The primary lumbar hernia with multiple defects: a rare case

Lumbar hernia is a rare entity of abdominal wall hernia. Due to varied presentation it poses a challenge in diagnosis and management to attending surgeon. The requirement of preoperative imaging and clinical examination has indispensable role in the diagnosis and surgical (open or laparoscopic) approach is the only treatment option. We are presenting a case of 44 year old male, diagnosed as lumbar hernia with multiple defects and successfully managed by laparoscopic mesh hernioplasty. The primary lumbar hernia is a rare entity that a surgeon may encounter once in his lifetime making it an interesting surgical challenge. The adequate knowledge of preoperative imaging and anatomy are indispensable. With advances in minimally invasive surgery, it can be applied to patients with lumbar hernia and management requires a more tailored approach. This condition can be managed by laparoscopic approach successfully.

A Review of the Therapeutic Management of Multiple Ventricular Septal Defects

Background and Aim: We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes. including reinterventions, for each subset. Methods: We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, and associated anomalies, and the effect of severe pulmonary hypertension. Results: Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between zero and 14.2%, with morbidity estimated between 6% to 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with need for reoperation is over four times higher. Perventricular hybrid approaches are useful for closure of high anterior or apical defects. Overall, results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical sub-sets. Conclusions: We have addressed the approaches, and the results, of therapeutic treatment in terms of co-existing discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.

Umbilical hernia repair and recurrence: need for a clinical trial?

Introduction Umbilical hernia repair, despite its perceived simplicity, is associated with recurrence between 2.7 and 27%, in mesh repair and non mesh repair respectively. Many factors are recognized contributors to recurrence however multiple defects in the linea alba, known to occur in up to 30% of patients, appear to have been overlooked by surgeons. Aims This systematic review assessed reporting of second or multiple linea alba defects in patients undergoing umbilical hernia repair to establish if these anatomical variations could contribute to recurrence along with other potential factors. Methods A systematic review of all published English language articles was undertaken using databases PubMed, Embase, Web of Science and Cochrane Library from January 2014 to 2019. The search terms ‘Umbilical hernia’ AND ‘repair’ AND ‘recurrence’ were used across all databases. Analysis was specified in advance to avoid selection bias, was registered with PROSPERO (154173) and adhered to PRISMA statement. Results Six hundred and forty-six initial papers were refined to 10 following article review and grading. The presence of multiple linea alba defects as a contributor to recurrence was not reported in the literature. One paper mentioned the exclusion of six participants from their study due multiple defects. In all 11 factors were significantly associated with umbilical hernia recurrence. These included: large defect, primary closure without mesh, high BMI in 5/10 publications; smoking, diabetes mellitus, surgical site Infection (SSI) and concurrent hernia in 3/10. In addition, the type of mesh, advanced age, liver disease and non-closure of the defect were identified in individual papers. Conclusion This study identified many factors already known to contribute to umbilical hernia recurrence in adults, but the existence of multiple defects in the linea, despite it prevalence, has evaded investigators. Surgeons need to be consider documentation of this potential confounder which may contribute to recurrence.

Numerical and Experimental Investigations of Fracture Behaviour of Welded Joints with Multiple Defects

