Risk factors of incisional hernia.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"4515",leadTitle:null,fullTitle:"Mitigation of Ionospheric Threats to GNSS: an Appraisal of the Scientific and Technological Outputs of the TRANSMIT Project",title:"Mitigation of Ionospheric Threats to GNSS",subtitle:"an Appraisal of the Scientific and Technological Outputs of the TRANSMIT Project",reviewType:"peer-reviewed",abstract:"TRANSMIT (Training Research and Applications Network to Support the Mitigation of Ionospheric Threats) is an initiative funded by the European Commission through a Marie Curie Initial Training Network. It provided a coordinated program of academic and industrial training, focused on atmospheric phenomena that can significantly impair a wide range of systems and applications that are at the core of several activities embedded in our daily life. TRANSMIT deals with the harmful effects of the ionosphere on these systems. 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Toxoplasmosis is a worldwide human protozoan infection caused by an intracellular protozoan,
Despite the clinical relevance of chronic toxoplasmosis, the biology of the cyst wall as yet has not been completely elucidated [4–9]. A 116‐kDa glycoprotein termed CST1 [7] and two lectins,
Our previous ultrastructural analysis demonstrated that the cyst wall displays endocytic activity through the engulfing of negatively charged molecules in the cystic wall [8]. These molecules are incorporated by tubules and vesicles formed from the membrane that delimits the cyst wall and localized in the granular region and posteriorly in the cyst matrix. Within the cyst, the presence of vesicles containing the tracer in close contact to the bradyzoite membrane or in its neighborhood suggests that it could be one of the incorporated molecule pathways from the host cell cytoplasm to intracystic parasites [8]. The current knowledge of mechanisms involved in the process of nutrient uptake by this parasite still presents many gaps, restricted to few reports [12, 13]. As an obligate intracellular parasite,
In all eukaryotes, endocytosis and intracellular vesicle traffic are events mediated by several proteins including a complex cytoskeleton network. Cytoskeleton proteins are indispensable components of a number of vital parasite structures and functions, like cell division, membrane and cytoplasmic architectures, parasite gliding motility (glideosome), and host‐cell invasion [18–20]. Besides conventional cytoskeleton elements, many components of
Herein, the putative mechanisms employed by
Mice infected with ME‐49 strain
Cysts were incubated with bovine serum albumin (BSA) labeled with fluorescein isothiocyanate (BSA‐FITC), a fluid phase endocytic tracer, for 2 or 3 h at 37°C and processed for analysis in a confocal laser scanning microscopy FV300/BX51 Olympus and differential interference contrast (DIC) microscopy. Serial optical sections of each cyst incubated with BSA‐FITC were converted into a volume performing 3D reconstruction. Additionally, the ultrastructural analysis was performed with two fluid phase endocytic tracers, BSA and peroxidase (HRP), both conjugated with colloidal gold (Au) particles.
\nBrain cryosections of
Confocal microscopy of
In order to examine whether the predicted protein labeling was in fact throughout the cyst wall, an ultrastructural analysis was conducted, incubating cysts with electron dense tracers, such as BSA‐Au and HRP‐Au. The incubation for 30 min at 4°C with BSA‐Au revealed the marker at the surface as well as within invaginations of the cyst wall (Figure 2A). The internalization of BSA‐Au occurred after 2 or 4 h of incubation at 37°C. Colloidal gold particles could be found within small vesicles and tubules localized at the granular region independent of the time of BSA‐Au incubation (Figure 2B and C).
\nTransmission electron microscopy of
Similar results were obtained with HRP‐Au by incubation of tissue cysts for 30 min at 4°C (Figure 3A). When the temperature was elevated to 37°C, the HRP‐Au particles were observed within uncoated vesicles and tubules localized in the granular region of the cyst (Figure 3B and C).
\nTransmission electron microscopy of
Aiming to reveal the cytoskeletal proteins in
Immunofluorescence for detection of myosin in
DIC microscopy (Figure 5A) and the immunofluorescence with the anti‐tubulin antibody revealed a homogeneous labeling along the cyst wall in an area correspondent to the granular region (Figure 5B). This intense wall labeling was better visualized in the merged figure (Figure 5C). Different virtual confocal sections of the same cyst disclosed the presence of tubulin inside bradyzoites (Figure 5D–I). In
Immunofluorescence for detection of tubulin in
Immunofluorescence for detection of tubulin and microtubule‐associated proteins (MAPs) in
The most intense fluorescence labeling was for actin detection in
Immunofluorescence for detection of actin in
The detection by ultrastructural immunocytochemical of actin and tubulin proteins in tissue cysts revealed many gold particles distributed along the granular region and dispersed in the cyst matrix of tissue cysts (Figure 8A). In bradyzoites, some particles were located in the cytoplasm, most of them inside amylopectin granules, along the cyst granular region (arrowhead) and in clusters in the parasite cytoplasm (Figure 8B). The immunogold reaction for tubulin identified some gold particles on the cyst wall membrane along the granular region and in the matrix (Figure 9A). In bradyzoites, tubulin gold particles were detected mainly inside and around the amylopectin granules as well as in the cytoplasm and membrane (Figure 9B).
