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Background Endometriosis of the abdominal wall is exceptionally rare, with malignant transformation to clear cell carcinoma being of even greater rarity. In this paper, the importance of accurate diagnosis and appropriate treatment is emphasized, including the possibility of mesh reconstruction of the abdominal wall. Case presentation A 53-year-old woman presented with a rapidly enlarging abdominal wall tumor, 19 years after undergoing a caesarean section. Prior to her referral to our facility, a peripheral hospital had already performed tumor resection with mesh-based abdominal wall reconstruction. Tumor histology had revealed endosalpingiosis without evidence of malignancy. However, a year later, the patient exhibited a relapse accompanied by renewed rapid growth. Both punch and open biopsies revealed endosalpingiosis. Due to its rapid growth, a total resection of the tumor was performed. This necessitated the removal of a significant portion of the abdominal wall musculature and fascia. The abdominal wall was then reconstructed using a two-layer mesh. Final histological examination revealed a clear cell carcinoma that had arisen from endometriosis. Following the complete healing, the patient received adjuvant platinum-based chemotherapy and radiation to the inguinal area. Conclusion Clear cell carcinoma of the abdominal wall arising from endometriosis is a rare and highly aggressive form of malignant transformation with a high rate of recurrence and metastasis. In rapidly growing abdominal wall tumors following gynaecological surgery, the objective should be radical resection. In addition to this, the selection of appropriate reconstruction procedures is crucial to achieving optimal oncological and functional results. Examples of such reconstruction procedures include a two-layer mesh reconstruction. This case aims to raise awareness of this rare and highly aggressive malignancy and to discuss diagnostic challenges and therapeutic strategies, including complex abdominal wall reconstruction.

Objectives To evaluate the efficacy and safety of ultrasound-guided percutaneous thermal ablation for abdominal wall metastases. Materials & methods We retrospectively analyzed patients with abdominal wall metastatic nodules who underwent ultrasound-guided microwave ablation (MWA) from August 2018 to September 2024. Tumor volume (V), volume reduction rate (VRR), pain scores, and University of Washington Quality of Life (Uw-QOL) scores were measured at one, three, and six months postoperative. Results A total of twelve patients were included in the study (8 males and 4 females), with one male patient excluded due to incomplete follow-up data. The median patient age was 51.5 years (range: 37–75). All patients were successfully treated, with no local recurrence noted during follow-up. Tumor volume reduction rates were 45.4%, 76.9%, and 96% at one, three, and six months, respectively. By the end of the follow-up period, the average pain scores decreased significantly from 7.09 ± 0.70 to 2.18 ± 1.16 ( p  < 0.001). The quality of life of patients was significantly improved, and the Uw-Qol of score increased from 1148.63 ± 94.07 to 1269.54 ± 118.25 ( p  < 0.05). No patient appeared serious complications. The clinical symptoms and quality of life of all patients were significantly improved. Conclusion Ultrasound-guided percutaneous thermal ablation is a safe and effective minimally invasive method for the treatment of metastatic nodules of abdominal wall, presenting a viable option for patients who are unsuitable for or unwilling to undergo surgery.

Purpose This study aims to investigate the use of dynamic MRI to assess abdominal wall biomechanics before and after hernia surgery, considering that such evaluations can enhance our understanding of physiopathology and contribute to reducing recurrence rates. Methods Patients were assessed using dynamic MRI in axial and sagittal planes while performing exercises (breathing, coughing, Valsalva) before and after their abdominal hernia surgery with mesh placement. Rectus and lateral muscles, linea alba, viscera area, defect dimensions and hernia sac were contoured with semiautomatic process to quantify the abdominal wall biomechanical temporal modifications. Results This study enrolled 11 patients. During coughing, the axial area of the hernia sac increased by 128 . 4 ± 199 . 2%. The sac increased similarly in axial and sagittal planes during Valsalva. Post-surgical evaluations showed a 26% reduction in inter-recti distance and a lengthening of all muscles ( p  ≤ 0 . 05). The post-operative rectus abdominis thickness change was negatively correlated with defect width during breathing ( p  ≤ 0 . 05). The largest change in linea alba displacement was observed in the surgical site ( p  = 0 . 07). Post-operatively, lateral muscles had a larger inward displacement during Valsalva ( p  ≤ 0 . 05). Rectus abdominis had a larger outward displacement during breathing ( p  = 0 . 09), reduced with the mesh size ( p  ≤ 0 . 05). A large inter-individual variability was observed. Conclusion Using a semi-automatic methodology, an in-depth analysis of the biomechanics of the abdominal wall was conducted, highlighting the importance of a patient-specific assessment. A broader study and consideration of recurrence would subsequently complete this methodological work.

