Bilateral differences in the trunk muscle volume of skilled golfers

Repetitive mechanical load applied to a body part may lead to hypertrophy of its muscles. If a movement requires asymmetric activation of bilateral muscles, this may result in differences in muscle size between the sides. This study aimed to investigate the degree of bilateral differences in the trunk muscle volume of golfers by comparing with non-golfers. Seventeen male right-handed golfers and eleven (nine right- and two left-handed) non-golfers participated. Trunk muscle volume was determined using magnetic resonance imaging, and the degree of asymmetry was calculated as the ratio of trunk muscle volume on the left to trunk muscle volume on the right side in right-handers and vice-versa in left-handers. Golfers had significantly larger lateral abdominal wall (LA) muscle volume than non-golfers: 12.36 ± 1.12 vs. 9.96 ± 0.94 cm3/kg; erector spinae: 9.12 ± 1.16 vs. 7.88 ± 0.84 cm3/kg; psoas major (PM): 6.27 ± 0.88 vs. 5.51 ± 0.98 cm3/kg; rectus abdominis (RA): 4.15 ± 0.54 vs. 3.50 ± 0.64 cm3/kg; and multifidus: 3.61 ± 0.41 vs. 3.05 ± 0.40 cm3/kg (p < 0.05). The degree of bilateral asymmetry of the LA, PM, and RA volume was significantly greater in golfers than in non-golfers (LA: -8.63 ± 7.40% vs. 1.94 ± 2.76%; PM: -9.10 ± 5.25% vs. -0.48 ± 5.96%; RA: 6.36 ± 6.50% vs. -2.12 ± 9.64%, respectively, p < 0.05). Right-handed golfers had greater left LA and PM volume compared to the right (LA: 5.89 ± 0.55 vs. 6.48 ± 0.65 cm3/kg; PM: 3.00 ± 0.42 vs. 3.27 ± 0.47 cm3/kg; p < 0.05) and had greater right RA volume compared to the left (2.15 ± 0.32 vs. 2.00 ± 0.24 cm3/kg, p < 0.05). These findings suggest that skilled, long-term golfers develop large volume and bilateral asymmetry of their trunk muscles.

[Thoracoabdominal primary endodermal sinus tumor: a case report]

INTRODUCTION

Endodermal sinus tumor is a malignant germ cell tumor that generally involves the gonads. Extra-gonadal localization out of midline organs is rare. We report a case of endodermal sinus tumor in the thoracoabdominal wall.

CASE REPORT

We discuss the case of an infant presenting an abdominal mass detected after a fall from his own height. Studies revealed anemia with abundant intraabdominal fluid and elevated alpha-fetoprotein. During surgery, a left thoracoabdominal wall-dependent tumor was identified, with involvement of the diaphragm and the costal cartilage. Complete resection was performed. Pathology report informed of an endodermal sinus tumor.

DISCUSSION

Abdominal wall location of endodermal sinus tumor is rare. Pathophysiology has not been completely outlined, however, it is presumed to be a consequence of aberrant migration patterns of the primordial cells. Pre-surgical diagnosis remains a challenge due to the low incidence.

Abdominal wall endometriosis treatment by ultrasound-guided high-intensity focused ultrasound ablation: a case report

Abdominal wall endometriosis (AWE) occurs in about 0.1% of people with endometriosis, and is often diagnosed postoperatively. Surgical resection is generally used to treat AWE. We successfully treated AWE with ultrasound-guided high-intensity focused ultrasound therapy (USgHIFU). A 37-year-old Korean female presented with a palpable subcutaneous nodule associated with cyclic pain and swelling during menstruation. She was recommended surgical excision three months ago. She had a history of laparoscopic surgery for endometriosis 4 years ago and was interested in less invasive methods of treatment. The 0.9 cm painful nodule was observed as a low-echoic shadow in transabdominal ultrasonography and as an iso-signal in T1 MRI images. USgHIFU treatment was performed under light sedation and completed when the hyperechoic area covered the entire lesion. HIFU treatment was effective without any postoperative complications such as blisters or skin burns. The lesion showed changes in hyper-intensity signal on T1 MRI images. Physical examination showed absence of pain or tenderness and three months later, the painful nodule shrunk, and the menstrual cyclic pain associated with the nodule disappeared. In conclusion, USgHIFU may represent an effective therapy for AWE.

