http://www.chcs.org.cn/upload/2014-09/14091721577197.pdf

Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(03)14746-0.pdf

Hernias: inguinal and incisional

Background : Previous studies have demonstrated high complication rates after harvest of iliac crest bone grafts. This study was undertaken to compare the morbidity related to the harvest of anterior iliac crest bone graft with that related to the harvest of posterior iliac crest bone graft and to determine differences in functional outcome.

Methods : The medical records of eighty-eight consecutive patients who had undergone a total of 108 iliac crest bone-grafting procedures for the treatment of chronic osteomyelitis from 1991 to 1998 were retrospectively reviewed. Demographic characteristics, the location of the harvest, the volume of bone graft that was harvested, the estimated blood loss, and postoperative complications were recorded. Fifty-eight patients completed a questionnaire pertaining to postoperative and residual pain, sensory disturbances, functional limitations, cosmetic appearance, and overall satisfaction with the bone-graft harvesting procedure.

Results : Sixty-six anterior and forty-two posterior bone-graft harvest sites were evaluated at a minimum of two years after the operation. A major complication was associated with 8% (five) of the sixty-six anterior sites and 2% (one) of the forty-two posterior sites. The rates of minor complications were 15% (ten) and 0%, respectively. In the series as a whole, there were ten minor complications (9%) and six major complications (6%). The rates of both minor complications (p = 0.006) and all complications (p = 0.004) were significantly higher after the anterior harvest procedures than they were after the posterior procedures. The postoperative pain at the donor site was significantly more severe (p = 0.0016) and of significantly greater duration (p = 0.0017) after the anterior harvests. No patient reported functional limitations at the latest follow-up evaluation.

Conclusions: In this series, the complication rate was lower than those previously reported by other investigators. Harvest of a posterior iliac crest bone graft was associated with a significantly lower risk of postoperative complications. On the basis of the results of this study, we recommend that iliac crest bone graft be harvested posteriorly whenever possible.

Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes.

In spite of an enormous amount of new experimental laboratory data based on evolving neuroscientific concepts during the last 25 years peripheral nerve injuries still belong to the most challenging and difficult surgical reconstructive problems. Our understanding of biological mechanisms regulating posttraumatic nerve regeneration has increased substantially with respect to the role of neurotrophic and neurite-outgrowth promoting substances, but new molecular biological knowledge has so far gained very limited clinical applications. Techniques for clinical approximation of severed nerve ends have reached an optimal technical refinement and new concepts are needed to further increase the results from nerve repair. For bridging gaps in nerve continuity little has changed during the last 25 years. However, evolving principles for immunosuppression may open new perspectives regarding the use of nerve allografts, and various types of tissue engineering combined by bioartificial conduits may also be important. Posttraumatic functional reorganizations occurring in brain cortex are key phenomena explaining much of the inferior functional outcome following nerve repair, and increased knowledge regarding factors involved in brain plasticity may help to further improve the results. Implantation of microchips in the nervous system may provide a new interface between biology and technology and developing gene technology may introduce new possibilities in the manipulation of nerve degeneration and regeneration.

A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance.

Several nerve guidance conduits (NGCs) and nerve protectant wraps are approved by the US Food and Drug Administration (FDA) for clinical use in peripheral nerve repair. These devices cover a wide range of natural and synthetic materials, which may or may not be resorbable. This review consolidates the data pertaining to all FDA approved materials into a single reference, which emphasizes material composition alongside pre-clinical and clinical safety and efficacy (where possible). This article also summarizes the key advantages and limitations for each material as noted in the literature (with respect to the indication considered). In this context, this review provides a comprehensive reference for clinicians which may facilitate optimal material/device selection for peripheral nerve repair. For materials scientists, this review highlights predicate devices and evaluation methodologies, offering an insight into current deficiencies associated with state-of-the-art materials and may help direct new technology developments and evaluation methodologies thereof.

