text:
Reconstruction of Complex Midline Abdominal Wall Defects, Is There a Gold Standard?
Ahmed M. Abdel Modaber1*, Ahmed Hammad1, VusalAliyev2
1Department of General Surgery, Faculty of Medicine, Mansoura University Hospitals, Egypt
2Department of General Surgery, Emsey Hospital, Istanbul, Turkey
Ahmed Abdel Modaber
Department of General Surgery
Mansoura University
E-mail: a.abdelmodaber@mans.edu.eg
Accepted Date: February 07, 2018
Published Date: February 17, 2018
Copyright: © 2018 Modaber AMA, et al.
Modaber AMA, Hammad A, Aliyav V. Reconstruction of Complex Midline Abdominal Wall Defects, Is There a Gold Standard?. Int J Surg Proced. 2018 Feb;1(1):103
The management of patients with open abdomens is an evolving concept. Certain techniques for managing the open abdomen patients can be effective in treating ACS. The goal of therapy is to maximize tissue perfusion and minimize potential intra abdominal complications, such as fistulas and hernias. Meticulous care of the bowel, minimizing trauma from techniques or systems used to cover abdominal contents and protection of the bowel from exposure to the environment can reduce the complications associated with the open abdomen. A Temporal Abdominal Closure should not only protect the intra abdominal contents, but facilitate primary closure of the fascia and minimize the need for secondary repairs of ventral hernias and subsequent repair. Serial bladder pressure monitoring should be a part of post-operative management protocols in high-risk patients and decompression of the abdomen with a pressure of > 25-30 mmHg should be considered even without clear clinical evidence of ACS. While many closure techniques are reported in the literature, a dynamic closure technique, such as Vacuum pack appears to have an advantage in meeting most requirements for managing an open abdomen. IAH and ACS remain the most significant considerations for the management of the open abdomen. IAH and ACS are in part iatrogenic and can be minimized with the appropriate resuscitation protocols. Complications found in patients with open abdomens may be minimized with Vacuum pack Therapy resulting in early closure of the abdomen. Consideration for the type of closure is based on the patient's clinical status with the optimal result of primary facial closure. When the fascia cannot be closed, skin over granulation tissue is preferred to skin grafting over granulation tissue to create ventral hernia. Several techniques have been described to repair created ventral hernias. In our work, three methods had been utilized for final reconstruction of complex midline anterior abdominal wall defects according to size of the defect and status of tissue bed ; (I) repair with autologous tissue to bridge the fascial gap using components separation technique (CST), (II) prosthetic repair to bridge fascial defects and (III) Shoelace Darn Repair.
Abdominal Wall; Complex Abdominal wall defects
The open abdomen is an iatrogenic disease of modern abdominal surgery. Deliberately leaving a laparotomy wound open is now the standard of care in clinical situations that require either planned reoperations or decompression of intra-abdominal hypertension. Damage control surgery(1) and management of severe abdominal infection are examples of the former (2), while leaving the abdomen open after repair of a ruptured abdominal aortic aneurysm or for abdominal compartment syndrome are examples of the latter(3, 4). Less commonly, partial loss of the abdominal wall (5, 6) or septic dehiscence of a laparotomy incision prohibit immediate definitive closure and result in an open abdomen (7).
The "state of the art" in definitive abdominal closure is currently undergoing a quiet revolution. Until recently, the two options available to surgeons were either early closure within a week or so after the original operation, or allowing the wound to granulate (the socalled "planned ventral hernia") with definitive closure 6–12 months later(8, 9).
Reconstruction of complex defects of the abdominal wall is both challenging and technically demanding for surgeons. Therefore, it is imperative that the operating surgeon is knowledgeable of the etiologies, pertinent anatomy and proper postoperative care of these patients. Although these defects can be attributed to a many etiologic factors, the objectives in abdominal wall reconstruction are consistent and include the restoration of abdominal wall integrity, protection of intra abdominal viscera and the prevention of hernia or bulge formation while maintaining an aesthetically favorable result(7).
The aim of this work is to evaluate the outcome after different methods of reconstruction of difficult types of abdominal wall defects.
This is a prospective study on fifty two patients in different age groups ranging from nineteen to sixty seven years with complex anterior abdominal wall defects, in which primary closure is impossible, whom were managed by different techniques for closure and reconstruction of the defect.
All the patients subjected to the study were complaining of a complex midline abdominal wall defect or large ventral incisional hernia defect, necessitating special techniques for closure or repair.
Patients were divided according to their presentation into two groups:
Type I defects with complex complete fascial defect (open abdomen) including thirty four patients.
Type II defects with intact or stable closed skin coverage over hernia defect (ventral hernia) including eighteen patients.
General preoperative assessment: Surgical planning for complex abdominal wall defects starts with a standard preoperative evaluation. Most patients with complex abdominal wall defects had a complex past medical histories that directly influence reconstructive options. Cardiac and pulmonary compromise can represent a significant associated risk during these surgeries. The risk of surgery is related not only to the reconstruction, but also to the hernia take down. It is hard to determine which aspect of the operation represents the greatest risk, but it is best to think of the risk in terms of the entirety of the case.
The preoperative evaluation included complete history, physical, general medical evaluation, basic laboratory work and other diagnostic or radiologic studies. The medication list was also carefully reviewed. Most patients with complex abdominal wall defects benefit from a CT scan of the abdomen with contrast to evaluate the extent of the defect, the anatomy and associated pathology (as infected mesh, abscess pockets and the extent of local inflammation and bowel adhesions). The CT scan also was used to evaluate the extent of loss of intra-abdominal domain.
Patients with evidence of pulmonary or cardiac compromise underwent preoperative pulmonary function tests and full cardiac evaluation, such as echocardiogram or cardiac stress test.
Management of the open abdomen (type I defects): Management had been based on the physiologic status of the patient. Recognizing the importance of long-term protection of the abdominal contents with the patient's physiologic status as the main determinant, we had used Vacuum- Assisted Closure (V.A.C.) Technique for primary closure after the initial surgery.
Patients that had been stable could have a primary closure (early primary closure within three days was done in five cases, in addition to two died cases, and delayed primary closure within seven to ten days was done in ten cases in addition to four died cases). In the remaining thirteen patients who remained unstable, creation of ventral hernia with remote secondary repair had been utilized where vacuum pack therapy had been continued and was changed every 48 hours. The abdominal wall had been allowed to granulate until the skin was closed over the granulation tissue or a skin graft was to be immediately placed directly over the granulating abdominal contents. After wound closure, these patients were discharged when medically stable.
Regardless of the initial cause, the acute recovery period was managed by temporary abdominal wall closure with interposition mesh, followed by split-thickness skin grafting once granulation of the wound bed had occurred. Following stabilization of the patient and resolution of the inflammatory process, the skin graft can be removed from the wound bed, and definitive closure of the abdominal wall could be achieved using the components separation technique. Time to definitive closure of the abdominal wall varied from as little as 6 months to well over 2 years from the time of initial injury.
Vacuum pack closure technique: Vacuum pack had been tried in open defect cases especially those associated with massive trauma and subsequent tissue loss or with severe sepsis.
First, the omentum, if present, has been used to cover the small bowel and should be spread caudally and laterally to act as an abdominal apron.
Next, an absorptive layer (surgical sterile towel 38 × 62 cm. or the polyurethane sponge of a commercially available vacuumassisted wound management system) has been encased in an adhesive polyethylene plastic dressing (90 × 85 cm loban™ (Figure 1). This plastic-encased towel has been placed over the intestines and tucked under the fascial edges in a 360° fashion. It has been sized appropriately so as to not draw out from the edges of the abdominal wall and allow for evisceration (Figure 2).
Sterile towel is covered on one side with adhesive plastic dressing (Ioban)
The towel is placed over the intestines and tucked under the fascial edges
Large bore, closed suction drains have been placed in the inferior or caudal end of the wound above the plastic encased towel in the deep subcutaneous gutters and brought out superiorly through long subcutaneous tunnels (10 cm) with exit sites over the lower chest (Figure 3). These subcutaneous tunnels have been important as they allow the next and outer layer of adhesive plastic to seal the wound. Drains resting on the skin allow air leaks once negative pressure is created and therefore the vacuum necessary for wound and intraabdominal fluid removal is not created.
Closed suction drains are placed above the towel, in the subcutaneous gutters, and brought out superiorly through long, subcutaneous tunnels
The abdominal closure has been completed with the placement of a second large loban™ sheet over the entire open abdomen (Figure 4). To ensure that the loban™ sticks securely to the skin, all abdominal wall hair, especially in the groin and suprapubic areas, has been shaved to promote adhesion.
A second, large adhesive drape is placed over the entire abdomen
Once the outer adhesive plastic is completely fixed to the abdominal skin, the drains have been placed to low continuous suction to create a vacuum effect, seal the wound, and remove excess fluid and blood (Figure 5).
The drains are placed to low continuous suction, creating a vacuum effect; the wound is sealed.
It is important to protect the bowel from the negative pressure. A three-layered technique was used; the inner layer that faced the viscera consisted of a fenestrated inert sheet (IV bag or ISO 1010 Drape) covering the entire viscera to the bilateral paracolic gutters to prevent adhesions of viscera to the overlying peritoneum. The middle layer was made of Kerlex, lap sponges, gauze, or blue towels designed to provide the suction media for the NPA. It is imperative that the middle layer does not contact the underlying viscera, as it would increase the risk of fistula formation. Drains were placed in this layer to apply the negative pressure.
The outer layer consisted of a bio-occlusive adhesive sheet (Ioban) that was secured laterally to the flank skin and provided enough integrity to the abdominal wall.
Methods used in definitive repair of abdominal wall defects in created ventral hernia in open cases and in closed defects: The determination of when to perform the definitive abdominal closure is crucial. The reconstruction is undertaken when the skin graft can be lifted from the underlying viscera without evidence of adhesions. Three procedures had been used in our series including:
Component Separation technique (in eight cases)
Shoelace Darn Repair (in ten cases)
Polypropylene mesh Repair (in thirteen cases)
All patients received general anaesthesia for definitive repair of their abdominal wall defect. Prophylactic intravenous antibiotics were administered and prophylaxis for venous thrombosis with sequential compression devices was instituted.
Abdominal wall components separation
Preoperative assessment: A careful history and physical examination are critical to ascertain what components of the anterior abdominal wall remain undisturbed from prior surgical procedures, tumors, infection or trauma. If the clinical examination cannot identify an intact rectus abdominis muscle and fascia, CT scan, or magnetic resonance imaging can be useful for identifying remaining anatomic structures.
This technique had been used in present work for repairing large midline defects less than 20 cm in diameter. Exclusion criteria for a rectus abdominis muscle advancement flap include:
Compromised vascular supply (as superior epigastric artery, deep inferior epigastric artery) to the rectus flap.
Extensive destruction of the components of the abdominal wall.
Reconstruction in a contaminated field.
Operative steps (10)
