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Large intraabdominal, retroperitoneal, and abdominal wall sarcomas provide unique challenges in treatment due to their variable histology, potential considerable size at the time of diagnosis, and the ability to invade into critical structures. Historically, some of these tumors were considered inoperable if surgical access was limited or the consequential defect was unable to be closed primarily as reconstructive options were limited. Over time, there has been a greater understanding of the abdominal wall anatomy and mechanics, which has resulted in the development of new techniques to allow for sound oncologic resections and viable, durable options for abdominal wall reconstruction. Currently, intra-operative positioning and employment of a variety of abdominal and posterior trunk incisions have made more intraabdominal and retroperitoneal tumors accessible. Primary involvement or direct invasion of tumor into the abdominal wall is no longer prohibitive as utilization of advanced hernia repair techniques along with the application of vascularized tissue transfer have been shown to have the ability to repair large area defects involving multiple quadrants of the abdominal wall. Both local and distant free tissue transfer may be incorporated, depending on the size and location of the area needing reconstruction and what residual structures are remaining surrounding the resection bed. There is an emphasis on selecting the techniques that will be associated with the least amount of morbidity yet will restore and provide the appropriate structure and function necessary for the trunk. This review article summarizes both initial surgical incisional planning for the oncologic resection and a variety of repair options for the abdominal wall spanning the reconstructive ladder.

Lymphedema continues to be a very challenging clinical problem. While compression and physical therapy remain the foundation of treatment, recent advances in microsurgery and super-microsurgery have allowed for the development of promising surgical options. One of these options is vascularized lymph node transfer (VLNT), which has gained significant popularity over recent years. However, there is no consensus on the ideal donor lymph node basin for VLNT. In addition, the most commonly reported donor sites, including the groin, supraclavicular, submental, and lateral thoracic nodes, carry the risk of iatrogenic lymphedema and/or visible scarring. In order to avoid these risks, the use of intra-abdominal donor sites for VLNT has been pursued. This article reviews the reported techniques and outcomes for each of the intra-abdominal donor sites for VLNT.

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Background: Recent studies support the prophylactic use of tranexamic acid during craniosynostosis surgery to reduce blood loss. The study aims to assess national trends and outcomes of tranexamic acid administration. Methods: The Pediatric Health Information System database was used to identify patients who underwent craniosynostosis surgery over a 9-year period (2010 to 2018). Search criteria included patients younger than 2 years with a primary diagnosis of craniosynostosis (International Classification of Diseases, Ninth Revision, 756.0; International Classification of Diseases, Tenth Revision, Q75.0) and CPT code for craniotomy (61550 to 61559). Tranexamic acid use, complications, length of stay, and transfusion requirements were recorded. Subgroup analysis was performed for fronto-orbital advancements and single-suture surgery. Results: A total of 1345 patients were identified. Mean patient age was 229 ± 145 days. Four hundred fifty-four patients (33.7 percent) received tranexamic acid. Tranexamic acid use increased from 13.1 percent in 2010 to 75.6 percent in 2018 (p = 0.005), and mean blood products per patient increased from 1.09 U to 1.6 U (p = 0.009). Surgical complication rate was higher in those receiving tranexamic acid (16.7 percent versus 11.1 percent; p = 0.004). Tranexamic acid administration was associated with increased transfusion requirements on univariate and multivariate analysis (1.76 U versus 1.18 U; OR, 2.03; p < 0.001). In the fronto-orbital advancement subgroup, those receiving tranexamic acid received more total blood products (2.2 U versus 1.8 U; p = 0.02); this difference was present but not significant within the single-suture group (0.69 U versus 0.50 U; p = 0.06). Conclusions: Tranexamic acid use in craniosynostosis surgery has increased dramatically since 2010. However, it was associated with higher transfusion and complication rates in this data set. Optimization of its use and blood loss mitigation in infant craniosynostosis deserve continued research. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.