Nabeel Ibrahim

Preoperative abdominal muscle elongation with botulinum toxin A for complex incisional ventral hernia repair

Surgical repair of recurrent abdominal incisional hernia(s) can be challenging due to complex operative conditions, intense post‐operative pain, potential respiratory compromise and lateral muscle traction predisposing to early recurrence. We report our preliminary results with botulinum toxin A (BTA) injection causing flaccid paralysis (relaxation) of the lateral abdominal wall muscles prior to surgery.

Developing a mesh-tissue integration index and mesh registry database: the next step in the evolution of hernia repair: Perspectives

The use of mesh in incisional hernia repair has been paramount in reducing recurrence rates when compared with suture closure only. Factors influencing early efficacy of hernia repair include adequate closure of the defect, the size and strength (weight) of mesh, and type and security of fixation. Long-term efficacy is dependent on tissue incorporation into the mesh scaffold. The degree of meshtissue ingrowth affects recurrence rate and tissue flexibility, which relates to functional outcome and resistance to mesh infection. There is a ‘Goldilocks’ state to be achieved in mesh-tissue integration (MTI) which is key to an adequate, durable and functional repair. Excessive tissue response results in dense fibrosis, mesh shrinkage, seromas and chronic pain. Inadequate response can result in infection and recurrence (Fig. 1). Numerous intrinsic and extrinsic factors are known to affect MTI. Hydrophilic mesh is favourable as it allows rapid tissue ingrowth. Microporous filaments (>10 μm) allow white blood cells to infiltrate, and macropore (>1.5 mm) components allow penetration of blood vessels and avoid coalescing of fibrotic capsule, resulting in a flexible and functional repair. Preserving macroporosity by ensuring technical factors during mesh placement, such as avoiding overstretching or folding of the mesh, is important. Patient factors such as tissue vascularity and systemic conditions determined by diabetes, smoking, obesity, steroids and genetics, influence tissue integration. Theoretically, adjuncts such as growth factors, fibrin and autologous leucocyte platelet-rich fibrin may enhance MTI. There are over 150 mesh products available that have Food and Drug Administration (United States) and/or Therapeutic Goods Administration (Australia) approval. There is no requirement for manufacturers to provide MTI data. By only reporting the compositional safety profile of meshes, surgeons choose a mesh based primarily on its physical characteristics and technical ease of insertion. While there are a number of papers about tissue response to mesh, the lack of evidence around MTI precludes adopting a more holistic and tailored approach to hernia surgery. Tailoring surgery to optimize outcomes in hernia repair requires a greater understanding of the biological response elicited by any given mesh and how this response may be manipulated. Broadening this understanding will challenge existing assumptions about how mesh products help achieve successful outcomes. We propose developing a standardized, numerical MTI index for meshes placed in the subrectus and intraperitoneal position. The purpose is to assist surgeons in selecting a mesh according to its tissue ingrowth characteristics, matched to the individual patient to achieve an optimal outcome. Devising an MTI index will involve measuring the rate and extent of tissue ingrowth in an animal model based on macroscopic (including visual integration, mesh shrinkage, number of adhesions and T-Peel testing), microscopic (including cell population, and proportion of immune cells, growth cells and mature collagen) and biologic (protein quantification of vascular endothelial growth factor, transforming growth factor-beta and platelet-derived growth factors) assessments at 1, 4, 8, 12 and 24 weeks post-surgery. By examining a number of time points, we can assess the rate of tissue ingrowth, which is lacking from published data. The index will range from 1 to 5. Meshes with an index of 1 will have poor tissue integration while those with an index of 5 will have excellent vascularized tissue ingrowth and adequate fixation within 4 weeks of insertion. A fibrosis sub-index (F) will define meshes according to foreign body reaction. The fibrosis sub-index will range from 1 to 5, with 5 indicating negligible amounts of giant cell infiltration and 1 indicating an excessive foreign body reaction. A mesh with an F-index of 5 will be flexible with minimal shrinkage, whilst a mesh with an F-index of 1 may have a high incidence of rigidity and marked shrinkage. For meshes placed intraperitoneally, an adhesion sub-index (A) will be calculated adapted from previous studies. The adhesion index will range from 1 to 5, with 5 indicating minimal or no adhesions and 1 indicating dense adhesions. Accordingly, the preferred mesh will display an MTI index of 5, an F-index of 5 and an A-index of 5, equating to a fully incorporated and fixed mesh within 4 weeks, with excellent flexibility and no shrinkage, rigidity or adhesions. The indices will require validation. It is simplistic to believe that indices based on animal studies will translate to predictable patient outcomes considering the diversity and complexity of patients. To fully appreciate the significance of MTI, a longitudinal database that records mesh indices and patient characteristics against outcomes is pivotal in progressing hernia management towards a truly holistic and tailored approach (Fig. 1). A well-designed and resourced database will allow systematic assessment and refinement of the use of mesh products in hernia surgery. It may then be possible to understand not only the predictors of successful outcomes but also the factors associated with failures. This in turn may allow surgeons to assess the role of adjuvant growth factors in subpopulations of patients to improve MTI or indeed adjuvant agents to downregulate excessive tissue response to mesh. Incisional hernia surgery is undergoing a conceptual shift from a ‘mechanical approach’ (e.g. component separation, huge mesh overlap) to a ‘biological approach’. A biological paradigm is multifaceted. It may involve preoperative optimization of the patient by use of botulinum toxin for muscle relaxation and appropriate selection of mesh, with growth factor adjuncts, with the aim to reduce

