Laparoscopic nephrectomy outside gerota fascia for management of inflammatory kidney

Background and Purpose: A nonfunctioning inflammatory kidney is a challenging surgical condition for urologists. Some investigators recommend open surgery because of the surgical difficulties caused by the inflammatory process, whereas others try to apply the advantages of a ""simple"" non-hand-assisted laparoscopic approach. We report our experience with simple laparoscopic nephrectomy for inflammatory kidney management. Patients and Methods: From July 2002 through December 2006, 50 pure laparoscopic nephrectomies were performed for inflammatory kidney ( 43 because of pyelonephritis, 5 for xanthogranulomatous pyelonephritis (XGP), and 2 for pyonephrosis). Histopathologic analysis was the criterion used for inflammatory kidney diagnosis. Pain or recurrent urinary tract infection associated with a nonfunctioning excluded kidney was the eligibility criterion for the procedure. Preoperatively, all patients underwent complete image and functional renal assessment. Morcellation was used to remove surgical specimens. Conversion index, surgical difficulties, operative time, and postoperative complications were evaluated. Results: Conversion was performed in 14 of 50 (28%) patients, including two with XGP and one with pyonephrosis. Adhesions, vascular (two inferior vena cava) lesions, and intestinal lesions (two colon) were the main causes of conversion. Acute pancreatitis developed in one patient, and one patient had a wound infection. Reoperations were unnecessary, and no deaths occurred. Conclusion: Pure laparoscopic nephrectomy was successful in 72% of patients with inflammatory kidneys. The laparoscopic dissection was useful even in those cases converted to open surgery. This is a high-risk procedure, however, and both surgeon and patient must be aware of that before the decision is made for this approach.

Analysis of the Strength of the Abdominal Fascia in Different Sutures Used in Abdominoplasties

Protrusion of the abdominal wall secondary to abdominoplasty may occur in patients with weakness of the aponeurotic structures. The anterior layer of the rectus abdominis muscle consists of fibers that are transverse rather than vertical. Based on this anatomical feature, vertical sutures are suggested for the correction of diastasis recti, since they include a greater amount of fascial fibers and thus would be more resistant to tensile strength than horizontal ones. The anterior layers of the rectus abdominis muscles of 15 fresh cadavers were dissected. Two vertical lines were marked on each side of the linea alba, corresponding to the site where plication is usually performed in abdominoplasties. Three abdominal levels were evaluated: the supraumbilical, umbilical, and infraumbilical levels. A simple suture was placed in the vertical direction in one group and in the horizontal direction in the other group, at each of the three levels previously described. These sutures were connected to a dynamometer, which was pulled medially toward the linea alba until rupture of the aponeurosis occurred. The mean strength required to rupture the aponeurotic structures in which the vertical sutures had been placed was greater than for the horizontal ones (p < 0.0001). The vertical suture of the rectus abdominis sheaths was stronger than the horizontal suture because of the more transversal arrangement of its aponeurotic fibers. Thus, routine use of the vertical suture in plications of the aponeurosis of the rectus abdominis muscles is suggested.

Bone defect repair on the alveolar wall of the maxillary sinus using collagen membranes and temporal fascia. An experimental study in monkeys

Few studies has been done using guided bone regeneration in maxillary sinus defects. Aim: To assess the bone repair process in surgical defects on the alveolar wall of the monkey maxillary sinus, which communicates with the sinus cavity, by using collagen membranes: Gen-derm - Genius Baumer, Pro-tape - Proline and autologous temporal fascia. Materials and Methods: In this prospective and experimental study, orosinusal communications were performed in four tufted capuchin monkeys (Cebus apella) and histologic analysis was carried out 180 days after. Results: In the defects without a cover (control), bone proliferation predominated in two animals and fibrous connective tissue predominated in the other two. In defects repaired with a temporal fascia flap, fibrous connective tissue predominated in three animals and bone proliferation predominated in one. In the defects repaired with Gen-derm or Pro-tape collagen membranes there was complete bone proliferation in three animals and fibrous connective tissue in one. Conclusions: Surgical defect can be repaired with both bone tissue and fibrous connective tissue in all study groups; collagen membranes was more beneficial in the bone repair process than temporal fascia or absence of a barrier.

