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. 2023 May 31;18(5):e0285988. doi: 10.1371/journal.pone.0285988

Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in a cadaveric model of bovine fetus

Carla Rozilene Guimarães Silva 1,‡,*, Thiago da Silva Cardoso 1,#, Késia Bandeira da Silva 1,#, Heytor Jales Gurgel 1,#, João Pedro Monteiro Barroso 1,#, Luiz Henrique Vilela Araújo 1,#, Luis Enrique Soza Altamirano 1,#, Loise Araújo de Sousa 1,#, Luiza Paula Araújo Alcântara 1,#, Marcos Emanoel Martins Ferreira 1,#, Lucas Santos Carvalho 1,#, José Leandro da Silva Gonçalves 1,#, Jhoisse Hamar Guimarães Rodrigues 1,#, Francisco Décio de Oliveira Monteiro 1,‡, Rinaldo Batista Viana 2,‡, Pedro Paulo Maia Teixeira 1,‡
Editor: Adolfo Maria Tambella3
PMCID: PMC10231838  PMID: 37256883

Abstract

Abdominal wall defects in calves are commonly diagnosed and treated via laparotomy. This technique has witnessed several advancements in the management of these disorders. This study aimed to create a study model and evaluate the feasibility of video-assisted percutaneous correction of abdominal wall defects in bovine fetuses (corpses) compared with the conventional technique. Sixteen bovine fetuses from pregnant cows slaughtered in slaughterhouses were included in this study. The fetuses were categorized into the control group (CG, n = 8), which was subjected to umbilical abdominorrhaphy via laparotomy, and the video-surgical group (VG, n = 8), which received video-assisted percutaneous sutures with two lateral accesses on the right flank. An abdominal wall defect was created in the VG group to generate a study model, which was corrected using the laparoscopic technique. The procedures were performed in two steps. The first step consisted of creating an abdominal wall defect in the umbilical region by laparoscopic approach in an iatrogenic manner (Step 1: E1). The second stage consisted of conventional abdominorrhaphy of the umbilical region wall defect in the CG group and video-assisted percutaneous suturing of the edges of the iatrogenic abdominal wall defect in the VG group, until reversal of the laparoscopic accesses (Step 2: E2). Step 1 showed no statistically significant difference between the two groups. However, a significant statistical difference (p < 0.0001) was observed between the two groups in step 2. The surgical time of step 2 was longer in the CG group (33.10 ± 0.43 minutes) than that in the VG group (10.13 ± 0.68 minutes, p < 0.0001), and the total surgical time was also longer in the CG group (38.48 ± 0.35 minutes) than that in the VG group (15.86 ± 0.67 minutes). The proposed laparoscopic technique allowed the creation of a study model for video-assisted percutaneous suturing with two portals and reduced the surgical time compared with the conventional technique. However, this method needs to be studied further in live animals.

Introduction

Breeds with dairy aptitude are more affected by umbilical hernias than beef breeds, and the problem is more common in females [1]. Abdominal wall defects in calves can often occur in production systems that do not perform preventive genetic selection and sporadically in other owners who are attentive to hereditary or congenital problems [2]. Umbilical hernias in calves may be noninfectious in origin, but they can also be infectious or incisional owing to technical failure of umbilical surgeries, errors in suture patterns, and concomitant infections of the umbilical remnants [3,4].

Hernia comprises three parts, namely, hernial ring, sac, and contents. An umbilical hernia usually occurs in calves because of the failure to close the umbilical cord. This failure results in the projection of the abdominal contents into the subcutaneous tissue, which causes a protrusion of the peritoneum and enlargement of the umbilical region [5].

Clinical signs, palpation, needle impression, and auscultation as well as rectal temperature, heart rate, and respiratory rate measurement can aid in the diagnosis [6,7]. Palpation can confirm the diagnosis of umbilical hernia, or even other hernias, as it reduces the hernial content to the abdominal cavity and differentiates it from other conditions, such as abscesses, edema, and idiopathic protrusions. When punctured, the intestinal content may be present in the obtained sample [6].

