OV08 TREATMENT OF THE INGUINAL HERNIA USING THE SHOULDICE REPAIR

Aim The Shouldice procedure is a layered reconstruction of the posterior wall in inguinal hernia repair and currently the preferred method if the layers of the abdominal wall are of good quality, the wish of the patient for a non-mesh repair and if a mesh method is not possible or available. The correct performance of the reconstruction of the posterior wall is essential part of the operation. Material and Methods A life educational video was made with the four-layer reconstruction in detail. The first layer of the reconstruction starts at the medial corner and the conjoint tendon is sutured to the caudal flap of the transversalis fascia using a continuous non resorbable suture. The second layer of the reconstruction is made by approximating the cranial flap of the transversalis fascia and the posterior part of the inguinal ligament. The third layer starts at the level of the deep internal inguinal ring and approximates the lower border of the internal oblique muscle with the inguinal ligament. The fourth and final layer approximates the internal oblique muscle again with the inguinal ligament. Results The four-layer reconstruction after splitting the transversalis fascia is shown in detail since treatment of the hernia sac is like the other techniques. Conclusions The instructional video can be used for the resident training as a start in a hernia course followed by the execution on a model before the actual execution on a patient.

P029 HOW DOES THE MADRID APPROACH WORK

Aim The Madrid APPROACH is the combination of an absorbable mesh and a permanent retromuscular mesh for the treatment of the complex abdominal wall problems. It has been controversial because of the need of two different meshes. We present a clinic case to show the utility of this technique and how it allows rebuilding the inguinal ligament. Material and Methods 78 years old woman who underwent a right ilioinguinal and obturatriz lymphadenectomy due to a melanoma. Incisional hernia fixed in 2018 with a retromuscular polyester mesh. New incisional iliac hernia (L3) over the right iliac vessels, with an absence of inguinal ligament, right rectus atrophy, and the previous mesh being part of the sac. Surgery: incision over the previous scar. Wide dissection of the preperitoneal space, Retzius space and lateral to the cuadratus lumborum, retrodiafragmatic dissection, lateral transverse abdominus release, and cross-over to the retrorectal left space. Preperitoneal BioA mesh and an upper 40x40cm medium weight polipropilene mesh set to both Cooper ligaments. Results After two and a half months, a PET-TC showed the BioA mesh perfectly adapted to the abdominal wall and rebuilt a new inguinal ligament. Also intense FDG capitation of the mesh due to the high cellular metabolism. Two years later the patient has a continent abdominal wall, the follow up TC shows the disappearance of the absorbable mesh and the perfect abdominal wall rebuilt. Conclusions The BioA mesh acts like a tissue scaffold for new conjunctive tissue as we see the intense FDG captation. The Madrid APPROACH allows giving response to very complex abdominal wall problems.

Combined Correction of Experimental Critical Ischemia of the Lower Extremities in a Rat Model

The purpose of our research was to study the effectiveness of correcting experimental critical ischemia (CI) of the lower extremities with a combination of udenafil, simvastatin, and autologous bone marrow mononuclear cells (ABMMC). Methods and Results: The experiments were carried out on 24-month-old Wistar rats, weighing 220–250g. The animals were randomized by sex and weight. Groups were formed according to the manipulations carried out during the operations. The animals were divided into 7 groups, each with 20 animals: Group 1 included intact animals; Group 2 - falsely operated animals; Group 3 (control group) - animals with simulated CI without treatment; Group 4- animals with CI and monotherapy with udenafil (daily oral administration of 8.6mg/kg for 28 days); Group 5 - animals with CI and simvastatin monotherapy (daily oral administration of 1.71mg/kg for 28 days); Group 6 - animals with CI and monotherapy with ABMMC (parenterally, once on Day 7 after modeling CI, 50μl at 4 points and, paravasally, above the inguinal ligament in the area where the lateral artery leaves the artery enveloping the femur from the internal iliac artery; in the area of the superficial artery that bends around the iliac bone under the inguinal ligament; into the area of origin of the muscular branch of the femoral artery r. muscularis, the place of attachment of the comb and long adductor muscles of the thigh; in the upper third of the gastrocnemius muscle]); Group 7 - animals with CI and combination therapy (udenafil and simvastatin drugs were administered intragastrically 0.86 mg/kg, once a day, for 7 days) and one-time parenteral administration of ABMMC, according to the same scheme as in Group 6. On Days 21 and 28 of the experiment, the level of blood microcirculation was determined in the muscles of the rat leg; for this, laser Doppler flowmetry was used. For further morphometric assessment of the leg muscles, they were removed. Preparations for morphometric analysis were prepared according to the standard technique with Van Gieson staining, as well as H&E. Our study demonstrated the effectiveness of combination therapy with udenafil, simvastatin, and ABMMC to correct critical lower limb ischemia in rats. The severity of morphological changes on the background of this combination was minimal, compared to the findings of other study groups, and the level of blood microcirculation in the ischemic zone on Day 28 was, significantly, 1.9 times higher than in animals of the control group. The results obtained allow us to recommend the use of the investigated combination (udenafil+simvastatin+ABMMC) for the treatment of patients with critical limb ischemia, both in outpatient and inpatient practice.