PurposeTo systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome.MethodsPubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients.ResultsWe identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport® or 200–300 units of Botox® are injected at 3–5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0–4.3, I2 = 0%, p < 0.001); 6.3 cm total elongation, and a significant but heterogeneous decrease in transverse hernia width (95% CI 0.2–6.8, I2 = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02–1.16, I2 = 0%, p = 0.02)].ConclusionThe injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely.Study registrationA review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246).

Purpose Radical resections for abdominal wall tumors are rare, thus yielding limited data on reconstruction of defects. We describe surgical management and long-term outcomes following radical tumor resection. Methods This was a single-center retrospective review of patients between January 2010 and December 2022. Variables included operative characteristics, wound complications, hernia development, tumor recurrence, and reoperation. A multivariable analysis compared wound morbidity for suture and mesh repairs while adjusting for defect width, fascial closure, and CDC wound class. Results 120 patients were identified. Mean follow-up was 3.9 ± 3.4 years. Seventy-five (62.5%) of the masses were primary; most commonly desmoid ( n  = 25) and endometrioma ( n  = 27). Forty-five masses were metastases. Mean tumor width was 6.2 ± 3.4 cm; mean defect width was 8.1 ± 4.1 cm. Sixty-one patients (50.8%) had mesh placed, with variation in technique. Postoperative CT scans were available for 88 (73.3%) patients. Forty SSOs (33.3%), 11 SSIs (9.2%), and 18 (15%) SSOPIs occurred within 30 days. On multivariable analysis, increased defect width was associated with SSOPI (OR 1.17, p  = 0.041) and CDC wound class II–III was associated with SSI (OR 8.38 and 49.1, p  < 0.05) and SSOPI (OR 5.77 and 17.4, p  < 0.05); mesh was not associated with these outcomes. Seven patients (5.8%) underwent 30-day reoperations and 35 (20.8%) required additional operations after 30 days. Thirteen percent developed abdominal wall ( n  = 8) or intra-abdominal tumor recurrence ( n  = 8) requiring reoperation. Twenty-seven (22.5%) patients developed hernias with a mean fascial defect width of 9.8 ± 7.2 cm. Conclusion Abdominal wall mass resections are morbid, often contaminated cases with high postoperative complication rates. Risks and benefits of mesh implantation should be tailored on an individual basis.

BackgroundTension-free abdominal closure is a primary tenet of laparotomy. But this concept neglects the baseline tension of the abdominal wall. Ideally, abdominal closure should be tailored to restore native physiologic tension. We sought to quantify the tension needed to re-establish the linea alba in patients undergoing exploratory laparotomy.MethodsPatients without ventral hernias undergoing laparotomy at a single institution were enrolled from December 2021 to September 2022. Patients who had undergone prior laparotomy were included. Exclusion criteria included prior incisional hernia repair, presence of an ostomy, large-volume ascites, and large intra-abdominal tumors. After laparotomy, a sterilizable tensiometer measured the quantitative tension needed to bring the fascial edge to the midline. Outcomes included the force needed to bring the fascial edge to the midline and the association of BMI, incision length, and prior lateral incisions on abdominal wall tension.ResultsThis study included 86 patients, for a total of 172 measurements (right and left for each patient). Median patient BMI was 26.4 kg/m2 (IQR 22.9;31.5), and median incision length was 17.0 cm (IQR 14;20). Mean tension needed to bring the myofascial edge to the midline was 0.97 lbs. (SD 1.03). Mixed-effect multivariable regression modeling found that increasing BMI and greater incision length were associated with higher abdominal wall tension (coefficient 0.04, 95% CI [0.01,0.07]; p = 0.004, coefficient 0.04, 95% CI [0.01,0.07]; p = 0.006, respectively).ConclusionIn patients undergoing laparotomy, the tension needed to re-establish the linea alba is approximately 1.94 lbs. A quantitative understanding of baseline abdominal wall tension may help surgeons tailor abdominal closure in complex scenarios, including ventral hernia repairs and open or burst abdomens.