Ultrasound shows satisfactory results as a complementary diagnostic method, and when complemented by videolaparoscopy, it can aid in exploring the umbilical region, identifying adhesions, and expanding the field of view [8]. Videolaparoscopy is used for the intra-abdominal diagnosis of umbilical remnants, including repair of umbilical hernias in other species. This method exhibits promising results as compared with conventional methods via laparotomy [9–11].

Laparoscopic techniques need to be practiced in study models so that the surgeon acquires the skills to perform the procedure in live animals [9,10]. However, there are no reports on any experimental training model for creating an abdominal wall defect via the videosurgical approach. Also, there is no description of the percutaneous correction technique assisted by abdominal videolaparoscopy.

Hence, this study aimed to create a study model and evaluate the viability of video-assisted percutaneous suturing of the abdominal wall technique in bovine fetuses (corpses) as compared with the conventional technique.

Materials and methods

This study was approved by the Ethics Committee for Research with Animals and Experimentation of the Federal University of Pará (protocol N° 4848261017).

Animals

A total of 16 bovine fetuses were included in the study, 2 males and 14 females, who were in their third trimester of pregnancy. The weight varied between 25 and 30 kg. All the pregnant cows were slaughtered in slaughterhouses under the supervision of the government health inspection service. All procedures were performed on cadavers.

Bovine fetuses were categorized into two groups: the control group (CG, n = 8) treated via umbilical abdominorrhaphy with laparotomy and the videosurgical group (VG, n = 8) treated via video-assisted percutaneous suture technique, with two lateral accesses on the right flank. A wall defect of approximately 15 cm was created to simulate hernia correction, with the VG as a study model. Subsequently, the defect was corrected via percutaneous suture assisted by videolaparoscopy.

Operative techniques

The umbilical abdominorrhaphy in the CG was performed according to the methods described by Sutradhar et al. [12]. The animals were placed in ventral–dorsal recumbency. An elliptical skin incision was made at both ends of the base of the umbilicus using a number 24 scalpel blade (Two Arrows Scalpel Blade, Shanghai Med., SN, China), and the excess was removed for better apposition. The incision was lateralized to the foreskin in male calves. A blunt dissection was performed in the subcutaneous tissue with surgical scissors to create a lesion in the abdominal cavity, which passed through the rectus abdominis muscle to incise the peritoneum.

The umbilical structures were detached from the abdominal wall with partial resection of the vein, umbilical arteries, and urachus using a Miller’s knot. All sutures were performed with 0.40-mm nylon thread (Linha de pesca Dourado Premium, Dourado, Londrina, Paraná, Brazil). Umbilical abdominorrhaphy was performed with an interrupted double-breasted suture to correct the defect (Fig 1A–1C). The subcutaneous tissue was sutured with continuous stitches using the Reverdin needle (Fig 1D), and the skin was sutured with interrupted stitches using a U-shaped suture (Fig 1E).

Fig 1. Umbilical abdominorrhaphy and dermorrhaphy in the laparotomy technique.

Fig 1

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(A) Beginning of the suture (white arrow) using interrupted stitches, jacket type. (B) Stitches (*) before being finished. (C) Peritoneum/muscle suture completed. (D) Subcutaneous suture to reduce dead space, and (E) dermorrhaphy with U suture. Cr, cranial; Cd, caudal; L, left; R, right.

The methodology adopted by Monteiro et al. [9] and Prządka et al. [13] was used for the establishment of access portals, creation of a study model with the defect in the abdominal wall, and the execution of video-assisted percutaneous suturing technique. The access ports were established in the right flank near the paralumbar fossa, caudal to the ribs, with the direct introduction of the trocar via a parietal incision. Skin incisions of approximately 8–10 mm for 10-mm ports and 3–5 mm for 5-mm ports were made using a scalpel to insert the trocars transmurally into the abdominal cavity while maintaining the triangulation of the access doors.