712 Outcomes of Infrainguinal Stents in Peripheral Arterial Disease

Background Endovascular therapy is an established treatment for peripheral arterial disease. In aortoiliac disease, above the inguinal ligament, percutaneous transluminal angioplasty (PTA) + stent results in good long-term patency rates[1]. In comparison, long-term patency rates of PTA + stent in femoropopliteal disease, below the inguinal ligament are inferior, despite advancements in stent technology[2]. Multi-level disease is more common, lesions are often longer in length and rates of re-stenosis remain high. There is a paucity of data of long-term outcomes in infrainguinal stents and therefore debate to what the optimal treatment strategy should be[3]. Method 5-year retrospective analysis of 59 patients between 2014 and 2019 in a UK regional vascular centre. Patients with Rutherford Score 3 - 6 were treated by Vascular Surgeons and Interventional Radiologists with PTA + stent. Outcomes included patency at 6, 12, 24, 36 months, need for revascularisation/reintervention, major amputation, and death. Results 12% of stents occluded at 30 days and 39% of stents occluded at 12 months. 34% patients required further intervention (PTA, femoropopliteal bypass, amputation) and 7 out of 59 (12%) target limbs were amputated. Conclusions Whilst PTA + stent demonstrates an effective intervention for a selection of patients, it is evident that further work is required in order to identify the best treatment strategy and most clinically useful outcome measure.

Femoral Hernia: Open and Laparoscopic Surgery Approaches

Femoral hernia comes out of abdominal cavity through the femoral canal and descends vertically to saphenous opening, and once escapes this opening it expands considerably, sometimes rising above the inguinal ligament. Due to its tortuous course, the hernia is usually irreducible and liable to strangulate. There are different open surgery choices. In low (Lockwood) operation, the sac is dissected out below the inguinal ligament via a groin-crease incision. In high (McEvedy) operation, the hernia is accessed via a horizontal (or vertical) incision made in lower abdomen at the lateral edge of rectus muscle. In Lotheissen’s operation, the hernia is approached through the inguinal canal. The last one is my preferred approach, as it also helps in dealing if the contents are strangulated. The laparoscopic approaches include both transabdominal preperitoneal repair (TAPP) and total extraperitoneal repair (TEP). This chapter will give an account of the advantages and disadvantages of these different surgical techniques.

ANATOMICAL VARIATIONS OF THE ORIGIN OF PROFUNDA FEMORIS ARTERY – A CADAVERIC STUDY

INTRODUCTION: The Profunda Femoris Artery (PFA) is a large branch arises from the lateral or posterolateral part of the Femoral Artery (FA), about 3 to 5cm below the inguinal ligament. The PFA is in close proximity to femoral vessels in the femoral triangle the precise anatomical knowledge of PFA and its branches is of great signicance in preventing profuse haemorrhage, pseudo aneurysms and traumatic AV stulae while doing any procedures or surgeries in that area. AIM & OBJECTIVES: To study the anatomical variations in source of origin, site of origin and distance of origin from midpoint of inguinal ligament of PFA. MATERIALS AND METHODS: The present observational study was conducted on the dissection of 70 lower limbs of 35 adult cadavers (27 male & 8 female) in the Department of Anatomy S.V.S Medical College, Mahabubnagar over a period of 2 years. Contents of the femoral triangle were dissected as per Cunningham's manual. The source of origin, site, distance of origin from mid points of inguinal ligament and course of PFA were noted. Collected data was analysed statistically. RESULTS: In the present study the PFA was arising from the femoral artery in all these 70 Lower Limbs. The commonest site of origin of PFA was postero lateral side of femoral artery in 17 (48.6%) Limbs on right side, 16(45.8%) limbs on left side, followed by lateral side of FA in14(40%) limbs on right side, 12(34.3%) limbs on left side ,followed by posterior in 4(11.4%) limbs on each side. The PFA was originating from medial side of FA only in 3 (4.29%) left limbs The PFA was taking origin below the inguinal ligament most commonly at the distance of 3-4cm in 10(29) limbs on right side, 15(43%) limbs on left side and at 4-5cm in 8(23%) limbs on right side, 5(14%) limbs on left side, at 2-3cm in 8 (23%) limbs on right side, 6(17%) limbs on left side, at 5-7cm in 3(8.5%) limbs on right in 1 (3%) limbs on left side. The PFA was taking origin higher level with in 2cm below the midpoint of inguinal ligament in 6 (17%) limbs on right side, 8(23%) limbs on left side. CONCLUSIONS: The knowledge of site and level of origin of Profundafemoris artery helps in avoiding the formation of iatrogenic femoral arteriovenous stula (0.1-1.5%) while performing femoral artery puncture during femoral puncture, cardiac catheterisation and radiological procedures