QUANTITATIVE AND QUALITATIVE ANALYSIS OF COLLAGEN TYPES IN THE FASCIA TRANSVERSALIS OF INGUINAL HERNIA PATIENTS

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QUANTITATIVE AND QUALITATIVE ANALYSIS OF COLLAGEN TYPES IN THE FASCIA TRANSVERSALIS OF INGUINAL HERNIA PATIENTS Alberto Meyer, Eduardo Berger, Orlando Monteiro Jr, Paulino Alonso, João Stavale* Departament of Surgery and Pathology* Hospital Professor Edmundo Vasconcelos São Paulo – SP, Brazil

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INTRODUCTION second most common surgical case 1:5 1:17 surgically corrected (Brazil) ? 200.000 (public hospitals) + 80.000 (private medicine) per year recurrent cases ? 5-30% (conditions of the patient him/herself) Rev Hosp Clin 2002;57(6):265-70. Lancet 1994;344:409-19. N Engl J Med 1997;336:1541-7.

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INTRODUCTION ? high insertion of the internal oblique muscle ? widening of the internal inguinal ring ? persistency of the vaginal peritoneum conduct anatomical abnormalities + ? intra-abdominal pressure ETIOPATHOGENY Rev Col Bras Cir 1976;3(2):66-80. Clin North Am 1998;78:953-72.

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INTRODUCTION children suffering from a clear vaginal process (< ½ with detectable hernia) indirect inguinal hernias in > 40 years old recurrent hernias (technically adequate surgeries ) ONLY ANATOMICAL CHANGES World J Surg 1989;13:506-155.

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INTRODUCTION ? Marfan Syndrome ? Ehlers-Danlos Syndrome ? Osteogenesis Imperfecta DISEASES IN THE CONNECTIVE TISSUE INGUINAL HERNIA Surgery 1997;122:114-5.

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INTRODUCTION COLLAGEN resistance structural integrity fascia transversalis last layer in the aponeurotic muscle of the abdomen Ann Clin Biochem 1992;29:430-6. Eur J Clin Invest 1997;27:863-8.

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fascia transversalis inguinal ligament inferior epigastric vessels superficialis inguinal ring

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fascia transversalis parietal peritoneum skin abdominal rectus muscle

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INTRODUCTION COLLAGEN TYPE I thicker fibers great resistance to the tension forces also not elastic tendon ligament dermis bone cornea aponeurosis Mem Isnt Osvaldo Cruz 1991;86(Suppl. III):1-11.

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INTRODUCTION COLLAGEN TYPE III reticular fibers loose mesh in several supportive tissues limited elasticity blood vessels marrow bone lymph tissue nerve lungs flat muscle Mem Isnt Osvaldo Cruz 1991;86(Suppl. III):1-11.

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COLLAGEN type III COLLAGEN type I

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INTRODUCTION WEAKNESS > production COLLAGEN type III widening of the fascia transversalis Rev Hosp Clin 2002;57(6):265-70.

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INTRODUCTION HERNIOGENESE Ann Surg 1993;218:754-60. Eur J Clin Invest 1997;27:863-8.

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GOAL DETERMINING THE QUANTITATIVE AND QUALITATIVE CHANGES OF COLLAGEN IN THE FASCIA TRANSVERSALIS OF INGUINAL HERNIA PATIENTS AND COMPARE THEM TO THE FINDINGS IN INGUINAL HERNIA-FREE CORPSES

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METHOD prospective case-control study HPEV (Professor Edmundo Vasconcelos Hospital) SVOC / USP (Serviço de Verificação de Óbitos da Capital) january and september of 2004

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METHOD 27 PATIENTS selected randomly and assisted at the General Surgery Infirmary of HPEV inguinal hernia 24 CORPSES passed away less than 8 hours no previous case of hernia consent forms signed by family-members

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INCLUSION CRITERIA inguinal hernia patients diagnosed less than 5 years male consent forms signed > 20 years < 65 years METHOD

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EXCLUSION CRITERIA those taking medicine diabetes Mellitus , high blood pressure and chronic obstructive lung disease cases Marfan Syndrome and Ehlers-Danlos Syndrome cases smokers not in agreement with the study METHOD

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LICHTEINSTEIN TECHNIQUE METHOD Eur J Surg 1996;6:447-53.