The first surgical step is to remove skin graft or the skin and subcutaneous tissues from the underlying fascia, extending from the costal margin cephalad to the pubis caudally, and to the anterior axillary line and iliac crest laterally (Figures 6 and 7a). Skin flaps are raised to expose the rectus and external oblique junction. Blunt dissection along the semilunar line was then carried out in a caudad direction. This dissection was done to preserve the periumbilical perforators from the rectus muscle to the skin, as well as decrease the amount of skin undermining, thereby minimizing seroma formation.
Component separation technique, skin flap dissection
The viscera are freed from the abdominal wall to allow the abdominal wall to be mobilized medially. This may include extensive enterolysis and/or reversal of skin level ostomy.
An incision is made in the external oblique aponeurosis 2 cm lateral to the semilunar line and extending from the costal margin to the inguinal ligament (Figure 7b).
The external oblique muscle is bluntly dissected from the underlying internal oblique muscle (Figure 7c). Meticulous care is taken not to disrupt the internal oblique muscle and the neurovascular supply. This should result in approximately 5 cm of advancement in the upper third of the abdomen, 10 cm in the mid-abdomen, and 3 cm in the lower third of the abdomen.
Component separation technique, plane of dissection
If there is insufficient advancement of the musculofascial flap to the midline, the rectus muscle may be dissected free of its posterior sheath (Figure 8). This secondary release should produce an additional 2-4 cm of flap advancement. Thus, in the middle third of the abdomen, a total of 20 cm of advancement is often possible (Figure 9).
Component separation technique, rectus muscle elevation; When additional advancement is needed while performing the technique, the muscle can be elevated from the posterior sheath in its entirety.
The abdominal wall defect is repaired using the component separation technique
Debridement until viable fascial edges with bleeding rectus muscle was carried out. The fascia was then closed recreating the midline. Closed suction drains were left at each semilunar line and also in the midline.
Excess skin was then excised allowing primary skin closure. No special effort was made to preserve the umbilicus. Drains are almost universally employed in an effort to prevent seromas that can occur beneath the skin flaps and adjacent to prosthetic material if used.
The patients were mobilized on postoperative day 1 and dietary intake was advanced as tolerated. The patient was deemed ready for discharge when normal bowel function and adequate pain control were present.
Prosthetic Repair; Retro Rectus Approach (11)
The essential steps are as follows:
Under general anesthesia, the old scar is excised and the hernia sac dissected free down to the myoaponeurotic edges of the hernial opening
The sac is then opened and its contents inspected
All adherent loops of bowel are freed and returned to the peritoneal cavity
The excess sac is excised and the peritoneum and sac are closed with a running absorbable synthetic suture; where there is insufficient peritoneum to close the sac, the omentum is sutured to the edges of the residual defect so that the prosthetic non absorbable mesh for the actual repair will not come in contact with bowel for fear of adhesions, sepsis, and fistula
The bed for the permanent prosthesis is prepared by slitting open the medial edge of each rectus sheath along the hernial defect and for 8 to 10 cm above and below it, and
The rectus muscles are separated from the posterior rectus sheaths up to the whole length of the lateral edge of the sheath.
A sheet of propylene mesh is cut longer than the length of the defect and wide enough to stretch from one lateral edge of the rectus sheath to the other. This sheet then is fixed under slight tension with a few non absorbable monofilament synthetic sutures. Thus, it will lay on the closed peritoneum and posterior rectus sheaths and will stretch above and below the defect and also from one lateral edge of the rectus sheath to the other, and in the plane behind the rectus muscles. The sutures are passed through the edge of the mesh and then along the line of the lateral edges of the rectus sheath (linear semilunaris), from inside the sheath, through the whole thickness of the abdominal wall and out through stab holes in the skin, using an Aneurysm needle (Figure 10). Each limb of the suture is passed through the abdominal wall separately but through the same stab wound. In some patients, when the abdominal wall is not too fatty, a stitch with a straight needle may be passed through the abdominal wall from the skin to the retro muscular space (Figure 11).
Rives-Stoppa technique; Mesh passing behind rectus abdominis muscle, passing the sutures through the abdominal wall.
Rives-Stoppa technique. Both ends of the transfixing suture are brought through the abdominal wall through separate musculofascial incisions but the same skin incision.
The passage of each end of the suture through the muscle must be separated by at least 1.5 cm. If they are closer, the muscle fibers may be cut by the knot.
The sutures are tied so that the knots come to lie on the outer surface of the external oblique muscle and each stab wound is closed with a suture.
The upper and lower edges of the mesh are sutured in a similar fashion. When the hernia defect reaches the upper part of the abdominal wall, the upper edge of the mesh is passed down to lie under the diaphragm.
The transfixing sutures are placed clockwise along each semilunar line (Spiegel line) and at each extremity of the laparotomy. Usually 12 transfixing sutures are sufficient but in the patient with a huge incisional hernia, up to 21 sutures may be used. Sutures are tied on one side and then the other side of the defect. Tailoring of the prosthesis is important so that sutures result in some tension of the prosthesis to re-establish the lateral muscle function that was lost because of their midline detachment.
In the lower abdomen, below the arcuate line of Douglas, the graft comes to lie in the pre-peritoneal plane and should be long enough to hang into the pelvis in the retropubic space of Retzius and in the spaces of Bogros.
In this case, it should be fixed with a few sutures to the back of the pubis and along the pectineal lines. Two vacuum drains are laid on the graft and brought out through separate stab wounds. The two anterior rectus sheaths then are sutured together along their cut medial edges with a continuous synthetic absorbable or nonabsorbable monofilament suture. The excess skin is excised and the wound is closed.
Postoperative care: Respiratory physiotherapy is resumed as soon as possible after surgery. Aspiration drains are monitored and usually removed on the third or fourth postoperative day. Antithrombo-embolism therapy must be used.
Technique of Shoelace Darn Repair (12): A vertical elliptic incision is used, excising the old scar. In obese patients with a large apron of fat hanging below the pubis, panniculectomy and abdominoplasty are combined with repair of the hernia. In this case a long transverse incision is used at the level of the supra-pubic crease and is extended almost to the back, curving up at its lateral ends. The skin and fat of the apron and of the abdominal wall are freed upward off the musculoaponeurotic layer to well up onto the anterior chest wall. After repair of the hernia the apron and the excess skin and fat of the lower abdominal wall, usually up to the level of the umbilicus, are excised. Should it become necessary, an inverted midline V of the remaining skin and fat is excised to create a tucked in waistline (Figure 12A).
In the usual case, the skin and fat are dissected off the sac of the hernia, as well as off the rectus sheath on each side (Figure 12B). The anterior rectus sheaths should be exposed sufficiently to allow for splitting off of the medial ribbon, as well as for suturing the second layer. Time need not be wasted on accurate delineation of the medial edge of the rectus sheaths or on leaving an absolutely clean surface on the hernial sac. With the first continuous suture for construction of the new midline, the sac, together with the adherent bits of scar tissue and even old sutures that cannot be easily removed, are returned to the abdominal cavity.
Shoelace Darn Repair
A. Incision and area of skin excised for panniculectomy and abdominoplasty.
B. The skin and fat dissected off the sac and off the rectus sheath.
The new linea alba is now constructed, using a vertical strip 1 to 1.5 cm wide split off the medial edge of each anterior rectus sheath as follows:
the abdominal wall around the hernial opening is defined,
an incision is made in each anterior rectus sheath about 1 cm or more from its medial edge to confirm the presence of rectus muscle
the incision is extended up and down the entire length of the hernial opening and for about 2 cm beyond, keeping the ends of the incision away from and parallel to the midline, above and below the hernia (Figure 13), and
the two strips are sewn together from above downward by a continuous over-and-over suture of 0 (metric 3.5) monofilament Polypropylene, starting at the top corners of the incision and incorporating the whole width of each strip (Figure 14A)
A. Shoelace Darn Repair; creating the medial ribbons of the anterior rectus sheaths.
B. The slit in the anterior rectus sheath.
This not only creates the new linea alba but also returns the unopened sac and its contents to the abdominal cavity (Figure 14B). The sac remains unopened throughout the operation. If it is opened inadvertently, it is closed with a synthetic absorbable suture. There is no need to open the sac and become involved in the tedious dissection for freeing the masses of adherent bowel from the sac walls and from each other unless dealing with an emergency case of strangulation and bowel obstruction or with a patient with a recent history of bowel obstruction.
In this way the posterior rectus sheaths and the rectus muscles have been approximated at the midline. The rectus muscles have been stretched wide and thinned, with their fibers running in many different directions.
Sometimes an alarming gap remains between the lateral cut edges of the rectus sheaths. This gap is closed by the second suture, for which a 6-m 0 or 1 length of heavy monofilament Polypropylene is used, doubled to form a loop 3 m long. The usual suture begins at the top end of the incision in the rectus sheaths from inside the sheath and passes out on that side, returning inside through the opposite corner and slipping through the loop. The flat muscles are now restored to their former lengths, and the recti muscles are restored to their normal thickness and position by the continuous heavy monofilament nylon suture passing to and fro in front of the rectus abdominis muscles, between the cut edges of the anterior rectus sheaths, and through the strong new midline anchor for the whole length of the hernia, in the manner of a shoelace tightening a boot (Figure 14C). Each bite on the rectus sheath passes vertically from above down, from outside in, and from inside out at least 2 cm from the edge, so that it crosses and pulls on the fibers of the rectus sheath at a right angle, thereby preventing the sutures from cutting out (Figure 15A).
A. The first suture line constructing the new linea alba and also returning the sac and its contents to the abdominal cavity.
B. The large gap between the cut edges of the anterior rectus sheaths after completion of the first suture line.
C. The continuous heavy Polypropylene shoelace suture passing in front of the rectus abdominis muscles, between the cut edges of the anterior rectus sheaths and through the new midline.
The sutures should be approximately 0.5 cm apart and fairly tense to narrow the gap considerably between the cut edges of the rectus sheaths.
Good anesthesia with relaxation is important at this stage. Each suture is fixed at its midpoint by passing through the new mid-line, thus preventing bow-stringing and reherniation between the sutures. Polypropylene is tied at the bottom end of the repair. The cut edges of the rectus sheaths have been brought parallel to each other (Figure 15B) and rectus muscles are brought at the mid-line in their normal anatomic positions, with their fibers running parallel to each other. With narrow or moderately wide hernias the edges of the anterior rectus sheaths may be approximated by this suture line. In the usual case of a large hernia, a gap of at least a few centimeters remains, with the continuous pliable to-and-fro shoelace suture adjusting itself to the differing widths and tension across the fascial defect and thus functionally substituting for the missing anterior rectus sheaths (Figure 15C and D). Excess skin and fat are excised.
A. Shoelace suture.
B. The completed repair.
C. Cross-section of the repair.
D. The shoelace suture substituting functionally for the missing anterior rectus sheath
A vacuum drain is placed on either side, and each is brought out through a separate stab. The incision is closed with automatic staples or a continuous suture of fine monofilament polyamide thread.
Postoperative outpatient follow up: All discharged patients were monitored frequently (approximately once weekly) until full healing occurred. Additional visits every two months.
