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Introduction: This report aimed to compare ventral extended vision extraperitoneal (ETEP) and preaponeurotic repair (REPA) techniques in terms of surgical procedure, outcomes, and patient evolution. Methods: This was a retrospective study performed at a tertiary care academic center between 2017 and 2022. All consecutive patients operated on for midline hernias and rectus diastasis using REPA and ETEP were included. Follow-up visits were at 15 days, 30 days, and 6 months postoperative. Age, sex, BMI, American Surgical Anesthesiologic Classification (ASA), surgical time, need for conversion to open surgery, time of stay, seroma, hematoma, surgical site infection (SSI), recurrence, and re-interventions were assessed. Results: For the present study, 148 patients were included. From them, 62 patients received the REPA procedure and 86 were operated on using the ETEP technique. REPA average time was 105 minutes (interquartile range [IR] 80-130), and ETEP average time was 120 minutes (RIC 95-285) (p = 0.03). Ambulatory procedures were 32.3% (n = 20) REPA and 20.9% (n = 18) ETEP (p = 0.23). In REPA, the mean time for drain extraction was 11.92 days and 8 days in ETEP (p < 0.001). Seroma incidence was identified in 40.3% (n = 25) of the REPA cases and 5.8% (n = 5) of the ETEP procedures (p = 0.001). In a multivariate analysis for seroma incidence REPA technique was associated with a significant risk of its incidence [odds ratio (OR) 16, 67 95% confidence interval ((CI95) 4.67-59.52), p < 0.001]. Conclusion: REPA and ETEP are safe and reproducible. Both approaches reported short hospitalization times and almost no major complications. We found a longer surgical time in ETEP and a higher incidence of seroma in REPA.

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INTRODUCTION: Recent studies have related the climacteric period with changes in connective tissue elasticity that may be related to diastasis recti abdominis. Mat Pilates is a method of exercise without impact that currently has more practitioners, due to its satisfactory results. However, there are no studies that evaluate the effectiveness of mat Pilates for women with diastasis recti abdominis. OBJECTIVE: To evaluate the effectiveness of the mat Pilates program in climacteric women with diastasis recti abdominis. METHODS: This randomized single-blinded clinical trial evaluated climacteric women with diastasis recti abdominis. The participants were randomized into the experimental group, which participated in 3 weekly sessions of mat Pilates for 12 weeks for a total of 36 sessions, and the control group (without exercises). The inter-rectus distance was measured with a digital caliper. The G*Power Version 3.1.9.2. software was used for the sample calculation, and the SPSS 20.0 program was used for statistical analysis. RESULTS: The study comprised 21 women, including 10 in the control group and 11 in the experimental group, with mean ages of 54.3 ± 7.1 and 55.3 ± 6.0 years and body mass index values of 28.8 ± 5.5 kg/m2 and 29.9 ± 4.48 kg/m2, respectively. In the experimental group, reductions were observed in all the measures related to diastasis recti abdominis (p<0.05) in the supraumbilical, umbilical, and infra-umbilical regions. CONCLUSION: The mat Pilates method is effective for reducing diastasis recti abdominis in the climacteric period.

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ABSTRACT While diastasis recti (DR) was long neglected by general surgeons, plastic surgeons considered conventional abdominoplasty as the only repair option. However, this scenario has changed recently, either due to a better understanding of the correlation between DR and abdominal wall function and greater risk of recurrence in abdominal hernia repairs, or due to the development of new minimally invasive techniques for repairing DR. One of these surgical procedures consists of the concept of an abdominoplasty, that is, supra-aponeurotic dissection and plication of the DR (with or without abdominal hernia) but performed through three small supra-pubic incisions by laparoscopy or robotic approach. More recently, this procedure has gained new stages. Liposuction and skin retraction technology have been associated with MIS plication of DR, which increases the indications for the technique and potentially improves results. For the first time in the literature, we describe these steps and the synergy between them.