\nTransmission electron micrographs (TEM) of
Transmission electron micrographs (TEM) of
This study reveals the ability of the
The exposure of Toxoplasma cysts to BSA‐FITC for 2 or 3 h exhibited for the first time, the incorporation dynamics of this endocytic marker located at and attached initially to the cyst wall and afterward, the transit within vesicles toward the cyst matrix. Ultrastructural images from cysts incubated with the two different fluid‐phase endocytic tracers (BSA‐Au and HRP‐Au) demonstrated that they were capable to associate with the cystic wall and be internalized via vesicle and tubules. The incubation of tracers and cysts at 37°C for periods 1–4 h displayed a heterogeneous labeling with formation of clusters on the cyst wall. Guimarães et al. [8] obtained similar images after cyst incubation with cationized ferritin. This labeling type may be due to the motility of cyst wall components or even the presence of different surface micro domains. Some images suggested fusion between the vesicles originating from invagination of the cyst wall with the parasite membrane. However, we have been unable to visualize vesicles discharging the marker or the marker inside the parasite. The present results corroborate previous data of our group with cationized ferritin showing vesicles and tubules containing particles in close contact with the membrane bradyzoite intracystics [8]. The previous data added together with those presented in this work suggest an active process of membrane fusion involved in the bradyzoite macromolecule uptake. It could be one of the pathways for parasite nutrient acquisition through the molecules available in the host cell cytoplasm (see Scheme 1, supplementary material). Moreover, we believe that the tubules and vesicles between the filaments of the cyst wall play a key role in delivering internalized molecules from the cyst wall to the intracellular bradyzoites and vice versa.
\nThis cyst wall property opens new perspectives to the investigation of cytoskeletal element involvement in the process of nutrient incorporation by
Until now, there has been no evidence of the fusion of these vesicles with the parasite membrane. However, we suggest that it might be an important pathway for host cell nutrient acquisition. Nutrient required for bradyzoites is extremely important, as the parasite is confined inside the tissue for long periods and can persist throughout the life of the host [1]. Di Cristina et al. [33] observed that fluorescence molecules, such as D‐luciferin, have access to bradyzoites within intact cysts both
In this way, our interest was to explain how these molecules are incorporated by the cyst wall and also how they can move within the cyst matrix considering that the cyst is not one cell but a structure that maintains various parasites in its interior. The endocytic activity of the cyst wall requires a stimulus induced by molecular signaling which involves cytoskeleton proteins as described for eukaryotic cells. Both actin and tubulin contribute to intracellular vesicle trafficking and endocytic activity in a series of dynamic events in the endomembrane system. The strong positive staining of tubulin and actin, revealed with polyclonal mammalian antibodies throughout the cyst matrix, indicated the presence of a cytoskeleton network within the cyst. Further investigation would be needed to evaluate the origin of these proteins. Eukaryotic cells exhibit tubulin dimers that can be easily altered by posttranslational modifications that differentially mark distinct microtubule subpopulations [34, 35]. Each microtubule subpopulation is organized for specific functions, such as the mitotic spindle, tracks for vesicular transport plus the basal body, and associated flagellar axoneme. In
Numerous protozoan parasites have the ability to form the cyst stage that normally allows them to survive under adverse environmental conditions. Chávez‐Munguía et al. [36] showed that during the encystation process of
Actin is a highly conserved microfilament protein that plays an important role for gliding motility and in
In conclusion,
Our work was supported by grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Fundação Oswaldo Cruz (Programa Estratégico de Apoio à Pesquisa em Saúde—PAPES IV e VI), Pronex—Programa de Apoio a Núcleos de Excelência—CNPq/FAPERJ, and Instituto Oswaldo Cruz/Fiocruz. MFFS is currently supported by the Re‐entry grant of the University of Cologne.
\nThe authors thank Carlos Bizarro, Genilton Vieira, Bruno Ávila for all the image management and Dr. Maurício Paiva for the scheme designed in this work. We are grateful to Sandra Maria for technical support. English review and revision by Mitchell Raymond Lishon, native of Chicago, Illinois, USA—UCLA 1969.
\nIt is documented that in the first century A.D., a Roman doctor named Aulus Cornelius described the closure of the abdominal wall and elaborated a detailed description of the pre- and postoperative care of the patient [1]. Later on, another famous Roman-Greek physician, Galen, provided a detailed description of the mass closure of the abdominal wall and described the significance of paramedian incision in order to prevent incisional hernia [2]. The advancement of technology like the advent of modern anesthesia and antiseptic and upgradation of skills in the field of surgery in the present era promotes laparotomy. On the other hand, along with increased number of laparotomy, the incidence of incisional hernia also increased consequently. Incisional hernia is a frequent long-term complication of abdominal surgeries with a reported incidence of 2–20% [3, 4, 5, 6, 7, 8]. In the USA alone, approximately 348,000 incisional hernia repairs are performed per year with total estimated procedural costs of $3.2 billion for ventral hernia repair [9, 10, 11, 12, 13]. Incisional hernia is more common than primary abdominal wall hernia, and both of these types are included in ventral hernia.