Patients were followed up by clinical examination in both supine and erect positions for the previous lesion or any new lesions.
Radiographic examination by computed tomography was requested only when recurrence was in question.
The collected data were tabulated and analyzed by SPSS (statistical package for the social science software) statistical package version 13 on IBM compatible computer.
Quantitative data were expressed as means and standard deviation (X + SD) and analyzed by applying mann Whitney U test for the not normally distrusted variables.
Qualitative data were expressed as number and percentage (No. and %) and analyzed by applying chi-square (X2) test and ANOVA (f) test.
Same letter means no significance difference. Different letters mean significant difference. All these tests were used as tests of significance at P < 0.05.
Our patients were 28 (53.8%) males and 24 (46.2%) females with age ranging from 19 to 67 with mean ±SD = 36.1 + 12.85 in cases with complete defects and 37.9 + 13.3 in those with partial defects. Also, males dominated in the first group with complete fascial defect (58.8%) while females were dominant the second group with partial defect (55.6%), with no statistically significant difference between the two groups regarding either gender or age of patients (Table 1).
Fascial defect
Complete fascial defect (Open Abdomen) No. = 34
Partial fascial defect (Ventral hernia) No. = 18
Mean L- Stcl
36.1+12.85
37.9 + 13.3
Table 1: Sex and Age in relation to the type of fascial defect.
Mann-Whitney Test, p = 0.377, No statistically significant difference, Independent Student "T" Test, p = 0.631, No statistically significant difference
Abdominal trauma with resultant abdominal wall tissue loss was the most common etiology of complete abdominal wall defect, in twelve out of thirty four patients (35.3%), followed by wound dehiscence following abdominal operations (29.4%), infection of recent laparotomies (26.5) and after abdominal wall desmoid tumor excision in one case (2.9%), while other cases were presented during the course of preparation for a second exploration in emergency situations (5.9%), there is a statistically significant difference, as shown in (Table 2).
Cause of complete fascial defect
Abdominal trauma
Acute dehiscence
Abdominal wall tumor
Planned re-exploration
Infection of recent laparotomy
Table 2: Causes of complete fascial defect (open abdomenen)
One sample kolmogorov-smirnov Test. P=0.008,statistically significant difference
In thirty four of our cases, it was impossible to primarily close the abdomen, thus a temporal closure was indicated. In 26% of cases, burst of the abdomen was the indication of temporal closure, while in 20% of cases; abdominal compartmental syndrome (ACS) was the indication. Also in emergency situations, damage control with relaparotomy was responsible for 15% of cases of temporal closure. Other indications of temporal closure were severe intra abdominal sepsis (11.8%), debridement of necrosis (8.8%), necrotizing fasciitis (5.9%) and lastly, excision of an abdominal wall tumor in (2.9%), with statistically significant difference as shown in (Table 3).
Indications of temporal closure
Intra-abdominal sepsis due to anastomotic disruption
Abdominal compartmental syndrome (ACS)
Damage control relaparotomy
Intra-abdominal sepsis due to contamination
Debridement of necrosis
Burst abdomen
Table 3:Indications of temporal closure
The time period consumed for temporal closure ranged from one day in emergency cases up to fifty seven days in cases with severe sepsis, intestinal fistula or necrotizing fasciitis and this had resulted in long hospital stay in such cases, with mean equals 19.15 and stander deviation of 11.33 as in Table (4).
Duration of Temporal closure (days)
Mean ± std Deviation
19.15±11.33
Table 4:Duration of Temporal closure (days) in "Open Abdomen"
In those presented with open fascial defect, out of twenty eight patients subjected to temporal vacuum assisted closure (VAC) as a bridge therapy for definitive closure, early primary closure was possible in only five patients (17.9%), in addition to two died cases, delayed primary closure could be done in another ten cases (35.7%), in addition to four died cases, while in the remaining thirteen cases (46.4%), creation of ventral hernia with secondary repair was done without any mortality and this is clear in (Figure 16).
Types of closure after temporal VAC in "Open Abdomen"
Summary of work up
(A) initial incision to relieve abdominal compartment syndrome;
(B) after 48 hours of V.A.C. therapy, abdominal compartment syndrome resolved; and
(C) abdomen is closed.
Burst of the abdomen following an urgent laparotomy for intestinal obstruction and small intestine resection in a diabetic patient
Stages of delayed primary closure after 15 days of vacuum pack dressing
Severe wound gapping and skin changes in a patient after two laparotomeis with intestinal resections for mesenteric ischaemia following remote splenectomy
Intraoperative steps of an elective incisional hernia repair with on lay prosthetic placement
Open abdomen with an end colostomy with the colostomy retracted, revision of the colostomy was done and component separation was mandatory to close the abdomen without tension
Pre-, intra- and post-operative photo of components separation technique
Intraoperative component separation technique in a patient with burst abdomen after exploration for blunt abdominal trauma with severe liver tear
Long standing incisional hernia with questionable viability of its colonic contents and impending necrosis of skin covering it, shoelace darn repair was done
Proposed plan for management of complex midline anterior abdominal wall defects
The time allowed for wounds to granulate ranged from fourteen to forty nine days with mean 19.90 and stander deviation 8.93, after granulation tissue formation we could do skin graft or flap to cover the defect and create an incisional ventral hernia, the time spent while creating ventral hernia ranged from one hundred sixty six days to three hundred fifty six days with mean 239.93 and stander deviation 60.27 (Table 5).
Time to granulate (days)
Time to create ventral hernia
Table 5: Time to granulate and Time to create ventral hernia (days) in late closure of "Open Abdomen"
Length as well as width of the defect was a major determinant factor in the choice of the techniques used for closure of the defect in cases with open abdomen, this is shown in (Table 6) as the defect length ranged from 15 -24, 12 -21 and 11 -23 cm in those underwent component separation technique, shoelace darn repair and propylene mesh repair respectively, While the width ranged from 10 -20, 8 -20 and 8 -18 cm respectively in the same order with no statistically significant difference between the three techniques.
Technique of late source
Component Separation technique (No.=8)
Shoelace Darn Repair (No.=10)
Propylene mesh Repair (No.=13)
Length of the defect (cm)
Width of the defect (cm)
ANOVA. P= 0.243. 0.430. No statistically significant difference.
Table (7) shows that the mean operative Time of final closure techniques was 161.06 ranging from 98 to 255 days and stander deviation of 48.17, it is also clear that the mean of the volume of blood loss was 232.23 ranging from 100 to 500 cc with stander deviation of 107.43.
Operative Time of final Closure technique
Blood loss (CC)
Table 7: Operative Time and Blood loss (CC) in final closure techniques of "Open Abdomen"
Some complications had followed the final defect closure techniques such as wound infection in the three techniques with different percentages; 12.5% in component separation technique, 10% with shoelace darn repair and 7.7% with propylene mesh repair. Other complications included: hematoma in10% of shoelace darn repair and in 7.7% of propylene mesh repair; also skin necrosis had occurred in 20% of cases with shoelace darn repair and in 7.7% of propylene mesh repair cases while mesh infection was seen in 7.7% of propylene mesh repair cases (Table 8).
Types complications of final closure techniques
Technique of late closure
Wound Infection
Skin necrosis Infected mesh
Table 8: Complications of final closure techniques in 31 patients
Kruskal Wallis Test. p=0.638. No statistically significant difference
Length of hospital stay was nearly equal in the three modalities; in component separation it ranged from thirty seven to sixty seven days with mean 48.25 and standard deviation 11.07, in shoelace darn repair hospital stay ranged from thirty three to sixty six days with mean 45.20 and standard deviation 10.87, while in propylene mesh repair hospital stay ranged from twenty one to sixty seven days with mean 41.23 and standard deviation 12.91 (Table 9).
Stay (days)
Table 9: Hospital Stay in ventral hernia and in late closure of open Abdomen
ANOVA, P=0.413. No statistically significant difference.
Recurrence rate was found to be low in those who underwent component separation technique (12.5%), Highest in shoelace darn repair (30.0%) with an intermediate incidence in patients with propylene mesh repair (23.1%) but with no significant statistical difference, and the time of recurrence is included in (Table 10).
Recurrence Time (mouths)
9. 10. 12
Table 10: Recurrence in 31 patients after ventral hernia repair and after late closure of open Abdomen
Kruskal-Wallis Test. P = 0.676. No statistically significant difference
All mortalities had occurred within cases presented to us with an open defect with no single case died among cases with covered defects or ventral hernias; this indicates that the cause of death was due to the associated original pathology rather than the defect itself or its repair, the mortality rate was (11.5%) with two cases died due to trauma, two cases died due to infection of recent laparotomy, one case died due to acute dehiscence and one case died during planning for relaparotomy as shown in (Table 11).
Clinical Data of mortality
Cause of complete facial defect
Indications of temporal
ACS CS
Intra abdominal sepsis due to contamination
Underlying primary operation in complete defect
Repair of Traumatic perforation of colon
Resection-anastomosis for gangrenous loop
Necrotizing pancreatitis
penetrating trauma with Intraperitoneal hemorrhage
Blunt trauma with liver injury
Table 11: Clinical Data of mortality cases
The present work focuses on midline abdominal wall defects that cannot be closed primarily, often resulting from intra-abdominal catastrophes, or recurrent incisional hernias. In these patients, a large fascial gap results from retraction of the rectus abdominis muscle prohibiting tension free primary closure of the fascia. In a considerable part of patients, these defects are accompanied by contamination or infection.
The open abdomen is becoming an increasingly common challenging problem for the general surgeon to manage. The OA is a planned surgical technique for managing damage control (DC) trauma patients, severe abdominal sepsis, intra abdominal hypertension (IAH), necrotizing infections of the abdominal wall and acute mesenteric ischemia (13), we agree with this statement as these were the etiologies in our patients in addition to abdominanal wall tumours as desmoids tumour. It is a temporizing measure that allows a planned escape from the operating theater to control medical bleeding, correct metabolic derangements and hypothermia or facilitate repeated abdominal debridement or bowel resections.
Prolonged laparotomy in critically ill trauma victims has a high mortality, principally by worsening the synergistic effects of the vicious triad of trauma; hypothermia, acidosis and coagulopathy (14).
In an effort to reduce this mortality, Rotondo et al.(15) introduced the concept of damage control surgery (DCS); an abbreviated laparotomy to control hemorrhage and limit contamination and placement of the patient on the intensive care unit for aggressive restoration of normal physiology before a second laparotomy 24 - 48 hours later. In this situation temporary abdominal closure is quick to apply and remove, limits heat and fluid losses and simplifies nursing care, we successfully used this technique in our study in open abdomen cases.
Preoperative predictors for DCS include penetrating torso trauma with hypotension, the need for resuscitative thoracotomy, blunt abdominal trauma with intra peritoneal hemorrhage and hypotension, severe pelvic fracture with hypotension, or severe multicavitary trauma (16).
Laboratory values including; a base deficit < -6 in patients < 55 years of age or < -15 in patients > 55 years of age, lactate > 5 mmol/L, prothrombin time > 16, or partial thromboplastin time > 50 have been associated with the need for DCS and decreased survival(16).
Any of these factors in a trauma patient undergoing open laparotomy should prompt the surgeon to perform an abbreviated first procedure and use TAC.
In the present study, damage control techniques have been utilized in 12 trauma patients, 7 due to ACS, 5 patients requiring rapid abbreviated and planned resuscitation due to liver laceration with pack to control bleeding, lacerated cecum and transected duodenum with coagulopathy, hypothermia and metabolic acidosis.
