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Reparación endoscópica prefascial de la diástasis de los rectos: descripción de una nueva técnica
Abstract
Introducción. La diástasis de los rectos es una secuela habitual tras el embarazo y puerperio. Se asocia frecuentemente a hernias de la línea media. Representa un problema estético y sintomático. El abordaje endoscópico prefascial podría resolver el defecto parietal con buenos resultados cosméticos. Objetivo: Describir un abordaje endoscópico prefascial. Material y métodos. Se presentan los casos de dos pacientes con diástasis de rectos de 46 mm y 68 mm, asociadas a hernia umbilical de 13 mm y 20 mm, respectivamente. Consultaron por dolor y tumoración epigástrica y umbilical, con un IMC menor de 30. Abordaje suprapúbico y ambas fosas ilíacas. Se crea neocavidad prefascial. Se realizó plicatura de los rectos con sutura barbada de polipropileno núm. 0 y descarga del oblicuo externo izquierdo a lo Albanese en la diástasis de mayor tamaño. Se colocó malla preaponeurótica de polipropileno de baja densidad. Se fijó con tackers absorbibles. El tiempo quirúrgico promedio fue de 107 minutos. Se dejaron drenajes aspirativos 48 horas. Resultados. No se registraron complicaciones intra- ni posoperatorias. El dolor posoperatorio máximo fue 3/10, según VAS, y la estancia hospitalaria, de dos días. La reinserción laboral tuvo lugar a los 14 días, y el seguimiento posoperatorio, de 20 meses. Hubo control clínico y ecográfico a los 12 meses, sin recidiva. La satisfacción de las pacientes fue del 100 %. Conclusiones. La cirugía endoscópica nos permitió resolver el defecto parietal con plicatura de los rectos y colocación de prótesis preaponeurótica, aumentando la seguridad de la plastia, disminuyendo la posibilidad de recidiva y sin entrar en la cavidad abdominal, con bajo nivel de dolor posoperatorio y buen resultado cosmético
... Además, la interpretación y el tratamiento de la patología de la pared abdominal como una unidad funcional (core) ha permitido comprender cómo otras patologías asociadas a la DRA (p. ej., lumbalgia, dolores pelvianos, constipación, entre otros) mejoran luego de su corrección [1][2][3][4][5] . Por lo tanto, se han descripto varias estrategias para el tratamiento de la DRA, y son en la actualidad los abordajes laparoendoscópicos como las técnicas: REPA (Reparación Endoscópica PreAponeurótica), e-TEP (extended-Totally ExtraPeritoneal) y eMILOS (endoscopic-Mini or Less Open Sublay technique) los más utilizados [5][6][7] . ...
... ej., lumbalgia, dolores pelvianos, constipación, entre otros) mejoran luego de su corrección [1][2][3][4][5] . Por lo tanto, se han descripto varias estrategias para el tratamiento de la DRA, y son en la actualidad los abordajes laparoendoscópicos como las técnicas: REPA (Reparación Endoscópica PreAponeurótica), e-TEP (extended-Totally ExtraPeritoneal) y eMILOS (endoscopic-Mini or Less Open Sublay technique) los más utilizados [5][6][7] . ...
... Therefore, several strategies have been described for the treatment of DRA. Currently, the most widely used laparoendoscopic techniques are REPA (endoscopic preaponeurotic repair), e-TEP (enhanced-view Totally ExtraPeritoneal), and eMILOS (Endoscopic Mini-or Less-open Sublay) approaches [5][6][7] . ...
Background:
Midline hernias associated with diastasis recti abdominis (DRA) are common. Simultaneous treatment of both conditions has been recommended to reduce recurrence. Minimally invasive techniques allow adequate treatment while reducing surgical site complications. However, there is still no consensus regarding the optimal technique.
Objective:
The aim of this study was to evaluate the short and mid-term outcomes of Trans-umbilical Endoscopic Sublay Repair (TESuR) in patients with midline defects and DRA.
Material and methods:
We conducted a retrospective descriptive observational study of patients undergoing TESuR between December 2020 and May 2023, with a minimum postoperative follow-up of 6 months. The demographic and perioperative variables were analyzed.
Results:
A total of 24 procedures were performed during the study period. All the patients were men. Mean age was 57 years (range 41-81) and body mass index (BMI) was 28.9 (21.7- 36.1) kg/m². Mean size of the defect was 8.8 cm2 (4-25) with a mean diastasis width of 5 cm (3-9). The rate of complications at 30 days was 17% (4/24) and were all are grade 1 of the Clavien-Dindo classification. After a mean follow-up of 18.6 months (range 6-25), there were no hernia recurrences, although 2 patients (8%) had a recurrence of DRA.
Conclusions:
TESuR showed low morbidity rate and absence of recurrences, constituting a safe and effective option for the management of DRA associated with midline defects.
... Posteriormente, la técnica se publicó en el año 2017 con buenos resultados y satisfacción de los pacientes 11,13,14 . Este abordaje endoscópico preaponeurótico nos permite resolver ambos problemas con la colocación de una prótesis de refuerzo supraaponeurótica, sin ingresar a la cavidad abdominal, con buenos resultados funcionales y cosméticos 1,2,7,8,14 . ...