Current standards related to welded joint defects (EN ISO 5817) only consider individual cases (i.e., single defect in a welded joint). The question remains about the behaviour of a welded joint in the simultaneous presence of several different types of defects, so-called multiple defects, which is the topic of this research. The main focus is on defects most commonly encountered in practice, such as linear misalignments, undercuts, incomplete root penetration, and excess weld metal. The welding procedure used in this case was metal active gas welding, a common technique when it comes to welding low-alloy low-carbon steels, including those used for pressure equipment. Different combinations of these defects were deliberately made in welded plates and tested in a standard way on a tensile machine, along with numerical simulations using the finite element method (FEM), based on real geometries. The goal was to predict the behaviour in terms of stress concentrations caused by geometry and affected by multiple defects and material heterogeneity. Numerical and experimental results were in good agreement, but only after some modifications of numerical models. The obtained stress values in the models ranged from noticeably lower than the yield stress of the used materials to slightly higher than it, suggesting that some defect combinations resulted in plastic strain, whereas other models remained in the elastic area. The stress–strain diagram obtained for the first group (misalignment, undercut, and excess root penetration) shows significantly less plasticity. Its yield stress is very close to its ultimate tensile strength, which in turn is noticeably lower compared with the other three groups. This suggests that welded joints with misalignment and incomplete root penetration are indeed the weakest of the four groups either due to the combination of the present defects or perhaps because of an additional unseen internal defect. From the other three diagrams, it can be concluded that the test specimens show very similar behaviour with nearly identical ultimate tensile strengths and considerable plasticity. The diagrams shows the most prominent yielding, with an easily distinguishable difference between the elastic and plastic regions. The diagrams are the most similar, having the same strain of around 9% and with a less obvious yield stress limit.

Robust Guided Wave Tomography Method for Large and Irregular Defects

Finding a fast, robust way to quantitatively measuring the remaining wall thickness of complex structures when multiple defects exist is one of the leading challenges in Nondestructive Testing (NDT). Traditional inversion algorithms like ray tomography and full waveform inversion (FWI) suffered from problems like convergence, limited resolution and slow speed. Diffraction tomography (DT) has speed advantage over the preceding methods and its resolution can be further amplified by integrating with other methods like bent-ray tomography and iteration. However, DT can only detect shallow and small defects. Compared with those methods, convolutional neural network (CNN) opens a new way for quantitative defect imaging, as with pre-trained data it can achieve significant speed and resolution than the traditional methods. In this paper, we investigated the performance of CNN in imaging multiple defects and the inversion results show that when dealing with multiple defects with complex shape on a plate-like structure, CNN can achieve better resolution than other methods with maximum errors below 0.54mm in most regions. This research provides the experimental guidance for future study in finding the possible ways to improve the resolution of the algorithms.

P–049 The presence of double heads is associated with increased frequency of the other sperm abnormalities

Study question Is there an association between the presence of spermatozoa with double heads and the other sperm abnormalities in human semen? Summary answer Patients with double-headed spermatozoa had a significantly increased percentage of morphological abnormalities (head, midpiece and tail defects). What is known already The morphological evaluation of spermatozoa has a prognostic value for successful IVF procedure. It has been proven that certain morphological defects have a negative impact on fertilization, embryo quality, and pregnancy outcome in in-vitro fertilization cycles. Sperm abnormalities, such as double head, double tail and thin midpiece are rarely observed. However, their effect on the other sperm defects has not been well studied yet. The aim of this study was to examine the effect of the presence of double-headed spermatozoa on the frequency of occurrence of the other sperm defects. Study design, size, duration This retrospective study includes 2140 men aged between 18 and 73 years, with a mean of 36 years. It was conducted at Nadezhda Women’s Health Hospital, Bulgaria between October 2015 and August 2020. A comparative analysis was performed between semen samples with and without double-headed spermatozoa and the other sperm abnormalities, as well as the percentage of morphologically normal forms. Participants/materials, setting, methods Morphological analysis was performed according to the Kruger’s strict criteria. Totally 23 types of abnormalities were determined: head defects (small, large, amorphous, elongated, round, pear-shaped, double, acephalic, detached head, small and large acrosomal areas and spermatozoa without acrosome), midpiece defects (thick, bent, asymmetric, thin midpiece and cytoplasmic droplets), tail defects (stumped, coiled and double tail), acrosomal vacuoles, nuclear vacuoles and multiple defects. Statistics: Mann-Whitney U-test and T-test; P ≤ 0.05. Main results and the role of chance Presence of double-headed spermatozoa was observed in 12.62% (270/2140) of the studied samples. In these patients the frequency of occurrence of double-headed spermatozoa ranged between 1% and 29% with a mean of 0.41%±1.71%. Men with double-headed spermatozoa had significantly higher percentage of spermatozoa with small heads (24.51%±22.65%, P = 0.04), round heads (11.69%±10.13%, P < 0.01), nuclear vacuoles (10.64%±5.25%, P < 0.01), sperm without acrosome (9.76%±8.61%, P = 0.05), asymmetric midpiece (4.73%±3.96%, P < 0.05), bent midpiece (8.9%±7.22%, P < 0.01), thin midpiece (2.13%±4.44%, P < 0.01), double tail (1.78%±0.8%, P < 0.01), detached head (1.98%±1.42%, P < 0.01), stumped tail (6.03%±5.19%, P = 0.02), and cytoplasmic droplets (8.86%±5.02%, P < 0.01) compared to the patients without double-headed spermatozoa. Moreover, the percentage of sperm with multiple defects in the double-headed group was significantly higher (35.53%±29.91%, P < 0.01), while the percentage of normal forms was significantly lower (2.93%±3.64%, P < 0.01) compared to the patients without double heads. Limitations, reasons for caution In this study unequal sample sized groups were compared. We also need to investigate whether the obtained results will be confirmed in patients with certain pathological states, such as oligozoospermia, teratozoospermia, and asthenozoospermia. Wider implications of the findings: The present study revealed that the presence of double-headed spermatozoa in the ejaculate is related to an increased frequency of the other semen abnormalities. The double-headed spermatozoa could be used as an indicator for the total morphological quality of human spermatozoa Trial registration number Not applicable