RESUMO Embora a diástase de reto abdominal (DR) tenha sido negligenciada por muito tempo pelos cirurgiões gerais, os cirurgiões plásticos consideravam a abdominoplastia convencional como a única opção de reparo. No entanto, esse cenário mudou recentemente, seja pelo melhor entendimento da correlação entre DR e a função da parede abdominal e o maior risco de recorrência na correção de hérnias abdominais, seja pelo desenvolvimento de novas técnicas minimamente invasivas (MIS) para reparo da DR. Um desses procedimentos cirúrgicos consiste no conceito de abdominoplastia, ou seja, dissecção supra-aponeurótica e plicatura da DR (com ou sem hérnia abdominal), mas realizada através de três pequenas incisões suprapúbicas por laparoscopia ou abordagem robótica. Mais recentemente, esse procedimento ganhou novas etapas. A lipoaspiração e a tecnologia de retração da pele têm sido associadas à plicatura MIS da DR, o que aumenta as indicações da técnica e potencialmente melhora os resultados. Pela primeira vez na literatura, descrevemos essas etapas e a sinergia entre elas.

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ABSTRACT Purpose: We present a technique for covering large midline loss of abdominal wall using a novel method by autologous tissues. Methods: Twenty-two patients (body mass index = 35,6 ± 6,9 kg/m2) were involved in the prospective cohort study. Acute and elective cases were included. The gap area was 450.1 ± 54 cm2. The average width of the midline gap was 16,3 ± 3,2 cm. The rectus muscles were mobilized from its posterior sheath. Both muscles were turned by180º medially, so that the complete abdominal wall gap could be covered without considerable tension. Changes in intra-abdominal pressure, quality of life and hernia recurrency were determined. Results: There was no significant increase in the intra-abdominal pressure. Wound infection and seroma occurred in four cases. Bleeding occurred in one case. Pre- and post-operative quality of life index significantly improved (23 ± 13 vs. 47 ± 6; p = 0,0013). One recurrent hernia was registered. The procedure could be performed safely and yielded excellent results. The method was applied in acute cases. The intact anatomical structure of rectus muscles was essential. Conclusions: The midline reconstruction with bilateral turned-over rectus muscles provided low tension abdominal wall status, and it did not require synthetic mesh implantation.

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Background: Meningiomas are slow-growing neoplasms, accounting for 20% of all primary intracranial neoplasms and 25% of all intraspinal tumors. Atypical and anaplastic meningiomas are infrequent, representing fewer than 5% of all meningiomas. Unusually, they can show aggressive behavior, and extracranial metastases are extremely rare, representing approximately 0.1% of all reported cases. Case Description: Fifty-six-year-old male patient diagnosed with atypical basal frontal meningioma with multiple resections, both endoscopic endonasal and transcranial. After hypofractionated radiosurgery, the patient showed new tumor recurrence associated to right cervical level II ganglionic metastasis. We opted for complete resection of the meningioma and reconstruction with anterior rectus abdominis muscle flap, as well as selective cervical ganglionectomy. Anatomical pathology showed neoplastic proliferation of meningothelial cells in syncytial cytoplasm, oval or spherical nuclei with slight anisocariosis and hyperchromasia, and intranuclear vacuoles, all compatible with anaplastic meningioma. Conclusion: Due to a lack of consensus on how to treat a metastatic malignant meningioma, this pathology requires a multidisciplinary approach, and treatment needs to be adapted to each particular case. Complete resection of the lesion is the primary goal, and this requires complex procedures involving endocranial as well as extracranial surgeries, which result in composite defects difficult to resolve. Microvascular free flaps are considered the gold standard in reconstructions of large skull base defects, with high success rates and few complications.

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Introducción: El dolor lumbar crónico en los universitarios oscila entre un 12,4 y 75 %. Se evidenció inicialmente que la alteración de la musculatura del recto abdominal puede estar asociada al dolor lumbar. Objetivo: Evaluar la asociación entre la distancia de los bordes mediales del músculo recto abdominal y la presencia de dolor lumbar. Métodos: Se realizó un estudio de casos y controles en estudiantes de una universidad privada de la ciudad de Lima. Se valoraron el dolor lumbar y la distancia entre los bordes mediales del músculo recto abdominal mediante la escala numérica de dolor, índice cintura cadera, el cuestionario nórdico y la escala de Oswestry. Se midió la distancia los bordes mediales del músculo recto abdominal con un Caliper digital. Resultados: La media y desviación estándar de la distancia de los bordes mediales del músculo recto abdominal fue 21,9 ± 3,5. Esta y la diástasis abdominal se asociaron con el dolor lumbar. Conclusiones: Se demostró que la distancia de los rectos abdominales y el dolor lumbar en los estudiantes universitarios guardan relación.

