I recently had an aneurysm in my right iliac artery operated on and
the operation went well, except that, after a few months, with my
stomach still protruding, another doctor had me have a  CT Scan of my
abdomen and pelvis. The scan showed "A broad are of laxity in the
right anterolateral pelvic wall, with atrophy of the lateral aspect of
the right rectus abdominus muscle, and bulging of the adjacent
abdominal wall fascia", hence a bulging stomach. My doctor/surgeon
(not the one who fixed the aneurysm) told me that my nerve of nerves
were cut, strectched or damaged in the operation and the only way to
fix the condition was to operate, fold the atrophied muscle and place
it in a mesh of material to hold it in place. He cautioned that I
probably would not be happy with the results, it might not last
forever, and that the mesh could become infected.  I want to obtain a
second opinion and have been looking for a surgeon who has a lot of
experience dealing with my condition and methods to cure the problem.
I found a group in Medford, Massachusetts which apparantly qualifies
"abdominal surgeons, but when I contacted them, they told me that
their policy was not to tell the publick who has been qualified by
them.

Hence, my question: Please find an experienced medical professional in
the New York or Northern New Jersey areas, who is familiar with my
condition and how to remedy it. I don't know if that person has to be
a surgeon, maybe a neurologist. I just don'tknow.

---

Request for Question Clarification by welte-ga on 26 Sep 2005 06:17 PDT

Hi shhh-ga,  Just wanted to ask if you would like additional contacts
and/or information than those provided in the Comments section.  I
don't want to duplicate others' efforts or give you an answer that you
don't feel goes further than what has already been provided.

        -welte-ga

---

Clarification of Question by shhh-ga on 26 Sep 2005 17:12 PDT

To Welte-ga

I would appreciate all the information and contacts I can get. Thanks.

Hi again shhh-ga, and thanks for your question.

I agree with one commenter who stated that you should seek a second
opinion from a qualified surgeon with experience in ventral hernia
repair.  Whether or not your problem has to do with severing nerves to
the abdominal muscles,

Here are a list of surgeons and some of their achievements:

___________

Dr. Maximo Deysine
An editor of the journal Hernia, a recently launched as the official
publication of the European Hernia Society (GREPA).
http://www.springeronline.com/sgw/cda/frontpage/0,11855,5-10054-70-1122050-0,00.html

Dr. Deysine has also edited a text on hernia infections:
http://www.ebooks.dekker.com/eBookCover.asp?eBookID=0824757696&type=ISBN

Winthrop University Hospital
Ambulatory Surgery Center
259 First St. 
Mineola, NY 11501	
516-663-0333
516-663-2995

___________

Dr. Dennis Fowler, the recent (now former) chairman of General Surgery
at Cornell, has a focus on hernia surgery and laparoscopic surgery and
has published several articles comparing various mesh materials.  He
has a great deal of experience in this area.

http://asp.cumc.columbia.edu/facdb/profile_list.asp?uni=dlf91&DepAffil=Surgery

NewYork-Presbyterian Hospital/Columbia
PH Room 126
622 West 168th St
New York, NY   10032

Phone: 212-305-0577
Fax: 212-543-8790
___________

Dr. Brooke Gurland at the Mount Sinai Medical Center has done recent
work on robot-assisted laparoscopic repair of ventral hernias.  Here
is her info:

http://directory.mssm.edu/faculty/facultyInfo.php?id=25830&deptid=36

Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY 11219

Abstract from one of his articles can be found here:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12820058&query_hl=4

___________

Another approach may be reconstructive plastic surgery.  Dr. Geoffrey
Gurtner at the Institute for Reconstructive Plastic Surgery at NYU
Medical Center has recently published a paper discussing the
possibility of dermal matrix island flaps to repair abdominal muscle
defects.  Here is a link to his group's abstract and his contact info:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12496583&query_hl=6

Geoffrey C. Gurtner, M.D. 
Assistant Professor of Surgery (Plastic Surgery)
(Breast Surgery, Microsurgical Reconstruction of the Breast, Head and
Neck, Trunk and Extremity, Facial Plastic Surgery, Cosmetic Surgery)
Phone: (212) 263-2990 - Fax (212) 263-0481
NYU Medical Center, 560 First Avenue, TH-169, New York, N.Y. 10016

Medical School: University of California, San Francisco
General Surgery Residency: Massachusetts General Hospital
Plastic Surgery Residency: NYU Medical Center, Institute of
Reconstructive Plastic Surgery
Fellowship: Microvascular Reconstructive Surgery, M.D. Anderson Cancer Center 

___________

Another member of the above institute who has done work in the area of
abdominal reconstruction is Dr. Jamie Levine.  Here is his contact
info and a recent publication:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11304595&query_hl=8

Jamie P. Levine, M.D.
Assistant Professor of Surgery (Plastic Surgery)

(Plastic Surgery, Microsurgical Reconstruction of the Head and Neck,
Trunk and Extremity, Trauma, Facial Plastic Surgery, Cosmetic Surgery

Phone: (212) 263-7337
Fax (212) 263-0481
NYU Medical Center, 
560 First Avenue, TH-169, 
New York, New York 10016
Medical School: Albany Medical College of Union University
General Surgery Residency: Maimonides Medical Center 
Plastic Surgery Residency: NYU Medical Center, Institute of
Reconstructive Plastic Surgery
Fellowship: Microsurgery, NYU Medical Center

___________


For the year 2002, the Center for Medical Consumers in New York City
has compiled the volumes of various types of cases done by surgeons in
the state.  Here is the main page:
http://www.medicalconsumers.org/index.html


The Center does not rank physicians or hospitals by volume, because
for those procedures for which a certain minimum volume of cases
correlates with better outcomes, the curve flattens so that having a
higher volume above some value does not necessarily mean that quality
also goes up.  Here's their explanation:

