Nematode as a Cause of Appendicular–Cutaneous Fistula

BackgroundCutaneous fistula may develop spontaneously as a complication of an perforating appendicitis. However, intestinal fistula caused by parasites is a rare report.Case presentationIn the operation, we found that expanded appendix was perforated from its distal part and was fistulized to the right lateral abdominal wall. The complications of postoperative was intestinal fistula. Colonoscopy was performed revealing some nematode around the appendiceal orifice. The development of fistula after bowel resection and anastomosis can be devastating. Immediate drainage and establishment of enteral nutrition can lead to spontaneous healing of fistula.ConclusionsTesting for nematode infection in a patient with suspected appendicitis is not routine, it still stands as a challenge in clinical practice. In view of this situation, killing parasites is necessary, otherwise it is difficult to cure.

O50 ALTERATIONS IN THE ABDOMINAL WALL MUSCULATURE AFTER ENDOSCOPIC ANTERIOR AND OPEN POSTERIOR COMPONENT SEPARATION

Aim Effects of component separation (CS) on abdominal wall musculature have only been investigated in smaller case series. The study aimed to compare abdominal wall alterations following endoscopic anterior component separation (EACS) or transverse abdominis release (TAR). Material and Methods Computed tomography scans were evaluated in patients who underwent open ventral hernia repair with TAR or EACS. Lateral abdominal wall muscle thickness and displacement were compared with preoperative images after bilateral CS and the undivided side postoperatively after unilateral CS. Results In total, 105 patients were included. The mean defect width was 12.2 cm. Fifty-five (52%) and 15 (14%) underwent bilateral and unilateral EACS, respectively. Five (5%) and 14 (13%) underwent bilateral and unilateral TAR, respectively. Sixteen (15%) underwent unilateral EACS and contralateral TAR. Complete fascial closure was achieved in 103 (98%) patients. The external oblique and transverse abdominis muscles were significantly laterally displaced with a mean of 2.74 cm (95% CI 2.29-3.19 cm) and 0.82 cm (0.07-1.57 cm) after EACS and TAR, respectively. The combined thickness of the lateral muscles was significantly decreased after EACS (mean decrease 10.5% [5.8-15.6%]) and insignificantly decreased after TAR (mean decrease 2.6% [-4.8-9.5%]), mean reduction difference EACS versus TAR 0.22 cm (-0.01-0.46 cm). One (1%) patient developed an iatrogenic linea semilunaris hernia after EACS. The recurrence rate was 19% after mean 1.7 years follow-up. Conclusions The divided muscle was significantly more laterally displaced after EACS compared with TAR. The thickness of the lateral muscles was slightly decreased after EACS and unchanged after TAR.

P010 FEASIBILITY OF MIDLINE RECONSTRUCTION WITHOUT MYOFASCIAL RELEASE (COMPONENT SEPARATION) AFTER PREOPERATIVE INFILTRATION OF LATERAL ABDOMINAL WALL MUSCULATURE WITH BOTULINUM TOXIN

Aim Aim of the analysis was to evaluate whether preoperative botulinum toxin infiltration may facilitate anatomical midline reconstruction without the need for – otherwise pre-operative assumed – surgical component separation. Material and Methods Total of 58 patients with complex abdominal wall hernias were included in our single-center retrospective analysis between 03/2015 and 12/2020. Size of the defect, HSV/ACV-ratio, rectus-to-defect-width-ratio (“Carbonell-Index”) as well as risk factors were analyzed. In all patients muscles of the lateral abdominal wall were infiltrated with 300-500 IE of botulinum toxin 4 weeks prior to the abdominal wall reconstruction. CT scans were performed before and 4 weeks after the botulinum toxin infiltration. Results Total of 58 patients (M/F-ratio 36:22), with a mean age of 63.8 years were included in our analysis. Mean BMI was 29.5 kg/m². Total of 50 incisional, 3 umbilical, 2 posttraumatic diaphragmatic hernias and 3 scrotal hernias were analyzed. Surgical component separation after the infiltration with botulinum toxin was necessary in 43% of the cases. Conclusions Preoperative infiltration of the lateral abdominal wall musculature with botulinum toxin facilitated midline reconstruction of the abdominal wall without the need for myofascial release in 57%. Reduction of surgical trauma could therefore be achieved in several patients.

P015 ABDOMINAL WALL PREPARATION PRECEDING COMPLEX ABDOMINAL WALL RECONSTRUCTION (CAWR) - SINGLE CENTER INITIAL EXPERIENCES UTILIZING BOTULINUM TOXIN A (BTA) ACCOMPANIED IN SELECTED PATIENTS BY PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM (PPP)

Aim Complex ventral hernia (CVH) treatment due to large abdominal wall defects or loss of domain is challenging. BTA-injection in lateral abdominal wall causing flaccid paralysis and elongation, so called chemical component separation (CCS), might facilitate closure of large fascial defects. Combining preoperative progressive pneumoperitoneum might help restore abdominal content in severe loss of domain situations. We studied the results after CAWR following abdominal wall preparation with BTA and possible PPP. Primary aim was to report fascial defect closure rate without need for surgical component separation. Material and Methods All electively operated patients to date that were treated preoperatively with BTA, including all patients treated with PPP. Results Hospital index patient received preoperative BTA in January 2018. Since then, altogether 42 patients underwent CCS prior to CAWR. Average patient suffered from obesity (mean BMI 31), 30% had diabetes, and a third were active smokers. Mean hernia defect area exceeded 200 cm2. All operations were mesh repairs. Surgical approach was mostly (88%) open retromuscular. Abdominal wall reconstruction via fascial closure was achieved in 93% of cases with only 21% needing surgical component separation. Preoperative morbidity was common in patients undergoing PPP. Around 40% of all patients had postoperative complications, half of which were surgical complications. One patient died of a yet unknown cause on the third postoperative day. There were no recurrences within median 15 months follow-up. Conclusions Restoring abdominal wall continuity without frequent need for surgical component separation seems likely in CVH following CCS.