Quantitative analysis of collagen and elastic fibers in the transversalis fascia in direct and indirect inguinal hernia

PURPOSE: Our previous studies demonstrated structural and quantitative age-related changes of the elastic fibers in transversalis fascia, which may play a role in inguinal hernia formation. To verify whether there were differences in the extracellular matrix between direct and indirect inguinal hernia, we studied the amount of collagen and elastic fibers in the transversalis fascia of 36 male patients with indirect inguinal hernia and 21 with direct inguinal hernia. MATERIAL AND METHODS: Transversalis fascia fragments were obtained during surgical intervention and underwent histological quantitative analysis of collagen by colorimetry and analysis of elastic fibers by histomorphometry. RESULTS: We demonstrated significantly lower amounts of collagen and higher amounts of elastic fibers in transversalis fascia from patients with direct inguinal hernia compared to indirect inguinal hernia patients. The transversalis fascia from direct inguinal hernia patients showed structural changes of the mature and elaunin elastic fibers, which are responsible for elasticity, and lower density of oxytalan elastic fibers, which are responsible for resistance. These changes promoted loss of resiliency of the transversalis fascia. CONCLUSION: These results improve our understanding of the participation of the extracellular matrix in the genesis of direct inguinal hernia, suggesting a relationship with genetic defects of the elastic fiber and collagen synthesis.

The temporoparietal fascia flap: a versatile tool in head and neck reconstruction.

PURPOSE OF REVIEW: The article reviews recent significant advances and current applications of the temporoparietal fascia flap (TPFF) in head and neck surgery. RECENT FINDINGS: The recent literature describes a wide span of new applications of the TPFF in many areas. Significant developments and refinements in the reconstruction of orbitomaxillary composite defects and orbital exenteration cavities are reported. The TPFF combined with alloplastic framework is gaining in importance in external ear reconstruction. Innovative prefabricated skin or soft-tissue grafts based on the TPFF are used to restore facial contour or in the reconstruction of complex facial defects. The free TPFF finds a role in laryngotracheal reconstruction as a vascular carrier to support cartilage grafts. SUMMARY: Owing to its reliability and unequalled structural properties, the TPFF still plays a central role in facial reconstruction. Future investigation will likely incorporate the free TPFF as a vascular carrier of bioengineered tissues, such as cartilage and mucosa, for various head and neck indications.

Avaliação histoquímica quantitativa do colágeno na fascia transversalis e na bainha anterior do músculo reto abdominal em doentes com hérnia inguinal

OBJETIVO: Avaliar a participação do colágeno na etiopatogenia das hérnias inguinais, através da análise quantitativa histoquímica do colágeno na bainha anterior do músculo reto abdominal e na fascia transversalis MÉTODO: Foram operados quarenta doentes do sexo masculino, na faixa etária entre 20 e 60 anos, portadores de hérnia inguinal tipo II e IIIA de Nyhus e realizadas autópsias em dez cadáveres frescos, na mesma faixa etária. Em ambos os grupos, amostras da bainha anterior do músculo reto abdominal e da fascia transversalis foram colhidas, coradas pela técnica histoquímica do picrocírius e submetidas a análise morfométrica quantitativa através de sistema computadorizado com a finalidade de identificar possíveis alterações quantitativas do colágeno, em cada um dos dois tipos de hérnias em comparação com indivíduos sem hérnias. RESULTADOS: Encontramos maior concentração do colágeno na bainha anterior do músculo reto abdominal, em comparação a fascia transversalis em todos os grupos estudados, embora esta diferença tenha sido estatisticamente significante apenas no grupo controle. Não encontramos diferenças na concentração do colágeno, na bainha anterior do músculo reto abdominal e na fascia transversalis, entre os doentes com hérnias tipo II e tipo IIIA de Nyhus. Não encontramos diferenças na concentração do colágeno quando comparamos os grupos com hérnias com o grupo controle. CONCLUSÃO: Não encontramos diferenças na quantidade do colágeno na bainha anterior do músculo reto abdominal e na fascia transversalis entre os pacientes portadores de hérnia inguinal tipo II e IIIA de Nyhus em comparação com indivíduos sem hérnias.