... Posteriormente, la técnica se publicó en el año 2017 con buenos resultados y satisfacción de los pacientes 11,13,14 . Este abordaje endoscópico preaponeurótico nos permite resolver ambos problemas con la colocación de una prótesis de refuerzo supraaponeurótica, sin ingresar a la cavidad abdominal, con buenos resultados funcionales y cosméticos 1,2,7,8,14 . ...
... Se trata de procedimientos menos invasivos, seguros y eficaces.En el año 2014, Juárez 8,14 realizó por primera vez la reparación endoscópica preaponeurótica, que denominó como REPA, y que fue publicada de manera definitiva en el año 2017 con una serie de 32 casos y un seguimiento de 18 meses, describiendo la reparación con malla macroporosa preaponeurótica, lo que permite la exposición cómoda de la DMRA y el defecto parietal para realizar la plicatura. Se concluyó que el procedimiento era una opción terapéutica eficaz, con disminución de recidivas y sin ingresar a la cavidad abdominal8,14 .En nuestra serie replicamos la técnica original publicada por Juárez en pacientes con defecto herniario pequeño y DMRA también de pequeño tamaño. Se utilizó malla macroporosa para reducir el riesgo de recidiva e infección; la malla supraaponeurótica permite aumentar la seguridad de la plicatura sin entrar en la cavidad abdominal, lo que evita el riesgo de complicaciones de la cirugía laparoscópica y reduce el costo de las mallas separadoras de tejidos intraperitoneales. ...
... The prosthesis is fixed with trackers, straps or absorbable points. Navel was reinserted with internal or external sutures [2]. Suction drainages were placed systemically in 100% of cases, with a 3.68 ± 1.8 days permanence (Fig. 6). ...
... In 2016, Juárez Muas presented in Argentina and published in Spain in 2017 his technique, Preaponeurotic endoscopic repair with prosthesis reinforcement, allowing to fix midline parietal defect with recti plication using bearded sutures. This could be associated to an external oblique muscle release, unilateral or bilateral in order to avoid a tension suture [2], reducing postoperative pain and in cases of + 10 cm diastasis, to reduce postoperative abdominal compartment syndrome [3]. In all cases, we placed a reinforcement preaponeurotic polypropylene mesh which is safer and reduces the risk of recurrence [2] Not entering the abdominal cavity as in laparoscopic surgery, we avoid mesh complications reducing its high cost. ...
... This could be associated to an external oblique muscle release, unilateral or bilateral in order to avoid a tension suture [2], reducing postoperative pain and in cases of + 10 cm diastasis, to reduce postoperative abdominal compartment syndrome [3]. In all cases, we placed a reinforcement preaponeurotic polypropylene mesh which is safer and reduces the risk of recurrence [2] Not entering the abdominal cavity as in laparoscopic surgery, we avoid mesh complications reducing its high cost. In our experience of a 39-month follow-up, with 18 months in 74% of the patients, there were no thermal skin lesions or postoperative ischemia complications, even in slim patients with a < 25 BMI. ...
Background
Diastasis recti is a common pathology during pregnancy and puerperium, usually associated with midline hernias, with aesthetic and symptomatic problems. This approach allows us to restore the alba line, without entering the abdominal cavity.
Materials and methods
Between April 2014 and July 2017, 50 patients underwent surgery, 94% female (mean age 38). Ultrasonography confirmed diagnosis. Recti diastasis was associated with midline defects in 100%. The preaponeurotic endoscopic repair is done with suprapubic approach and in both iliac fossae. A preaponeurotic new cavity was created with dissection of the subcutaneous cellular tissue and then recti plication with barbed suture was performed. The wall is reinforced with polypropylene mesh. Drainage is left systematically.
Results
Diastasis recti < 50 mm (55.5%) was diagnosed, from 51 to 80 mm (29.6%), and > 81 mm (14.9%). Recti plication with bearded suture was performed. It was associated with external oblique release in 32% of patients, being unilateral (87.5%). Light/intermediate (90%) and heavy (10%) polypropylene meshes were placed, being fixed with absorbable (62%) and non-absorbable material (38%). Navel was reinserted using internal or external sutures. The average surgical time is 83 min. There are no intraoperative complications, but PO seroma finding 12%. The average hospital stay was 1.3 days, with pain level 3/10 according to AVS. The patients returned to their usual activities after 16.5 days. No complications or recurrences were observed by clinical and sonographic control at 18 months in 74% of patients. The patients were followed up at 39 months. Patient satisfaction was reported as 96%.
Conclusions
Diastasis recti is a common pathology with aesthetic and symptomatic problems. Endoscopic surgery allowed us to resolve the parietal defect with plication of recti and placement of preaponeurotic reinforcement prosthesis, increasing the safety of the repair, without entering the abdominal cavity, with a short hospitalization and no complications or recurrence in 3 years.