Abdominal Wall Pain: Clinical Evaluation, Differential Diagnosis, and Treatment

Abdominal wall pain is often mistaken for intra-abdominal visceral pain, resulting in expensive and unnecessary laboratory tests, imaging studies, consultations, and invasive procedures. Those evaluations generally are nondiagnostic, and lingering pain can become frustrating to the patient and clinician. Common causes of abdominal wall pain include nerve entrapment, hernia, and surgical or procedural complications. Anterior cutaneous nerve entrapment syndrome is the most common and frequently missed type of abdominal wall pain. This condition typically presents with acute or chronic localized pain at the lateral edge of the rectus abdominis that worsens with position changes or increased abdominal muscle tension. Abdominal wall pain should be suspected in patients with no symptoms or signs of visceral etiology and a localized small tender spot. A positive Carnett test, in which tenderness stays the same or worsens when the patient tenses the abdominal muscles, suggests abdominal wall pain. A local anesthetic injection can confirm the diagnosis when there is 50% postprocedural pain improvement. Point-of-care ultrasonography may help rule out other abdominal wall pathologies and guide injections. The management of abdominal wall pain depends on the etiology. Reassurance and patient education can be helpful. Local injection with an anesthetic and a corticosteroid is an effective treatment for anterior cutaneous nerve entrapment syndrome, with an overall response rate of 70% to 99%. For refractory cases that require more than two injections, surgical neurectomy generally resolves the pain.

Application of ARFI-SWV in Stiffness Measurement of the Abdominal Wall Musculature: A Pilot Feasibility Study

The purpose of this study was to assess the feasibility of acoustic radiation force impulse shear wave velocity and textural features for characterizing abdominal wall musculature and to identify subject-related and technique-related factors that can potentially affect measurements. Median shear wave velocity measurements for the right external abdominal oblique were the same (1.89 ± 0.16 m/s) for both the active group (healthy volunteers with active lifestyles) and the control group (age and body mass index-matched volunteers from an ongoing hernia study). When corrected for thickness, the ratio of right external abdominal oblique shear wave velocity -to-muscle thickness was significantly higher in the control group than in the active volunteers (4.33 s^-1 versus 2.88 s^-1; p value 0.006). From the textural features studied for right external abdominal oblique, 8 features were found to be statistically different between the active and control groups. In conclusion, shear wave velocity is a feasible and reliable technique to evaluate the stiffness of the abdominal wall musculature. Sonographic texture features add additional characterization of abdominal wall musculature.

Use of the AccuVein AV400 during RARP: an infrared augmented reality device to help reduce abdominal wall hematoma

INTRODUCTION

Abdominal wall hematoma (AWH) is a self-resolving, yet common complication from the insertion of trocars during laparoscopic surgery. Particularly, its appearance may increase patient anxiety and may reduce overall surgical satisfaction.

MATERIALS AND METHODS

In a retrospective study analyzing data from 724 robot-assisted radical prostatectomy cases (RARP), trocar insertion sites were examined on postoperative day 7 with Foley removal for AWH. AWH was defined by a sizable collection of blood below the skin as a result of the surgery. The AccuVein AV400 system was utilized to generate real-time images of venous structures beneath the skin. Comparative outcomes were performed with a series of 114 men where the AccuVein AV400 device was applied over trocar insertion markings to help modify port placement.

RESULTS

The pre-incision imaging of the AccuVein system modified port placement in 74 of 114 cases (65%), and reduced AWH from 8.8% to 2.6% (p = 0.03) as compared to transabdominal illumination. Port placement adjustments were most prevalent in the lateral regions of the abdomen, prompting attention for lateral trocar insertion to avoid vessels such as the thoracoepigastric veins. Notably, the body mass index (BMI) of patients experiencing AWH who received the pre-incision imaging of AccuVein was significantly higher than patients receiving standard transabdominal illumination (34.2 and 27.9 kg/m² respectively; p = 0.02).

CONCLUSION

The AccuVein AV400 device appears to be an effective adjuvant for decreasing rates of AWH during lower abdominal wall trocar insertion, though its effectiveness is limited in patients with extreme BMI. Additionally, special attention should be directed towards trocar insertion in the lateral regions of the abdomen.

Myoepithelioma of the lateral abdominal wall: A case report

RATIONALE

Soft-tissue myoepithelioma is a rare neoplasm. It usually occurs in the distal or proximal extremities, but seldomly arises in the abdominal wall.

PRESENTING CONCERNS OF THE PATIENT

The patient is a 40-year-old woman who presented with a painless mass at the lateral abdominal wall for 6 months. Computed tomography scan revealed a lobulated and well-defined iso-density mass showing heterogeneously moderate enhancement. The mass exhibited intermediate T1 signal and obvious high T2 signal on magnetic resonance imaging.