A 10-mm rigid endoscope with a diameter of 0° (Karl Storz SE & Co, Tuttlingen, Germany) was used, which was coupled to the microcamera system (Combo Endosurgery System, GDI, Ribeirão Preto, São Paulo, Brazil) and lighting cable (Cable of Light 495 Optical Fiber, Karl Storz SE & Co, Germany), connected to the light source (Led Light Source, GDI, Ribeirão Preto, São Paulo, Brazil). Zscan (Image Capture Software, Zscan, Goiânia, Goiás, Brazil) was used for capturing the images. Anatomical specimens of the VG group were placed in the left lateral recumbency position and subjected to laparoscopy using two laparoscopic access ports in the right flank, with one 10-mm cannula in the first and one 5-mm cannula in the second port for access.

A skin incision of approximately 5 mm was made for the second portal, and both the trocars were inserted directly (direct introduction of the trocar through a parietal incision). The assistant operated the optic toward the umbilical base, and the clipping and resection of the umbilical vein, urachus, and umbilical arteries were simulated using laparoscopic scissors, with a cut close to the umbilical ring (UR) (Fig 2A and 2B). The umbilical structures were detached with partial resection, and dissection was performed with laparoscopic scissors in the umbilical base (Fig 2C and 2D), thereby creating a lesion of approximately 15 cm in the abdominal wall (Fig 2E). The opening was confirmed with the visualization on the monitor (Fig 2F).

Fig 2. Creation of the study model for performing the percutaneous suture.

Fig 2

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(A) Resection of the umbilical vein (UV). (B) Resection of the right (RUA) and left (LUA) umbilical arteries and urachus (U). (C) Umbilical ring (UR) after resection of the umbilical structures. (D) Beginning of the abdominal wall lesion. (E) End of the abdominal wall lesion. (F) Final result of the defect (white arrows) in the abdominal wall.

Video-assisted percutaneous suture was performed after confirmation of the injury in the abdominal wall in the VG. The defect was corrected using a rigid endoscope with internal suturing of the edges of the wound percutaneously. Isolated stitches were applied with the aid of a catheter (16G Teflon Intravenous Peripheral Catheter, Descarpack, São Paulo, São Paulo, Brazil) passing through the nylon thread.

All catheter movements were performed from outside the abdominal cavity, with direct camera control (Fig 3A and 3B). The mandrel of the transcutaneous catheter was introduced at each point, crossing the two edges of the abdominal defect (Figs 4A, 4B, 5A and 5B). The nylon thread was passed through the guide catheter, crossing the edges of the wound (Figs 4C and 5C). The catheter was passed through the same dermal orifice but lateralizing the passage approximately 15 mm in the muscular layer at the edge of the surgical wound. The thread was again passed through the guide catheter, and the surgeon’s knot was performed (Fig 4D and 4E). Both the distal and proximal ends of the knot were subcutaneous (Figs 4F and 5D).

Fig 3. External view during the video-assisted percutaneous suturing technique.

Fig 3

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(A) Beginning of the suture using the guide catheter (white arrow) and (B) completion of the percutaneous suture with isolated stitches (*).

Fig 4. Schematic representation of the video-assisted percutaneous suturing technique.

Fig 4

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(A) Identification of anatomical structures. (B) Introduction of the guiding catheter on one side of the wound edges and placement of the nylon thread. (C) Nylon thread passed through the wound edges after removal of the catheter. (D) Nylon thread re-passed via the catheter directed on the opposite side to the first placement. (E) Nylon thread after removal of the catheter at the edges of the wound. (F) Finishing the stitch with a surgery knot in the subcutaneous region. I-Skin. II-Muscle. III-Subcutaneous. IV-Catheter.

Fig 5. Internal view during video-assisted percutaneous suturing technique.

Fig 5

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(A) Introduction of the mandrel (white arrow) of the catheter into the abdominal cavity, (B) Beginning of the first stitch, with the mandrel directed to the other side of the edge of the surgical wound, (C) Nylon threads applied to the surgical wound, and (D) Completion of the video-assisted percutaneous suture technique.

The pneumoperitoneum was undone, the trocar cannulas and laparoscopic portals were removed, and two or three more sutures were performed according to the size of the abdominal wall defect. Myorrhaphy and dermorrhaphy were performed to make the sutures with crossed stitches (Sultan) and U suture in each incision, respectively.