... With the advent of video laparoscopy, different techniques have been described for the primary closure of the midline with intracorporeal or transfascial knots [15][16][17]. One of these was the laparoscopic ventral hernia repair with the intraperitoneal mesh (IPOM and IPOM plus) [18,19]. ...
... An abdominal binder was utilized for at least a month postoperative [6]. Since the usage of a drain diminishes the formation of postoperative seromas in similar procedures, it was decided to use it in every patient [15]. ...
Purpose
To evaluate the outcomes of REPA and establish if any differences in complications and evolution are present between males and females.
Methods
A retrospective study including consecutive patients operated by REPA approach between November 2017 and April 2019 was conducted. Demographic data, operative times, postoperative complications, and hospital stay were analyzed. The EuraHS-QoL score was used to assess postoperative pain, daily activity constraints, and aesthetic discomfort. The results were compared between sexes. Statistical analysis was performed using SPSS 19.
Results
Fifty-four patients were included and 53.7% were male. Patients had a mean age of 50.7 years and a mean BMI of 28.7. The average RAD (Rectus Abdominis Diastasis) size was 2.6 cm (range of 2–5 cm). Seroma was significantly more frequent in males, with an incidence of 55.2 and 24% for females (p = 0.02). Three cases required reintervention (5.5% of total cases), which corresponded to a cystic seroma, an abdominal wall hematoma, and a hernia recurrence. The three cases were males and a p value of 0.04 was obtained when comparing reintervention rates between males and females. No cases of surgical wound infection nor cutaneous necrosis were recorded. No conversions were needed. The mean postoperative pain was 2.25, the mean daily activity constraints score was 2.63, and the degree of aesthetic discomfort was 1.23 with no significant differences between groups.
Conclusion
The correction of small midline defect associated with minor RAD using REPA seems feasible and reproducible. REPA had achieved good results in females, but in males, the outcomes were poorer.
... To obtain an acceptable and effective treatment for diastasis recti, a new standardized technique for minimally invasive repair was widespread: reparacion endoscopica pre-aponeurotica (REPA), also known as preaponeurotic endoscopic repair. The technique was conceived and performed for the first time in 2014 by Juárez Muas [9] and then introduced by our group in Europe in 2017 [10]. ...
... Women with a desire for motherhood were excluded from the procedure (high risk of recurrence). All patients underwent surgery according to the REPA technique as described by Juárez Muas [9]. In the operating room, antibiotic prophylaxis was carried out with cefazolin sodium 2 g i.v. ...
Background
Diastasis recti is a pathology that affects not only the abdominal wall but also the stability of lumbopelvic muscles, consequently altering urinary and digestive functionality. Preaponeurotic endoscopic repair (REPA) is an endoscopic alternative to tummy tuck for the treatment of diastasis. In this study, the outcomes of REPA application by a single surgeon are presented.
Methods
A total of 172 patients underwent REPA for the treatment of diastasis recti between August 2017 and December 2019. One hundred twenty-four patients were followed for at least one year. Sixty-three patients responded to a survey on satisfaction and quality of life 12 months after surgery.
Results
Three (2.4%) recurrences occurred, of which two occurred in the same patient. The main postoperative complications observed were 12 (9.7%) seromas, 3 (2.4%) haematomas, a single wound infection, 3 (2.4%) cases of skin fold formation, and a case of trophic skin lesion that required negative pressure therapy. Quality of life after surgery, as reported by 63 patients who responded to the survey, was satisfactory.
Conclusions
REPA is a safe and effective technique for diastasis recti treatment, representing a valid alternative to abdominoplasty. Since there is no need to access the peritoneal cavity and the mesh is onlay, there are no risks of bowel damage or adhesions between the intestine and prosthesis.
... La DR aparece en ambos sexos (también en la infancia), pero con una mayor prevalencia incide en la mujer tras el embarazo (entre un 30-70 %) y puede ser (siempre es permanente) voluminosa hasta en el 15 %, especialmente en multíparas 1 . Por lo general, se asocia a hernias de la línea media: umbilicales, epigástricas y/o incisionales 2 , y representa un problema estético, incluso con cierta frecuencia clínico, que se manifiesta por dorsolumbalgias (68 %), posibles trastornos digestivos (estreñimiento), alteración muscular del suelo pélvico con patología uroginecológica (60 %), etc., lo que afecta a la calidad de vida de estas pacientes 3,4 . ...
... Esta opción técnica no invade la cavidad abdominal, como sí ocurre en la cirugía laparoscópica IPOM, lo que evita las complicaciones de la malla en contacto visceral y no precisa el uso ni el gasto de una malla separadora de tejidos. Esta técnica de cirugía endoscópica permite realizar una disección con hemostasia exhaustiva al controlar los vasos perforantes y lavar-aspirar el tejido adiposo devitalizado o sobrenadante antes de colocar la prótesis, todo ello con el objetivo de reducir ese factor de riesgo de infección posoperatoria 3,4 . Durante la disección a nivel de la línea media, en la zona umbilical o en los defectos herniarios puede abrirse el peritoneo, situación que ocurrió en 10 casos de nuestra serie (4.6 %), ...