Introduction: Chronic low back pain in university students ranges between 12.4 and 75 %. It was initially evidenced that the alteration of the musculature of the rectus abdominis may be associated with low back pain. Objective: To evaluate the association between the distance from the medial edges of the rectus abdominis muscle and the presence of low back pain. Methods: A case-control study was conducted in students of a private university in the city of Lima. Low back pain and the distance between the medial edges of the rectus abdominis muscle were assessed using the numerical pain scale, the waist-hip index, the Nordic questionnaire and the Oswestry scale. The distance between the medial edges of the rectus abdominis muscle was measured with a digital Caliper. Results: The mean and standard deviation of the distance from the rectus abdominis was 21.9 ± 3.5. This and abdominal diastasis were associated with low back pain. Conclusions: The distance between the medial edges of the rectus abdominis muscle and low back pain in university students was shown to be related.

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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.

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Gestational diabetes mellitus (GDM) is recognized as a "window of opportunity" for the future prediction of such complications as type 2 diabetes mellitus and pelvic floor muscle disorders, including urinary incontinence and genitourinary dysfunction. Translational studies have reported that pelvic floor muscle disorders are due to a GDM-induced-myopathy (GDiM) of the pelvic floor muscle and rectus abdominis muscle (RAM). We now describe the transcriptome profiling of the RAM obtained by Cesarean section from GDM and non-GDM women with and without pregnancy-specific urinary incontinence (PSUI). We identified 650 genes in total, and the differentially expressed genes were defined by comparing three control groups to the GDM with PSUI group (GDiM). Enrichment analysis showed that GDM with PSUI was associated with decreased gene expression related to muscle structure and muscle protein synthesis, the reduced ability of muscle fibers to ameliorate muscle damage, and the altered the maintenance and generation of energy through glycogenesis. Potential genetic muscle biomarkers were validated by RT-PCR, and their relationship to the pathophysiology of the disease was verified. These findings help elucidate the molecular mechanisms of GDiM and will promote the development of innovative interventions to prevent and treat complications such as post-GDM urinary incontinence.

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BACKGROUND: Ex-vivo myography enables the assessment of muscle electrical activity response. This study explored the viability of determining the physiological responses in muscles without tendon, as rectus abdominis muscle (RAM), through ex-vivo myography to assess its potential as a diagnostic tool. RESULTS: All tested RAM samples (five different samples) show patterns of electrical activity. A positive response was observed in 100% of the programmed stimulation. RAM 3 showed greater weight (0.47 g), length (1.66 cm), and width (0.77 cm) compared to RAM 1, RAM 2, RAM 4 and RAM 5 with more sustained electrical activity over time, a higher percentage of fatigue was analyzed at half the time of the electrical activity. The order of electrical activity (Mn) was RAM 3 > RAM 5 > RAM 1 > RAM 4 > RAM 2. No electrical activity was recorded in the Sham group. CONCLUSIONS: This study shows that it is feasible to assess the physiological responses of striated muscle without tendon as RAM, obtained at C-section, under ex vivo myography. These results could be recorded, properly analyzed, and demonstrated its potential as a diagnostic tool for rectus abdominis muscle electrical activity.