Single port component separation: endoscopic external oblique release for complex ventral hernia repair

BackgroundComponent separation (CS) is a technique which mobilizes flaps of innervated, vascularized tissue, enabling closure of large ventral hernia defects using autologous tissue. Disadvantages include extensive tissue dissection when creating these myofascial advancement flaps, with potential consequences of significant post-operative skin and wound complications. This study examines the benefit of a novel, ultra-minimally invasive single port anterior CS technique.MethodsThis was a prospective study of 16 external oblique (EO) releases performed in 9 patients and 4 releases performed in 3 fresh frozen cadavers. All patients presented with recurrent complex ventral hernias, and were administered preoperative Botulinum Toxin A to their lateral oblique muscles to facilitate defect closure. At the time of elective laparoscopic repair, patients underwent single port endoscopic EO release using a single 20-mm incision on each side of the abdomen. Measurements were taken using real-time ultrasound. Postoperatively, patients underwent serial examination and abdominal CT assessment.ResultsSingle port endoscopic EO release achieved a maximum of 50-mm myofascial advancement per side (measured at the umbilicus). No complications involving wound infection, hematoma, or laxity/bulge have been noted. All patients proceeded to laparoscopic or laparoscopic-open-laparoscopic intraperitoneal mesh repair of their hernia, with no hernia recurrences to date.ConclusionsSingle port endoscopic EO release holds potential as an adjunct in the repair of large ventral hernia defects. It is easy to perform, is safe and efficient, and entails minimal disruption of tissue planes and preserves abdominal wall perforating vessels. It requires only one port-sized incision on each side of the abdomen, thus minimizing potential for complications. Further detailed quantification of advancement gains and morbidity from this technique is warranted, both with and without prior administration of Botulinum Toxin A to facilitate closure.

ClosureFast endovenous radiofrequency ablation for great saphenous vein and small saphenous vein incompetence. Efficacy and anatomical failure patterns

Background Recurrence rates and patterns after endovenous radiofrequency ablation (ERFA) are poorly documented. Objective To assess the incidence and anatomical recurrence patterns of saphenous vein reflux after ERFA. Method Two hundred patients previously treated with ERFA were recalled for clinical assessment and venous-duplex ultrasound at three years post-treatment. Results A total of 106 patients (68F, 38M) with a mean age of 49.4 years (SD +11.5y) were assessed. Mean follow-up was 42.1 months (SD + 20.1m). Further varicose veins were identified in 31 patients (29.2%). Recanalization/recurrence/failure was diagnosed in 16 patients (15.1%), including 18 trunks (8.7%), 13 great saphenous vein (6.3%) and 5 small saphenous vein (2.4%). Twenty-seven patients (25%) developed neo-incompetence in 31 trunks and 12 non-saphenous veins. All patients with truncal recanalization had a body mass index > 29 (range 29–42). Conclusion Disease progression was twice as high as the recanalization rate at three years post-treatment using ERFA in this study. Raised body mass index may be a contributing factor; however, further longitudinal studies are required. Patient self-selection bias may have also influenced our results.

