictors of outcome following abdominal wall surgery.

BACKGROUND: One of the primary complications associated with large incisions in abdominal surgery is the increased risk of fascial closure rupture and incisional hernia development. The choice of the fascial closure method and closing with minimal tension and trauma is crucial for optimal results, emphasizing the importance of uniform pressure along the suture line to withstand intra-abdominal pressure.
OBJECTIVE: To evaluate the resistance to pressure and tension of stapled and sutured hand-sewn fascial closure in the abdominal wall.
METHODS: Nine abdominal wall flaps from human cadavers and 12 pigs were used for the experimentation. An abdominal defect was induced after the resection of the abdominal wall and the creation of a flap in the cadaveric model and after performing a midline incision in the porcine models. The models were randomized into three groups. Group 1 was treated with a one-layer hand-sewn small bite suture, Group 2 was treated with a two-layer hand-sewn small bite suture, and Group 3 was treated with a two-layer stapled closure. Tension measurements were assessed in cadaveric models, and intra-abdominal pressure was measured in porcine models.
RESULTS: In the human cadaveric model, the median threshold for fascial rupture was 300N (300-350) in Group 1, 400N (350-500) in Group 2, and 350N (300-380) in Group 3. Statistical comparisons revealed non-significant differences between Group 1 and Group 2 (p=0.072, p>0.05), Group 1 and Group 3 (p=0.346, p>0.05), and Group 2 and Group 3 (p=0.184, p>0.05). For porcine subjects, Group 1 showed a median pressure of 80 mmHg (85-105), Group 2 had a median of 92.5 mmHg (65-95), and Group 3 had a median of 102.5 mmHg (80-135). Statistical comparisons indicated non-significant differences between Group 1 and Group 2 (p=0.243, p>0.05), Group 1 and Group 3 (p=0.468, p>0.05), and Group 2 and Group 3 (p=0.083, p>0.05).
CONCLUSIONS: Stapled and conventional suturing resist similar pressure and tension thresholds.

BACKGROUND: Abdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction.
METHODS: All patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion.
RESULTS: In 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75-43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34-8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention.
CONCLUSIONS: Patients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk.

BACKGROUND: Infectious affections are the most frequent post-operative complications, the rate have been reducing due to the administration of perioperative antibiotics and they are rarely serious. They are usually associated to pelvic collections, fistulas, urinary tract stenosis and, exceptionally, necrotizing fasciitis (FN) and pelvic organ necrosis. There is no well-codified treatment.
METHODS: A 42-year-old female patient, was referred to our department for a stage IIIC2 adenocarcinoma of the uterine cervix. Two months after surgery, the patient presented with fever. Abdominal CT scan revealed a recto-vaginal fistula. The patient underwent a surgical evacuation of the collection and a bypass colostomy. Post-operative period was marked by the occurrence of an extensive necrosis to pelvic organs and medial left leg\'s thigh compartments muscles. She also presented a thrombosis of the left external iliac vein and artery. Given the septic conditions, a revascularization procedure was not feasible. A bilateral ureterostomy was required and a ligature of the left external iliac vessels. Then she received palliative treatment.she died one month after surgery because of multivisceral failure due to sepsis.
CONCLUSIONS: Necrotizing fasciitis is extremely rare and serious condition, the diagnosis is clinical and radiological, CT scan is helpful for the. There are predisposing factors such as diabetes, neoadjuvant radiotherapy or chemotherapy. The prognosis can be improved with rapid management and appropriate medical and surgical excisions of necrotic tissue, and antibiotic therapy adapted to the suspected germs, essentially anaerobic ones.

BACKGROUND: Aging is associated with muscle atrophy, as typified by sarcopenia. Loss of abdominal muscle strength can cause abdominal wall laxity. The purpose of this study was to investigate the relationship between the sacral vertebra-abdominal wall distance (SAD) and movement performance using a simple lateral spine X-ray image for measuring the SAD.
METHODS: In this retrospective study, we included women aged ≥ 65 years who were attending the outpatient clinic for osteoporosis at our hospital. A total of 287 patients (mean age ± SD, 76.8 ± 7.1 years) with measured SAD were included in the analysis. Patients were divided into two groups based on SAD cutoff (160 mm) and age (75 years), respectively. The patients were examined using the two-foot 20 cm rise test, 3 m Timed Up and Go (TUG) test, two-step test, open-eyed one-leg standing time, and spinal alignment. Normally distributed data are expressed as means (standard deviations) and non-normally distributed data as medians (interquartile range), depending on the results of the Kolmogorov-Smirnov test. Student\'s t-test and χ2 test were used for between-group comparisons. Regression analysis was performed with SAD as the objective variable. A two-sided p < 0.05 was considered statistically significant.
RESULTS: The shorter SAD group performed better in the two-step test, TUG test, and open-eyed one-leg standing time (p < 0.001) as well as in the two-foot 20 cm rise test (p < 0.01) compared to the longer SAD group. Spinal alignment was better in the shorter SAD group than in the longer SAD group, with a shorter sagittal vertical axis (p < 0.001), smaller pelvic tilt (p < 0.001), and greater sacral slope (p < 0.05).
CONCLUSIONS: SAD was associated with posterior pelvic tilt and movement performance parameters. In addition to testing for osteoporosis, movement performance parameters should be evaluated in women with osteoporosis who are aged ≥ 65 and have greater SAD (≥ 160 mm in this study). The SAD is a new assessment method, and further research is required to verify its validity and reproducibility. This is the first attempt to determine how age and SAD affect movement performance in older adults.

BACKGROUND: The eTEP Rives-Stoppa (RS) procedure, increasingly used for ventral hernia repair, has raised concerns about postoperative upper abdominal bulging. This study aims to objectively evaluate changes in the abdominal contour after eTEP RS and explore potential causes using a novel analytical tool, the Ellipse 9.
METHODS: Thirty patients undergoing eTEP RS without posterior rectus sheath closure were assessed before and 3 months after surgery using CT scan images. Key measurements analyzed included the distance between linea semilunaris (X2), eccentricity over the Cord (c/a Cord), superior eccentricity (c/a Sup), Y2, and the superior perimeter of the abdomen. The Ellipse 9 tool, which provides graphical images and numerical representations, was utilized alongside patient-reported outcomes to assess perceived abdominal changes.
RESULTS: The study group exhibited a trend toward a flatter abdomen with reduced distance between linea semilunaris(X2). However, 17% of patients developed upper abdominal bulging (5). Significant differences in c/a Cord, c/a Sup, Y2, and the superior perimeter of the abdomen, confirmed with Bonferroni corrections, were noted between bulging (5 patients) and non-bulging groups (25 patients). There was a notable disparity between patient perceptions and objective outcomes.
CONCLUSIONS: The eTEP RS procedure improved abdominal contour in most patients from a selected cohort. The Ellipse 9 tool was valuable for the objective analysis of these changes. The cause of bulging post-eTEP RS is probably multifactorial. Notably, there was often a discrepancy between patient perceptions of bulging and objective clinical findings.