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Introducción. La diástasis de los rectos abdominales es una patología frecuente en el postparto. Aunque se puede resolver de forma espontánea y natural, la mayoría requiere tratamiento basado en la terapia física. Dentro de las principales modalidades se encuentran ejercicios de activación del transverso del abdomen, ejercicios abdominales, entrenamiento de piso pélvico y vendaje abdominal. Al ser estrategias ampliamente utilizadas, se requiere estudiar su efectividad. Objetivo. Describir los reportes de la literatura científica acerca de la efectividad de la terapia física en el manejo de la diástasis de los rectos abdominales en el periodo postparto. Metodología. Se realizó una scoping review según la metodología propuesta por Arksey y O´Malley y PRISMA-ScR. Se efectuó una búsqueda en las bases de datos PubMed, Lilacs, ScienceDirect, Scielo, Scopus y Scholar Google incluyendo artículos en inglés y español publicados entre 2012 y 2022, seleccionados acorde al tema de investigación. Resultados. Se incluyeron 22 artículos en la síntesis cualitativa y se resume la evidencia seleccionada en 5 dimensiones: participantes, evaluación, intervención, resultados de la efectividad de la terapia física en la disminución de la distancia inter-rectos y otros resultados. Conclusión. Existe variada evidencia científica y de poca calidad metodológica respecto a la modalidad y efectividad de la terapia física en el tratamiento de la diástasis de los rectos abdominales. Se sugieren programas individualizados que consideren los nuevos paradigmas de evaluación, enfocando en la funcionalidad de la pared abdominal.

Background. Diastasis recti abdominis is a common pathology in the postpartum period. Although it can be resolved spontaneously and naturally, most require treatment based on physical therapy. Transverse abdominis exercises, abdominal exercises, pelvic floor training, and abdominal binder are among the primary modalities. Thus, it is necessary to study their effectiveness as widely used strategies. Objective. Describe the reports in the scientific literature about the effectiveness of physical therapy in the management of diastasis recti abdominis in the postpartum period. Methods. This scoping review was carried out according to the methodology proposed by Arksey and O'Malley and PRISMA- ScR. Besides, a quest was developed in the PubMed, Lilacs, ScienceDirect, Scielo, Scopus and Scholar Google databases, including articles in English and Spanish published between 2012 and 2022, selected according to the research topic. Results. Twenty-two articles were included in the qualitative synthesis, and the chosen evidence was summarized in five dimensions: participants, evaluation, intervention, results of the effectiveness of physical therapy in reducing the inter-rectus distance, and other results. Conclusion. There is diverse scientific evidence and poor methodological quality regarding to the modality and effectiveness of physical therapy in the treatment of diastasis recti abdominis. Individualized programs are suggested, that consider new evaluation paradigms, focusing on the functionality of the abdominal wall.

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INTRODUCTION: Diastasis recti abdominis (DRA) and pelvic floor dysfunction (PFD) occurs commonly with aging; however, little is known about what leads to these changes. OBJECTIVE: We aimed to investigate and compare the presence or absence of DRA and PFD in peri- and postmenopausal women. METHODS: This cross-sectional study involved 150 participants who answered questions on their sociodemographic and clinical profiles related to urinary and fecal incontinence and pelvic organ prolapse. Diastasis recti abdominis was diagnosed with a digital caliper. RESULTS: Supra-umbilical diastasis occurred in 37.3% of cases, and 78.6% of participants with DRA had PFD. No significant differences existed between participants with and without DRA in terms of background and clinical variables. However, participants with DRA were 2.6 times more likely to have PFD than participants without DRA. Furthermore, the presence of DRA was significantly shown to be a risk factor for PFD on binary logistic regression analyses (p = .01, OR = 3.2). CONCLUSIONS: This cross-sectional study suggests that DRA is a predictive factor of PFD in women aged over 50 years.

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BACKGROUND: The components separation technique (CS) is used for the reconstruction of complex abdominal wall defects. Release and undermining of the rectus abdominis muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline, reducing recurrence of ventral hernia, but causes major changes in the physiology of abdominal wall. The purpose of the study was to determine which muscle release and undermining produces the lowest tension on the midline. METHODS: Twenty fresh cadavers were dissected and the anterior and posterior layers of the rectus sheath were isolated in the midline. The forces necessary to advance the layers of the rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after release and undermining of the right RAM and left EOM; and after release and undermining of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for the different muscles involved, layers of the rectus sheath, measurement points, and stages of separation. RESULTS: Tension on the abdominal midline after the release and undermining of both the RAM and EOM was reduced by 56% (p <0.05), 42% after the release and undermining of the EOM alone (p <0.05), and 35% after release and undermining of the RAM alone (p <0.05). CONCLUSION: Release and undermining of the EOM by CS led to lower tension on the abdominal midline compared to that associated with the release of the RAM alone.