The abdominal wall consists of the skin, fascia (Camper’s and Scarpa’s fascia), muscles (external oblique, internal oblique, transverse abdominis), rectus sheath, aponeurosis, linea alba, ligaments, openings, rings, blood vessels and nerves. Figure 1 showed the formation of rectus sheath at three different levels on the abdominal wall. Above the costal margins, only the external oblique muscle with its aponeurosis forms the rectus sheath. In between xiphisternum and umbilicus, the external oblique remains in front, but the internal oblique splits to enclose the rectus muscles. The transverse abdominis is behind the internal oblique (Figure 1). All these muscles fuse to form the linea alba in the midline. The rectus abdominis muscles run vertically on either side of the linea alba. This area between the xiphisternum and umbilicus is the strongest area as compared to above the costal margin or below the semilunar line. Below the semilunar line, all the three aponeurosis are anterior to the rectus muscle and fuse in the midline to form the linea alba. So posterior rectus sheath is absent below the semilunar line, and that is why incisional hernias are more common below the umbilicus. On the other hand, the linea alba is the strongest layer of abdominal wall and less likely to develop incisional hernia if it has repaired properly with good bites through the linea alba.
Rectus sheath formation.
The umbilicus is usually situated in the midline at the level of the superior iliac spine or at the level between the third and fourth lumbar vertebrae. The umbilicus is a strong fibrous ring. Hernia through the umbilicus may occur in children, obese patient and in multiparous women due to childhood umbilical infection, weak muscles and stretching of muscles due to repeated pregnancies, respectively.
The development of incisional hernia is multifactorial. It may be related to the patient, surgical technique and experience of the surgeon, type of disease for which the incision was given or biological factors. Table 1 summarized the various risk factors for the development of incisional hernia.
Age more than 60 years Gender: female after cesarean section Smoking Socioeconomic condition: low profile Occupation: lifting heavy weight Comorbidities: diabetes mellitus, chronic cough, benign hypertrophy of the prostate, stricture of the urethra, chronic constipation, ascites, obstructive jaundice, chronic renal failure and certain connective tissue diseases (Marfan’s syndrome, osteogenesis imperfecta and Ehlers-Danlos syndrome) Post-organ transplant patient on immunosuppressive agents/corticosteroids Obesity: (BMI >25 kg/m2) Wrongly placed incision: lumbar incision, subcostal incision, lower midline incision and large transverse incision Wound has not been approximated appropriately Low surgical skill to close the abdomen Strength and length of suture used is not appropriate Emergency operations Type of surgery: bowel surgery, abdominal aortic aneurism, stoma closure, operations for peritonitis Re-laparotomy Wound infection Long operating time Increased blood loss Damaged control surgery in trauma Open abdomen: in the case of severe septicaemia, chance of abdominal compartment syndrome Nutritional deficiencies Collagen and metalloproteinase synthesis |
Risk factors of incisional hernia.
The incisional hernias are more common in the elderly age group because of multifactorial reasons including weak abdominal muscles, occurrence of comorbidity like DM, malignancies and poor immunity. A BMI > 24.5 kg/m2 is considered as an important risk factor for the development of incisional hernia [14, 15, 16, 17, 18, 19, 20, 21]. The patient with low socioeconomic profile is more prone to develop incisional hernia because of malnourishment and being bound to lift heavy weight. Comorbidities like diabetes mellitus, malignancies, chronic lung diseases, benign hypertrophy of the prostate, chronic constipation as well as heavy weight lifting are well-known risk factors for hernia development by increasing the intra-abdominal pressure and delaying the wound healing. The use of immunosuppressant and steroids in organ transplant and other chronic disease patients increases the rate of wound infection, wound dehiscence and incisional hernia [22, 23, 24, 25, 26, 27]. Smoking increases the risk of the development of incisional hernia by decreasing the blood flow and tissue oxygenation as well as collagen deposition in the surgical wound, and all these increase the infection rate and synergistically the incisional hernia as well [28, 29]. Abstinence from smoking 30 days preoperatively reduces the adverse effects of smoking on wound healing significantly. This emphasized the contributing role of smoking in causing incisional hernia [30, 31].
Despite advancements in techniques for abdominal wall closure, the incisional hernia rate following laparotomy is as high 15–20% [32]. Poor surgical technique may result in wound dehiscence and delay the wound healing. During closure of fascial edges, if it is not approximated properly, not using the suture with appropriate length and strength, then definitely in the postoperative period, there is a chance of wound dehiscence and development of incisional hernia especially if other predisposing factors are also present [33, 34, 35]. The preferably paramedian, oblique and transverse incisions are better than midline, large transverse, subcostal and lumbar incisions to prevent the occurrence of incisional hernia [36, 37, 38, 39].
Wound infection and wound dehiscence are the major risk factors for the development of incisional hernia [18, 29, 35, 36, 37, 40, 41, 42, 43, 44, 45]. Cases operated for infected intra-abdominal conditions like perforation peritonitis, gangrene of the intestine, severe necrotizing pancreatitis, etc. usually develop incisional hernia. The incidence of infection is less in a diabetic patient if their perioperative glycaemic control is adequate [46]. Furthermore, chance of infection in diabetic patient is higher than nondiabetic patient even after controlling for hyperglycaemia [47]. Re-laparotomy is a strong risk factor for IH [29]. Incidence of incisional hernias in open abdomen for severe septicaemia or for damaged control surgery ranged from 21% at 21 months to 54% after 5 years of follow-up [48, 49, 50]. Burst abdomen and open abdomen after the damage control surgery are the most important factors for the occurrence of incisional hernia. In the case of long operative time and where blood loss is more, the chance of IH development is also more. Incisional hernia has been also reported after traumatic abdominal injury [51]. Emergency surgeries are also associated with a higher incidence of incisional hernia development.