Estudo da técnica da sindesmoplastia extra-articular com fascia lata autógena: modelo em cães

OBJETIVO: Avaliar a eficácia da técnica extra-capsular para o tratamento de ruptura do ligamento cruzado anterior em cães. MÉTODOS: Foi realizada a reparação cirúrgica extra-articular, sem artrotomia do ligamento cruzado anterior, com a utilização da fáscia lata autógena para estabilização da articulação do joelho em seis animais que apresentaram claudicação grave e movimento de gaveta positivo. RESULTADOS: A técnica cirúrgica extra-articular foi eficaz com boa estabilização articular e evolução satisfatória. CONCLUSÃO: A via extra capsular com uso da fáscia lata para correção da ruptura do ligamento cruzado anterior mostrou-se útil haja vista tratar-se de um procedimento simples e de rápida execução, causando o mínimo dano tecidual e recuperação pós-operatória eficiente.

Immunohistochemical evaluation of fibrillar components of the extracellular matrix of transversalis fascia and anterior abdominal rectus sheath in men with inguinal hernia

OBJECTIVE: to evaluate the role of fibrillar extracellular matrix components in the pathogenesis of inguinal hernias. METHODS: samples of the transverse fascia and of the anterior sheath of the rectus abdominis muscle were collected from 40 men aged between 20 and 60 years with type II and IIIA Nyhus inguinal hernia and from 10 fresh male cadavers (controls) without hernia in the same age range. The staining technique was immunohistochemistry for collagen I, collagen III and elastic fibers; quantification of fibrillar components was performed with an image analysis processing software. RESULTS: no statistically significant differences were found in the amount of elastic fibers, collagen I and collagen III, and the ratio of collagen I / III among patients with inguinal hernia when compared with subjects without hernia. CONCLUSION: the amount of fibrillar extracellular matrix components did not change in patients with and without inguinal hernia.

Ruptura do ligamento cruzado em cães: estudo retrospectivo da reconstituição com fascia lata

Trata-se de um estudo retrospectivo de 35 casos de ruptura de ligamento cruzado atendidos pelo Serviço de Cirurgia de Pequenos Animais da FMVZ-UNESP-Campus de Botucatu, no período janeiro de 1991 a junho de 1997. Os cães foram submetidos à técnica de PAATSAMA (1952), modificada para reconstituição do ligamento cruzado, que consistiu na passagem do retalho de fascia lata através da articulação do joelho e fixação no côndilo medial da tíbia e epicôndilo medial do fêmur. Pelos resultados obtidos, concluiu-se que esta técnica permite boa estabilização das superfícies articulares, com trans e pós operatório sem complicações, e permite recuperação completa da capacidade funcional do membro afetado.

Bone defect repair on the alveolar wall of the maxillary sinus using collagen membranes and temporal fascia: an experimental study in monkeys

Few studies has been done using guided bone regeneration in maxillary sinus defects. AIM: To assess the bone repair process in surgical defects on the alveolar wall of the monkey maxillary sinus, which communicates with the sinus cavity, by using collagen membranes: Gen-derm - Genius Baumer, Pro-tape - Proline and autologous temporal fascia. MATERIALS AND METHODS: In this prospective and experimental study, orosinusal communications were performed in four tufted capuchin monkeys (Cebus apella) and histologic analysis was carried out 180 days after. RESULTS: In the defects without a cover (control), bone proliferation predominated in two animals and fibrous connective tissue predominated in the other two. In defects repaired with a temporal fascia flap, fibrous connective tissue predominated in three animals and bone proliferation predominated in one. In the defects repaired with Gen-derm or Pro-tape collagen membranes there was complete bone proliferation in three animals and fibrous connective tissue in one. CONCLUSIONS: Surgical defect can be repaired with both bone tissue and fibrous connective tissue in all study groups; collagen membranes was more beneficial in the bone repair process than temporal fascia or absence of a barrier.