... La DR aparece en ambos sexos (también en la infancia), pero con una mayor prevalencia incide en la mujer tras el embarazo (entre un 30-70 %) y puede ser (siempre es permanente) voluminosa hasta en el 15 %, especialmente en multíparas 1 . Por lo general, se asocia a hernias de la línea media: umbilicales, epigástricas y/o incisionales 2 , y representa un problema estético, incluso con cierta frecuencia clínico, que se manifiesta por dorsolumbalgias (68 %), posibles trastornos digestivos (estreñimiento), alteración muscular del suelo pélvico con patología uroginecológica (60 %), etc., lo que afecta a la calidad de vida de estas pacientes 3,4 . ...
... Esta opción técnica no invade la cavidad abdominal, como sí ocurre en la cirugía laparoscópica IPOM, lo que evita las complicaciones de la malla en contacto visceral y no precisa el uso ni el gasto de una malla separadora de tejidos. Esta técnica de cirugía endoscópica permite realizar una disección con hemostasia exhaustiva al controlar los vasos perforantes y lavar-aspirar el tejido adiposo devitalizado o sobrenadante antes de colocar la prótesis, todo ello con el objetivo de reducir ese factor de riesgo de infección posoperatoria 3,4 . Durante la disección a nivel de la línea media, en la zona umbilical o en los defectos herniarios puede abrirse el peritoneo, situación que ocurrió en 10 casos de nuestra serie (4.6 %), ...
AUTORES:Juárez Muas, DerlinM1; Palmisano EzequielM2; Pou Santoja Guillermo3; Cuccomarino Salvatore4; González Higuera Luis G5; Mayo Pablo6; Martínez Maya Juan D7; Domínguez Guillermo8; Ayala Acosta Juan C9; Chichisola Agustín10.1 Salta, Argentina; 2 Rosario, Argentina; 3 Valencia, España; 4 Turín, Italia; 5 Bogotá, Colombia; 6 San Martín de Los Andes, Argentina; 7 Medellín, Colombia; 8 Buenos Aires, Argentina; 9 Bogotá, Colombia; 10 La Plata, Argentina. (Grupo Iberoamericano de Hernias)LUGAR DE TRABAJO: Hospital Público Materno Infantil. 1302 Sarmiento Ave. Salta, Argentina. Tel: 54 9 387- 432500. Ext. 4123 – Cell Phone: 54 9 387- 5175176. Mail: derlinjmuas@yahoo.com.arRESUMEN: INTRODUCCIÓN:La diástasis de los rectos es una patología habitual en puerperio, asociado a hernias de la línea media. La cirugía endoscópica nos permite restaurar la línea alba. METODO: Estudio multicéntrico y prospectivo entre abril de 2014 y julio de 2018, se operaron 215 pacientes, 94% mujeres con edad promedio de 40 años. Se confirmó el diagnóstico mediante TAC (51,6%) y ecografía (45,5%).RESULTADO: La diástasis de los rectos se asoció con hernias de la línea media en 93,4%.Se diagnosticó diástasis de losrectos <50 mm (55,5%), de 51 a 80 mm (29,6%) y > 81 mm (14,9%).Se realizó plicatura de losrectos con sutura barbada.Se asocióa descarga del músculooblicuo externo en 8,8%, siendo unilateral (8%).Se colocaron mallas de polipropileno ligeras / intermedias (97,3%) y pesadas (2,7%), fijadas con agrafes absorbible (76,2%) , no absorbible (8,8%),adhesivos (7%) y puntos poliglactina 910 (8%). Se colocó drenajes en el 100%. El tiempo quirúrgico promedio 107 minutos.Complicaciones intraoperatorias (1,39%): 2 hipercapnia y 1 lesión térmica de piel umbilical. Complicaciones postoperatoria (12,5%): seroma (9,7%), hematoma preaponeurótico (1,4%).Estancia hospitalaria: 1.6 días.Retorno laboral promedio15 días.Control clínico y ecográfico a los 12 meses (58,6%), sin complicaciones ni recurrencias.CONCLUSION:La cirugía endoscópica nos permitió resolver el defecto parietal con plicatura de los rectos y prótesis preaponeurótica de refuerzo, aumentando la seguridad de la reparación, sin ingresar a la cavidad abdominal, hospitalización reducida, baja tasa de complicaciones, sin recurrencia, evidenciándose la factibilidad, seguridad y reproductibilidad de éste acceso.KEYWORDS: REPARACIÓN ENDOSCÓPICA PREAPONEURÓTICA – PLICATURA DERECTOS - DIÁSTASIS DE RECTOS REPAIR ENDOSCOPIC PREAPONEUROTICA (REPA) OF THE DIASTASIS OF THE RECTI ASSOCIATED OR NOT TO HERNIAS OF THE MIDDLE LINE. MULTI-CENTER STUDYSUMMARY:INTRODUCTION: Diastasis of the recti is a common pathology in puerperium, associated with middle line hernias. Endoscopic surgery allows us to restore the linea alba.METHOD: Multicenter and prospective study between April 2014 and July 2018, 215 patients were operated, 94% women with an average age of 40 years. The diagnosis was confirmed by CT (51.6%) and ultrasound (45.5%).RESULT: Diastasis of the recti was associated with midline hernias in 93.4%. Diastasis of the recti were diagnosed <50 mm (55.5%), from 51 to 80 mm (29.6%) and> 81 mm (14.9%). Plication of the recti with a barbed suture was performed. It was associated with discharge of the external oblique muscle in 8.8%, being