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SUMMARY: The inferior epigastric artery (IEA) is a major blood vessel that supplies the anterior abdominal wall. The aim of the current study was to provide clinicians, surgeons, and obstetricians with sufficient anatomical data on the inferior epigastric artery, such as its origin and branching pattern. The study included 20 embalmed cadavers, these cadavers were dissected, and the inferior epigastric artery and vena comitans/venae comitantes were identified and traced downwards to the external iliac vessels. The origins, caliber, course and pedicle length of both the artery and the vein(s) were studied. The inferior epigastric artery arose independently from the distal external iliac artery deep to the inguinal ligament in 19 (95 %) cadavers. The artery entered the rectus abdominis muscle at its middle third in 13 (65 %) cases and at its lower third in the remaining specimens. In this study, we found that the artery divided into two branches in 18 (90 %) of the cases; in the remaining two cases, it continued as one trunk. The average pedicle length was 7.2 cm. The mean caliber of the IEA was 3.7 mm. In 18 (90 %) dissections, the venous drainage consisted of a pair of venae comitantes that united to form a common vessel at their draining point on the external iliac vein. The average diameter was 3.9 mm. The current study focuses on the anatomical features of the inferior epigastric artery to increase the success rate of abdominal and pelvic operations in clinical practice.

RESUMEN: La arteria epigástrica inferior (AEI) es un vaso sanguíneo principal que irriga la pared abdominal anterior. El objetivo del presente estudio fue proporcionar a los médicos, cirujanos y obstetras suficientes datos anatómicos sobre la arteria epigástrica inferior, como su origen y patrón de ramificación. El estudio incluyó 20 cadáveres embalsamados, los que se disecaron y se identificó la arteria epigástrica inferior y la vena concomitante y se siguieron hasta los vasos ilíacos externos. Se estudiaron los orígenes, calibre, trayecto y longitud del pedículo tanto de la arteria como de la (s) vena (s). La arteria epigástrica inferior surgió independientemente de la arteria ilíaca externa profunda al ligamento inguinal en 19 (95 %) cadáveres. La arteria ingresó al músculo recto del abdomen en su tercio medio en 13 (65 %) casos y en su tercio inferior en las muestras restantes. En este estudio, encontramos que la arteria se dividió en dos ramas en 18 (90 %) de los casos; en los dos casos restantes, continuó como un tronco. La longitud media del pedículo fue de 7,2 cm. El calibre medio del AEI fue de 3,7 mm. En 18 (90 %) disecciones, el drenaje venoso consistió en un par de venas concomitantes las que formaron un vaso común en su punto de drenaje en la vena ilíaca externa. El diámetro medio fue de 3,9 mm. El estudio actual se centra en las características anatómicas de la arteria epigástrica inferior con el propósito de mejorar la tasa de éxito de las cirugías abdominales y pélvicas en la práctica clínica.

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Abstract Objective To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings. Methods The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and duringmobilization), analgesia requirement, and return of bowel motility. Results The postoperative pain scores were similar at the 2nd, 6th, 12th, and 18th hours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times. Conclusion In the group with only parietal peritoneum closure, the pain scores at the 6th and 12th hours were higher. Rectus abdominismuscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility.

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Objetivo: verificar se a intervenção fisioterapêutica no puerpério imediato contribui para a redução da diástase. Métodos: estudo de intervenção com randomização de dois grupos de 25 puérperas recrutadas em uma maternidade de Vitória-ES. Ambos foram submetidos à avaliação e mensuração da diástase através de um paquímetro, e no grupo de tratamento além da avaliação foi aplicado um protocolo de tratamento fisioterápico às 06 e 18 horas após o parto. Os dados foram analisados através dos testes de Wilcoxon, Mann-Whitney e teste t pareado. Resultados: houve diminuição da diástase abdominal entre a primeira e a última avaliação em ambos os grupos, no entanto, a análise entre grupos identificou uma redução mais acentuada no grupo de tratamento (p<0,001). Conclusão: os achados deste estudo mostram que o atendimento fisioterápico no puerpério imediato é capaz de influenciar positivamente na redução da diástase abdominal, proporcionando às puérperas uma recuperação mais rápida