Damage control techniques and use of the OA may also be utilized in other populations; patients with abdominal compartment (ACS) syndrome, defined as sustained intra abdominal pressure > 20 mmHg with the onset of new organ dysfunction, both occur as a sequel of a rapid rise in intra abdominal pressure against a closed abdominal wall decreasing visceral blood flow. ACS may develop following an intra abdominal surgical procedure (primary ACS) or following third space accumulation secondary to aggressive resuscitation (secondary ACS) in conditions such as pancreatitis and burns (17).
ACS should be managed with decompressive laparotomy and creation of an OA. Treatment requires early recognition of intra abdominal hypertension followed by decompression before the onset of Multi Organ Dysfunction Syndrome (MODS) (18).
Patients with acutely increased intra abdominal pressures > 25 mmHg without acute organ dysfunction should also be considered for prophylactic decompressive laparotomy. Lastly, patients at high risk for postoperative ACS should be left open prophylactically following completion of surgery. These patients include those requiring > 15 L of crystalloid, or 10 units of PRBC intra operatively or patients with increased peak inspiratory pressures > 40 mmHg upon fascial closure (17).
The OA is also used in the management of ''second-look'' or staged laparotomy, which may occur after an embolic phenomenon or mesenteric venous occlusive disease. It is also employed in patients with severe abdominal sepsis necessitating repeated debridement, most specifically severe pancreatic necrosis. In our thesis, large contaminated abdominal wall defects occurred after infection of recent laparotomy wounds in 9 patients.
There appear to be two groups of patients with OA; the first group is relatively uncomplicated and can be closed within 4–7 days, these patients generally have a high rate of primary fascial closure and likely do well regardless of the choice of TAC (19). In our study, five out of the thirty four open defect cases are present in this group. The second group, for many reasons, has more complicated and prolonged resuscitative efforts and hospital courses, the timing of abdominal closure in this group tends to extend beyond 7 days, generally to 20–40 days (20). In our study, ten cases belong to that group. The rates of primary closure are much lower in these patients, and the type of TAC chosen may have a significant impact on their ability to achieve primary facial closure. Several risk factors have been found that predict a more prolonged or complicated course— and subsequently a diminished rate of primary closure; prolonged duration of OA, multisystem injuries, particularly colonic or duodenal and active infection(21).
Teixeira et al. (21) have also indicated that patients with conservative fluid resuscitation (< 20 L) and fewer transfusions, or a net negative fluid balance, have improved rates of primary closure.
In our patients, regardless of the initial cause, the acute recovery period were managed by temporary abdominal wall closure.
Unfortunately none of the techniques described so far controls the release of the often large volumes of exudate that are liberated from the partially exposed edematous bowel. In order to address this worry, wall suction was utilized to extract the fluid from beneath a temporary abdominal closure; so called 'Vacuum pack' therapy. The application of negative pressure was also postulated to increase closure rates. Barker et al reported a series of 112 patients treated in this manner over a 7 year period with a 55% primary fascial closure rate, although if the patients who died before abdominal closure was attempted are excluded this would rise to 69%(22).
In our study, we agree with this as the rate of primary closure (either early or late) is 44% but if we exclude the mortalities from calculation, the rate will rise to 53%. Delays beyond 6 days from injury were however associated with a much lower chance of success of primary closure because of fascial retraction and adherence of the viscera to the abdominal wall.
Quyn et al. (23) suggested that VAC induces some degree of tissue stretching, a stimulus to increased proliferation, angiogenesis and promotion of matrix synthesis. Vacuum-assisted closure is an evolution of the 'do-it-yourself' vacuum dressings that utilizes subatmospheric pressure to manage a variety of acute and chronic wounds including the open abdomen.
A purpose made fenestrated non adherent sheet is placed over the abdominal cavity to retain the contents and prevent their adhesion to the abdominal wall. The defect between the two fascial edges of the abdominal wall is then filled with a foam sponge cut by the surgeon to fit precisely. The whole abdomen is then covered by an adhesive drape for at least 5cm beyond the wound edges and the end of a length of suction tubing is embedded in the sponge through a small cut in the top drape.
Intermittent suction increases the amount of granulation tissue in a healing wound by 13% compared to continuous suction. The majority of the evidence for VAC therapy comes from small non randomized trials, animal studies or experimental data relating to VAC for chronic wound management, although some of the advantages may also be applicable to open abdominal wounds.
The overwhelming aim of VAC therapy however is to improve management of the open abdomen to decrease the rate of planned ventral hernia, requiring subsequent reconstructive surgery, by maximizing the rate of delayed primary fascial closure.
In the present series, out of 34 patients treated with VAC, 15 had primary closure (44%); 5 within 3 days and 10 within 17 days, with a mortality of 17%. Quyn et al. (23) reported similar results. The highest delayed primary closure rates were seen with the Wittmann patch and VAC.
This three-layered vacuum pack was able to maintain visceral containment, prevent desiccation and allow continuous evacuation of peritoneal fluids. The authors achieved primary fascial closure in 68% of patients with a 5% incidence of fistula formation (19).
Boele van Hensbroek et al. (24) have reported success using similar systems with primary fascial closure rates ranging from 35% to 92% (usually > 50%). Fistula rates ranged from 0% to 15% with an average of 5.7%.
In our series, the rate of fistula was two cases (15.3%) which is much more lell than these, this difference may be explained by a difference in the nature of cases and the method and place of case collection.
The principle worry when using VAC over exposed bowel is one of entero-cutaneous fistula, especially if there are exposed intestinal anastomoses, given that fistula in these circumstances rarely heal with conservative management compared to 80% healing rates seen when the abdominal wall is intact(23, 25).
This complication has been reported in most series reporting treatment of the open abdomen. The bowel is vulnerable during dressing changes and further surgery, edema, adhesions, ischemia and malnutrition increase the risk of injury (26).
Miller et al. (20) reported only a single fistula in 53 successive patients (1.88%) treated with the commercial VAC system. Where as in present work, the fistulation occurred in 2 out of 34 patients (5.9%) with VAC.
Teixeira et al. (21) suggested that the risk of fistula is increased with intra abdominal sepsis and anastomoses directly underneath the vacuum pack, particularly colonic or duodenal ones. Fistula rates were also increased by an increased duration of OA and in patients in whom primary closure was not possible.
In vacuum pack "sandwich" technique, the visceral sac is first wrapped by a polyethylene sheet which is tucked between the bowel and the abdominal wall to be a physical barrier that prevents adhesion formation between the bowel and the abdominal wall. In other words, it preserves the peritoneal space and greatly delays the onset of "frozen abdomen".
Many patients were treated with the VAC device up to 14 days, and at that time, skin grafts were placed on granulated mesh or bowel. As the authors have gained experience, VAC times longer than 14 days have allowed primary closure of abdominal wounds previously thought un closable during the same hospital stay. Time to definitive closure of all layers of the abdomen without a hernia was, therefore, dramatically reduced and a second delayed closure procedure was avoided.
Towel clips and sutures can tear soft tissue or fascia and damage the tissue needed for final abdominal wall closure. When used in combination or in sequence with traditional reconstructive procedures, therapy with VAC has provided early quality closures of the abdominal wall. Large defects associated with a great deal of inflammation or contamination can be shrunk with the use of VAC (27).
Following stabilization of the patient and resolution of the inflammatory process, 13 of 34 patients with open abdomen, in present work, failed to be closed primarily due to several causes; entero cutaneous fistula in two patients, persistent abdominal sepsis in one patient, need of debridement in one patient and large fascial defect in nine patients.
In the presence of sepsis or multiple organ dys function, the patient typically continues to accumulate fluid and interstitial edema, a process that may take weeks to resolve. Lateral retraction of the wound edges results in a progressively larger gap in the fascia (9).
From the perspective of abdominal closure, the granulation process obliterates the peritoneal space between the abdominal wall and the abdominal visceral mass, so that the abdominal contents get adherent to the undersurface of the anterior abdominal wall. If the abdomen cannot be closed by the end of the first week, granulation tissue starts to develop, and a "frozen abdomen" is evident by the end of the second week, this creates a hostile environment for early fascial closure and thus necessitates secondary staged fascial closure methods (28).
This "frozen abdomen" precludes definitive abdominal closure because it is impossible to mobilize the abdominal wall off the adherent bowel loops (29).
The granulating wound is thus covered with a skin graft and allowed to undergo gradual contraction and maturation over several months, the so-called "planned ventral hernia", a concept first introduced by Fabian et al as a safe strategy for managing the open abdomen(9).
Our policy for the management of these patients, based on recent advances in literature, had been to continue with vacuum pack which is to be changed every 48 hours, allowing granulation tissue to cover intestine followed by Split-thickness skin graft applied when granulation tissue was adequate. Skin graft can be removed later from the wound bed and definitive closure of the abdominal wall can be achieved.
Initial skin graft closure of open abdominal wounds in patients with a frozen abdomen is advantageous for several reasons; it allows wound control and a return to normal homeostasis and in patients with fistula, skin grafting improves comfort allowing application of an ostomy appliance, in addition, skin grafts have a low morbidity. Once control of the abdominal cavity and wound is accomplished, attention can be directed towards a delayed definitive closure of the defect. Time to definitive closure of the abdominal wall has varied from as little as 6 months to well over 2 years from the time of initial injury (28).
The time allowed for wounds to granulate in 13 of our patients with open abdomen ranged from fourteen to forty nine days with a mean of 19.90 +8.93 days and the time for creating ventral hernia ranged from 166 – 356 days with a mean of 239.93 + 60.27 days.
As with many surgical techniques, it is not the particular operation that has failed or has been met with success, but instead it is the choice of procedures that is of utmost importance. No one procedure is ideal for all situations and it is therefore incumbent upon the surgeon to select the proper procedure to fit the particular needs of the situation. In addressing complicated defects of the abdominal wall, the components separation technique can be viewed as simply a part, albeit a very important one, of the armamentarium necessary to address these deficits based upon their location, depth of the defect, timing of presentation, background milieu of the wound bed and the patient himself or herself. Rohrich and colleagues, in 2000 and Mathes and colleagues, also in 2000, had addressed this issue, each with their own approach and algorithms. Several techniques have been described to repair created ventral hernias (30).
In our work, three methods had been utilized for final reconstruction of complex midline anterior abdominal wall defects;
repair with autologous tissue to bridge the fascial gap, using components separation technique (CST).
prosthetic repair to bridge fascial defects.
Shoelace darn repair.
The CST is a useful technique for large midline abdominal hernias. Proposed benefits of this procedure focus on its use of innervated vascularized autologous tissues for reconstructing anterior abdominal wall defects. Additionally, beyond providing a tensionless closure, the use of these innervated myofascial flaps helps to recreate the dynamic nature of the native abdominal wall.
Ger and Duboys (31) recognized the benefits of innervated contractile muscle over denervated fascia or synthetic mesh, citing its ability to better resist strain and to better redistribute tension over the broad expanse of the abdominal wall.
Components separation is ideal for large midline myofascial defects. Bilateral relaxing incisions and release allow for approximately 12 cm, 22 cm and 10 cm of advancement in the upper, middle and lower thirds of the abdomen respectively (32).