P021 OUTCOME AFTER USE OF THE STAPLED MIDLINE CLOSURE TECHNIQUE AND SELF-FIXATING MESH FOR ABDOMINAL WALL RECONSTRUCTION

Aim To evaluate surgical outcomes after introduction to our unit of the stapled opening and closure of the linea alba in reconstruction of the abdominal wall using the GIA linear stapler (linea alba stapling – LAS) and self-fixating mesh for medium and large defects. Material and Methods Since 2018, we have transitioned from the Rives – Stoppa (with or without component separation) (R-S) to the LAS technique for abdominal wall reconstruction. We compared our outcomes with the LAS technique with matched historic R-S controls (in terms of defect size, duration of surgery and skin related complications). Results Thirty-three cases of LAS reconstruction have been performed in our unit: 15 with defects larger than 10 cm. After exclusion of patients who underwent additional procedures such as adhesiolysis and bowel resection, the mean duration of surgery was 165 min. There were no skin related complications. Comparable cases who underwent R-S reconstruction took 213 min; and, wound infection developed in one patient and skin necrosis in two. Conclusions Provisional results indicate significantly lower operative times and incidence of wound complications (including infections and fluid collections). Notable advantages include a shorter skin incision, a small incision in the anterior rectus sheath to introduce the linear stapler rather than the standard laparotomy and lateral abdominal wall dissection (with ligation of perforators) necessary in the R-S method. Self-fixating mesh eliminates the requirement of sutured mesh fixation which may also be associated with more extensive dissection and longer operative times.

The Use of Botulinum Toxin in Complex Hernia Surgery: Achieving a Sense of Closure

Abdominal wall surgeons have developed a host of tools to help facilitate fascial closure. Botulinum toxin A is one of the most recently identified treatments and has grown in popularity over recent years; showing great promise in a number of case series and cohort studies. The toxin paralyses lateral abdominal wall muscles in order to increase laxity of the tissues—facilitating medialisation of the rectus muscles. Several research groups around the world are developing expertise with its use-uncovering its potential. We present a review of the relevant literature over the last two decades, summarising the key evidence behind its indications, dosing and effects.

Point-of-Care Respiratory Muscle Ultrasound in a Child with Medical Complexity

Point-of-care ultrasound of the diaphragm is a simple, noninvasive, dynamic bedside evaluation of diaphragm function that involves no ionizing radiation, does not require patient transport, and enables the serial evaluation of diaphragmatic function over time. Adverse effects on the diaphragm attributed to ventilator-induced diaphragm dysfunction include longer weaning times, ventilation time and weaning failure. Recent investigations of point-of-care ultrasound evaluating the expiratory muscles of the lateral abdominal wall have found similar adverse effects of mechanical ventilation on these important respiratory muscles resulting in weaning difficulty as well as impaired airway clearance. Children with medical complexity have significant chronic health conditions that may involve multisystem disease (congenital or acquired), high medical fragility, functional and psychosocial impairment, technology dependence (tracheostomies, mechanical ventilation, feeding tubes) and high resource utilization (frequent and/or prolonged hospitalizations). Weaning children dependent on mechanical ventilation is a common rehabilitation goal that has beneficial effects on the quality of life, ease of care, and functionality for transitioning to home care. We present a case of weaning difficulty in a child with medical complexity and the important role of point-of-care ultrasound in the evaluation of the diaphragm and expiratory muscles during a spontaneous breathing trial.

A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction

Purpose To systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome. Methods PubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients. Results We identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport® or 200–300 units of Botox® are injected at 3–5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0–4.3, I2 = 0%, p < 0.001); 6.3 cm total elongation, and a significant but heterogeneous decrease in transverse hernia width (95% CI 0.2–6.8, I2 = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02–1.16, I2 = 0%, p = 0.02)]. Conclusion The injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely. Study registration A review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246).

Abdominal Wall Expanding System. Intraoperative Abdominal Wall Expansion as a Technique to Repair Giant Incisional Hernia and Laparostoma. New and Long-Term Results From a Three-Center Feasibility Study

Background The abdominal wall expanding system (AWEX) was first applied in 2012 and published in 2017. This novel technique was developed to reconstruct complex incisional hernias and residual skin-grafted laparostoma after treatment of an open abdomen, when primary midline closure was impossible. The main aim was the anatomical reconstruction of the abdominal wall and the avoidance of dissecting techniques (component separation). Methods Between 2012 and 2019, 33 patients underwent AWEX hernia repair in three certified hernia centers. The retracted abdominal wall was stretched with the AWEX system intraoperatively for approximately 30 min. Hernia size was measured preoperatively, on CT, and intraoperatively. The gain in length on the lateral abdominal wall (decrease in width of the defect) after stretching and any residual midline gap were determined in the OR. Results 33 patients underwent AWEX procedures. Six cases were evaluated separately because of additional procedures (TAR, four cases) and preoperative application of botulinum toxin (two cases). The median (95% confidence interval) measured width of hernia defects was 13 (12–16) cm, the median gain in length on the lateral abdominal wall was 12 (10–15) cm. After median follow-up of 29 (12–54) months, one recurrence from the broken mesh was observed. No method-related complications occurred. Conclusion Based on the 2017 and current results, the AWEX system represents an alternative or supplemental procedure to current techniques for complex abdominal wall reconstruction. The system proved again to be time-saving, safe, effective, and easy to learn. Further studies with enhanced technology are in progress.