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NYHUS CLASSIFICATION METHOD

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INCISION BIOPSY (0,5 X 0,5 CM) ? HASSELBACH TRIANGLE METHOD inferior epigastric vessels abdominal rectus muscle internal inguinal ring inguinal ligament Hasselbach triangle

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METHOD INCISION BIOPSY (fascia transversalis) Pathological Anatomy Service at HPEV formol at 10% CODE TABLE

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METHOD Bx paraffin hematoxilin-eosin (HE) coloring Pricosirius coloring polarized light dense connective tissue subjective amount of collagen types I and III PATHOLOGICAL ANATOMY SERVICE AT HPEV

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Student t test for independent samples level of rejection of the nullity hypothesis ? 5% (0,05) meaningful values ? asterisk METHOD ESTATISTIC ANALYSIS

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RESULTS

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RESULTS average rate ? standard deviation P=0,876, Student t test

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Figure 1 – fascia transversalis of a corpse (control) showing collagen in pink-redish color (H.E. – 200x). RESULTS

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Figure 2 – fascia transversalis of a corpse (control) showing collagen in pink-redish color (H.E. – 400x). RESULTS

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RESULTS Figure 3 – fascia transversalis of a corpse (control) using Pricosirius coloring enhanced 400 times (400x).

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RESULTS Figure 4 – fascia transversalis of a corpse (control) using Pricosirius coloring enhanced 400 times (400x).

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RESULTS Figure 5 – comparison between collagen type I and type III found in patients and controls. P=0,788 P=0,022?

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RESULTS P=0,033?, Student t test

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Read (direct inguinal hernia) thickness of aponeurosis of the rectus abdominis thinner less weight in area fascia transversalis ? Wagh rectus abdominis sheath weak less weight in area more evidently in bilateral hernia DISCUSSION Am J Surg 1970;120:610-4. Proc Soc Exp Biol Med 1971;137:382-4.

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Wolwacz (2003) average percent collagen area 33% smaller in patients Peacok / Bellón not find meaningful differences in the amount of collagen in their patients group HPEV ? average percent area of collagen = 73% (75%) DISCUSSION Acta Cir Bras 2003;18(3):196-202. Ann Surg 1984;200(3):321-7. Eur J Clin Invest 1997;27:510-6.

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Bórquez (2003) qualitative changes in the density of the collagen fibers the density of the collagen fibers was 52% smaller in inguinal hernia patients Friedman substitution of collagen type I by collagen type III Klinge changes in the proportions of collagen types I and III DISCUSSION Rev Méd Chile 2003;131:1273-9. Ann Surg 1993;218:754-60. Int J Surg Investig 1999;1:219-27.

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Rosh genetic expression in fibroblasts derived from skin diminished proportion of collagen types I and III Pans (2001) not show meaningful difference in qualitative collagen increase in the concentration of collagen in indirect inguinal hernia HPEV ? qualitative change of the collagen fibers greater amount of collagen type III in the patients compared to the controls DISCUSSION BMC Medical Genetics 2002;3:1471-2350. J Surg Res 2001;95:107-13.

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HPEV ? greater concentration of collagen type III direct inguinal hernia (Nyhus IIIa) remodeling process in the connective tissue ? DISCUSSION

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There was no meaningful difference in the amount of collagen in the fascia transversalis of the patients compared to the controls. A qualitative difference in the amount of collagen was found, which makes it evident a meaningful increase of collagen type III in inguinal hernia patients. Based on the result, inguinal hernia patients classified as Nyhus IIIa have greater amount of collagen type III when compared to the other inguinal hernia patients. CONCLUSION

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