Medical Case Reports

Biography

Biography: Beniamino Palmieri

Abstract

Case: A 66 year old caucasian male went to our second opinion medical office complaining of long tending severe abdominal discomfort due to marantic abdominal muscle atrophy , and an enormous laparocele with visible bowel movements across the very thin skin with dermal atrophy. He was obese and diabetic With an infra-renal aortic prosthesis and could not perform A normal daily activity because of excruciating pain due to the heavy abdominal burden of the visceral contents pressing the thin subcutaneous layer with the impending risk of pressure ulcer or of traumatic gut laceration. He had been judged absolutely unoperable after many surgical consultation because of the very bad abdominal skin quality, the severe muscle & fascia atrophy and the impossibility to bury any mesh under such a fragile tissue courtain. We are supposed to turn him to operating room after an attempt to increase the abdominal wall thickness, from 0,3 up to O, 8 -1 cm infiltrating a great amount of highly cross-linked hyaluronic acid in the space between the sub cutis and epidermis. We thus planned that 1kg. of this compound would be necessary to perform the procedure, ignoring on the other hand ,the kinetics and the possible side effects of such a great volume suddenly bioavailable into the belly ,especially considering the heparin like properties of this glucosaminoglycan class. The patient took the challenge , signed an informed consent after local ethical committee approval, and was sub-dermally injected with local anesthesia with 3 mm size 30 cm long lipoflling cannulae through 5 holes in the different quadrants of the abdomen under ultrasound control in order to prevent peritenl leaking !; he tolerated the procedure very well and was immediately discharged from the day surgery unit without any untoward effect ; an homogenous sub-dermal layer of hyaluronic acid ( VISCODERM, the most highly cross-linked and dense cosmetic medicine market available filler for wrinkles, was complimentary supplied by ADODERM GmBh,GERMANY ) was monthly monitored by ultrasounds in the following months up to one year. When the sub-dermal layer appeared homogenously and steadily thick, the patient was admitted to the operating room, and a wide 70x70 collagen mesh was sutured to repair the wide abdominal gap, to the approximated musculo aponeurotic margins. The patient had some minor post op complications, but he recovered pretty soon, and the abdominal artificially thickened skin showed a very good resistance to the abdominal pressure and collagen mesh integration without necrosis or ischemia even in presence or previous incisional scars. Actually, due to collagen mesh reabsorption, laparocele is still present, but the abdominal wall is much thicker, and more stiff and no pain and no movements limitations are any more complained by the patient. This case is quite paradigmatic of an unconventional very useful (in this case probably “life-saving”) approach to cross-linked hyaluronic acid on a mini-vasive abdominal wall filling basis, ancillary to major surgical procedures. Safety and biocompatibility of this fermentative produced muchopolisaccharide even at very high dosages have been definitely stressed by the present case, and the indication described as well as the method should be taken in account for similar clinical conditions