In present work, component separation technique corrected defects 10-20 cm in width. Although the component separation technique is an attractive method for the reconstruction of abdominal wall defects, this method has five major disadvantages; First, the reherniation rate is relatively high, this might be related to the rather complex hernias which were included in the study and the 35% of reconstructions that were done under contaminated conditions but because no reasonable alternative for reconstruction under these circumstances is available, the component separation technique seems to be valuable. Second, the skin and subcutaneous tissue must be mobilized over a large distance to reach the aponeurosis of the external oblique muscle, which is retracted far laterally into the flank, this creates a large wound surface that covers the whole ventral abdominal wall from the costal margin to the pubic bone and predisposes to hematoma or seroma formation and infection. Also, mobilization of the skin and subcutaneous tissue endangers its blood supply, which can lead to skin necrosis in the midline. If the musculocutanous perforators of the epigastric artery are transected, the blood supply of the skin depends solely on the intercostal arteries.
Interference with the blood supply from the intercostal arteries by scars, enterostomies, or even drains can result in skin necrosis, as was found in 20% of the patients in the study by Lowe and colleagues in 2000, here in our study the skin necrosis had occurred in 12.5% of those undergoing CST. Third, the technique de-stabilizes the outer layer of the abdominal wall, allowing shifting of the skin in relation to the underlying myoaponeurotic tissue, this makes application in patients with enterostomies difficult. Under these circumstances, we now use a modified technique in which separate incisions are made just lateral to the rectus sheath for transection of the aponeurosis of the external oblique muscle, in this way, the wound surface is markedly reduced and the blood supply to the skin via the dominant musculocutaneous perforators of the epigastric artery is preserved. A well vascularized compound flap is created that can be advanced to the midline. Existing enterostomies can be left in place and new enterostomies are facilitated because shifting of the skin in relation to the rectus muscle has been prevented (33).
Wound complications are reported in about a quarter of patients, this is explained by the very large wound surface, averaging 700 cm2, which is created by mobilizing the skin and the subcutaneous fascia from the ventral abdominal wall muscles, in combination with transection of the peri umbilical epigastric perforating arteries, thus compromising the blood supply of the skin. Transection of the external oblique muscle and mobilization from the underlying internal oblique muscle further enlarges the wound surface and these very large wounds are predisposed to seroma and hematoma formation, also skin necrosis may occur because the blood supply to the ventral abdominal skin is insuficient especially when the blood supply via the intercostal, superficial circumfex iliac and external pudendal arteries is compromised owing to previous transverse or subcostal incisions(34).
Seroma and hematoma formation and the compromised blood supply of the skin in concert with long operations, sometimes performed in a contaminated field, predispose to the development of wound infections and these were found in about 20% of patients (35).
Because all but one of the series are retrospective and the method of wound surveillance and follow up are mentioned in only three studies, the overall complication rate is probably underestimated (35).
It is remarkable that after CST, which is frequently complicated by wound healing disturbances, reherniation rates of less than 10% have been reported.
In the study by de Vries Reilingh et al.(36), which exhibited the highest rate of recurrence (32%), midline fascial closure was achieved using an absorbable running suture of polydioxanone (PDS-loop).
Prosthetics require reliable skin and subcutaneous coverage and an adequate wound bed. The main problem with mesh material is that it provides no dynamic support to the abdominal wall. Problems occur at the interface between the dynamic native abdominal tissues and the static prosthetic mesh material. Fistula formation and infection are potential complications, but in most series are below 3%. Attempts should be made to interpose omentum between bowel and mesh to avoid adhesions.
The ideal prosthetic material for abdominal wall repair is not available. In very large hernias, where the peritoneum and/ or the greater omentum are often lacking, dense adhesions to the bowels or damage to the intra abdominal viscera may occur when polypropylene is used (37).
The ideal prosthesis combines two conflicting properties: incorporation of the mesh into the fibrocollagenous tissue for adequate anchorage to the adjacent fascia and no adhesions to the mesh. Moreover, prosthetic repair increases the risk of infection, which is a major risk in patients with large hernias since wound complications are frequent.
De Vries Reilingh et al. (35) carried out a RCT comparing CST and prosthetic repair in patients with giant midline abdominal wall hernias. Both procedures produced a similar high wound complication rate; hematoma in 5%, seroma in 28%, skin necrosis 13% and wound infection in 5%. This coincides with our findings. These complications had major consequences for patients who underwent prosthetic repair, as the prosthesis had to be removed owing to infection in 38%.
Reherniation, including that in patients with explanted the prostheses, occurred in 60% after prosthetic repair and 53% after CST, at a follow-up of 24 months.
The shoelace darn repair is superior to re-suture or synthetic nonabsorbable mesh repair for the following reasons (38):
Quick, easy, extra-peritoneal method that simply returns the unopened hernial sac and its contents to the abdominal cavity and thus avoids the tedious and perhaps risky dissection of the adherent loops of the bowel on the inner surface of the sac required in the re-suture and in the mesh repair.
The repair restores the functional anatomy of the abdominal wall as it reconstructs a strong new linea alba and allows the rectus muscles to straighten and lie along side each other at the midline, it also reconstructs the anterior rectus sheaths and fixes them to the new linea alba.
Tension free repair.
Minimal suture material requirement.
The shoelace darn repair, in present series, had comparable results as CST and prothetic repair as regards incidence of the postoperative complications, hospital stay and recurrence rate.
Abrahamson and Elder (38) wrote that he has no deaths and 2% recurrence; he concluded that since the operation is entirely extra peritoneal and technically relatively simple and quick, it is eminently suitable for elderly patients with other general medical problems.
The management of patients with open abdomens is an evolving concept.
Certain techniques for managing the open abdomen patients can be effective in treating ACS.
A Temporal Abdominal Closure should not only protect the intraabdominal contents, but facilitate primary closure of the fascia and minimize the need for secondary repairs of ventral hernias and subsequent repair.
Serial bladder pressure monitoring should be a part of postoperative management protocols in high-risk patients and decompression of the abdomen with a pressure of > 25-30 mmHg should be considered even without clear clinical evidence of ACS.
While many closure techniques are reported in the literature, a dynamic closure technique, such as Vacuum pack appears to have an advantage in meeting most requirements for managing an open abdomen.
IAH and ACS remain the most significant considerations for the management of the open abdomen.
Complications found in patients with open abdomens may be minimized with Vacuum pack Therapy resulting in early closure of the abdomen.
Consideration for the type of closure is based on the patient's clinical status with the optimal result of primary facial closure.
When the fascia cannot be closed, skin over granulation tissue is preferred to skin grafting over granulation tissue to create ventral hernia.
Several techniques have been described to repair created ventral hernias.
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As producers of the materials and investors in some of the research behind Graded Motor Imagery, it is our hope that users will utilise it as well as possible. Questions from patients and clinicians pour in daily, although The Graded Motor Imagery Handbook has eased some of the pressure. These Notes look at the most common questions and issues around stage 1 of GMI – left right discrimination. The main reference for all the answers is The GMI Handbook and particularly research by Sarah Wallwork and Jane Bowering at the University of South Australia and Lorimer Moseley at numerous institutions.
First – Left right discrimination – what is it?
Left right discrimination (LRD) or 'laterality' is the ability to identify an image of a body part as left or right or in the case of the spine, to identify if the person in the image is turning (leaning/rotating) to the left or right side.
Is this a left or right hand?
Is this person turning (leaning/rotating) to the left or right?
LRD is known to be altered in a number of neuropathic pain states such as CRPS and phantom pain and we have repeated anecdotal evidence of left right discrimination changes in a variety of states ranging from post spinal cord injury pain, fibromyalgia, carpal tunnel syndrome, limb immobilisation and dyslexia. We would not be surprised to observe changes in any neuropathic pain state nor would we be surprised if left right discrimination ability was intact.
See the section on 'tools' below for information about getting a free Recognise trial and low cost downloads of the Recognise Apps (hands or feet) for the next 5 days.
Everyone asks us this. I am not sure I know what a normal human being is, but here are a few suggestions from the studies so far.
Accuracy of 80% and above, but why not aim for more!
The above figures should be quite stable, i.e. they don't fade out with stress and are consistent for at least a week.
A judgement will also be needed on the personal relevancy of the responses. For example, minor left right discrimination changes may not be so relevant in a person who has a severe pain related incapacity, whereas they may be more relevant in a person with a much more minor problem. This is a clinical reasoning judgement.
Now that is a good question. You may need to remember that you may have a patient with unrelenting neuropathic pain for 10 years, untouched by any therapy who can't begin to comprehend that the problem may be in their brain. Give 1 in 10 of such a patient significant relief and you will be doing better than the most powerful drugs on the market.
Maybe your patient is a rabbit? In acute experimental states, it has been noted that participants are faster on the sore side. That kind of makes sense if you want to protect a sore part you can make an evaluative bias. In a chronic state – whenever that is (is it a few weeks or a few months?) – it appears that they get slower. It's one of those things – all output systems seem to vary over time as the self seeks homeostasis.
No, there is nothing special about being a leftie.
No, we oldies are pretty slick. Nor is there any gender effect and I guess you wouldn't expect there to be.
Why are there rotated images?
We have had a few queries about the rotated images. The reason for rotation is to push the brain that little bit more. An image which is upside down (rotated by 180 degrees) will always take longer, or is more difficult, to judge as left or right than if it was upright or on its side.
There are always plenty of GMI tools at your fingertips. Run through your Facebook photos or dust off the albums and pick out all the left hands. Use a magazine to do the same. Try turning it upside down!
We have also built some easy to use and accessible tools. Recognise is the computer program and anybody can sign up for a free 5 login trial to test their LRD or do motor imagery exercises.
Apps are available as 'Recognise hands' and 'Recognise feet' for iPhones and Androids. Go to the iTunes App store (iPhones) or Google Play (Androids) to get the App for an unusually low price over the next 5 days! This offer ends July 18, 2012.
Flash cards are available as sets of 48 pictures (24 lefts and 24 rights) in Hands, Feet, Necks, Shoulders and Backs. Play games like 'fish', 'snap' or 'memory'. Build a fear hierarchy based on the different postures and work through them gradually.
The NOI Mirror Box is also useful for progression through the stages in GMI.
We love hearing about any experiences you've had (good or bad) using GMI. Your feedback helps us to direct research, develop tools and share anecdotes. Get in touch on recognise@noigroup.com.
Does evidence support physiotherapy […] in CRPS-1. A systematic review, 2009.
Hot NOI courses in the next 2 months!
This entry was posted on July 12, 2012 at 2:19 am and is filed under 2012.	You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