INTERVENTIONS

The tumor was excised. Hematoxylin-eosin stain and immunohistochemical stain showed that the tumor was myoepithelioma.

OUTCOMES

The patient did not undergo chemotherapy and radiotherapy. No recurrence or metastasis was noted during the 1 year follow-up.

LESSONS

Radiologists should consider myoepithelioma in the differential diagnosis when finding a tumor in the abdominal wall.

The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations

PURPOSE

Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap.

METHODS

We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients' characteristics, such as abdominal surgery history.

RESULTS

CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm).

CONCLUSIONS

Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.

Evaluation of Large-Aperture Imaging Through the ex Vivo Human Abdominal Wall

Current clinical abdominal imaging arrays are designed to maximize angular field of view rather than the extent of the coherent aperture. We illustrate, in ex vivo experiments, the use of a large effective aperture to perform high-resolution imaging, even in the presence of abdominal wall-induced acoustic clutter and aberration. Point and lesion phantom targets were imaged through a water path and through three excised cadaver abdominal walls to create different clinically relevant clutter effects with matched imaging targets. A 7.36-cm effective aperture was used to image the targets at a depth of 6.4 cm, and image quality metrics were measured over a range of aperture sizes using synthetic aperture techniques. In all three cases, although degradation compared with the control was observed, lateral resolution improved with increasing aperture size without loss of contrast. Spatial compounding of the large-aperture data drastically improved lesion detectability and produced contrast-to-noise ratio improvements of 83%-106% compared with the large coherent aperture. These studies indicate the need for the development of large arrays for high-resolution abdominal diagnostic imaging.

Anterior abdominal wall parasitic leiomyoma: case report

The leiomyomas are a common gynecologic entity that may present unusual growth patterns or unusual locations. Its atypical presentations creates a diagnostic challenge. This is a case report of a parasitic leiomyoma located in the anterior abdominal wall in a 53 years old woman with pelvic compressive and urinary symptoms, with no history of any gynecological surgery. This case illustrates the diagnostic difficulties and describes the complementary images used in the preoperative evaluation.

Adult Acute Scrotal Edema - When Radiologists Can Help to Avoid Unnecessary Surgical Treatment

Acute idiopathic scrotal edema is a commonly painless self-limiting condition causing scrotal swelling, and is usually seen in children. In some cases, this condition is difficult to differentiate it from other causes of acute scrotum. In the right clinical scenario, ultrasonography has been used to confirm the diagnosis. We describe the ultrasound and CT findings of acute idiopathic scrotal edema in a 72-year-old male with coexistent involvement of the inferior abdominal wall.

[Abdominal wall paresis as a complication of herpes zoster]

BACKGROUND

Herpes zoster is an illness which is especially common amongst the elderly in the Netherlands and which can express itself in various ways. Besides affecting sensory nerves, which leads to postherpetic pain, the varicella zoster virus may also invade motor nerves.

CASE DESCRIPTION

A 73-year-old female went to the surgeon with symptoms of a painful swelling in the left lower abdomen. She had experienced herpes zoster at the site of the swelling a few months earlier. A CT scan revealed asymmetry of the abdominal wall musculature, which led us to suspect a link between motor involvement of herpes zoster and the abdominal swelling. EMG revealed denervation of the affected abdominal wall muscle, which confirmed the link with herpes zoster in that dermatome.

CONCLUSION

Abdominal wall paresis caused by herpes zoster is a rare condition. It can be diagnosed on the basis of clinical findings and may be confirmed by EMG investigation of the affected muscle. In view of the temporary nature of the paresis, it is possible to opt for conservative management of the condition.

Lymphedema of the Transplanted Kidney and Abdominal Wall with Ipsilateral Pleural Effusion Following Kidney Biopsy in a Patient Treated with Sirolimus: A Case Report and Review of the Literature