Apart from obesity, malnourishment is also the contributing factor for the development of incisional hernia by causing delayed wound healing and wound dehiscence [52, 53, 54]. Defective collagen metabolism with reduced ratio of collagen I-collagen III as well as a reduced ratio of matrix metalloproteinase 1 (MMP1)-MMP2 plays an important role in the development of IH [55]. Micronutrients like copper and zinc are required for the synthesis of the enzyme lysyl oxidase, and this enzyme is very important for the integrity of collagen molecule. So deficiency of these elements may cause the incisional hernia to occur. The plasminogen activator inhibitor, urokinase plasminogen activator inhibitor, in the scar tissue may contribute in the development of IH [56, 57, 58].
Various classifications for ventral hernia are available in literature, but unfortunately none of them have been widely accepted. Various classification systems are proposed by Chevrel and Rath, Korenkov et al., Schumpelick et al., Dietz et al., Ammaturo and Bassi and Miserez et al. [59, 60, 61, 62, 63, 64]. They all have used variables like size and number of hernia defects, size of hernia sac and its ratio with anterior abdominal wall, primary or incisional hernia, recurrent hernia, location of hernia, and other symptoms and risk factors, in various combinations. To make it standardized, European Hernia Society (EHS) has divided the abdominal wall hernia as “Primary abdominal wall hernia” which is also called as ventral hernia and other “Incisional hernia” rather than either term. Recurrent hernia after treatment for primary abdominal wall hernia would fall in the group of incisional hernia. According to this system, classification of incisional hernias uses localisation and size of hernia as the two variables, as shown in Table 2. To avoid confusion with primary abdominal wall hernias (small, medium and large), a coded taxonomy was chosen (W1 < 4 cm; W2 ≥ 4–10 cm; W3 ≥ 10 cm) instead of a nominative one, and yes or no is used for the recurrent incisional hernia in EHS Table 2.
Showing EHS classification of incisional hernia.
Here the abdomen was divided into a midline zone and a lateral zone.
The borders of the midline area are defined as follows:
Cranial: the xiphoid
Caudal: the pubic bone
Lateral: the lateral margin of the rectal sheath
Thus, all incisional hernias between the lateral margins of both rectus muscle sheaths are classified as midline hernias. A simple and easily memorable classification from M1 to M5 going from the xiphoid to the pubic bone is summarized in Figure 2a. Therefore, we define 5 M zones as follows:
M1: subxiphoidal (from the xiphoid till 3 cm caudally)
M2: epigastric (from 3 cm below the xiphoid till 3 cm above the umbilicus)
M3: umbilical (from 3 cm above till 3 cm below the umbilicus)
M4: infraumbilical (from 3 cm below the umbilicus till 3 cm above the pubis)
M5: suprapubic (from the pubic bone till 3 cm cranially).
(a) 5M zone of incisional hernia. (b) 4L zone of incisional hernia.
Lateral hernias: The borders of the lateral area are defined as in Figure 2b:
Cranial: the costal margin
Caudal: the inguinal region
Medially: the lateral margin of the rectal sheath
Laterally: the lumbar region
Thus, 4L zones on each side are defined as follows:
L1: subcostal (between the costal margin and a horizontal line 3 cm above the umbilicus)
L2: flank (lateral to the rectal sheath in the area 3 cm above and below the umbilicus)
L3: iliac (between a horizontal line 3 cm below the umbilicus and the inguinal region)
L4: lumbar (latero-dorsal of the anterior axillary line)
History of surgery in the past.
History of infection during the first surgery, postoperative cough, constipation, etc. is usually present.
Serosanguinous discharge on the fourth postoperative day through the main suture line is a signal of the development of partial or total wound dehiscence. Such cases later develop an incisional hernia.
Burst abdomen and open abdomen are more likely to develop incisional hernia (Figure 3).
There is bulge or swelling around the scar (Figure 4).
The scar is thin and evidence of secondary changes like ulceration or skin color changes may be present (Figure 5).
Expansile impulse on cough and reducibility may be present.
Intraoperatively during creation of pneumoperitoneum, the bulge/swelling through the scar becomes more obvious (Figure 6).
After reduction of the contents, a defect can be palpated through the scar. Defect depends upon the number of stiches that have given away.
In case of obstructed or impacted content in the defect, the patient may complain of pain in that area.
Features of bowel obstruction or strangulation may be found in complicated cases.
In most people, hernias limit patients’ physical activities either due to the associated symptoms or as a precaution to avoid worsening.
Burst abdomen prone to develop incisional hernia.
Complex Hernia with visible bulge.
Lower abdominal wall hernia hanging up to the scrotum with secondary changes.
Prominent hernial defect after pneumoperitoneum.
In most of the cases, hernial content can be palpated. In few cases even the edges of hernial defect can be appreciated, and the size can be measured. Except in obstructed and strangulated hernia, impulse on coughing and reducibility are present.
Percussion guides us to assess whether the content of the hernia sac is solid, liquid or gas.
If the content of the sac is bowel loop, a peristaltic bowel sound may be heard and confirm the content of sac as bowel loop.
Although most cases of an incisional hernia are diagnosed with a history and physical examination, imaging is sometimes indicated in early stages, obese patients, or complex cases especially to outline the extent of defect and plan the surgical procedure. The first imaging modality in case of incisional hernia is ultrasonography, but the computed tomography scan (CT) is the most commonly used method for the diagnosis as well as for planning of operative management especially for complex cases [65, 66]. CT scan evaluates the incisional hernia by confirming its diagnosis, sizing the defect, identifying the hernia content and assessing the abdominal cavity to plan the surgical treatment. Magnetic resonance imaging (MRI) can also be used to assess abdominal wall hernias but are less commonly used for academic purpose only.