"We chose not to list hospitals or physicians in rank order by volume.
Instead they are listed alphabetically by name or by location. A
ranking by volume would suggest that the first hospital or physician
listed (and the one with highest volume) is the best, and the second
listed is the second best, and so on. Even if the relationship between
volume and a good outcome is strong for a given procedure there are
likely an optimum number of procedures beyond which there is no or
very little effect on quality. For example, experience shows that
hospitals should perform a minimum of 200 cardiac bypass surgeries
annually to achieve good outcomes. But, we have no indication that a
hospital doing more than the threshold of 200 surgeries will, as a
result, achieve any better outcome. There is, we believe, an
additional reason not to rank order physicians by volume. A very high
volume could be an indication that a physician overuses a procedure.
Overuse, the provision of unnecessary medical care, is poor quality
medicine."

Here is the page for Hernia repairs:
http://www.medicalconsumers.org/Performance_Reports_2002/NY/Hernia2002_NY/page1.html

You can select from this page listings based on hospitals or
physicians, sorted by either location or simply alphabetically.  You
can also select only those physicians or hospitals doing more than 30
hernia repairs in 2002, which I would recommend for your type of
condition.

Here's a listing of all physicians who reported doing 30 or more
hernia repairs in New York state in 2002:
http://www.medicalconsumers.org/Performance_Reports_2002/NY/Hernia2002_NY/page4.html

===========

New Jersey, being quite a bit smaller than New York, has fewer well
known hernia surgeons and researchers.  One notable individual to
consider contacting would be Dr. Edwin Deitch, Chairman of General
Surgery at the University Hospital at the University of Medicine &
Dentistry of New Jersey (UMDNJ).  One of his areas of focus is hernia
surgery.  Here is his contact info:

http://www.umdnj.edu/cgi-bin/cgiwrap/quinnaj/76a9-cdb5.cgi?Last_Name=Deitch&First_Name=Edwin

(973) 972-5045

===========

A problem you may encounter with centers such as The Hernia Center
(mentioned by one commenter) is that many of these smaller
non-academic centers tend to do a large volume of routine hernia
repairs.  Your abdominal repair is likely to be much more complicated
than the standard 45 minute inguinal hernia repair under local
anesthetic that is more common.


===========


Also of potential interest, a group in Japan published an article a
couple of years ago discussing a very similar problem to what you
describe:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12891119&dopt=Abstract

Yamada M, Maruta K, Shiojiri Y, Takeuchi S, Matsuo Y, Takaba T. 
Atrophy of the abdominal wall muscles after extraperitoneal approach
to the aorta.  J Vasc Surg. 2003 Aug;38(2):346-53.
PMID: 12891119 

If you like, you can request a reprint of this article from Dr. Yamada:
dayama@med.showa-u.ac.jp


There have been other similar reports:

Goodman P, Balachandran S.	Postoperative atrophy of abdominal wall
musculature: CT demonstration.  J Comput Assist Tomogr. 1991
Nov-Dec;15(6):989-93.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1834706&query_hl=11


There is also some literature discussing the outcomes of women who
have have reconstructive breast surgery using TRAM flap techniques,
where a portion of the rectus abdominis muscle is moved up to the
chest, leaving many of them with a denervated lateral portion of the
rectus muscle.  Here's one study from Italy that looked at how well
the remaining portion of the rectus muscle contributed to abdominal
wall stability:

Galli A, Adami M, Berrino P, Leone S, Santi P.  Long-term evaluation
of the abdominal wall competence after total and selective harvesting
of the rectus abdominis muscle.
Ann Plast Surg. 1992 May;28(5):409-13. 

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1535765&query_hl=11

_________________________________

I hope this information was useful.  I wish you the best with the
evaluation and treatment of your condition.  Please feel free to
request any clarification.

Best,

                 -welte-ga

Hi,

As you mentioned "bulging stomach" after aneurism surgery...it 
happens due to disconnection of nerve supply as these nerve lie within
the abdominal muscles and may get cut during abdominal surgery. Nerve
supply is required for proper functioning and maintaining the tone of
the muscle. As you lost nerve supply to rectus abdominus muscle it has
lost it's function and tone and is gettig atrophied. This condition is
like (but not exactly) paraumbilical heria in which abdominal muscles
gets weak and then gaps and abdominal contents like intestne bulge out
through the abdominal wall. If this problem is not treated then it may
end up in a abdominal hernia..umbilical or paraumblical.

So you should consult a surgeon who has expertise in Hernia repair and
you will need the mesh because there is no other way to strengthen
your abdominal wall which has atrophied rectus abdominus.
As far Neurosurgeon is concerned...you may consult but not of much use
as once the nerves are cut they can rarely be reattached and rarely
regrow and if regrow then at a very very low speed.

It mmay be better if you go to some med school surgery department as
there you can get consultation from both surgeon for hernia and
neurosurgeon. For this problem fist for treatment and prognosis you
should consult a surgeon who is expert in Hernial surgery.

Few of the names I am giving you here if can of some use...

New York...Dr. James Pacholka, location unknown except in Manhattan

New York University med school.


North Penn
Hernia Institute
2100 N. Broad St. Lansdale, PA 19446
215-368-1122
Fax:215-368-3569


New Jersey

http://www.theherniacenter.com/

http://somersetmedicalcenter.org/body.cfm?id=193

Washington university.
http://www.georgetown.edu/

Good Luck.

Hi,

One more thing consult your surgeon about the prognosis if you do not
undergo mesh repair as he/she knows how many neves supply is cut. Take
a surgeons advice and ask him/her about prognosis with or without
repair as only the examining surgeon can tell you about this.

Good Luck.