La rinascita del Lido Iride. Progetto di riqualificazione della fascia costiera di Platamona

Questo progetto, maturato in seguito a profonde riflessioni basate sull’analisi e la valutazione della situazione territoriale, è scaturito dalla volontà di fornire una risposta alle carenze funzionali e strutturali di un’area dalle molteplici potenzialità. La fascia costiera di Platamona è stata al centro di progetti di lottizzazione che, invece di tutelare l’aspetto naturalistico e unificare un sistema costiero che si estende per circa otto chilometri, hanno inserito strutture prevalentemente ricettive e turistiche in maniera piuttosto arbitraria e senza tener conto della possibilità di organizzare il progetto d’intervento tramite un apposito strumento urbanistico. Il risultato, un tessuto edilizio disomogeneo e disorganizzato, non contribuisce certo alla volontà di attribuire un carattere e un’identità al luogo; anzi, la frequenza di aree in stato di abbandono, che rischiano di diventare discariche a cielo aperto fa quasi pensare ad una situazione di stallo e di incuria sia da parte delle amministrazioni che dei privati. L’idea del progetto deriva da un approccio che ha come obiettivo il massimo sfruttamento delle risorse locali e il minor impatto possibile sul paesaggio e sul sistema attuale. La volontà è quella di riorganizzare e riqualificare gli spazi più significativi, inserendoli all’interno di un sistema di percorsi e connessioni che vogliono unificare e rendere fruibile l’intero sistema costiero fra Platamona e Marina di Sorso. Inoltre è da rivalutare l’aspetto naturalistico del SIC dello Stagno e Ginepreto di Platamona, un’oasi naturalistica che ha tutte le potenzialità per essere posta al centro di un’attività di ricerca e diventare la meta di un turismo mirato. Nel Piano di gestione dello stagno sono già stati previsti e realizzati percorsi su passerelle in legno che si snodano fra i canneti e la pineta limitrofa, con alcune torrette di avvistamento, attualmente posizionate nella zona a sud. Uno degli obiettivi è dunque quello di completare questi percorsi per gran parte del perimetro dello stagno e di stabilire un percorso ciclo-pedonale ad anello che circondi e renda fruibile l’intera area del SIC. A livello di percorsi e connessioni, oltre alla nuova pista ciclabile che correrà parallelamente alla SP 81, si cercherà di fornire nuovi collegamenti anche all’ambito della spiaggia. L’idea è di costruire una passeggiata sul fronte mare che si articoli con leggere passerelle in legno fra le dune irregolari. Si snoderebbe dalla rotonda di Platamona fino alla piazza di Marina di Sorso, per una lunghezza di circa otto chilometri. Il suo scopo è di rendere fruibile l’intera fascia di spiaggia in modo da evitare un eccessivo calpestio del sistema dunario, che purtroppo risente della forte presenza antropica dei mesi estivi. Nel ripensare questi collegamenti e percorsi, si rende necessaria la creazione di aree di sosta attrezzate che si presentano con una certa periodicità, dettata dai pettini e dalle discese a mare. Vi saranno punti di sosta ombreggiati con alberature, aiuole, sedute, fontane e giochi per bambini. Diventa dunque prioritario il fatto di rendere evidente il concetto di unitarietà del sistema costiero in questione, rendendolo riconoscibile tramite l’organizzazione di spazi, episodi e percorsi. Infine il tentativo che riguarda nello specifico il Lido Iride, è quello relativo al suo recupero. L’intento è di restaurarlo e destinarlo a nuove funzioni ricreative-culturali. La struttura principale è mantenuta invariata, soprattutto le stecche che costituivano le cabine sulla spiaggia (elementi alquanto evocativi e radicati nella memoria del luogo). Il complesso sarà riorganizzato in previsione di ospitare workshop e corsi formativi riguardanti la cultura del mare e della salvaguardia dell’ambiente. Molto attuale e sempre più emergente anche in Sardegna risulta l’archeologia subacquea, a cui sono già state dedicate apposite strutture nelle zone di Cagliari e di Orosei. Dunque si riadatteranno le cabine con lo scopo di farle divenire alloggi temporanei per coloro che seguiranno tali corsi, mentre gli altri edifici del complesso fungeranno da supporto per delle lezioni all’aperto (l’arena e la piscina) e per il ristoro o l’allestimento di spazi espositivi (l’edificio centrale del lido). A causa della posizione del complesso balneare (a ridosso della spiaggia) si presuppone che il suo utilizzo sarà prevalentemente stagionale; perciò si è pensato di fornire una struttura di supporto e d’ausilio, la cui fruizione sia auspicabile anche nei mesi invernali: il Nuovo Centro Studi di Platamona. Questo nuovo complesso consiste in una struttura dotata di laboratori, aule conferenze, alloggi e ristorante. Si attesterà sul fronte mare, seguendo la direttrice del nuovo camminamento e innalzandosi su piattaforme e palafitte per non essere eccessivamente invasivo sul sistema dunario. Consisterà in due edifici di testata alti rispettivamente tre e quattro piani, ed entrambi avranno la peculiarità di avere il basamento aperto, attraversato dall’asse della passeggiata sul mare. L’edificio a tre piani ospiterà i laboratori, l’altro il ristorante. Dietro l’edificio dei laboratori si svilupperà una corte porticata che permetterà di giungere alla sala conferenza. Nella parte retrostante i due edifici di testata saranno distribuiti delle stecche di alloggi su palafitte immerse nel verde, caratterizzate da coperture con volte a botte. Lo stile architettonico del nuovo complesso si rifà all’architettura mediterranea, che s’identifica tramite l’utilizzo di basamenti e piccole aperture in facciata, l’uso di pietre e materiali da costruzioni locali, le bianche superfici che riflettono la luce e il forte segno architettonico dei muri che marcano il terreno seguendone l’orografia fino a diventare un tutt’uno.