unilateral (8%). Lightweight / intermediate (97.3%) and heavy (2.7%) polypropylene meshes, fixed with absorbable (76.2%), non-absorbable (8.8%), adhesive (7%) and 910 polyglactin stitches were placed (8%). Drainage was placed in 100% of the cases. The surgical time average was 107 minutes. Intraoperative complications (1.39%): 2 hypercapnia and 1 thermal umbilical skin lesion. Postoperative complications (12.5%): seroma (9.7%), preaponeurotic hematoma (1.4%). Hospital stay: 1.6 days. Average return to work activity was of 15 days. Clinical and ultrasound check-up at 12 months (58.6%), without complications or recurrences.CONCLUSION: Endoscopic surgery allowed us to resolve the parietal defect with plication of the recti and reinforcement preapponeurotic prosthesis, increasing the safety of the repair, without entering the abdominal cavity, reduced hospitalization, low rate of complications, without recurrence, evidencing the feasibility, security and reproducibility of this approach.KAYWORDS: PREAPONEUROTIC ENDOSCOPIC REPAIR – RECTI PLICATION - DIASTASIS RECTI
... Since the article published by Bellido-Luque in 2015 [11], the preaponeurotic plane has been increasingly considered as a space of possible use for the treatment of midline defects. After the publication of Bellido-Luque, other authors published the same approach almost simultaneously [41,42]. Most of the techniques belonging to this group involve the placement of an onlay mesh (Table 3), and they registered low complication rates as well as good results from a functional point of view (wound complications 0.8-6.4%, ...
Purpose
this systematic review aims to classify and summarize the characteristics and outcomes of the different laparoendoscopic extraperitoneal approaches for the repair of ventral hernias and diastasis recti described in the last 10 years.
Methods
a literature search was performed by two reviewers in December 2023 including articles from January 2013, 01 to December 2023, 15. The techniques were selected according to the surgical access site (anterior or posterior to the rectus sheath), the access type (laparoendoscopic, single incision laparoscopic, mini or less open), the main space used to repair the defect (subcutaneous or retromuscular) and the mesh place (onlay, sublay-retromuscular or sublay-preperitoneal) and classified as anterior or posterior approaches.
Results
the literature search retrieved 1755 results and 27 articles were included in the study. The studies included 1874 patients, the mean age ranged from 37.8 to 60.2 years. The access site was anterior in 16 cases and posterior in 11 cases. The mesh was positioned onlay in 13 cases and sublay in 13 cases, with only one study using no mesh. Complications were: seroma, ranging from 0.8 to 81%, followed by skin complications (leak, ischemia, necrosis) from 0.8 to 6.4%, surgical site infections and bleeding. Recurrences ranged from 0% to 12,5%, with a mean follow-up from 1 to 24 months.
Conclusion
this systematic review confirms the presence of several new minimally invasive extraperitoneal techniques for the repair of abdominal wall defects, with different advantages and disadvantages. Further studies, with more extensive follow-up data and wider patient groups, are necessary to define specific indications for each technique.
... A partir de ese momento, distintos autores han contribuido con sus aportes de mínima invasión. Faria Correa describió la técnica de abdominoplastia subcutánea; Champault acuñó el concepto de videoparietoscopia de la pared abdominal y finalmente, en 2017, se introdujo la denominada reparación endoscópica preaponeurótica (REPA) como la opción técnica mínimamente invasiva más usada en el tratamiento de la diástasis de los músculos rectos [14][15][16][17][18] . ...
... Drainage is systematically left. Due to the patient's complaints and the aesthetic problems that diastasis recti could have, it is convenient to carry out this work in order to show all the treatment options that exist to date as well as to highlight the importance of preaponeurotic endoscopic repair [10,11]. ...
... Bellido Luque y cols. realizaron la técnica en un estudio de cohortes en 21 pacientes utilizando una sutura barbada no reabsorbible 1/0 sin malla de refuerzo posterior y con un seguimiento medio de 20 meses, y observaron una ausencia significativa en la recidiva de la diástasis y una mejoría del dolor lumbar 24 . Juárez Muas utilizó la técnica en 50 pacientes con colocación de malla (de los que un 94% eran mujeres, todas con hernias concomitantes) y obtuvo únicamente un 12% de seromas sin otras complicaciones y ausencia de recidivas a los 18 meses 25 . ...