Objective: to verify if the physiotherapeutic intervention in the immediate puerperium contributes to the reduction of the diastasis. Methods: randomized intervention study of two groups of 25 mothers recruited at a maternity hospital in Vitória-ES. Both were submitted to diastasis evaluation and measurement using a caliper, and in the treatment group, in addition to the evaluation, a physical therapy protocol was applied at 06 and 18 hours after delivery. Data were analyzed by Wilcoxon, Mann-Whitney and paired t-tests. Results: there was a decrease in the abdominal diastasis between the first and last evaluation in both groups and the variables studied, however, the analysis between groups identified a sharper decline in the treatment group (p <0.001). Conclusion: the findings of this study show that the physiotherapeutic care in the immediate puerperium is able to positively influence the reduction of the abdominal diastasis, providing a faster recovery to the puerperal women

Objetivo: verificar si la intervención de fisioterapia en el período posparto inmediato contribuye a la reducción de la diástasis. Métodos: estudio de intervención aleatorizado de dos grupos de 25 madres reclutadas en un hospital de maternidad en Vitória-ES. Ambos fueron sometidos a evaluación y medición de la diástasis utilizando un calibrador, y en el grupo de tratamiento, además de la evaluación, se aplicó un protocolo de fisioterapia a las 06 y 18 horas después del parto. Los datos fueron analizados por Wilcoxon, Mann-Whitney y pruebas t pareadas. Resultados: hubo una disminución en la diástasis abdominal entre la primera y la última evaluación en ambos grupos y las variables estudiadas, sin embargo, el análisis entre los grupos identificó una reducción más marcada en el grupo de tratamiento (p <0.001). Conclusión: los resultados de este estudio muestran que la atención de fisioterapia en el período posparto inmediato puede influir positivamente en la reducción de la diástasis abdominal, proporcionando a las mujeres puerperales una recuperación más rápida

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Resumen Objetivo: Demostrar la anatomía y aplicación de la vaina anterior de los rectos para la reparación de defectos herniarios gigantes de la línea media abdominal mediante la cirugía de separación de componentes más la aplicación de un colgajo aponeurótico tipo turn over. Materiales y Método: Disección anatómica con descripción vascular y dinámica de la vaina anterior de los rectos. Posterior aplicación de la técnica en pacientes con hernias gigantes de la línea media. Seguimiento clínico de recidiva y complicaciones locales como sistémicas. Resultados: 8 pacientes fueron seleccionados. La edad promedio fue de 58,6 años y el tamaño del defecto hemiario 19,6 cm. En todos los pacientes se pudo aplicar la técnica sin inconvenientes. Sólo 1 paciente presentó una complicación local (dehiscencia y necrosis parcial del colgajo cutáneo) que se manejó con resección y reavance sin incidentes. No se describen complicaciones sistémicas ni mortalidad. Discusión: Las hernias abdominales gigantes y con pérdida a derecho de domicilio son un desafío quirúrgico. Se han desarrollado importantes avances con abordajes quirúrgicos innovadores. Nuevos materiales biológicos y sintéticos se han convertido en una parte integral del arsenal quirúrgico, sin embargo, involucran muchas veces asumir grandes costos y complicaciones propias a los materiales utilizados, además, de no cumplir con la adaptación dinámica adecuada de la pared requerida. Conclusión: Esta modificación técnica es segura, útil y accesible para los pacientes con eventraciones gigantes. La tasa de complicaciones es baja y está dada principalmente por problemas relacionados al sufrimiento de los colgajos cutáneos.

Aim: To demonstrate the anatomy and application of the anterior rectus sheet in the repair of giant abdominal wall hernias through a classic component surgery plus a turn over flap. Materials and Method: Anatomic dissection with vascular and dynamic description of the anterior rectus sheet. Posterior application of the technique in patients with giant abdominal wall hernias. Clinical follow up of recurrence, local and systemic complications. Results: 8 patients were selected. The average age was 58.6 years old and the abdominal wall defect 19.6 cm wide. The technique could be applied in every patient without inconveniences. Only 1 patient had a complication (dehiscence and partial skin flap necrosis) that was successfully treated with resection and readvancement. No systemic complications nor mortality was described. Discussion: Giant abdominal wall hernias are a surgical challenge. Great and innovative advances have been made. New biological and synthetic materials have been developed, nevertheless they frequently involve great costs and complications related to them. Also, they do not adapt adequately to the dynamic required for the abdominal wall. Conclusion: This technical modification is useful, safe and accessible for the patients who present giant wall hernias. The complication rate is low and it's principally given from problems related to skin flap blood flow.