text:
Q: Why inside a loop, scanf() with %d does not wait for the user input in case it received an invalid input previously? I am using what scanf() returns when it gets what is expects or when it doesn't. What happens is it gets stuck in thewhile()` loop.
To my knowledge test = scanf("%d", &testNum); returns a 1 if it receives a number and a 0 if not.
My code:
#include<stdio.h>

int main(void) {
    while (1) {
        int testNum = 0;
        int test;
        printf("enter input");
        test = scanf("%d", &testNum);
        printf("%d", test);
        if (test == 0) {
            printf("please enter a number");
            testNum = 0;
        }
        else {
            printf("%d", testNum);
        }
    }
    return(0);
}

A: The problem here is, upon encountring an invalid input, (a character, for example), the incorrect input is not consumed, it remains in the input buffer.
So, in the next loop, the same invalid input is again read by scanf().
You need to clean up the buffer after identifying incorrect input. A very simple approach will be,
    if (test == 0) {
        printf("please enter a number");
        while (getchar() != '\n');  // clear the input buffer off invalid input
        testNum = 0;
    }

That said, either initialize test, or remove printf("%d", test);, as test being an automatic variable, unless initialized explicitly, contains indeterminate value. Attempt to use that can invoke undefined behavior.
That said, just to be nit-picky, return is not a function, don't make it look like one. It's a staement, so return 0; is much more soothing to the eyes and much less confusing, anyway.

