Complex Abdominal Wall Reconstruction Research Articles

625 Complex abdominal wall reconstruction in colorectal cancer abdominal wall metastases - a case report

Abstract Introduction Resection of abdominal wall metastases with curative intent followed by complex abdominal wall reconstruction is seldom performed due to difficulty in ensuring complete resection and need for abdominal reconstruction. It is difficult to successfully localise the boundaries of these metastases for complete excision whilst balancing excessive tissue loss. We present a patient with anterior abdominal wall metastases from colorectal cancer who had this procedure performed successfully at our hospital. Case Presentation This 46-year-old lady originally underwent emergency Hartmans for a perforated sigmoid tumour invading surrounding tissues; pT4pN0R1. She had postoperative chemotherapy, HIPEC/debulking surgery and immunotherapy. A CT scan then suggested disease progression; however, the only active deposits appeared to be in her bilateral recti, so she underwent curative intent surgery - excision of bilateral rectus abdominis metastases, abdominal wall mesh reconstruction, and abdominoplasty. Histology confirmed completely excised colorectal metastatic adenocarcinoma. She did well postoperatively; currently, she continues immunotherapy and works 70 hours/week! Discussion Localisation and R0 resection of rectus metastases is technically challenging; it involves intensive preparation and working closely with the radiological team. The margins of bilateral rectus metastases were localised via immediate pre-operative CT- guided wire placement by an experienced radiologist interacting continuously with the surgeon in the CT room. Conclusion It is possible to safely excise abdominal wall metastases with intensive preoperative planning with the theatre team and radiologists; resultant abdominal wall defects can be repaired appropriately with resultant good quality of life. This procedure should be considered as an option in the management of abdominal wall colorectal metastases with curative intent in selected patients.

Surgeon volumes: preserving appropriate surgical outcomes in higher-risk patient populations undergoing abdominal wall reconstruction.

It is increasingly recognized that complex abdominal wall reconstruction (cAWR) necessitates specialized training. No studies have been conducted to assess whether a volume-outcomes relationship is present in cAWR. We sought to determine if outcomes for patients undergoing cAWR varied based on surgeon volume among participants in the Abdominal Core Health Quality Collaborative (ACHQC). All patients with ventral hernias undergoing elective cAWR with component separation (lateral component release) were selected from ACHQC database. Surgeons were ranked based on annual number of cAWR procedures performed and then grouped in tertiles. Patient characteristics, hernia risk factors, operative details, and 30-days outcomes were evaluated. A total of 9206 patients were identified, of which 310 (3.4%), 723 (7.9%) and 8173 (88.7%) cAWRs were performed by low (105 surgeons), medium (49) and high-volume (66) surgeons, respectively. Patients operated upon by high-volume surgeons tended to have more comorbidities and higher ASA class (72.5% of class ≥ III, vs 53.5%). Hernia characteristics demonstrated that high-volume surgeons more commonly operated on patients presenting with recurrent hernias (50.2% vs 42%), wider hernias (13.5cm vs 10.5cm), associated ostomies (13% vs 3.6%), and prior of surgical site infections (32% vs 26%, P = 0.035). High-volume surgeons more commonly performed posterior component separation procedures (92% vs 84%), utilized permanent mesh (92% vs 88%), and placed mesh in sublay position. In spite of operating on more advanced hernias, high-volume surgeons achieved comparable rates (all P > 0.4) of 30-day surgical site infections (SSI: 6.9% vs 7.1%) and surgical site occurrences requiring procedural intervention (SSO-PI: 8.9% vs 10%). High-volume surgeons maintain comparable outcomes following cAWR despite performing operations on patients with more comorbidities and advanced hernia disease. These findings should be integrated into the debates related to regionalizing abdominal wall reconstruction procedures among high-volume surgeons.

Preoperative Glucose Predicts Postoperative Complications After Complex Abdominal Wall Reconstruction.

