Shackelford's Surgery of the Alimentary Tract

In the last decade, in the search for abdominal-wall hernia etiology, attention has been brought to alterations in the connective tissue ultrastructure as the probable etiological factor. These may cause weakening of connective tissue, which in turn may form ground for hernia formation. To investigate this hypothesis in depth, we compared the ultrastructure of the connective tissue in hernia patients and the control group. The study group consisted of five patients with primary inguinal hernia (Nyhus II = 4, Nyhus IIIa = 1). Another five patients posted for emergency appendectomy created the control group. Tissue specimens, harvested intraoperatively from the rectus muscle sheath (RAMS) and fixed in 4% glutaraldehyde, underwent staining by the Masson, H-E and methylene blue techniques and were assessed by microscopy (light and scanning electron). The examinations showed significant differences in the rectus sheath ultrastructure. They included altered architecture, placement and quantity of collagen and elastic fibers, differences in the caliber of individual fibers and disrupted ground matter-to-fiber ratio. In patients with hernias, chaotic arrangement of collagen fibers was seen, as well as their thinning and a decrease in the general amount of elastic fibers, replaced by ground matter. Our research has shown significant differences in the structure of the RAMS between patients with hernias and healthy individuals. This supports the theory linking connective tissue alterations with the etiology of hernia, and stating that these alterations include connective tissue at locations distant from the hernia site as well, as the rectus sheath itself does not form a hernial defect.

Etiology of inguinal hernia: ultrastructure of rectus sheath revisited.

Purpose: This study assessed the collagen deposition and correlated it with local inflammatory responses to evaluate the length of time required for fibroplasia when polypropylene meshes are used to repair incisional abdominal wall hernias in rats. Methods: Thirty-six male Wistar rats underwent longitudinal resection of a peritoneal and musculoaponeurotic tissue segment (3x2 cm) of the abdominal wall followed by defect reconstruction with polypropylene mesh bridging over aponeurosis. The animals were divided into 6 groups according to the time points for the analysis of fibroplasia: 1, 2, 3, 7, 21 and 30 days post-implantation. Animals were sacrificed at each time point, and the site where the polypropylene mesh was implanted was evaluated histologically to assess inflammatory response and percentage of collagen using computer-assisted videomorphometry. Results: Total collagen was found at the mesh site on the 3rd day post-implantation, and increased progressively on all subsequent days up to the 21st day, when it reached its highest percentage (p 0.001). Type I collagen was first found between the 7th and 21st days; it reached its highest percentage on the 21st day and then remained stable until the 30th day. The type I to type III collagen ratio increased significantly and progressively up to the 30th day (p<0.001). Neutrophils were found at the mesh site from the 1st to the 21st day post-implantation. Macrophages, giant cells and lymphocytes were seen on the 2nd day. Thirty days after mesh implantation, neutrophils disappeared, but the percentages of macrophages, giant cells and lymphocytes remained stable (p<0.001). Conclusions: This study showed that total collagen was first seen on the 3rd day post-implantation, with a higher percentage of type I collagen at the last observational time point. The prolonged healing inflammatory response and the persistence of chronic inflammation surrounding to the mesh did not affect the length of time required for fibroplasia.

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Fibroplasia after polypropylene mesh implantation for abdominal wall hernia repair in rats

BACKGROUND: Inguinal hernia is the second most common surgical case in our field. The anatomical factors alone are not enough to explain the inguinal hernia. Studies show changes in the proportion and quantity of collagen fibers in the developing of inguinal hernia. The greater production of collagen type III compared to the type I could justify the thinning of the fascia transversalis and its weakness. AIM: To determine the quantitative and qualitative changes of collagen in the fascia transversalis in inguinal hernia patients and compare them to findings from corpses without inguinal hernia. METHOD: Prospective case-control study based on the biopsy of fascia transversalis of 27 patients and 24 corpses. The technique used was hematoxylin-eosin and picrosirius colorimetry. RESULTS: The medium percent area of collagen (types I + III) and collagen type I, in both groups, show no statistic difference. The quantity of collagen type III was greater in the patients. Patients classified with Nyhus IIIa presented greater quantity of collagen type III. CONCLUSION: There is no significant difference in the quantity of collagen in the fascia transversalis of patients compared to the controls. An increase in the quantity of collagen type III was found in patients with inguinal hernia and a greater quantity in those patients classified with Nyhus IIIa.

