The Preservation of Umbilical Blood Supply in Combined Ventral Hernia Repair and Abdominoplasty: A Narrative Review.

INTRODUCTION: Combined ventral hernia repair and abdominoplasty treat risk factors such as high body mass index and weak abdominal musculature, providing excellent intraoperative exposure and improved patient outcomes. Unfortunately, a combination of traditional procedures is unfeasible as the umbilical blood supply would be compromised, leading to increased umbilical necrosis risk. This narrative review aimed to identify new techniques and solidify evidence in preserving umbilical blood supply and associated level of evidence. METHODS: Two authors conducted a thorough literature search on PubMed, Scopus and Cochrane CENTRAL databases from January 1901 to July 2023, adhering to the methodologies of the preferred reporting items for systematic reviews and meta-analyses. Studies were reviewed for their surgical technique and quality of evidence. The primary outcomes of interest consisted of umbilical complications of this combined procedure. RESULTS: Six techniques were identified that included laparoscopic, pre-rectus, unilateral, distal bilateral, proximal bilateral, and inferior midline approaches. All techniques demonstrated as viable options in preserving umbilical blood supply as reported complications were few, minor, and compounded by risk factors. However, all included techniques were limited to low-to-moderate-quality evidence. CONCLUSION: Despite the lack of high-quality evidence, all techniques remain viable options for combined ventral hernia repair and abdominoplasty. Large-scale high-quality RCTs are required to compare the effectiveness of various approaches with additional outcomes of hernia recurrence rates, intraoperative time, and patient- and surgeon-reported satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Incisional abdominal hernia repair with concomitant abdominoplasty: Maintaining umbilical viability.

INTRODUCTION: Abdominoplasty and abdominal hernia repair are often carried out in two-stage procedures, and those describing single-stage surgery require careful dissection to preserve often only partial blood supply to the umbilicus to maintain its viability. This paper aims to describe the surgical method of laparoscopic umbilical hernia repair in association with abdominoplasty. CASE PRESENTATION: A patient presents with an incisional hernia at a previous periumbilical port site of size 14 x 9 mm observed on ultrasound as well as a recurrent left inguinal hernia from previous bilateral laparoscopic inguinal hernia repair, oophorectomy, and laparoscopic cholecystectomy. A laparoscopic mesh repair of the hernia defect followed by abdominoplasty was performed. The patient made an uncomplicated recovery and was discharged home on day 5 post operation. There was complete healing of the umbilicus and remainder of the wounds. At 24-month follow-up, there was no recurrence of hernia. CONCLUSION: Previously documented methods of concomitant abdominoplasty and hernia repair use an open technique to repair the hernia. A laparoscopic approach is faster, but it poses a significant risk to the vascular supply to the umbilicus. This not only increases positive aesthetic outcomes and patient satisfaction but also reduces rates of postoperative complications and recovery time.

The Role of CT cholangiography in the Detection and Localisation of Suspected Bile Leakage Following Cholecystectomy.

BACKGROUND: Most bile duct injuries are not recognized at the time of initial surgery. Optimal treatment requires early recognition. CT IVC has become increasingly important in identifying bile leaks and their source after cholecystectomy. Our study aims to report the outcomes of using CT IVC post operatively and how accurately it can detect or localise bile leaks. METHODS: From 2000 - 2009, twenty patients were managed for suspected bile leak post cholecystectomy within the Alfred Hospital. The study included a retrospective evaluation of the initial procedure, presenting symptoms, site of ductal injury, diagnostic procedures and therapeutic interventions. Results were analysed to determine success of the imaging procedure, and to correlate imaging diagnosis with results both diagnostically and clinically. RESULTS: Twenty patients had a suspected bile leak, of which 3 were detected at the time of surgery. Seven patients had a CTIVC as their primary investigation. It identified bile leak in 6 and the anatomical site in 5. One had a leak excluded and was managed conservatively. CONCLUSIONS: CT Cholangiography is a feasible and low-risk tool for imaging of the biliary tract in suspected bile leaks post cholecystectomy. It is a valuable non-invasive investigation that may help avoid endoscopic retrograde Cholangiography or surgery.