Intraoperative analyses

The transoperative time was measured for each stage, and any intercurrence at each stage was recorded in all procedures. Data on total operative time and steps were subjected to descriptive statistics for CG and VG.

The procedures involved the following steps: step 1 (E1): access to visualization and exploration of the umbilical base, resection of the umbilical structures, and creation of the lesion in the abdominal wall, surgical techniques; step 2 (E2): umbilical abdominorrhaphy via laparotomy in the CG group and video-assisted percutaneous suturing of the wound edges in the VG group and final exploration until reversal of the accesses.

Statistical analysis

The Shapiro–Wilk test was used to confirm the normal distribution of the data. The t-test was used to compare the total operative time of each step. The Mann–Whitney test was used for non-normal distribution of the data. Statistical evaluation was performed using the Bioestat 5.3 package, and p < 0.05 was considered significant.

Results

The bovine fetus model was effective in establishing the operative technique, with visualization, manipulation of the structures, creation of the incision in the abdominal wall, correction with percutaneous suture, and accomplishment of the comparison between the groups. The technique was performed in all 16 animals with visualization of the umbilical structures without major complications. The right lateral approach, with the establishment of laparoscopic accesses, allowed the execution of the procedures properly, as it guaranteed access to the abdominal wall defect with a wide field of view, contributing to the feasibility of the technique.

There was no statistical difference between the groups (Table 1) in step 1 with regard to performing the accesses, viewing and exploring the umbilical base, resecting the umbilical structures, and creating the lesion in the abdominal wall. The size of the incisions was 9.4–14.5 cm, with a mean of 11.73 cm. Two incisions of approximately 5–10 mm were made via laparoscopy for the introduction of the two portals.

Table 1. Surgical time in the different stages.

Step CG (min) VG (min) Valor de p
E1 5.38 ± 0.23 5.73 ± 0.15 0.0032
E2 33.10 ± 0.43 10.13 ± 0.68 <0.0001*
Total surgical time 38.48 ± 0.35 15.86 ± 0.67 <0.0001*
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Surgical time in the steps of abdominirrhaphy after laparotomy and percutaneous suture guided by laparoscopy in bovine fetuses. CG: Control group, VG: Video-surgical group, p: Probability of significance.

Resection of the umbilical structures via laparotomy was performed with a Miller’s knot. The simulation of clipping of the umbilical vein (UV), urachus, and umbilical arteries was performed via laparoscopy. The defect in the abdominal wall of the umbilical base was established with laparoscopic scissors after video-assisted resection of the umbilical structures.

Surgical techniques were performed, and the final exploration until reversal of the accesses was done in step 2. The creation of the abdominal wall defect was possible with video-assisted percutaneous suture and umbilical abdominorrhaphy via laparotomy. A statistically significant difference was observed between the groups in this aspect (Table 1). There was a small intercurrence during the performance of the suture in the VG group, where the base of the catheter was detached from the mandrel but without compromising the technique.

Diaeresis was performed to close the abdominal cavity with more layers of sutures, and dermorrhaphy was done with broken points in the postsurgical wound of 15–20 cm in the CG group. Dermorrhaphy in the postoperative wound of approximately 5 and 10 mm was performed in the VG group. The total surgical time was longer in the CG group than that in the VG group (Table 1), and stage 2 mostly influenced the duration of the total surgical procedure.

Discussion

Percutaneous suturing has been used in humans [14], canines [15], and swine [13]. Percutaneous internal ring suturing is a minimally invasive surgical technique for laparoscopic hernia repair. Umbilical hernias are the most frequent form of hernias reported in calves. These hernias can be caused by delayed closure of the UR owing to morphological changes [2], congenital defects, or infections of the umbilical vessels or urachus [16]. The treatment involves surgery performed via laparotomy and other methods [7]. In this study, the proposed technique involved creating a wound in the abdominal wall and using laparoscopy to perform the percutaneous suture.

The umbilical structures, liver, and abomasum were partially visualized in the abdominal cavity during the accesses via laparotomy. The UV and a large part of the hepatic parenchyma were initially visualized via laparoscopy, with great access to a large part of the abdominal cavity. The UV was first inspected as the laparoscope was focused directly on it [9]. The remaining umbilical structures were located by directing the laparoscope toward the umbilical base.