... (9) Una técnica híbrida ( abierta con instrumentales endoscópicos) fue iniciada por el Dr Reinpold ,donde a través de una mínima insición en la piel accede al espacio preperitoneal (sublay) colocando una malla protésica y realizando el cierre de la línea media, esta técnica es conocida como técnica MILOS. (10) Existen además alternativas endoscópicas como la descrita por el Dr. Juárez Muas en la que propones un abordaje endoscópico supraaponeurótico para corregir la DR y otros defectos primarios de la línea media, realizando plicatura de la vaina de los rectos con colocación de una prótesis de refuerzo supra aponeurótica con el fin de asegurar la reparación, sin abordar la cavidad abdominal y con buenos resultados cosméticos, (11) siendo esta última técnica descrita la que se presenta en el caso clínico reportado. ...
Rectus diastasis (RD) consists of the separation between the rectus abdominis anterior muscles, it is not considered a hernia defect but an alteration of the alba line. It is associated with age, multiparity, weight gain and clinically manifests with a bulging of the midline and usuallyac companies other midline defects (umbilical and epigastric hernia).We report the case of a 40-year-old female patient with a 4 cm. rectus diastasis who underwent repair by supraaponeurotic endoscopic approach and with prosthetic reinforcement.
S oc ied a d H i s p a n oa me r ic a n a d e H ernia P r o C h ir ug ia et S c i e n t i a www.grupoaran.com Rev Hispanoam Hernia. 2023;11(1):1-3 Editorial Propuesta de una única denominación en el tratamiento endoscópico de la diástasis abdominal: una necesidad científi ca Proposal for a single name in the endoscopic treatment of abdominal diastasis: a scientifi c need En los últimos años hemos asistido a una verdadera revolu-ción científi ca en el conocimiento de la diástasis de los músculos rectos (DR), desde un olvido total en la literatura clásica (1900-2000) hasta convertirse en la novedad más discutida de la década. Este cambio de paradigma se sustenta en una nueva forma de entender la DR: antes, como una cuestión de estética relegada a unas pocas mujeres; ahora, como una patología más de la pared abdominal que es causa de síntomas, especialmente en multípa-ras, pero que también afecta a muchos hombres, que suma a una gran parte de la población adulta. Antes solo los cirujanos plásticos trataban esta «condición» con su mentalidad estética, pero actualmente se ha despertado un enorme interés entre los cirujanos generales, especialmente entre los dedicados a la patología de la pared abdominal, tras asumir que la DR es una «enfermedad» y su tratamiento puede benefi ciar clínicamente a muchas personas, evitarles sufrimiento y mejorar su calidad de vida. Este interés se ve refl ejado en la publicación de más de un centenar de artículos relacionados con la DR en los últimos dos años (bases de datos e índices en los que están incluidos las revistas científi cas), en la propuesta de una clasifi cación por parte de la Sociedad Alemana de Hernia e Inter-nacional de Endohernia 1 y, como corolario fi nal en el año 2021, la publicación de dos guías de manejo de la DR, una por parte de la Sociedad Hispanoamericana de Hernia 2 y otra de la europea 3. Desde 1995 se han descrito y se han publicado distintos pro-cedimientos destinados a la reparación de la DR asociada o no a hernias de la línea media (tabla I), la gran mayoría utilizando un acceso miniinvasivo (pequeñas incisiones) y trabajando en el es-pacio supraaponeurótico, emulando los pasos de una abdomino-plastia sin resección del colgajo dermograso y evitando una gran cicatriz (similar a las técnicas de los cirujanos plásticos) (tabla II). El acceso suprapúbico con colocación de una malla de poli-propileno macroporosa de mediana densidad implantada en el espacio supraaponeurótico tras la aproximación de los bordes mediales de los músculos rectos constituye el denominador co-mún y el principio básico de la gran mayoría de los procedimien-tos publicados, con mínimas diferencias técnicas entre unos y otros. Debemos reconocer que existen más de diez denominacio-nes distintas, pero todas ellas muy semejantes, de diferentes au-tores, países e idiomas, para denominar procedimientos similares e incluso en la mayoría de las ocasiones exactamente iguales 4. Es incuestionable destacar a Faria Correa (Brasil) como el cirujano plástico que dio los primeros pasos en el tratamiento miniinva-sivo de la DR 5. No obstante, esta alternativa de manejo bajo los principios técnicos actuales ha conseguido su popularidad gra-cias a las publicaciones en español e inglés de Juárez Muas (Ar-gentina) 6,7 y de Claus (Brasil) 8. Siempre se ha destacado el valor de la lengua inglesa como el idioma más hablado en el mundo y por su predominio en la lite-ratura científi ca internacional, sin embargo, fue la publicación de esta técnica en la Revista de la Sociedad Hispanoamericana de Hernia la que propició un espacio de difusión fundamental para quienes compartimos el español como lengua materna. Contar con una denominación unifi cada es un reto de enorme madurez científi ca y académica, pero para ello es necesario la contribu-ción de los comités editoriales de las revistas, quienes tienen la posibilidad (obligación) de evitar la publicación de trabajos con distintos nombres para una misma técnica, de aceptar los nom-bres en la lengua original del autor para obviar que cada uno proponga una nueva denominación en otro idioma diferente y que los cirujanos líderes al dar conferencias se aseguren no de usar el nombre que más les guste, sino el propuesto inicialmente
Introduction
Minimally invasive surgery for diastasis recti has gained attention in the recent past, with several reports with different names and particularities being suggested by the authors. SCOLA (Subcutaneous OnLay endoscopic Approach) is an example of this technique, described here in standardized technique.