One hundred fascia-sparing myocutaneous rectus abdominis flaps: An update

Major efforts have been undertaken to reduce donor-site morbidity after abdominal flaps, which eventually culminated in the introduction of the deep inferior epigastric perforator (DIEP) flap. However, due to anatomical variations (absence of dominant perforators) and the risk of ischaemic complications, the selection of patients qualifying for a DIEP flap is limited. Furthermore, DIEP flaps can only be used as free flaps. We present our long-term experience with a dissection technique of rectus abdominis myocutaneous (RAM) flaps that was developed to circumvent these drawbacks. The dissection is characterised by preventing to sacrifice any perforators nourishing the flap and by fully preserving the anterior rectus sheath, but not the muscle. The study comprises a consecutive series of prospectively assessed patients, treated between February 2000 and April 2008. A total of 100 fascia-sparing RAM flaps were operated on 97 patients (age 22-84 years, median 64 years). Free flaps were mainly used for breast reconstruction (47 flaps/24 patients), and cranially (34) or caudally (19) pedicled flaps for soft-tissue coverage after sternectomy, urogenital tumour resection or rectum amputation. Eighty patients had a total of 213 risk factors, such as cardiovascular diseases, obesity, hyperlipidaemia, diabetes mellitus, smoking or steroid medication. Partial tissue loss (skin or fat necrosis) occurred in 13 flaps, out of which seven required surgical revision. The ischaemic complications were evenly distributed between the patient subsets. At a follow-up of 2-89 months (median 20 months), one patient showed a flap harvest-related abdominal bulge after bilateral-free transverse rectus abdominis myocutaneous (TRAM) flap. We conclude that the present dissection technique provides maximal perforator-related perfusion and minimal donor-site morbidity even in pedicled flaps and high-risk patients. In free flaps, it may, therefore, be recommended as an alternative to the DIEP flap.