redpajama_set_name: RedPajamaStackExchange


text:
From£3
Samsung Galaxy Note 5 review: the same but an awful lot better
Take Note - we love this phone
Good S Pen use
Only as powerful as S6
Battery life lower
By T3 Online published 1 May 16
The Samsung Galaxy Note 5 is a phone (well, a phablet) that's much more iterative than we were expecting. It's the same phone as last year, in many ways, but with a new design that keeps it more in line with the all-conquering Galaxy S6 range from earlier in the year.
Spec-wise we're not seeing a huge jump - and internally it's very similar too. Apart from 4GB of RAM and the two size options (32GB or 64GB) there's not a lot different in terms of raw power than we saw on the Samsung Galaxy S6.
Check out the Galaxy S6 Edge+
Samsung Galaxy S6 Edge+ vs iPhone 6 Plus vs Nexus 6 vs LG G4 – the battle for phablet supremacy
The screen is obviously larger at 5.7 inches, helping keep the Note 5 firmly in phablet territory, and of course the S Pen is still present and correct.
Unlike in previous years Samsung hasn't imbued the Note 5 with new stylus-based powers, with the same line-up of Air View, Screen Write and more available when you hover the nib over the screen.
One awesome change is the way you get the S Pen out of its housing in the chassis of the Note 5: a little push will see the stylus (yes, Samsung, that's what it is, no matter what you say) click out in a really satisfying way.
While it sounds like I was unimpressed by the lack of changes bar the design, that's not really the case. Firstly, the design is really rather nice, curving away on the back at the edges to help the Note 5 sit more nicely in the hand.
Given this is a large phone already, little tweaks like this to make it more ergonomic really do help when trying to cradle your new phablet.
The metallic rim, the same style used on the S6 and S6 Edge pairing, is improved to used series 7000 aluminium, making it lighter and more durable.
The screen, while 'still' QHD resolution, is pin sharp as ever, with the Super AMOLED technology making everything look colourful and vivid. Watching movies on the Note 5 - let's not forget this thing has more pixels than most 50-inch TVs - is a simply brilliant experience.
Some will still dislike the fact TouchWiz is onboard, with the Note 5 not looking a lot different to the predecessor apart from the new flatter interface.
However, the speed under the finger is more than good enough, and once you get settled with what goes where in Samsung's UI, there's very little that causes consternation.
The camera, once again, is improved to include things like RAW support for the snapping fiends, and you can also start a live-streamed YouTube video that you can share privately to friends.
A simple text message will get them into your portal, so you can recreate Wayne's World to your heart's content.
The battery life on the Note 5, often one of the selling points for Samsung's range of phablets, looks to be pretty solid again. The dual wireless charging is present and correct, but the smaller 3000mAh battery (down from 3220mAh power pack from last year) is a bit of a worry. Samsung seems to have placed design over battery life again, which is a worrying trend we hope it drops soon.
In fact, Samsung has even added in the ability to charge the Note 5 faster than ever before, so you won't need to worry about being tethered to a charger for long.
Early verdict
The Note 5, while not bringing a huge amount new to the table, is still an excellent device and one that 'power users' will be undoubtedly lusting over, should they be able to get their hands on one.
T3 Online
T3.com is one of the UK's leading consumer lifestyle websites, visited by over 10 million people every month. You can follow us on Twitter, Facebook and Instagram. We present products in helpful buying guides and carefully curated deals posts across style, living, auto, smart home, watches, travel, fitness and more. We also have a monthly magazine which you can buy in newsagents or subscribe to online – print and digital versions available.
Garmin Fenix 7 review: a brilliant Swiss army knife disguised as a rugged multisport watch
The Garmin Fenix 7 is bigger, bolder and more versatile than most rugged smartwatches on the market today
By Matt Kollat • Published 18 January 22
Garmin epix review: Fenix 7 meets Venu 2 in this stylish adventure smartwatch
The Garmin epix combines everything that's great in the Fenix and Venu series and makes it 10 times sexier

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Ignore uri segments I need to be able to add the first uri segment which is 'admin' to my list ignore list but It is not working. It works with uri segment 2 & 3 but not with 'admin' is uri segment 1.
How can I make it ignore uri segment 1 'admin' as well
I use codeigniter 3 and HMVC
$route['admin'] = "admin/common/login/index";
Core/Controller.php
<?php if ( ! defined('BASEPATH')) exit('No direct script access allowed');

class Controller extends MX_Controller {

public function __construct() {
    parent::__construct();

    $url = $this->uri->segment(2).'/'.$this->uri->segment(3);

    if (isset($url)) {
        $route = '';

        $part = explode('/', $url);

        if (isset($part[0])) {
            $route .= $part[0];
        }

        if (isset($part[1])) {
            $route .= '/' . $part[1];
        }

        $ignore = array(
            'common/dashboard',
            'common/login',  // renamed admin in routes.php
            'common/logout',
            'common/forgotten',
            'common/reset',
            'error/not_found',
            'error/permission'
        );

        if (!in_array($route, $ignore, $this->uri->segment(1)) && !$this->permission()) {
            redirect('admin/permission');
        }
    }
}

public function permission() {
    $path = $this->uri->segment(2).'/'.$this->uri->segment(3);
    return in_array($path, $this->session->userdata('access'));
}

}


text:
Bosses of failed Sleaford caravan company hid half a million in assets from liquidator
Food firm recruiting new staff at Manton Wood
Why 2021 was a year of transformation - a column by Adrian Reynolds, managing director of Duncan & Toplis
It's fair to say that the past two years have been the most challenging, turbulent and exhausting years business leaders have faced in a generation. While 2020 saw the pandemic arrive in the UK, 2021 has been just as critical for business as we all find ways of adapting to what may be a long term endemic.
By David Philip
Monday, 10th January 2022, 11:19 am
Adrian Reynolds, managing director of Duncan & Toplis
Last January, we were looking forward to a new year in which we could recover and rebuild only to have our hopes dashed by the worst wave of the pandemic we've experienced so far. Businesses, which had already been through so much, had to face yet another lockdown as we pinned all our hopes for normality on a successful vaccination programme. Meanwhile, we prepared ourselves for the biggest change in the UK's international trading relationships for almost fifty years as the Brexit transition period came to an end.
Since then, businesses across the country have been rocked by a stop-start economy, rising inflation, widespread labour shortages, importing and exporting challenges and a cultural shift which has transformed expectations related to work, retail and leisure.
Whether it's the merits and consequences of lockdowns and mask-wearing, Brexit, remote working and online vs physical retail, there will be debates about each of these for many years to come. Every one of these changes has demonstrated that the most important thing for any business is the ability to adapt.
Although many good businesses have fallen over the course of the pandemic, the most successful organisations are the ones which accepted change, adjusted to new situations, capitalised on new opportunities and avoided the pitfalls.
It has also demonstrated the importance of giving and receiving help; whether it's from shoppers making an effort to buy local, companies accepting government support packages, or the sharing of advice and guidance, the strength of community was made clear over the course of the year.
There are still challenges for many businesses - manufacturers struggling to export, retailers picking up the cost of supply chain and logistical difficulties, entertainment venues trying to draw in reluctant crowds and care homes and cafes eager for more workers - but things are looking brighter.
The more we face, the stronger we become as a result as creative or tried-and-tested solutions are explored. Agricultural businesses have diversified their income streams, hauliers have increased pay to attract and retain drivers, manufacturers have revised their supply streams and target markets while retailers, large and small, have embraced online sales like never before.
On top of this, almost every business has been forced to reevaluate their own impact on their workers, the wider community and the world. Initially forced by social distancing, and then in response to a subsequent cultural shift, organisations have been compelled to readjust the work/life balance along with their broader offer to workers. Now, the option of remote and flexible working is an expectation among job-hunters, helping people to make work fit around their home lives and not the other way around.
Meanwhile, with the UK having hosted the COP 26 summit this year, businesses have been inspired to make great strides when it comes to climate change and caring for the environment. Carbon offsetting, green energy production and electric vehicle use is surging and there seems to be a real passion among business leaders to make a change for the greater good of the planet.
As we head into 2022, I wish I could confidently say that the worst of the pandemic is now behind us, but with omicron now spreading across the country, I can't be sure. Equally, I can't say that the economy will boom and that all the problems of Brexit have been ironed out – they haven't.
But when it comes to who we are as a business community and how strong and enduring our businesses are, I think 2021 has been a very successful year and our best is yet to come.
Whatever happens in the next year, I would urge business leaders to continue doing what they've excelled in doing throughout the pandemic: Keep adapting, evolving and adjusting. Don't be afraid to make changes to improve, look after your workers and the planet, accept and seek help when you need it, and, above all, don't give up hope.
Food firm recruiting new staff at Manton Wood... Business
New traders hoping to put the buzz back into historic Skegne... Business
Proposed B&M store in Mablethorpe could create 40 new jobs... Business
Pub near Skegness goes on market for £260k... Business
Trading Standards warning to wax melt sellers... Business


The beautiful building of Apartment Perungudi is surrounded by Chennais scenic beauty which makes the guest's experience the roots of the city. The rooms are well-lit, well-furnished and loaded with the basic amenities, making it a very comfortable and cozy accommodation for the guests to stay. Surrounded by greenery, the residence provides the guests with loads of other facilities like seating area, dining area, in-house restaurant, parking and laundry facilities and even a refreshing swimming pool in the beautiful infrastructure of the property. With this, they allow card payments and have CCTV cameras for the security of the guests.