Description of the technique
Basic steps to perform the procedure are detailed, beginning with patient and surgical team positioning, including trocar placement and tips and tricks of the subcutaneous dissection, steps needed to achieve full dissection of the preaponeurotic space, diastasis recti plication, mesh positioning and fixation and drain positioning with fixation of the umbilical stalk.
Discussion
Regardless of different names and small technical variations, endoscopic pre-aponeurotic mesh positioning can be performed with well-established steps on a reproducible fashion, aiming to achieve better results. Careful attention should be paid to appropriate patient selection and drain placement to reduce seroma rate, the most common complication.
La diástasis de los músculos rectos del abdomen es uno de los temas de mayor interés en la actualidad a nivel de consultas sobre patología de pared abdominal. Pero sigue siendo controvertido respecto a su consideración de «problema patológico» o «estético » por parte de los profesionales implicados en su tratamiento. Años atrás, todos hemos tenido pacientes en nuestras consultas que acudían por esta patología y los enviábamos a cirugía plástica para su valoración.
Ilioinguinal and iliohypogastric nerve blocks may be used in the diagnosis of chronic groin pain or for analgesia for hernia repair. This study describes a new ultrasound-guided approach to these nerves and determines its accuracy using anatomical dissection control.
After having tested the new method in a pilot cadaver, 10 additional embalmed cadavers were used to perform 37 ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve. After injection of 0.1 ml of dye the cadavers were dissected to evaluate needle position and colouring of the nerves.
Thirty-three of the thirty-seven needle tips were located at the exact target point, in or directly at the ilioinguinal or iliohypogastric nerve. In all these cases the targeted nerve was coloured entirely. In two of the remaining four cases parts of the nerves were coloured. This corresponds to a simulated block success rate of 95%. In contrast to the standard 'blind' techniques of inguinal nerve blocks we visualized and targeted the nerves 5 cm cranial and posterior to the anterior superior iliac spine. The median diameters of the nerves measured by ultrasound were: ilioinguinal 3.0x1.6 mm, and iliohypogastric 2.9x1.6 mm. The median distance of the ilioinguinal nerve to the iliac bone was 6.0 mm and the distance between the two nerves was 10.4 mm.
The anatomical dissections confirmed that our new ultrasound-guided approach to the ilioinguinal and iliohypogastric nerve is accurate. Ultrasound could become an attractive alternative to the 'blind' standard techniques of ilioinguinal and iliohypogastric nerve block in pain medicine and anaesthetic practice.
Purpose:
Tension-free mesh repair of inguinal hernia has led to uniformly low recurrence rates. Morbidity associated with this operation is mainly related to chronic pain. No consensus guidelines exist for the management of this condition. The goal of this study is to design an expert-based algorithm for diagnostic and therapeutic management of chronic inguinal postoperative pain (CPIP).
Methods:
A group of surgeons considered experts on inguinal hernia surgery was solicited to develop the algorithm. Consensus regarding each step of an algorithm proposed by the authors was sought by means of the Delphi method leading to a revised expert-based algorithm.
Results:
With the input of 28 international experts, an algorithm for a stepwise approach for management of CPIP was created. 26 participants accepted the final algorithm as a consensus model. One participant could not agree with the final concept. One expert did not respond during the final phase.
Conclusion:
There is a need for guidelines with regard to management of CPIP. This algorithm can serve as a guide with regard to the diagnosis, management, and treatment of these patients and improve clinical outcomes. If an expectative phase of a few months has passed without any amelioration of CPIP, a multidisciplinary approach is indicated and a pain management team should be consulted. Pharmacologic, behavioral, and interventional modalities including nerve blocks are essential. If conservative measures fail and surgery is considered, triple neurectomy, correction for recurrence with or without neurectomy, and meshoma removal if indicated should be performed. Surgeons less experienced with remedial operations for CPIP should not hesitate to refer their patients to dedicated hernia surgeons.
Neuralgic pain caused by entrapment of peripheral nerves can be a difficult clinical problem. The objective of the present study was to assess pain and quality of life in women with pain secondary to ilioinguinal nerve entrapment.
In a controlled prospective crossover study, women with ilioinguinal nerve entrapment were randomly allocated to either medical treatment or surgical resection of the ilioinguinal nerve.
A university hospital.
19 women, 21-60 years of age with pelvic pain of more than 6 months' duration.
Visual analogue (VA) scales and psychological general well-being (PGWB) scales were used to validate pain and quality of life, respectively.
Improvements were found in the group randomly allocated to surgery, p < 0.008 for the VA scale and p < 0.0098 for the PGWB scale, respectively. Nine of 10 women discontinued the medical arm of treatment because of side effects and/or lack of effect. After being shifted over to surgery, similar improvements were noted (p < 0.0002 and p < 0.0043, respectively).