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BACKGROUND: Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated. METHODS: The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy. DISCUSSION: To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

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ABSTRACT Background: Abdominoperineal excision of the rectum (APR) remains the only potential curative treatment for very low rectal adenocarcinoma and squamous cell carcinoma of the anus. Yet, it implies a significant perineal exenteration and has set the attention on the perineal reconstruction. Aim: To present technique used in one case of APR for anal cancer, with resection of the vaginal posterior wall with large perineal defect which has called for the necessity of a flap for reconstruction Method: To cover the large perineal defect and reconstruct the posterior vaginal wall was perform a standardized and reproducible surgical technique using oblique rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap is thick and well vascularized by both superficial branches and perforators of the superior epigastric artery and the deep inferior epigastric artery which serves as the vascular pedicle for the ORAM flap. Results: This procedure was applied in a 65-year-old woman with recurrent squamous cell carcinoma of the anus infiltrating the posterior wall of the vagina. Was performed an APR with en-bloc resection of the vaginal posterior wall in order to achieve tumor-free margins. Postoperative course was uneventful and she was discharged home at postoperative day 9. Final pathological report confirmed the oncological adequacy of the procedure (R0) and showed a rypT4N0 lesion. Conclusion: Flap reconstruction is an effective way to cover the perineal wound reducing both perineal complication rate and wound healing delay. The ORAM is particularly interesting for female whose tumors require resection and subsequent reconstruction of the posterior wall of the vagina.

RESUMO Racional: A amputação abdominoperineal do reto (APR) continua sendo o único tratamento curativo nos casos de adenocarcinoma retal muito baixo e carcinoma espinocelular do ânus. No entanto, implica em exenteração perineal significativa e exige atenção na reconstrução perineal. Objetivo: Propor, ilustrando com um caso clinico, proposta de APR para câncer anal com ressecção da parede posterior da vagina com cobertura do grande defeito perineal através de reconstrução com retalho miocutâneo oblíquo do reto abdominal (ORAM). Método: Para cobrir o defeito e reconstruir a parede vaginal posterior, realizou-se técnica de retalho miocutâneo oblíquo do reto abdominal (ORAM). A pele subjacente desse retalho por ser espessa e bem vascularizada por ramos perforantes superficiais da artéria epigástrica superior e pela artéria epigástrica inferior profunda serviu como pedículo vascular. Resultado: Este procedimento foi aplicado em uma mulher de 65 anos com recidiva de carcinoma espinocelular do ânus infiltrado na parede posterior da vagina. Foi realizada APR com ressecção em bloco da parede posterior vaginal com o objetivo de obter margens livres de tumor. O pós-operatório transcorreu sem intercorrências e a paciente recebeu alta hospitalar no 9° dia pós-operatório. O relatório patológico final confirmou a adequação oncológica do procedimento (R0) e mostrou uma lesão rypT4N0 de 6,5 cm. Conclusão: A reconstrução perineal com utilização de retalho é maneira eficaz de fechar a ferida operatória, reduzindo a taxa de complicações perineais e o atraso na cicatrização. O retalho de tipo ORAM é particularmente interessante para mulheres cujos tumores requerem ressecção e subsequente reconstrução da parede posterior da vagina.