FDA approved guidance conduits and wraps for peripheral nerve injury: A review of materials and efficacy

Closure of large abdominal-wall defects usually requires the transposition of remote myocutaneous flaps or free-tissue transfers. The purpose of this study was to determine if separation of the muscle components of the abdominal wall would allow mobilization of each unit over a greater distance than possible by mobilization of the entire abdominal wall as a block. The abdominal walls of 10 fresh cadavers were dissected. This demonstrated that the external oblique muscle can be separated from the internal oblique in a relatively avascular plane. The rectus muscle with its overlying rectus fascia can be elevated from the posterior rectus sheath. The compound flap of the rectus muscle, with its attached internal oblique-transversus abdominis muscle, can be advanced 10 cm around the waistline. The external oblique has limited advancement. These findings were utilized clinically in the reconstruction of abdominal-wall defects in 11 patients, ranging in size from 4 x 4 to 18 x 35 cm. This study suggests that large abdominal-wall defects can be reconstructed with functional transfer of abdominal-wall components without the need for resorting to distant transposition of free-muscle flaps.

“Components Separation” Method for Closure of Abdominal-Wall Defects: An Anatomic and Clinical Study

Microneurosurgical techniques to reconstruct nerve gaps with nerve grafts frequently fail to achieve excellent functional results and create donor-site morbidity. In the present study, 15 patients had gaps of 0.5 to 3.0 cm (mean 1.7 cm) in digital nerves reconstructed by one surgeon with a bioabsorbable polyglycolic acid (PGA) tube. A final evaluation of sensibility was done by a second surgeon at a mean postoperative interval of 22.4 months (range 11 to 32 months). These were all secondary reconstructions. The evaluation included a digital nerve block with local anesthetic for the intact (not reconstructed) digital nerve. Excellent functional sensation (moving two-point discrimination less than or equal to 3 mm and/or static two-point discrimination less than or equal to 6 mm) was present in 33 percent and good functional sensation (moving two-point discrimination of 4 to 7 mm and/or static two-point discrimination of 7 to 15 mm) in 53 percent of the digital nerve reconstructions. One patient with poor sensory recovery and one with no recovery were judged as functional failures (14 percent). Absence of pain at the site of reconstruction was judged by the patient to be excellent in 40 percent, good in 33 percent, and poor in 27 percent. We conclude that reconstruction of nerve gaps of up to 3.0 cm with a bioabsorbable PGA tube gives clinical results at least comparable to the classic nerve graft technique while avoiding donor-site morbidity.

Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube

The successful treatment of the painful neuroma remains an elusive surgical goal. This report evaluates one approach to the management of this problem which entails neuroma excision and placement of the proximal end of the nerve away from denervated skin, away from tension, and into a well-vascularized environment: muscle. Seventy-eight neuromas in 60 patients with a mean follow-up of 31 months (range 18 to 43 months) were evaluated. Sixty-seven percent of these patients involved Workmen's Compensation and 57 percent had had at least one previous operation to treat their pain. The results demonstrated good to excellent results in 82 percent of the treated nerves in the entire group. Factors that were predictive of a poorer outcome were (1) digital neuroma (p less than 0.0005), (2) Workmen's Compensation (p less than 0.01), and (3) three or more previous operations for pain (p less than 0.01). Transposition of nerves into small superficial muscles or muscles with significant excursion resulted in treatment failures. The etiology and histopathology of treatment failures are reviewed. Treatment of radial sensory neuromas by transposition of the radial sensory nerve into the brachioradialis muscle when any associated injury to the lateral antebrachial cutaneous nerve was also treated, gave good to excellent relief of pain, and improved hand function in 88 percent of the patients.

Treatment of the painful neuroma by neuroma resection and muscle implantation.

Three cases are reported to illustrate the potential danger of silicon-polymer intubulation of nerve for either nerve repair or following neurolysis Since silicon-polymer intubulation of nerve is now a proven model for producing chronic nerve compression, its use clinically may be contraindicated where neural regeneration is the desired goal

Complications from silicon-polymer intubulation of nerves.

Reconstruction of a short nerve gap by a nerve graft produces donor-site scarring, loss of donor nerve function, and neuroma formation. This study compared the regeneration achieved after 1 year in 16 monkeys across a 3-cm upper arm ulnar nerve gap with a bioabsorbable polyglycolic acid nerve condui

A. L. Dellon

Papers

“Components Separation” Method for Closure of Abdominal-Wall Defects: An Anatomic and Clinical Study

Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube

Treatment of the painful neuroma by neuroma resection and muscle implantation.

Complications from silicon-polymer intubulation of nerves.

An alternative to the classical nerve graft for the management of the short nerve gap.