text:
Privacy: Legal and Ethical Issues
█ JUDSON KNIGHT
Among the foundational principles of the Western liberal tradition that binds the American political system is the belief that the rights of the individual, wherever possible, must be preserved against the authority of the state. Emanating from that principle is the implication that individuals have a right to privacy, a right implied—as noted by several distinguished Supreme Court justices over time—in the U.S. Constitution. Balancing and sometimes apparently contradicting this right to privacy is the need for security on a national and sometimes a local level. This conflict of needs and aims has given rise to public debate over numerous specific issues, including national security measures undertaken in the wake of the September 11, 2001, terrorist attacks.
Privacy Rights in Tort and Constitutional Law
A wide array of U.S. laws, both tort and constitutional, support the individual's right to privacy. In tort law, persons have a right to seek legal redress for invasions of privacy undertaken for the purposes of material gain, mere curiosity, or intention to defame. These protections extend to all persons under U.S. law, though public figures—a term strictly defined in legal statutes—have somewhat less broad rights of privacy.
Some national constitutions spell out the rights of the individual, with the assumption that all other privileges belong to the government. The U.S. Constitution, by contrast, delineates government authority, with the provision that all other rights belong to individuals. To James Madison and other founders of the republic, these guarantees did not go far enough, and therefore, Congress passed the Bill of Rights, or the first 10 amendments to the Constitution. Among these are several that would later figure heavily in debates over privacy: the First Amendment, with its protection of free speech; the Fourth Amendment, against unlawful search and seizure; and the Fifth Amendment, which provides for due process under law. The Fourteenth Amendment, passed after the Civil War to protect the rights of freed slaves, extends Fifth Amendment provisions to states as well.
Contrary to popular belief, neither the Constitution nor its amendments contain any reference to privacy as a right per se. The concept of "The Right to Privacy" comes from an influential 1890 Harvard Law Review article by that title, under which Supreme Court Justice Louis Brandeis, writing with Samuel Warren, put forward the proposition that privacy rights extend beyond mere protection against clear-cut intrusions on privacy. Thereafter, a number of landmark decisions in the Supreme Court broadened the concept of privacy as defined in constitutional law. Among these was Griswold v. Connecticut (1965), involving a state law that prohibited the use of contraceptives. Writing for the Court, which struck down the law, Justice William O. Douglas held that the "penumbra" of the First, Fourth, and Fifth collectively provides a "zone of privacy".
The Revolution of the 1970s
The 1970s saw a revolution in privacy rights, not only through the Court—whose Griswold decision set the stage for the protection of abortion rights in Roe v. Wade (1973)—but also in the legislative branch of government. In 1974, Congress passed the Privacy Act, which restricts the authority of government agencies to collect information on individuals or to disclose that information to persons other than the individual. The Privacy Act also requires agencies to furnish the individual with any information on him or her that the agency had in its files.
In 1967, Congress had passed the Freedom of Information Act (FOIA), which limits the ability of U.S. federal government agencies to withhold information from the public by classifying that information as secret, but it greatly expanded FOIA provisions in 1975. Together with the Privacy Act—the two are often referred to collectively as the Freedom of Information-Privacy Acts (FOIPA)—these served to further extend the rights of individuals against government intrusion. Like FOIA, the Federal Wiretapping Act of 1968 had been passed earlier, but it, too, was extended in the 1970s. (Today, all U.S. states have laws against wiretapping and telephone recording.)
Many of these changes occurred as a response, either directly or indirectly, to the Watergate scandal and the subsequent revelations of illegal wiretapping, recording, and surveillance activity conducted by the Nixon White House and other compartments of the federal government. In 1976, Congress passed the Foreign Intelligence Surveillance Act (FISA). FISA, which became law in 1978, placed checks and balances on the authority of government agencies to conduct surveillance on persons accused of conducting espionage—authority that had been misused by Federal Bureau of Investigation director J. Edgar Hoover in some domestic intelligence campaigns during the 1950s and 1960s.
Privacy Issues in the 1990s and Beyond
In September, 1997, Congress passed the Fair Credit Reporting Act (FCRA), which requires potential employers to obtain written authorization from a job candidate or employee before accessing records from a consumer reporting agency. The employer is also required to notify the employee or applicant if any adverse action is taken pursuant to a negative report. Thus federal law extended privacy rights to protect the individual from intrusion by businesses as well as the government.
Many privacy issues at the dawn of the twenty-first century involved new technologies and new developments in the national security environment. In the area of technology, the broadening of access to the Internet brought with it a number of concerns regarding government monitoring of e-mail and other traffic—concerns heightened by the revelation, in the late 1990s, that the National Security Agency and counterparts in other parts of the English-speaking world monitor global communications through the Echelon surveillance system. On the one hand, the Internet has provided new venues for illegal activity such as the dissemination of child pornography; on the other hand, groups such as the American Civil Liberties Union (ACLU) contend that government monitoring of such activities is often used against innocent persons.
The ACLU has been among the most vocal opponents to intensified security measures undertaken in the wake of the September 2001 bombings. In October 2001, Attorney General John Ashcroft presented a proposed antiterrorism bill that would broaden government authority under FISA. Questioning these and other measures, ACLU spokespersons, acknowledging the need for heightened security, stated that the ACLU's goal is to monitor the proposal for increased law enforcement power to ensure that they have maximum effectiveness with a minimal erosion of civil liberties."
█ FURTHER READING:
Alderman, Ellen, and Caroline Kennedy. The Right to Privacy. New York: Knopf, 1995.
Branscomb, Anne W. Who Owns Information? From Privacy to Public Access. New York: Basic Books, 1994.
Diffie, Whitfield, and Susan Eva Landau. Privacy on the Line: The Politics of Wiretapping and Encryption. Cambridge, MA: MIT Press, 1998.
Harrison, Maureen, and Steve Gilbert. Landmark Decisions of the United States Supreme Court. Beverly Hills, CA: Excellent Books, 1991.
Henderson, Harry. Privacy in the Information Age. New York: Facts on File, 1999.
Rosen, Jeffrey. The Unwanted Gaze: The Destruction of Privacy in America. New York: Random House, 2000.
Computer Keystroke Recorder
Domestic Intelligence
FOIA (Freedom of Information Act)
Foreign Intelligence Surveillance Act
Genetic Information: Ethics, Privacy and Security Issues
Internet Surveillance
Security Clearance Investigations
Telephone Caller Identification (Caller ID)
Telephone Recording Laws
Telephone Recording System
Telephone Scrambler
Telephone Tap Detector
Encyclopedia of Espionage, Intelligence, and Security
"Privacy: Legal and Ethical Issues ." Encyclopedia of Espionage, Intelligence, and Security. . Encyclopedia.com. 28 Dec. 2021 <https://www.encyclopedia.com>.
"Privacy: Legal and Ethical Issues ." Encyclopedia of Espionage, Intelligence, and Security. . Encyclopedia.com. (December 28, 2021). https://www.encyclopedia.com/politics/encyclopedias-almanacs-transcripts-and-maps/privacy-legal-and-ethical-issues
"Privacy: Legal and Ethical Issues ." Encyclopedia of Espionage, Intelligence, and Security. . Retrieved December 28, 2021 from Encyclopedia.com: https://www.encyclopedia.com/politics/encyclopedias-almanacs-transcripts-and-maps/privacy-legal-and-ethical-issues
Civil Liberties , william blackstone described civil liberty as "the great end of all human society and government … that state in which each individual has the power… Barron V. Baltimore , Barron v. Baltimore In Barron v. City of Baltimore, 32 U.S. (7 Pet.) 243, 8 L.Ed. 672 (U.S. 1833), the U.S. Supreme Court ruled that the fifth amendm… Usa Patriot Act , The USA PATRIOT Act (or Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism) was passed Oct… Slaughterhouse Cases , Slaughter-House Cases The U.S. Supreme Court ruling in the Slaughter-House cases, 83 U.S. (16 Wall.) 36, 21 L. Ed. 394 (1873), was the first High Cou… Privacy Act , The Privacy Act of 1974 (5 U.S.C.A. 552a) is a federal law that places restrictions on the federal government's collection, use, and dissemination of… Copyright , The Framers of the Constitution delegated to the national government authority to enact copyright laws. The copyright power, together with the patent…
Privacy, Legal and Ethical Issues
American Civil Liberties and the War on Terror
Freedom of Information Act 80 Stat. 378 (1966)
Constitutional History, 1945–1961
Writing Citizenship into the Constitution
Right of Privacy
Ninth Amendment
Privacy: Issues, Policies, Statements
Privacy, Privacy Laws, and Workplace Privacy
Privacy Threat
Privacy Regulation on the Internet
Privacy Policy Statements
Privacy of School Records
Privacy in Healthcare
Privacy and the First Amendment
Privacy and Privacy Rights
Privacy and Encryption
Privacy and Confidentiality in Research
Privacy and Communication
Privacy Act 88 Stat. 1896 (1974)
priv.
Priuli, Giovanni
Pritzker Architecture Prize Recipients ( (table))
Pritts, Kim Derek
Pritikin programme
Pritikin Diet
Prithvi Raj
Privalov, Ivan Ivanovich
Privalova, Irina (1968–)
Privat De Molières, Joseph
Private Affairs
Private and Independent Schools
Private Attorney General
Private Benjamin
Private Bill
Private Buckaroo
Private Confessions
Private Contentment
Private Correspondence
Private Discrimination
Private Duty Nurses
Private Fears in Public Places
Private Health Insurance Originates with Blue Cross and Blue Shield
Private Hell 36
Private Industrial Sector, Role of
Private Insurance Plans
Private Interests