The positive results found here indicate that surgery is superior to medical treatment in ilioinguinal nerve entrapment of unknown cause as well as after previous surgery. More randomized trials from different centers with larger numbers of women are needed to confirm these results.
Chronic inguinal neuralgia is one of the most significant complications following inguinal hernia repair. Routine ilioinguinal nerve excision has been proposed as a means to avoid this complication. The purpose of this report is to evaluate the long-term outcomes of neuralgia and paresthesia following routine ilioinguinal nerve excision compared to nerve preservation.
Retrospective chart review identified 90 patients who underwent Lichtenstein inguinal hernia repairs with either routine nerve excision (n = 66) or nerve preservation (n = 24). All patients were contacted and data was collected on incidence and duration of postoperative neuralgia and paresthesia. Comparison was made by chi(2) analysis.
The patients with routine neurectomy were similar to the group without neurectomy based on gender (male/female 51/15 vs. 19/5) and mean age (68 +/- 14 vs. 58 +/- 18 years). In the early postoperative period (6 months), the incidence of neuralgia was significantly lower in the neurectomy group versus the nerve preservation group (3% vs. 26%, P <0.001). The incidence of paresthesia in the distribution of the ilioinguinal nerve was not significantly higher in the neurectomy group (18% vs. 4%, P = 0.10). At 1 year postoperatively, the neurectomy patients continued to have a significantly lower incidence of neuralgia (3% vs. 25%, P = 0.003). The incidence of paresthesia was again not significantly higher in the neurectomy group (13% vs. 5%, P = 0.32). In patients with postoperative neuralgia, mean severity scores on a visual analog scale (0-10) were similar in neurectomy and nerve preservation patients at all end points in time (2.0 +/- 0.0 to 2.5 +/- 0.7 vs. 1.0 +/- 0.0 to 2.2 +/- 1.5). In patients with postoperative paresthesia, mean severity scores on a visual analog scale (0-10) were similar in the neurectomy and nerve preservation patients at 1 year (2.5 +/- 2.2 vs. 4.0 +/- 0.0) and 3 years (3.5 +/- 2.9 vs. 4.0 +/- 0.0).
Routine ilioinguinal neurectomy is associated with a significantly lower incidence of postoperative neuralgia compared to routine nerve preservation with similar severity scores in each group. There is a trend towards increased incidence of subjective paresthesia in patients undergoing routine neurectomy at 1 month, but there is no significant increase at any other end point in time. When performing Lichtenstein inguinal hernia repair, routine ilioinguinal neurectomy is a reasonable option.
Chronic severe pain following inguinal hernia repair is a significant post-operative problem. Its exact cause and lack of evidence-based treatment path present problems in the effective management of this surgical complication. We retrospectively reviewed the records of patients diagnosed with chronic pain following open inguinal hernia repair between November 1995 and November 2000, who were under the care of the senior author. Over the five-year period, 146 patients underwent inguinal hernia repair. 88 (60%) had suture repair (darn & modified Bassini's) and 58 (40%) underwent a Lichtenstein mesh repair. Thirteen patients (9%), (3 in suture vs. 10 in mesh group, p = 0.004) developed chronic severe pain. Examination revealed maximal tenderness over the genitofemoral nerve (GF) distribution (n = 5), over the medial end of the scar (n = 3), over the pubic tubercle (n = 1) and in the ilioinguinal nerve distribution (n = 1) No abnormality was detected on clinical examination in the cases of three patients. Treatment involved GF nerve block (n = 5), local injection of Chirocaine and Methylprednisolone acetate into the medial end of the scar (n = 3), Chirocaine and Methylprednisolone acetate into the pubic tubercle (n = 1), ilioinguinal nerve block (n = 1), re-exploration with re-suturing of the mesh (n = 1), and Amitriptyline (n = 2). At a median follow up of 45 months (range: 24-87), 10 (77%) are completely pain free; two (15.4%) had mild pain and one patient still has significant persistent pain. To conclude, chronic severe pain occurred in nine percent of patients following primary open inguinal hernia repair. The majority of patients were successfully treated by therapeutic injection into the point of maximal tenderness.
Selective ambulatory transabdominal retroperitoneal laparoscopic neurectomy to treat refractory neuropathic groin pain
- A Moreno-Egea
- E Borrás-Rubio
Moreno-Egea A, Borrás-Rubio E. Selective ambulatory transabdominal
retroperitoneal laparoscopic neurectomy to treat refractory neuropathic
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Anatomía aplicada a la neurectomía del iliohipogástrico laparoscópica extraperitoneal
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Anatomy of the Ilioinguinal and Iliohypogastric Nerves With Observations of Their Spinal Nerve Contributions
- Z Klaassen
- E Marshall
- R S Tubbs
- R G Louis
- C T Wartmann
- M Loukas
Klaassen Z, Marshall E, Tubbs RS, Louis RG Jr, Wartmann CT,
Loukas M. Anatomy of the Ilioinguinal and Iliohypogastric Nerves
With Observations of Their Spinal Nerve Contributions. Clin Anat.
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