P–007 Effect of swim-up on sperm morphology

Study question To evaluate the effect of swim-up on the percentage of certain morphological defects in the semen population Summary answer Swim-up preparation led to significantly lower percentage of spermatozoa with cytoplasmic droplets, thick neck and also multiple defects. What is known already Swim-up is routinely used sperm preparation technique in ART practice. It is widely known that swim-up enhances sperm quality in terms of motility and sperm morphology. However, the effect of swim-up on the frequency of occurrence of the specific sperm morphological abnormalities is still missing. Study design, size, duration This observational study involved 30 teratozoospermic patients of Nadezhda Women’s Health hospital between December 2020 and January 2021. Sperm morphology was evaluated before and after swim-up preparation. Participants/materials, setting, methods Native semen was liquefied and was subjected to swim up. Semen analysis performed according to WHO 2010. Native semen and swim up samples from the same men were subjected to Kruger strict morphological evaluation. The analyzed sperm morphological defects included: head defects (large, small, tapered, pyriform, round, amorphous and double heads); midpiece defects (bent, asymmetrical, thin, thick, presence of cytoplasmic droplet); tail defects (short, hairpin, bent, coiled tail and terminal droplet) and multiple defects. Main results and the role of chance Wilcoxon paired test showed that the percentage of morphologically normal spermatozoa was significantly higher in the swim-up samples in comparison to the native semen (8.5±4.2% vs 4.9±3.2%, p < 0.05). In addition, the percentage of spermatozoa bearing multiple defects was found to be significantly lower in the swim-up samples than in the native semen (25.8±11.6% vs 37.0±15.0%, p < 0.05). Two specific sperm morphological defects were found to be significantly lower after swim-up preparation: the presence of cytoplasmic droplets (6.0±1.0% vs 8.6±1.5%, p < 0.05) and the thick neck (9.7±5.5% vs 12.8±5.8%, p < 0.05). No significant different were observed in the other morphological defects between swim up samples and native semen (p > 0.05). Limitations, reasons for caution Results obtained from this study need to be confirmed by larger group of samples. Wider implications of the findings: Our study showed a significant reduction of certain midpiece defects after swim-up. The observed selection of spermatozoa without thick necks and cytoplasmic droplets explains the effectiveness of swim-up on ART. In addition, the obtained results can serve as a guide for future validation of new sperm preparation techniques. Trial registration number Not applicable