Reducing band slippage in laparoscopic adjustable gastric banding: the mesh plication pars flaccida technique.

BACKGROUND: Band slippage is a significant complication of laparoscopic adjustable gastric band (LAGB) surgery for the treatment of morbid obesity. This involves prolapse of part of the stomach, with varying degrees of gastric obstruction. The original perigastric technique (PGT) was associated with slippage rates of up to 25%. The pars flaccida technique (PFT) is the more commonly used technique today, reducing slippage rates to as low as 1.4%. We report a technique not previously described, the modified PFT with the use of mesh, and compare slippage rates between these three techniques for band placement. METHODS: A prospectively entered, retrospective review of 1,446 consecutive patients undergoing LAGB by a single surgeon was undertaken. Patients were divided into five consecutive groups: PGT learning curve (PGTLC) (n = 68), PGT (n = 19), mesh PFT (MPFT) (n = 415), mesh plication PFT (MPPFT) (n = 131), and MPPFT with inadequate follow-up (n = 813). Patient characteristics, band slippage, and other complication rates were compared between groups. RESULTS: The slippage rates for each group were: PGTLC (10%), PGT (5%), MPFT (0.8%), and MPPFT (0%). This demonstrated a statistically significant difference between the slippage rates for each group (p < 0.001). Combining the MPFT and MPPFT groups, there was a statistically significant difference in band slippage compared to the PGT group (p < 0.001). CONCLUSION: While the MPFT is associated with low band slippage rates, the MPPFT results in further reductions in band slippage. The routine use of this modification to the MPFT is safe and may reduce operative morbidity. A randomized comparison of these techniques is warranted.

Preventing postoperative haematomas in microvascular reconstruction of the head and neck: lessons learnt from 126 consecutive cases.

BACKGROUND: Free tissue transfer has become a safe and reliable means for repairing soft tissue and bony defects of the head and neck. Although operative success has reached 98%, the incidence of significant postoperative complications is also relatively high (32%). One common and significant complication is haematoma formation, occurring at both donor and recipient sites, and yet there are minimal published studies on its incidence, aetiology or outcome. A retrospective analysis of both donor- and recipient-site wound haematoma was carried out to identify causative factors and the effect on patient outcome. METHODS: A 5-year review of 132 consecutive microvascular free tissue transfers to head and neck defects at The Royal Melbourne Hospital, for the period February 2001 to February 2006, was conducted. RESULTS: Of 126 included cases, 27 postoperative haematomas resulted. Statistically significant associations were found for each of smoking, non-steroidal anti-inflammatory drug use and the use of corticosteroids preoperatively with the incidence of postoperative haematoma formation. Postoperative blood pressure control and the adequacy of primary tumour excision at the flap recipient site were also found to have significant associations with haematoma formation. Drain tube outputs served as accurate indicators for haematoma. CONCLUSION: There are significant reversible factors that contribute to the development of postoperative haematomas in head and neck reconstructive surgery. Preoperative modifications should, therefore, be sought. Similarly, close monitoring of patient blood pressure during the initial 24 h postoperative period by theatre and recovery staff is important, as is the adequacy of postoperative analgesia.

A tale of two colleges: do specialist trainees receive adequate hospital-based training?

BACKGROUND: Both medical and surgical trainees have a dual reliance on their specialist training college and their respective teaching hospitals to maintain standards in teaching and training. Although guidelines are in place for the administration of this teaching, hospital-based teaching has been minimally regulated. A review of trainee satisfaction with current levels of hospital-based training was performed, both to reflect the thoughts of trainees themselves and to highlight specific areas requiring improvement. METHODS: Sixty-four basic specialist trainees (44 surgical [BSTs] and 20 physician [BPTs]) from all of the major Melbourne metropolitan teaching hospitals completed an anonymous survey. RESULTS: Surgical trainees considered all areas of hospital-based training to be deficient, with overall dissatisfaction significantly greater for BSTs compared with BPTs (P=0.046). A requirement for increased hospital-based training was similarly greater for BSTs (P=0.0072). CONCLUSION: The study confirms the need for a change in the regulation and administration of hospital-based teaching for surgical trainees.