The management of incisional hernia includes nonoperative and operative management. Nonoperative management is indicated in patients who are not fit for surgery, those who require preoperative optimization or those who have highly complex hernia like loss of abdominal wall domain, patient with diagnosis of metastatic cancer, advanced cirrhosis, severe cardiopulmonary disease and super obesity (BMI ≥ 50 kg/m2).
Weight reduction is very important before operating for incisional hernia. It is required to bring the BMI < 30–40 Kg/m2.
Control of COPD, definitive treatment of benign prostatic hyperplasia, stricture of the urethra and all other conditions who may increase the intra-abdominal pressure in postoperative period in view to avoid the recurrence.
Cessation of smoking is very helpful for good outcome.
To get the relief from symptoms
Prevention of complication like pain, incarceration, bowel obstruction and strangulation
To improve the quality of life
There are various operations for the treatment of incisional hernia depending upon the size of the defect, location of the hernia, patient choice as per their economical conditions as laparoscopic repair may be costly and surgeon expertise. Table 3 summarized the different surgical options for incisional hernia.
Suture repair Mesh repair Primary fascial closure Different mesh fixation techniques Bridge repair Anterior component separation (ACS) Perforator-sparing ACS Endoscopic ACS Posterior component separation Tissue expanders Progressive pneumoperitoneum |
Surgical options for incisional hernia repair.
Although minimal invasive surgery is widely acceptable and treatment of choice in present era, but open surgery still plays a very important role in incisional hernia repair especially in conditions contraindicated for laparoscopic surgery like very large, non-reducible hernia and strangulated hernia. Besides these contraindicated cases, for small umbilical hernias, open repair is preferred choice. Open repair can be done either by suture repair or by applying mesh. Recurrence rate after suture repair is 42% and after mesh repair only 24%. Ideally if the defect size is more than 4 cm, mesh placement should be the preferred approach, but even for the smaller defect which is less than 2 cm in size, the recurrence rate is 5.6% with suture method as compared to mesh where only 2.2% recurrence rate occurs. Three main positions of the mesh placement for incisional hernia are onlay, inlay and sublay positions (Figure 3).
Onlay mesh is placed over the anterior fascia and under the subcutaneous tissue. Inlay mesh is placed to the margin of the aponeurosis. In this case the mesh acts as bridge between the two fascial edges. Sublay mesh is placed retro muscularly and preperitoneally. The sublay mesh placement has been reported to be the best regarding recurrence and skin and soft tissue infection but is associated with higher risk of chronic pain. The main principle to place the mesh is that the mesh should be overlapped at least 5 cm all around the defect. Otherwise, the plane is created between the posterior rectus sheath and rectus muscle, and the mesh is placed in that location, and the anterior rectus sheath is sutured. This is called retro muscular sublay mesh repair. Before placing the mesh, the sac is opened, the greater omentum is excised, and the content is reduced followed by closure of the peritoneum. A mesh is kept in place. In all these repairs, tensionless, nonabsorbable suture repairs are done. Seroma formation is a common complication in open mesh repair which can be overcome by placing drain before closing the wound.
First time in 1993, LeBlanc and Booth introduced the laparoscopic method for incisional hernia repair [67], and since then various studies and approach have been published in literature [68]. Laparoscopic repair of incisional hernia is a very safe procedure and having all the advantages of minimal access surgery like earlier recovery, decreased hospital stay and less wound infections. It has been reported to have a low conversion rate of 2.4%, an enterotomy rate of 1.8% and recurrence rate of 4.2%; however recent randomized trials have shown a similar recurrence in laparoscopic and open hernia repair.
Contraindications to laparoscopic incisional hernia repair are almost the same as for other laparoscopic surgeries which are summarized in Table 4.
The larger defect is usually more than of 10–15 cm Prior multiple open surgeries Ascites with child class C cirrhosis Inability to create a working space |
Contraindications of laparoscopic incisional hernia repair.
Complete all the preanaesthetic checkup and preoperative order like Nil per orally 12 hours prior to surgery and securing IV line for fluid administration, antibiotic test dose and shifting the patient to the operation room.
Take the patient on the table in supine position, and after general anesthesia, pneumoperitoneum is created.
Three working ports are placed as far as possible from the scar of the previous abdominal surgeries.
Start the adhesiolysis if indicated and repose the sac content into the peritoneal cavity.
Primary fascial closure may be done to restore the normal anatomy. The technique for this primary fascial closure may be intracorporeal closure, extracorporeal closure or with the help of suture passing needle. This step prevents the postoperative bulge and seroma formation. It also allows wider lateral mesh overlap, thereby preventing recurrence.
Overlap of mesh should be ideally 5 cm in all directions because of significant postoperative shrinkage of mesh.
Before fixing the mesh, the intra-abdominal pressure should reduce to 5–8 mmHg, so that the abdominal wall is minimally stretched revealing the true size of the hernia defect.
Fixation of mesh is usually done by tacker or suture.
The open and the laparoscopic techniques are used for small- and medium-sized defects but are not sufficient for very large defects which are too large to allow the fascial to be approximated. In such large size defect, a novel method of abdominal component separation was being developed. According to the EHS, large ventral hernia is defined as a hernia with defect greater than 10 cm and loss of domain defined by more than 50% of visceral contents lying chronically beyond the bounds of the abdomen. In such defect repair by open or laparoscopic method is usually not possible and component separation is required which was first introduced by Ramirez and colleagues in 1990 [69]. Component separation may be anterior, posterior, perforator-sparing ACS or endoscopic ACS.