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ABSTRACT Objectives: described by Dr. Jorge Daes, principles of the enhanced view totally extraperitoneal (eTEP) has been widely used in the armamentarium of ventral hernia repair recently. Robotic assisted eTEP technique feasibility has been proved, however, a complete understanding of retromuscular abdominal wall planes and its landmarks still uncertain in a majority of general surgeons. The aim of this report is to propose a technical standardization and its anatomic concepts in the robotic-assisted eTEP ventral hernia repair. Methods: our group describes 10 key steps in a structured step-by-step approach for a safe and reproducible repair based on well defined anatomic landmarks, identification of zones of dissection and correct restoration of the linea alba. Results: the standardization has been developed 2 years ago and applied to all patients. A robotic-assisted surgery with 3 robotic arms is performed in a lateral docking setup. Feasibility is established and reproducibility is high among general surgeons. Conclusion: we present a standardized side docking robotic assisted eTEP approach for ventral hernia repairs with 10 key steps. We believe understanding the landmarks and a step-by-step guidance based on the concepts of retromuscular abdominal wall anatomy foment a safe learning of minimally invasive restoration of the abdominal wall integrity regarding non-expert surgeons.

RESUMO Objetivo: descritos pelo Dr. Jorge Daes, os princípios da visão aprimorada totalmente extraperitoneal (eTEP) têm mais recentemente sido utilizados no arsenal de reparos de hérnias ventrais. A realização da técnica de reparo totalmente extraperitoneal com o uso da robótica mostrou-se viável. No entanto, o verdadeiro conhecimento dos planos da parede abdominal retromuscular e os referenciais ainda são incertos para a maioria dos cirurgiões gerais. O objetivo deste artigo é propor padronização técnica e conceitos anatômicos no reparo de hérnia ventral robótico totalmente extraperitoneal (eTEP VHR). Métodos: nosso artigo descreve 10 etapas essenciais em abordagem estruturada passo a passo para procedimento seguro e reprodutível com base em referenciais anatômicos bem definidos, identificação de zonas de dissecção e restauração correta e completa da linha alba. Resultados: a padronização foi desenvolvida há 2 anos e aplicada a todos os pacientes. A cirurgia robótica é realizada com três braços da plataforma e por docking lateral. Conforme descrita, a reprodutibilidade e segurança são altas entre os cirurgiões gerais. Conclusão: apresentamos abordagem padronizada da técnica robótica de reparo de hérnia ventral totalmente extraperitoneal (eTEP VHR) em docking lateral por meio de 10 etapas essenciais. Acreditamos que a compreensão dos referenciais anatômicos e orientação passo a passo com base nos conceitos da anatomia do espaço retromuscular fomentam o aprendizado seguro, na atuação de cirurgiões não experientes durante a restauração minimamente invasiva da integridade da parede abdominal.

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ABSTRACT BACKGROUND: Sarcopenia may affect patients with liver cirrhosis and worsen disease outcomes. OBJECTIVES: To evaluate ultrasound-measured psoas major (PM) and rectus abdominis (RA) thickness for predicting survival among patients with liver cirrhosis. DESIGN AND SETTING: Prospective cohort study in a tertiary-level hospital. METHODS: 61 patients with liver cirrhosis were prospectively included during a 15-month period and followed up for at least six months. Cirrhosis was classified using the Child-Pugh score. Sarcopenia was assessed using surrogate parameters: handgrip strength (HGS), mid-arm muscle circumference (MAMC) and SGA (subjective global assessment). We used ultrasound to measure RA and PM thickness at admission. RESULTS: There were 41 men. The patients' mean age was 58.03 ± 10.8 years. 26.22% of them were Child-Pugh A, 45.9% B and 27.86% C. The patients were followed up for 11.9 ± 5.63 months. RA thickness correlated moderately with MAMC (r = 0. 596; P < 0.0001) and HGS (r = 0.515; P < 0.0001) and decreased with increasing SGA class (A, 10.6 ± 2.8 mm; B, 8.3 ± 1.9 mm; C, 6.5 ± 1.9 mm; P < 0.0001). Survival at six months was independently predicted by using the model for end-stage liver disease-serum sodium score (odds ratio, OR 1.305; 95% OR confidence interval 1.083-1.572; P = 0.005). Survival during follow-up was independently predicted by RA thickness (hazard ratio, HR 0.701; 95% HR confidence interval 0.533-0.922; P = 0.011) and ascites (HR 1.876; 95% HR confidence interval 1.078-3.267; P = 0.026). PM thickness did not have any predictive value. CONCLUSIONS: As a surrogate marker of sarcopenia, RA thickness may predict survival among patients with liver cirrhosis.

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