BACKGROUND Sirolimus is a mammalian target of rapamycin (mTOR) inhibitor, which is used in immunosuppressive treatment regimens in organ transplant recipients. Although mTOR inhibitors are well tolerated, their adverse effects have been reported. Sirolimus treatment in transplant recipients has been reported to be associated with lymphedema of the skin and subcutaneous tissues, and with pleural effusion, but edema of internal organs and organomegaly have not been previously reported. A case is presented lymphedema of the transplanted kidney and abdominal wall with ipsilateral pleural effusion following kidney biopsy in a patient treated with sirolimus. CASE REPORT A 32-year-old woman with a history of end-stage renal disease of unknown etiology had undergone right renal transplantation from an unrelated living donor, eight years previously. She was referred to our hospital with dyspnea, localized abdominal pain, and swelling of the transplanted kidney. The symptoms appeared following a kidney biopsy and the replacement of cyclosporin with sirolimus four months previously. On examination, she had localized swelling of the abdominal wall overlying the transplanted kidney, and a right pleural effusion. Hydronephrosis and nephrotic syndrome were excluded as causes of kidney enlargement. Following the withdrawal of sirolimus therapy her symptoms resolved within three months. CONCLUSIONS A case is described of lymphedema of the transplanted kidney and abdominal wall with ipsilateral pleural effusion following kidney biopsy attributed to her change in anti-rejection therapy to sirolimus. This case report should raise awareness of this unusual complication of sirolimus anti-rejection therapy and its possible effects on the lymphatic system.

Abdominal wall endometriosis: an update in clinical, imagistic features, and management options

Abdominal wall endometriosis (AWE) is a rare condition defined by the presence of endometrial tissue in the subcutaneous fatty layer and the muscles of the abdominal wall. It is usually caused by the dissemination of endometrial tissue in the wound at the time of obstetrical and gynecological surgeries. AWE is rare and difficult to diagnose. The most frequent clinical presentation is that of a palpable subcutaneous mass near surgical scars associated with cyclic pain and swelling during menses. AWE may be an underreported pathology partly because it has scarcely received attention in the radiologic literature. Its frequency is expected to rise along with the increasing rate of cesarean deliveries; thus, it is important that physicians or sonographers are familiar with this pathology. The purpose of our review is to present the latest data regarding risk factors, clinical and imagisticfindings, and management of AWE.

Twisted intra-abdominal cyst in a neonate: a surprise revelation

We, herein, present a male neonate with an antenatally detected intra-abdominal cyst who presented at 18 days of life at which time, the ultrasound revealed a 5×4 cm cyst. Since he was asymptomatic, we planned to repeat the ultrasound a month later and operate if the cyst showed no regression. However, a week later, he presented with an acute abdomen, irritable cry and a repeat ultrasound showing a larger (8×6 cm) cystic mass with debris within. He was taken up for an emergency laparotomy. Intraoperatively, the cyst was found arising from the left lateral abdominal wall free from all structures with a twisted pedicle. Histopathology surprisingly revealed seminiferous tubules within the cyst wall with the vas deferens, thus confirming the diagnosis of a torsion of intra-abdominal testis. Hence, we emphasise the importance of examining for an undescended testis when dealing with a male neonate presenting with a cystic intra-abdominal mass.

A Case of Incisional Endometrioma that Presented as an Abdominal Mass

Although endometriosis is a common condition in women of reproductive age, the incidence of endometrioma in prior surgical incision sites is rare.We present a case of an abdominal wall mass in a female patient with a history of obstetrical surgery. The mass was visualized with ultrasound and computerized tomography, removed by wide excision, and identified via frozen section. This case demonstrates the importance of a thorough surgical and obstetrical history in any woman who presents with an abdominal wall mass.

Abdominal wall endometriosis: differentiation from other masses using CT features

PURPOSE

To assess the utility of morphologic and quantitative CT features in differentiating abdominal wall endometriosis (AWE) from other masses of the abdominal wall.

METHODS

Retrospective IRB-approved study of 105 consecutive women from two institutions who underwent CT and biopsy/resection of abdominal wall masses. CTs were independently reviewed by two radiologists blinded to final histopathologic diagnoses. Associations between CT features and pathology were tested using Fisher's Exact Test. Sensitivity, specificity, positive, and negative predictive values were calculated. P values were adjusted for multiple variable testing.

RESULTS

24.8% (26/105) of patients had histologically proven abdominal wall endometriosis. The other most common diagnoses included adenocarcinoma NOS (21%; 22/105), desmoid (14.3%; 15/105), and leiomyosarcoma (8.6%; 9/105). CT features significantly associated with endometriosis for both readers were location below the umbilicus (P = 0.0188), homogeneous density (P = 0.0188), and presence of linear infiltration irradiating peripherally from a central soft tissue nodule (i.e., "gorgon" sign) (P < 0.0001). The highest combined sensitivity (0.69, 95% CI: 0.48-0.86) and specificity (0.97, 95% CI: 0.91-1.00) for both readers occurred for patients having all three of these features present. Border type (P = 0.0199) was only significant for R2, peritoneal extension (P = 0.0188) was only significantly for R1, and the remainder of features were insignificant (P = 0.06-60). There was overlap in Hounsfield units on non-contrast CT (N = 26) between AWE (median: 45HU, range: 39-54) and other abdominal wall masses (median: 38.5HU, range: 15-58).