Infected umbilical structures were resected via laparotomy and decrease of the bacterial load to improve prognosis [17]. The resection of the umbilical structures can be en bloc for the surgical treatment of infections of the umbilical vessels, persistent urachus, and umbilical hernias via laparoscopy as well as the conventional technique [18].

The clipping of the internal umbilical structures was simulated with subsequent resection in the VG group. This procedure was performed easily. The positioning of the laparoscopic portals allowed direct access to the structure, thus avoiding perforation of organs or tissues and safe and uncomplicated execution during the procedure [19,20].

Bovine fetuses (corpses) were used in the present study to obtain a study model by creating a defect in the abdominal wall. A lesion was created to simulate the anatomical changes caused by umbilical hernias. This allowed the practice and training of the execution of the technique of umbilical abdominorrhaphy in the CG and the video-assisted percutaneous suture in the VG group. Training is required to perform a laparoscopic technique accurately. Some study models that help surgeons acquire basic laparoscopic skills exist [21].

Umbilical hernias are ovoid defects in the ventral abdominal wall [6,17]. These defects can be repaired using two surgical methods: closed and open. Simple hernias measuring 1–3 cm are common, but they can also be >3 cm with the presence of organs or with serious complications [1]. Umbilical herniorrhaphy is recommended for hernias >5 cm. This procedure in bovine fetuses was performed during umbilical herniorrhaphy after the incision of the hernia sac and peritoneum, with the introduction of the viscera into the abdominal cavity [2,20].

Abdominal wall injuries created in the tested groups were adequate for performing the techniques. A 16-G catheter was used to make the percutaneous suture with the aid of an injection needle to perform the extracorporeal suture in the VG group [14,15]. This technique is a minimally invasive alternative that is easy to perform [13]. Laparoscopic techniques to reduce hernias have a faster recovery after the procedures compared with conventional methods [7].

The total surgical time was statistically longer in the CG group than that in the VG group. The largest incisions via laparotomy and the suturing of the subcutaneous tissue with simple anchorage using continuous stitches in the musculature, in addition to dermorrhaphy, were performed with pattern interrupted suture [16]. The time for correction of the abdominal wall defect in the umbilical region was shorter with the aid of laparoscopy [7,9]. This suture has lower complication rates than conventional surgical techniques in video-assisted surgery [7,22].

Conclusions

The study model allowed the execution of the video-assisted percutaneous suture technique for wound repair in the abdominal wall with less surgical time compared with the conventional technique. However, further studies are needed in a larger cohort, including live animals that require surgical procedures for umbilical hernias to confirm the results of the present study.

Supporting information

S1 File

(DOCX)

Click here for additional data file. (13.9KB, docx)

Acknowledgments

Ethics committee approval: This research was approved by the Ethics Committee on the Use of Animals at the Universidade de Federal do Pará (CEUA/UFPA N°. 4848261017).

Data Availability

All relevant data are within the paper.

Funding Statement

The authors would like to thank CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - "Higher Education Personnel Improvement Coordination") and PROPESP (Pró-Reitoria e Pesquisa e Pós Graduação - "Dean of Research and Graduate Studies")/UFPA (Universidade Federal do Pará - "Federal University of Pará) for financially supporting this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Adolfo Maria Tambella

21 Nov 2022

PONE-D-22-23559Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in an animal modelPLOS ONE

Dear Dr. Silva,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Reviewers raised minor concerns about the manuscript. It is recommended that the authors follow the suggestions of the reviewers and then modify the manuscript accordingly.

In addition, the following aspects need to be clarified or changed. 

English-language proofreading of the entire text of the manuscript is required (please have the correct form of writing by a native English speaker or use an English writing service); 

More specifics about the method used are required, especially in the VG group, so that the reader will potentially be able to reproduce it, in particular:

-precisely describe the positioning of the trocars and ports (it is not enough to write "through the right flank");

-methods of entry of the CO2 into the abdominal cavity in the induction phase of the pneumoperitoneum (for example use of the Verres needle or direct introduction of the trocar through a parietal incision?);

-please specify the length of the catheter used.