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Quantitative and qualitative analysis of collagen types in the fascia transversalis of inguinal hernia patients.

The purpose of this study was to evaluate the amount of total and types I and III collagens of samples from the linea alba in patients with hernias (epigastric, umbilical, and incisional) on the anterior wall of the abdomen, comparing them to findings obtained from a cadaver control group without hernias. Samples of the linea alba aponeurosis from 26 patients with hernias on the anterior abdominal wall and from 32 cadavers without hernias were analyzed and compared for qualitative and quantitative evaluation of the total and the types I and III collagens. Sirius-red staining was used to evaluate the total collagen, and for types I and III collagens, immunohistochemistry was used with monoclonal antibody anticollagen types I and III, respectively. The amount of total collagen was 18.05% smaller in patients with hernias than in cadavers (p<0.05). Type I collagen was 20.50% smaller in patients than in cadavers (p<0.05). There was no significant difference in the amount of type III collagen between cases and controls (p=0.383). The results of this study indicate a relationship between hernias of the anterior abdominal wall and smaller amounts of total and type I collagens.

Qualitative and quantitative evaluation of total and types I and III collagens in patients with ventral hernias

OBJETIVO: Analisar quanto a espessura, elementos constitutivos e quantificacao do colageno total amostras de fascias transversais de pacientes entre 20 e 60 anos de idade, com hernia inguinal direta, coletadas no momento da correcao videolaparoscopica, comparando-as com amostras do mesmo tecido, retiradas de cadaveres. METODOS: Biopsias de 23 pacientes e de 22 cadaveres foram analisadas e comparadas. Utilizaram-se as tecnicas de coloracao de Hematoxilina-Eosina e Picrosirius. As imagens captadas foram analisadas por tecnica videomorfometrica assistida por computador. RESULTADOS: Constatou-se uma espessura de fascia transversal nos controles, em media, de 4.5 milimetros. A espessura da fascia transversal dos pacientes com hernia foi, em media, 58 % menor (p< 0.001). Nao se evidenciou algum processo de degeneracao das fibras de colageno atribuivel a senilidade. O principal elemento constitutivo da fascia, nos dois grupos, foi o tecido conjuntivo denso, representando cerca de 75 % nos controles e sendo um terco menor nos pacientes (p< 0.001). A area media percentual de colageno no campo amostral dos pacientes encontrada foi metade da area dos controles (p< 0.001), resultando em uma menor quantidade de colageno na parede posterior herniada. CONCLUSAO: Os pacientes com hernia inguinal direta apresentam menor quantidade de colageno tanto absoluta quanto relativamente aos demais elementos constitutivos da fascia transversal.

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O colágeno em fáscia transversal de pacientes com hérnia inguinal direta submetidos à videolaparoscopia

OBJETIVO: O objetivo do presente estudo é o de identificar os elementos histológicos constituintes da fáscia transversal em 23 pacientes com hérnia inguinal direta, comparando-os com a fáscia de 22 cadáveres sem esta doença. MATERIAIS E MÉTODOS: As biópsias dos pacientes foram obtidas no momento da correção videolaparoscópica. As fáscias foram estudadas histologicamente, sendo empregadas as técnicas de coloração de hematoxilina-eosina e anticorpo monoclonal para colágeno tipo I. RESULTADOS: O tecido conjuntivo denso foi o principal elemento constitutivo das fáscias de pacientes e controles, embora em menor presença nos primeiros, seguido do tecido adiposo. Identificamos, através da técnica de imuno-histoquímica, o colágeno tipo I como sendo a principal proteína das fáscias. CONCLUSÃO: Os autores concluem que a fáscia transversal é constituída principalmente por colágeno tipo I e sugerem o uso de técnicas de correção de hérnia inguinal que aumentem a deposição de colágeno na fáscia, como quando do uso de próteses.

Igor Wolwacz Júnior

Papers

O colágeno em fáscia transversal de pacientes com hérnia inguinal direta submetidos à videolaparoscopia

A fáscia transversal e o colágeno na hérnia inguinal direta