CONCLUSION

CT features are helpful in differentiating AWE from other abdominal wall soft tissue masses. Such differentiation may assist decisions regarding possible biopsy and treatment planning.

Locally advanced colon cancer with cutaneous invasion: case report

BACKGROUND

Locally advanced colon cancer with direct abdominal wall and skin invasion is an extremely rare finding with most data being derived from case reports, historical autopsy-based or single-center retrospective studies. We present a unique case of a colon cancer with direct cutaneous invasion and colocutaneous fistulization.

CASE PRESENTATION

Eighty-six year old Caucasian female with multiple comorbidities, referred to Surgical Consultation due to ulcerated skin lesion in the abdomen. She had a long-standing large umbilical hernia but with no previous episodes of incarceration or occlusive symptoms. She denied any digestive or constitutional symptoms. Physical examination showed a large non-reducible umbilical hernia, with an associated painless firm mass within the hernia sac and cutaneous ulcerated growth. Colonoscopy revealed transverse colon cancer (endoscopic biopsy of the tumor and skin punch biopsy confirmed adenocarcinoma of the colon). Computed tomography showed a tumoral mass within the umbilical hernia, with cutaneous infiltration and enlarged regional lymph nodes. Rapid local progression led to colocutaneous fistula with total fecal diversion. We performed an extended right hemicolectomy with en bloc excision of the hernia sac and infiltrating cutaneous mass.

CONCLUSIONS

In the current era of widespread use of screening colonoscopies, initial diagnosis of locally advanced colon cancer is decreasing. However, this unique case presented an opportunity to recall the advantages of multivisceral resections.

Recovery after abdominal wall reconstruction

Incisional hernia is a common long-term complication to abdominal surgery, occurring in more than 20% of all patients. Some of these hernias become giant and affect patients in several ways. This patient group often experiences pain, decreased perceived body image, and loss of physical function, which results in a need for surgical repair of the giant hernia, known as abdominal wall reconstruction. In the current thesis, patients with a giant hernia were examined to achieve a better understanding of their physical and psychological function before and after abdominal wall reconstruction. Study I was a systematic review of the existing standardized methods for assessing quality of life after incisional hernia repair. After a systematic search in the electronic databases Embase and PubMed, a total of 26 studies using standardized measures for assessment of quality of life after incisional hernia repair were found. The most commonly used questionnaire was the generic Short-Form 36, which assesses overall health-related quality of life, addressing both physical and mental health. The second-most common questionnaire was the Carolinas Comfort Scale, which is a disease specific questionnaire addressing pain, movement limitation and mesh sensation in relation to a current or previous hernia. In total, eight different questionnaires were used at varying time points in the 26 studies. In conclusion, standardization of timing and method of quality of life assessment after incisional hernia repair was lacking. Study II was a case-control study of the effects of an enhanced recovery after surgery pathway for patients undergoing abdominal wall reconstruction for a giant hernia. Sixteen consecutive patients were included prospectively after the implementation of a new enhanced recovery after surgery pathway at the Digestive Disease Center, Bispebjerg Hospital, and compared to a control group of 16 patients included retrospectively in the period immediately prior to the implementation of the pathway. The enhanced recovery after surgery pathway included preoperative high-dose steroid, daily assessment of revised discharge criteria and an aggressive approach to restore bowel function (chewing gum and enema on postoperative day two). Patients who followed the enhanced recovery after surgery pathway reported low scores of pain, nausea and fatigue, and were discharged significantly faster than patients in the control group. A non-significant increase in postoperative readmissions and reoperations was observed after the introduction of the enhanced recovery after surgery pathway. Study III and IV were prospective studies of patients undergoing abdominal wall reconstruction for giant incisional hernia, who were compared to a control group of patients with an intact abdominal wall undergoing colorectal resection for benign or low-grade malignant disease. Patients were examined within a week preoperatively and again one year postoperatively. In study III, the respiratory function and respiratory quality of life were assessed, and the results showed that patients with a giant incisional hernia had a decreased expiratory lung function (peak expiratory flow and maximal expiratory pressure) compared to the predicted values and also compared to patients in the control group. Both parameters increased significantly after abdominal wall reconstruction, while no other significant changes were found in objective or subjective measures at one-year follow-up in both groups of patients. Lastly, study IV examined the abdominal wall- and extremity function, as well as overall and disease specific quality of life. We found that patients with a giant hernia had a significantly decreased relative function of the abdominal wall compared to patients with an intact abdominal wall, and that this deficit was offset at one-year follow-up. Patients in the control group showed a postoperative decrease in abdominal wall function, while no changes were found in extremity function in either group. Patients reported improved quality of life after abdominal wall reconstruction. In summary, the studies in this thesis concluded that; standardization of patient-reported outcomes after incisional hernia repair is lacking; enhanced recovery after surgery is feasible: after abdominal wall reconstruction and seems to lower the time to discharge; patients with giant incisional hernia have compromised expiratory lung function and abdominal wall function, both of which are restored one year after abdominal wall reconstruction.