In Statistical analysis, what’s the meaning of “with the post test”? Perhaps do authors mean a post-hoc test? But if so, it seems inappropriate given that, being a comparison between two groups, a t-test was rightly done, and not an ANOVA. Furthermore, it is not necessary to specify "Wilcoxon" in parentheses, “Mann-Whitney test” is sufficient. 

In abstract and method section the authors define the surgical steps with S1 and S2, then in results (Table 1) with E1 and E2: please homogenize by using the same acronyms in the whole manuscript (the same for GV and VG, as suggested by the reviewer). 

Authors should please indicate major limitations of the study. 

==============================

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study was done to develop a study model for laparoscopic surgical correction of umbilical defects in calves. The manuscript is well presented and can be accepted with minor corrections mentioned below.

Title: The title should include "study model" as no live animal was involved in the surgical correction to observe the prognosis.

Abstract: The video-surgical group (line 33) was termed VG but in Materials and methods it was denoted GV (lines 87, 89, 141). Please correct this.

Line 109: the meaning of Cd is should be caudal.

In fig 4, please mention the labeling of I-IV.

Statistical analysis: p < 0.05 should be considered significant.

Reviewer #2: It is interesting work with great finding.

However, I have some comments that should be addressed to increase clarity

Abstract:

Add a good background and conclusive statement for the abstract

Introduction:

Better to indicate the differential dx for hernia in general and umbilical hernia in specific such as hematoma, tumor....

Material and methods:

Better to say Study animals/ experimental animals

What breed of cattle were used?

Regarding your criteria for inclusion, why do you like to use pregnant animals as your experimental animal? Do you think the case more frequent on pregnant animals if so please indicate this on the introduction section.

Please indicate limitation of you study.

Discussion

Please try to also provide an update on what new technique can be adopted from this experimental study as compared to already existing techniques? This will increase visibility of your research.

Conclusion

It should be related with your main findings of the experiment.

Reviewer #3: Accepted without any comments, In fact, this study contains a scientific addition and a new and modern method in laparoscopy without problems or complications, and the care after the operation is simple and uncomplicated.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Moinul Hasan

Reviewer #2: Yes: Haben Fesseha

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2023 May 31;18(5):e0285988. doi: 10.1371/journal.pone.0285988.r002

Author response to Decision Letter 0

27 Feb 2023

Academic Editor

English-language proofreading of the entire text of the manuscript is required (please have the correct form of writing by a native English speaker or use an English writing service.

Response:

More specifics about the method used are required, especially in the VG group, so that the reader will potentially be able to reproduce it, in particular:

-precisely describe the positioning of the trocars and ports (it is not enough to write "through the right flank");

Response: Suggestion inserted in the manuscript (113-117)

-methods of entry of the CO2 into the abdominal cavity in the induction phase of the pneumoperitoneum (for example use of the Verres needle or direct introduction of the trocar through a parietal incision?);

Response: Suggestion inserted in the manuscript (127)

-please specify the length of the catheter used.

Response: Suggestion inserted in the manuscript (124)

In Statistical analysis, what’s the meaning of “with the post test”? Perhaps do authors mean a post-hoc test? But if so, it seems inappropriate given that, being a comparison between two groups, a t-test was rightly done, and not an ANOVA. Furthermore, it is not necessary to specify "Wilcoxon" in parentheses, “Mann-Whitney test” is sufficient.

Response: Corrected in manuscript (186)

In abstract and method section the authors define the surgical steps with S1 and S2, then in results (Table 1) with E1 and E2: please homogenize by using the same acronyms in the whole manuscript (the same for GV and VG, as suggested by the reviewer).

Response: Corrected in manuscript

Authors should please indicate major limitations of the study

As limitations of this study, the laparoscopic techniques are influenced by the surgeon's experience, in cases of very large hernias they can be difficult, not using meshes in these procedures and obtaining bovine fetuses to perform the techniques.