The component separation technique was first described by Ramirez in 1990. It is very effective for reconstructing large or complex midline abdominal wall defects, and it has the advantage of restoring the innervated dynamic abdominal wall integrity without producing undue tension on the repair. It is a myofascial release that separates the components of the abdominal wall allowing their mobilization into adjacent tissue defects. Classic CST involves releasing the rectus muscle from its posterior sheath and releasing the aponeurosis of the external oblique muscle along the lateral side of the rectus, allowing the rectus muscle to slide towards the midline with its attached internal oblique and anterior rectus fascia. In fact this is called anterior component separation. Fascial defects up to 10 cm wide at the upper abdomen, 20 cm at the waistline and 6 cm at the suprapubic region may be closed using this method.
Through a laparotomy incision, the posterior rectus sheath is cleared bilaterally of any attachments to the viscera through careful lysis of adhesions.
The rectus muscle is loosely attached to its posterior sheath and can be freed from the posterior sheath at this point, as Ramirez did. Freeing the rectus muscle from its posterior sheath allows advancement of this muscle by 3 cm in the upper third, 5 cm in the middle third and 3 cm in the lower third.
Separate the skin and subcutaneous tissues from the anterior rectus sheath using electrocautery. Develop this plane until about 2 cm beyond the lateral edge of the rectus sheath. Further lateral dissection in patients with limited subcutaneous tissue may place the resulting skin flaps at risk for ischemia and failure resulting in a large soft tissue defect that will require split-thickness skin grafting.
Carefully incise the external oblique aponeurosis 2 cm lateral to the lateral edge of the rectus sheath. Extend this incision parallel to the rectus muscle, superiorly advancing at least 5–7 cm above the costal margin and inferiorly down to the suprapubic region. The plane between the external and internal oblique aponeuroses is relatively avascular and should be bluntly dissected free down to the mid to posterior axillary line.
The surgical site infection (SSI), site dehiscence, seroma, hematoma, site necrosis and recurrences have been reported to be highest with ACS compared to other component separation techniques.
In order to gain further mobility of the rectus sheath, Crbonell et al. introduced the concept of posterior component separation (PCS) which involved extending the retro muscular plane laterally between the internal oblique and transverse abdominis. Further modification of the technique was done by Novinsky et al. with the release of transverse abdominis muscle and entry into the retro rectus space, and dissection is carried till lateral of psoas muscle, avoiding skin flap necrosis. A mesh is placed in sublay position after closing the posterior rectus sheath in the midline. PCS is the CS procedure of choice to obtain medial fascial advancement and the creation of huge space for the mesh placement.
An incision is made in the posterior rectus sheath within 0.5 cm of its medial border. This incision is extended superiorly and inferiorly along the entire length of the rectus muscle. Dissection is continued medial to lateral as blunt or sharp preventing injury to the epigastric vessels as it lies within the muscles. The lateral limit of this dissection in PCS is the linea semilunaris up to the lateral border of the rectus muscle, the area of fusion of the anterior and posterior rectus sheaths. It is important to identify and preserve intercostal neurovascular structures entering the posterior aspect of the rectus muscle. Superiorly, this plane extends to the retroxiphoid/retrosternal space and inferiorly into the space of Retzius. In many circumstances, dissection in the retrorectus space up to the linea semilunaris is insufficient to permit adequate abdominal wall reconstruction, and there is also insufficient retrorectus space to permit adequate prosthetic reinforcement for hernia. In order to extend the retrorectus dissection lateral to the linea semilunaris, intramuscular dissection is possible by diving the internal oblique muscle; further dissection is performed within the preperitoneal plane or with transverse abdominis release (TAR). Incision is made approximately 0.5 cm medial to the linea semilunaris in the posterior sheath to expose the transverse muscle. It is easy in the upper half of the abdomen where the muscle belly is well developed. With electrocautery, transection of the transverse abdominis muscle is done to prevent injury to the transversalis fascia or peritoneum. This plane may extend superiorly beyond the costal margin to the diaphragm, inferiorly to the myopectineal orifice and laterally to the psoas muscle. Similarly, TAR is completed on the contralateral side. This is followed by reconstruction of the posterior layer with re-approximation of the posterior rectus sheath in midline using running suture. A large mesh is used to cover the space created at the retro muscular space up to the lateral border of dissection. The anterior rectus sheath is approximated in the midline.
In situations where fascial closure cannot be achieved even after CS, several other options have been described, each with its own advantages and disadvantages. Hybrid Operation have been described where fascia is partially closed & reminder is bridge with an absorbable mesh in underlay or sublay position. Addition of vacuum-assisted closure to reduce the SSO and SSI in hybrid procedures has also been described. An alternative to these procedures is preoperative tissue expansion or flap and tissue transfer.
Tissue expanders are used to provide soft tissue coverage and restore abdominal domain by increasing both the size and the vascularity of the donor tissue by producing a strong, vascularized capsule around the expanders. Various sites of placing tissue expanders have been described like in the subcutaneous space, abdominal wall intramuscular spaces (between the internal oblique and transverse abdominis muscles), intermuscular sites (between the external and internal oblique muscles) and finally intra-abdominally. The expanders can be insufflated over various weeks depending on patient tolerance. Before starting filling of the expander, a period of wound healing is usually awaited for 3 weeks to prevent expander exclusion. Expanded skin retracts after removal of expanders, hence overexpansion is necessary. Complications like expulsion, exposure or infection of implants can occur in about 15% cases.