[Thinning of the deep inferior epigastric artery perforator flap based on the vascular structure of the arterial perforator]

OBJECTIVE

To explore flap thinning based on the study of the arterial structure and blood perfusion of the deep inferior epigastric artery perforator (DIEP) flap using computed tomography (CT) angiography.

METHODS

Clinical imaging study: Preoperative CT angiography was performed in 15 patients with DIEP flap reconstruction to investigate the vascular structure of arterial perforator. Cadaveric imaging study:10 abdominal specimens harvested from fresh cadavers were cannulated with trocar and injected with contrast medium in the deep inferior epigastric artery perforator. During the perfusion of the contrast medium in the flap,the flap was scanned by three-dimensional CT. The CT data was then sent to CT workstation and the images were processed and reformatted to study the vascular structure of arterial perforators and the blood perfusion.

RESULTS

75 artery perforators in clinical study and 40 artery perforators in cadaveric study were chosen and analyzed. The major deep inferior epigastric artery perforators run directly across the deep layer of adipose tissue without bifurcating beneath the Scarpa's fascia. Above the Scarpa's fascia, the artery perforators bifurcate and ultimately terminate in the subdermal vascular plexus. Blood perfusion mode: The subdermal vascular plexus served as the only pathway for blood perfusion between perforasomes. There are two different pathways for blood perfusion in the perforasome: the subdermal plexus and the existing vascular structure of perforator.

CONCLUSIONS

Based on the vascular structure of arterial perforator and blood perfusion of the DIEP flap, thinning of the DIEP flap under the Scarpa's fascia is safe while thinning above the Scarpa's fascia should performed according to the blood supply zone of the DIEP flap.

The Effect of the Pressure Exerted on the Maternal Abdominal Wall by the US Probe on Fetal MCA Peak Systolic Velocity

Purpose To quantify the pressure exerted on the maternal abdominal wall during ultrasound examination and evaluate its effect on the fetal middle cerebral artery (MCA) peak systolic velocity (PSV). Materials and Method Gravid women with singleton pregnancies in their 2nd-3 rd trimester undergoing fetal sonographic evaluation for various indications were recruited. Each subject underwent transabdominal US measuring fetal distance from the probe, abdominal thickness, amniotic fluid index and biophysical profile. The applied pressure was measured simultaneously using an electronic pressure sensor attached directly to the US probe. For each subject baseline values of the pressure required for proper visualization were obtained. Fetal MCA was then demonstrated using color Doppler US. The PSV was measured at different pressure ranges with each subject used as her own control. Care was taken not to exceed the baseline pressure for each subject. Results 29 women were recruited. 24 subjects (82.7 %) demonstrated a statistically significant positive correlation between the pressure exerted and MCA-PSV (R-0.37, p < 0.0001). Of these, 4 subjects (13.8 % of study population) demonstrated elevation of PSV values above 1.29 MOM and 5 subjects (17.2 %) demonstrated elevation of PSV values above 1.5 MOM for gestational age with increasing pressure. In total, 9 subjects (31 %) demonstrated significant changes in the MCA-PSV measurements (owing to increase in pressure applied) that could potentially falsely influence clinical obstetric diagnosis and management. Conclusion The pressure exerted on the maternal abdominal wall during US examination is an important parameter, producing clinically significant measurable changes in fetal MCA hemodynamics. Further study is needed in order to demonstrate the potential effect of pressure as a parameter influencing the diagnostic accuracy of the MCA-PSV in the setting of fetal anemia.