Reviewer Comments:

5. Review Comments to the Author

Reviewer 1:

The study was done to develop a study model for laparoscopic surgical correction of umbilical defects in calves. The manuscript is well presented and can be accepted with minor corrections mentioned below.

Title: The title should include "study model" as no live animal was involved in the surgical correction to observe the prognosis.

Response: Suggestion included in the manuscript (2)

Abstract: The video-surgical group (line 33) was termed VG but in Materials and methods it was denoted GV (lines 87, 89, 141). Please correct this.

Response: Corrected in manuscript

Line 109: the meaning of Cd is should be caudal.

Response: Corrected in manuscript

In fig 4, please mention the labeling of I-IV.

Response: Corrected in manuscript (163)

Statistical analysis: p < 0.05 should be considered significant.

Response: Corrected in manuscript (187-188)

Reviewer 2: It is interesting work with great finding.

However, I have some comments that should be addressed to increase clarity

Abstract:

Add a good background and conclusive statement for the abstract

Response: Suggestion included in the manuscript

Introduction:

Better to indicate the differential dx for hernia in general and umbilical hernia in specific such as hematoma, tumor....

Response: Suggestion included in the manuscript

Material and methods:

Better to say Study animals/ experimental animals

What breed of cattle were used?

Response: Mixed breed animals.

Regarding your criteria for inclusion, why do you like to use pregnant animals as your experimental animal? Do you think the case more frequent on pregnant animals if so please indicate this on the introduction section.

Response: We did not use pregnant animals in the study, we used fetuses obtained from pregnant animals that were slaughtered for consumption.

We use dead fetuses as these are newly developed techniques and surgeons need to gain necessary skills in cadavers without causing pain or suffering to live animals.

Please indicate limitation of you study.

The limitations of this study were during the collection and conservation of bovine fetuses. Most of the cows that were destined for slaughter were not pregnant and the slaughterhouse was far from the place where this experiment was carried out. To get the total number of bovine fetuses planned, several displacements were necessary.

After obtaining the fetuses, they were kept under refrigeration for conservation until the period of the experiment. In the first moment, days before the practices, there was a power outage, the refrigerated chamber stopped working and all the animals were not suitable for use, they were lost. In the second moment after obtaining more animals, the experiment was carried out.

Discussion

Please try to also provide an update on what new technique can be adopted from this experimental study as compared to already existing techniques? This will increase visibility of your research.

Conclusion

It should be related with your main findings of the experiment.

Decision Letter 1

Adolfo Maria Tambella

27 Mar 2023

PONE-D-22-23559R1Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in an animal model (study model)PLOS ONE

Dear Dr. Silva,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The quality of the manuscript has improved since the first revision, however there are still minor revisions to be made. 

English-language proofreading of the new version of the whole text is still suggested to increase the clarity of the manuscript.

The following specific aspects need to be clarified or changed.

-Keywords: please replace “invasive minimally technique” with “minimally invasive technique”.

-Title: please avoid redundancy in the title; First suggested option for title: “Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in an animal model”. Second suggested option for title: “Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in a cadaveric model of bovine fetus”.

-lines 37-42: please rephrase to facilitate the reader's understanding.

-line 89: please replace “All these pregnant cows” with “All the pregnant cows”.

-line 91: delete “without causing pain or suffering to the animals.” To avoid redundancy as cadavers are used.

-line 126: please replace "lighting" with "lighting cable".

-lines 164-169 (capture of figure 4): please replace “nylon” with “nylon thread”, as in caption of figure 5. 

-line 187: please replace “, surgical techniques:” with “;”

-lines 202-203: please rephrase to facilitate the reader's understanding. 

-line 212: Since in the table is reported the p-values, it is suggested to delete “p≤0.05” from the caption.

-line 222: It is not clear what these values “(08/01–12.5%)” indicates. Maybe you mean “(1 case out of 8, 12.5%)”? Please clarify or delete. 

-lines 224-225: please rephrase to facilitate the reader's understanding.

-line 236: please delete “and other methods”.

-lines 271-273: please rephrase to facilitate the reader's understanding.