The sural nerve: Sonographic anatomy, variability and relation to the small saphenous vein in the setting of endovenous thermal ablation

Background Neurological complications are well documented in association with both surgical stripping or disconnection and thermal ablation of the small saphenous vein. The sural nerve (medial sural cutaneous nerve) is most vulnerable due to its close relationship to the small saphenous vein. Objective This is a cross-sectional observational study of the sonographic anatomy of 115 Australian patients to determine the course of the sural nerve and its relationship to the small saphenous vein, and to identify its relevance in the thermal ablation of the small saphenous vein. Method Sonographic mapping of the right sural nerve was performed with a Philips L12.5 and Sonosite 10.5 MHz ultrasound machine on 115 patients. The sural nerve was traced proximally from the level of the lateral malleolus to the popliteal fossa in order to measure its distance from the small saphenous vein at four reference points in the lower leg. Results A total of 115 patients were studied (females 82, males 33). The sural nerve was identified in 100% of patients; 64 patients (55.7%) showed usual sural nerve anatomy, while 51 patients (44.3%) demonstrated a range of anatomical variations, including the sural nerve becoming epifascial at a higher point than usual. Conclusion The sural nerve was identifiable on duplex ultrasound in 100% of cases. Classic anatomical relations and the perceived protection of the sural nerve conferred by the deep fascia of the upper calf are unreliable. Preoperative strategies can help to approach and protect the sural nerve in the endovenous ablation setting.

Hydrodisplacement of sural nerve for safety and efficacy of endovenous thermal ablation for small saphenous vein incompetence

Background Endovenous radio frequency ablation for small saphenous vein incompetence by and large appears to be superior and safer than conventional open surgery. Small saphenous vein ablation from approximately mid-calf to the point proximally where the small saphenous vein dives into the popliteal fossa is considered to be safe, as the sural nerve is in most cases separated from this segment of the small saphenous vein by the deep fascia. The outcome of the distal incompetent small saphenous vein remains unclear. Efficacy of the endovenous radio frequency ablation can be enhanced by increasing the length of the ablatable small saphenous vein segment. Methodology To optimise endovenous radio frequency ablation outcome, the distal small saphenous vein may be made amenable to ablation if safety of the sural nerve can be assured. The sural nerve was successfully located using duplex ultrasound in 100% of our cohort in this study. The standard entry point for venous access was just above the lateral malleolus. After introduction of the introducer sheath, the radio frequency catheter was advanced proximally; the sural nerve was displaced from the small saphenous vein by approximately 1 cm with the administration of tumescent anaesthesia (hydrodisplacement). A total of 118 patients underwent extended endovenous radio frequency ablation of 124 incompetent small saphenous vein trunks using the method described. Results Successful extended ablation of the small saphenous vein was achieved in 100% of cases and it was confirmed by duplex scanning at one and six weeks. Two neurological events were recorded during the study:  1. One patient with temporary foot drop lasting for less than 6 h with complete recovery.  2. A second patient with a sural nerve sensory deficit reported by the patient at day 2–3, which remains current at six weeks. Conclusions Extended endovenous radio frequency ablation of the small saphenous vein to optimise length of the ablatable vein segment is feasible with careful identification and hydrodisplacement of the sural nerve. This method is shown to be associated with fewer neurological complications than other methods reported in the literature.

Abdominal Wall Miscellaneous

Methods: From March 2008 to June 2013, a total of 11 hepatic cirrhotic patients with intractable ascites and umbilical hernia received mesh repair. All the patients were placed a Jackson-Pratt drain in lower abdominal cavity for ascites decompression. The drain tube was placed for one month and the amount of ascites drainage was around 1000 ml per day. Patients were followd up one to six months after operation ..Burst abdomen, incisional hernias and stomal hernias : a Swedish population-based register study