Reduction of contents of giant hernias may result in abdominal compartment syndrome. Progressive pneumoperitoneum technique is used to stretch the abdominal wall muscles before repair. Progressive pneumoperitoneum (PPP) increases the capacity of the retracted abdominal cavity, performs a pneumatic lysis of intestinal adhesions, allows the reduction of the hernia contents and improves diaphragmatic function. Air, CO2 or NO is insufflated over a period of a few weeks every couple of days to about a total of 15–20 L depending on patient tolerability monitored by the development of scapular pain, dyspnoea or subcutaneous emphysema. Once tissue expansion is obtained, hernia repair is attempted.
An alternative to tissue expansion is the use of plastic surgery procedures of flap and tissue transfer like latissimus dorsi, tensor fascia lata or rectus femoris flaps, but they are more complex and result in donor site defects and functional limitations.
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Utkin",authors:[{id:"16132",title:"Dr.",name:"Andrei",middleName:"B.",surname:"Utkin",slug:"andrei-utkin",fullName:"Andrei Utkin"}]},{id:"73811",doi:"10.5772/intechopen.94103",title:"Introduction to Quantum Computing",slug:"introduction-to-quantum-computing",totalDownloads:1206,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Quantum computing is a modern way of computing that is based on the science of quantum mechanics and its unbelievable phenomena. It is a beautiful combination of physics, mathematics, computer science and information theory. It provides high computational power, less energy consumption and exponential speed over classical computers by controlling the behavior of small physical objects i.e. microscopic particles like atoms, electrons, photons, etc. Here, we present an introduction to the fundamental concepts and some ideas of quantum computing. This paper starts with the origin of traditional computing and discusses all the improvements and transformations that have been done due to their limitations until now. Then it moves on to the basic working of quantum computing and the quantum properties it follows like superposition, entanglement and interference. To understand the full potentials and challenges of a practical quantum computer that can be launched commercially, the paper covers the architecture, hardware, software, design, types and algorithms that are specifically required by the quantum computers. It uncovers the capability of quantum computers that can impact our lives in various viewpoints like cyber security, traffic optimization, medicines, artificial intelligence and many more. At last, we concluded all the importance, advantages and disadvantages of quantum computers. Small-scale quantum computers are being developed recently. This development is heading towards a great future due to their high potential capabilities and advancements in ongoing research. Before focusing on the significances of a general-purpose quantum computer and exploring the power of the new arising technology, it is better to review the origin, potentials, and limitations of the existing traditional computing. This information helps us in understanding the possible challenges in developing exotic and competitive technology. It will also give us an insight into the ongoing progress in this field.",book:{id:"10209",slug:"quantum-computing-and-communications",title:"Quantum Computing and Communications",fullTitle:"Quantum Computing and Communications"},signatures:"Surya Teja Marella and Hemanth Sai Kumar Parisa",authors:[{id:"297632",title:"Mr.",name:"Surya Teja",middleName:null,surname:"Marella",slug:"surya-teja-marella",fullName:"Surya Teja Marella"},{id:"336267",title:"Mr.",name:"Hemanth Sai Kumar",middleName:null,surname:"Parisa",slug:"hemanth-sai-kumar-parisa",fullName:"Hemanth Sai Kumar Parisa"}]}],mostDownloadedChaptersLast30Days:[{id:"73811",title:"Introduction to Quantum Computing",slug:"introduction-to-quantum-computing",totalDownloads:1206,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Quantum computing is a modern way of computing that is based on the science of quantum mechanics and its unbelievable phenomena. It is a beautiful combination of physics, mathematics, computer science and information theory. It provides high computational power, less energy consumption and exponential speed over classical computers by controlling the behavior of small physical objects i.e. microscopic particles like atoms, electrons, photons, etc. Here, we present an introduction to the fundamental concepts and some ideas of quantum computing. This paper starts with the origin of traditional computing and discusses all the improvements and transformations that have been done due to their limitations until now. Then it moves on to the basic working of quantum computing and the quantum properties it follows like superposition, entanglement and interference. To understand the full potentials and challenges of a practical quantum computer that can be launched commercially, the paper covers the architecture, hardware, software, design, types and algorithms that are specifically required by the quantum computers. It uncovers the capability of quantum computers that can impact our lives in various viewpoints like cyber security, traffic optimization, medicines, artificial intelligence and many more. At last, we concluded all the importance, advantages and disadvantages of quantum computers. Small-scale quantum computers are being developed recently. This development is heading towards a great future due to their high potential capabilities and advancements in ongoing research. Before focusing on the significances of a general-purpose quantum computer and exploring the power of the new arising technology, it is better to review the origin, potentials, and limitations of the existing traditional computing. This information helps us in understanding the possible challenges in developing exotic and competitive technology. It will also give us an insight into the ongoing progress in this field.",book:{id:"10209",slug:"quantum-computing-and-communications",title:"Quantum Computing and Communications",fullTitle:"Quantum Computing and Communications"},signatures:"Surya Teja Marella and Hemanth Sai Kumar