Please submit your revised manuscript by May 11 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Adolfo Maria Tambella, DVM, MSc

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Moinul Hasan

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2023 May 31;18(5):e0285988. doi: 10.1371/journal.pone.0285988.r004

Author response to Decision Letter 1

29 Apr 2023

Ref: PONE-D-22-23559R1

Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in an animal model (study model)

Answers to the reviewers

Academic Editor

English-language proofreading of the new version.

Response: Yes (Enclosed English proofreading certificate).

- Keywords: please replace “invasive minimally technique” with “minimally invasive technique”

Response: Suggestion inserted in the manuscript.

-Title: please avoid redundancy in the title; First suggested option for title: “Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in an animal model”. Second suggested option for title: “Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in a cadaveric model of bovine fetus”.

Response: Second suggestion inserted in the manuscript.

-lines 37-42: please rephrase to facilitate the reader's understanding.

Response: Suggestion inserted in the manuscript.

“The procedures were performed in two steps. The first step consisted of creating an abdominal wall defect in the umbilical region by laparoscopic approach in an iatrogenic manner (Step 1: E1). The second stage consisted of conventional abdominorrhaphy of the umbilical region wall defect in the CG group and video-assisted percutaneous suturing of the edges of the iatrogenic abdominal wall defect in the VG group, until reversal of the laparoscopic accesses (Step 2: E2).”

-line 89: please replace “All these pregnant cows” with “All the pregnant cows”.

Response: Suggestion in manuscript.

-line 91: delete “without causing pain or suffering to the animals.” To avoid redundancy as cadavers are used.

Response: Suggestion inserted in manuscript.

-line 126: please replace "lighting" with "lighting cable".

Response: Correction inserted in manuscript.

-lines 164-169 (capture of figure 4): please replace “nylon” with “nylon thread”, as in caption of figure 5.

Response: Suggestion inserted in manuscript.

-line 187: please replace “, surgical techniques:” with “;”

Response: Substitution realized in manuscript.

-lines 202-203: please rephrase to facilitate the reader's understanding.

Response: Correction inserted in manuscript.

“The right lateral approach, with the establishment of laparoscopic accesses, allowed the execution of the procedures properly, as it guaranteed access to the abdominal wall defect with a wide field of view, contributing to the feasibility of the technique.”

-line 212: Since in the table is reported the p-values, it is suggested to delete “p≤0.05” from the caption.

Response: Suggestion inserted in manuscript.

-line 222: It is not clear what these values “(08/01–12.5%)” indicates. Maybe you mean “(1 case out of 8, 12.5%)”? Please clarify or delete.

Response: Values excluded in the manuscript.

-lines 224-225: please rephrase to facilitate the reader's understanding.

Response: Correction inserted in manuscript.

“Dieresis of the musculature and peritoneum was performed to correct the iatrogenic defect of the abdominal wall with subsequent dermarrhaphy by separate simple suture in the CG group.”

-line 236: please delete “and other methods”.

Response: Suggestion inserted in manuscript.

-lines 271-273: please rephrase to facilitate the reader's understanding.

Response: Correction inserted in manuscript.

“The time for correction of the abdominal wall defect in the umbilical region was shorter with the aid of laparoscopy”.

Attachment

Submitted filename: Response to reviewers R2.docx

Click here for additional data file. (17.7KB, docx)

Decision Letter 2

Adolfo Maria Tambella

7 May 2023

Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in an animal model (study model)

PONE-D-22-23559R2

Dear Dr. Silva,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Adolfo Maria Tambella, DVM, MSc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

After carefully considering the old and new versions of the manuscript, the scientific quality has grown and now it can be considered suitable for publication. Congratulations to the authors.

Reviewers' comments:

Acceptance letter

Adolfo Maria Tambella

22 May 2023

PONE-D-22-23559R2

Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in a cadaveric model of bovine fetus

Dear Dr. Silva:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Adolfo Maria Tambella

Academic Editor

PLOS ONE

Associated Data

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    Click here for additional data file. (13.9KB, docx)
    Attachment

    Submitted filename: Response to reviewers R2.docx

    Click here for additional data file. (17.7KB, docx)

    Data Availability Statement

    All relevant data are within the paper.

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