Purpose Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. Method A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. Results Imaging post-BTA revealed hernia width reduction of 1.9 cm ( p  = 0.002), lateral abdominal wall muscle elongation of 3.1 cm ( p  < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L ( p  < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L ( p  = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% ( p  < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH 2 O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. Conclusion BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

BackgroundThe enhanced-view totally extraperitoneal (eTEP) hernia repair technique was first described for laparoscopic inguinal hernia repair and later applied to laparoscopic ventral and incisional hernia repair. We present our center’s early operative outcomes utilizing principles of this technique during robotic ventral and incisional hernia repair for implementation of the robotic eTEP Rives–Stoppa (eRS) and eTEP transversus abdominis release (eTAR) techniques.MethodsA review of a prospectively maintained database of hernia patients was conducted identifying 37 patients who underwent robotic eTEP for ventral, incisional, flank or parastomal hernia repair between March and October 2017. All patients underwent retrorectus dissection with selective utilization of transversus abdominis release (TAR) as indicated.Results37 patients including 13 male and 24 female with mean age, body mass index, and ASA score of 54, 35.5, and 2.4, respectively, underwent a mean operation room time of 198 min. Mean length of stay was 0.7 days. There were no intraoperative complications. Two patients developed subcutaneous seromas requiring interventional radiology drainage. One patient was readmitted at 30 days for PO intolerance that was managed expectantly. Mean postoperative follow-up visit occurred at 36 days with no sign of early hernia recurrences.ConclusionThe enhanced-view totally extraperitoneal approach is both safe and feasible in robotic-assisted repair of ventral and incisional hernias. Although long-term outcomes and patient selection criteria require further study, we believe this technique will become an important tool in the armamentarium of minimally invasive hernia surgeons.

Repair of contaminated abdominal wall defects entails the dilemma of choosing between synthetic material, with its presumed risk of surgical site complications, and biologic material, a costly alternative with questionable durability. Thirty-two studies published between January 1990 and June 2015 on repair of (potentially) contaminated hernias with ≥25 patients were reviewed. Fifteen studies solely described hernia repair with biologic mesh, 6 nonabsorbable synthetic meshes, and 11 described various techniques. Surgical site complications and hernia recurrence rates were evaluated per degree of contamination and mesh type by calculating pooled proportions. Analysis showed no benefit of biologic over synthetic mesh for repair of potentially contaminated hernias with comparable surgical site complication rates and a hernia recurrence rate of 9% for biologic and 9% for synthetic repair. Biologic mesh repair of contaminated defects showed considerable higher rates of surgical site complications and a hernia recurrence rate of 30%. As only 1 study on synthetic repair of contaminated hernias was available, surgical decision making in the approach of contaminated abdominal wall defects is hampered. •Repair of potentially contaminated abdominal wall defects using biologic or synthetic mesh results in comparable surgical site complication and a hernia recurrence rates.•Biologic repair of contaminated defects results in considerable higher rates of surgical site complications and a hernia recurrence rate of 30%.•No benefit of biologic mesh over synthetic mesh could be demonstrated for potentially contaminated defects. For contaminated defects, lack of reports on synthetic mesh repair hamper surgical decision making.

PurposeTo provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used.MethodsThe guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument.ResultsFor many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE.RecommendationsWhen considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.