Parisa",authors:[{id:"297632",title:"Mr.",name:"Surya Teja",middleName:null,surname:"Marella",slug:"surya-teja-marella",fullName:"Surya Teja Marella"},{id:"336267",title:"Mr.",name:"Hemanth Sai Kumar",middleName:null,surname:"Parisa",slug:"hemanth-sai-kumar-parisa",fullName:"Hemanth Sai Kumar Parisa"}]},{id:"71370",title:"Complex Space Nature of the Quantum World: Return Causality to Quantum Mechanics",slug:"complex-space-nature-of-the-quantum-world-return-causality-to-quantum-mechanics",totalDownloads:1001,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"As one chapter, we about to begin a journey with exploring the limitation of the causality that rules the whole universe. Quantum mechanics is established on the basis of the phenomenology and the lack of ontology builds the wall which blocks the causality. It is very difficult to reconcile the probability and the causality in such a platform. A higher dimension consideration may leverage this dilemma by expanding the vision. Information may seem to be discontinuous or even so weird if only be viewed from a part of the degree of freedoms. Based on this premise, we reexamined the microscopic world within a complex space. Significantly, some knowledge beyond the empirical findings is revealed and paves the way for a more detailed exploration of the quantum world. The random quantum motion is essential for atomic particle and exhibits a wave-related property with a bulk of trajectories. It seems we can break down the wall which forbids the causality entering the quantum kingdom and connect quantum mechanics with classical mechanics. The causality returns to the quantum world without any assumption in terms of the quantum random motion under the optimal guidance law in complex space. Thereby hangs a tale, we briefly introduce this new formulation from the fundamental theoretical description to the practical technology applications.",book:{id:"10076",slug:"quantum-mechanics",title:"Quantum Mechanics",fullTitle:"Quantum Mechanics"},signatures:"Ciann-Dong Yang and Shiang-Yi Han",authors:[{id:"158670",title:"Prof.",name:"Ciann-Dong",middleName:null,surname:"Yang",slug:"ciann-dong-yang",fullName:"Ciann-Dong Yang"},{id:"315900",title:"Dr.",name:"Shiang-Yi",middleName:null,surname:"Han",slug:"shiang-yi-han",fullName:"Shiang-Yi Han"}]},{id:"72922",title:"Analysis of Quantum Confinement and Carrier Transport of Nano-Transistor in Quantum Mechanics",slug:"analysis-of-quantum-confinement-and-carrier-transport-of-nano-transistor-in-quantum-mechanics",totalDownloads:622,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Quantum mechanics is the branch of physics that consists of laws explaining the physical properties of the nature of nano-particles and their characteristics on an atomic scale. The study of nano-particles significantly challenges our current perception of the universe and the fabric of reality itself. Quantum particles have both wave-like and particle-like characteristics. The fundamental equation that predicts the physical behaviour of a quantum system is the Schrödinger equation and the Poisson equation using Monte Carlo simulations. This gives rise to the wavefunction, electron and hole densities, energy levels and band structure of the system which contains all the measurable information about the particle such as time and position, where position is represented using probabilities. This is because particles do not have one definite position during the time before measurement. In fact, they exist as a fuzzy distribution of all possible states where the likelihood of finding the particle in some states is more probable than others. This is known as being in a superposition of all states. When the quantum system is observed, however, its wavefunction collapses so it consequently falls into one specific position. Moreover, in this chapter we present the simulation results of conduction band profile, electron density (classical and quantum mechanical), eigenstate and eigenfunctions for Si, SOI and III-V MOSFET structures at bias voltage 1.0 V using 1D Poisson-Schrödinger solver.",book:{id:"10076",slug:"quantum-mechanics",title:"Quantum Mechanics",fullTitle:"Quantum Mechanics"},signatures:"Aynul Islam and Anika Tasnim Aynul",authors:[{id:"316001",title:"Dr.",name:"Islam",middleName:null,surname:"Aynul",slug:"islam-aynul",fullName:"Islam Aynul"},{id:"325161",title:"BSc.",name:"Anika Tasnim",middleName:null,surname:"Aynul",slug:"anika-tasnim-aynul",fullName:"Anika Tasnim Aynul"}]},{id:"71547",title:"Dipolar Interactions: Hyperfine Structure Interaction and Fine Structure Interactions",slug:"dipolar-interactions-hyperfine-structure-interaction-and-fine-structure-interactions",totalDownloads:636,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The interaction between the nuclear spin and the electron spin creates a hyperfine structure. Hyperfine structure interaction occurs in paramagnetic structures with unpaired electrons. Therefore, hyperfine structure interaction is the most important of the fundamental parameters investigated by electron paramagnetic resonance (EPR) spectroscopy. For EPR spectroscopy the two effective Hamiltonian terms are the hyperfine structure interaction and the electronic Zeeman interaction. The hyperfine structure interaction has two types as isotropic and anisotropic hyperfine structure interactions. The zero-field splitting term (electronic quadrupole fine structure), the nuclear Zeeman term, and the nuclear quadrupole interaction term are among the Hamiltonian terms used in EPR. However, their effects are not as much as the term of the hyperfine structure interaction. The zero-field splitting term and the nuclear quadrupole interaction term are the fine structure terms. The interaction of two electron spins create a zero-field splitting, the interaction between the two nucleus spins form the nuclear quadrupole interaction. Hyperfine structure interaction, zero-field interaction, and nuclear quadrupole interaction are subclasses of dipolar interaction. 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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. 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After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. 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