Despite advances in surgical methods, complication rates after complex abdominal wall reconstruction (CAWR) remain high. Identification of preoperative risk factors can assist surgeons with risk stratification and patient counseling. The deleterious effects of hyperglycemia on wound healing are well established. With the increasing prevalence of diabetes (diabetes mellitus) and prediabetes, a greater proportion of patients are likely to have increased blood glucose levels that may contribute to poor surgical outcomes. The primary aim of this study was to determine whether preoperative hyperglycemia predicted surgical outcome. The secondary aim was to establish glucose thresholds to assist with surgical risk stratification. All patients who underwent CAWR by the senior author at a single institution from 2002 to 2021 were retrospectively reviewed. Patients were stratified into 4 groups based on preoperative blood glucose: <100 mg/dL (n = 184), 100-140 mg/dL (n = 207), 140-180 mg/dL (n = 41), and >180 mg/dL (n = 16). Patient demographics, risk factors, surgical techniques, complications, and outcomes were recorded and compared. The study cohort comprised of 478 patients. Mean age was 53.9 ± 12.3 years. Mean body mass index was 32.1 ± 7.8 kg/m2. Higher age (P = 0.0085), higher body mass index (P = 0.0005), the presence of diabetes (P < 0.0001), and hypertension (P = 0.0004) were significantly associated with higher glucose. Overall complication rates ranged from 26% (glucose <100 mg/dL) to 94% (glucose >180 mg/dL), whereas recurrence rates ranged from 10% (glucose <100 mg/dL) to 37% (glucose 140-180 mg/dL). Multivariate logistic regression analysis revealed preoperative glucose to have a significant, independent effect on overall complication rate (P < 0.0001), major complication rate (P < 0.0001), and recurrence rate (P < 0.0031). Preoperative hyperglycemia is an important predictor of postoperative complications and recurrence after CAWR. Point-of-care glucose levels are routinely gathered before surgery and may help to establish thresholds for which elective CAWR might be deferred. Strategies to lower preoperative glucose should be part of an optimization protocol for improving outcomes.

One-step totally robotic Hartmann reversal and complex abdominal wall reconstruction with bilateral posterior component separation: a technical note.

This paper describes a robotic approach to combined gastrointestinal continuity restoration and complex abdominal wall reconstruction after Hartmann's procedure complicated by large midline and parastomal hernias. A robotic Hartmann reversal is performed, followed by robotic retromuscular abdominal wall reconstruction of all ventral defects with bilateral posterior component separation using the double-docking approach. Surgical steps are thoroughly described, and the accompanying video highlights critical steps of the procedure, anatomical landmarks and technical details relevant to successful completion. Complete restoration of the anatomy was achieved with an operative time of 6.5 h. Mobilization occured on day 1, and bowels were opened on day 3. Surgical discharge was possible on day 5. No intra-operative surgical complication occurred and follow-up at 6 months showed no recurrence or mid-term complication. Combined minimally invasive reconstruction of the gastrointestinal tract and abdominal wall was feasible using a robotic system. In addition, potential advantages of postoperative rehabilitation and reduced surgical site complications are suggested. Prospective evaluation of the technique is ongoing.

OC-065 THE USE OF CAROLINAS COMFORT SCALE TO COMPARE MESH-RELATED SENSATION BETWEEN BIOSYNTHETIC AND SYNTHETIC MESH: A PILOT STUDY

Abstract Aim Bio-synthetic meshes potentially disappear from the body after certain timeframe leaving behind strengthening scaffold matrix when used for Complex Abdominal Wall Reconstruction (CAWR). We used Carolinas comfort scale (CCS) to assess mesh sensation differences between biosynthetic and synthetic mesh at different time points. Material and Methods This pilot study focusses on patients having undergone CAWR within the unit in the last 3 years. Patients were categorised into four groups of 10 patients each; those repaired with synthetic mesh or biosynthetic mesh within the last 8 months and beyond 18 months. All 40 patients answered all questions of the Carolinas CCS. Decision of mesh type was governed by patient characteristics. Results 10 patients were included in each group (total 40 patients) consecutive retrospective enrolment. We excluded those who had further abdominal surgery or clinical recurrence since. 20 patients repaired with biosynthetic and 20 with synthetic were included. Two-way ANOVA and post HOC Turkey's difference test showed significant difference (p&amp;lt;0.05) in scores in favour of less scores for patients repaired with biosynthetic mesh. This was more pronounced in the beyond 18 month group. Component separation did not make a significant difference in mesh sensation. Logistic Regression analysis revealed patients scored higher on questions related to bending, sitting up and exercise and these were linked. Conclusions This outcome provides a review of current surgical practises and meshes, helping surgeons &amp; patients make better informed decisions. Bio-synthetic meshes have better comfort outcomes for patients with lower CCS scores in the long term.

OC-032 SAFETY OF PERFORMING CONCOMITANT GASTROINTESTINAL RESECTIONAL SURGERY WITH COMPLEX ABDOMINAL WALL RECONSTRUCTION

Abstract Aim The literature regarding combined complex abdominal wall reconstruction (CAWR) and gastrointestinal surgery (GIS) is limited and largely suggests staged procedures due to a reported increased incidence of surgical site occurences (SSO), hernia recurrence and anastomotic leak. However this exposes patients to the risks of two substantial procedures and having general anaesthetic twice. This study aimed to evaluate outcomes of single-stage GIS involving a substantial GI resection with CAWR. Materials &amp; Methods Analysis of a 8 years prospectively maintained single surgeon CAWR database of 205 patients identified 14 such patients who had undergone concomitant CAWR GIS cases (5 segmental colonic resections, 2 completion proctectomies, 5 Hartmann's reversals and 2 small bowel resection and anastomoses) but excluding cholecystectomy, gynaecological surgery and adhesiolysis alone. Results CAWR-GIS mean operating time was significantly longer (5.8hrs vs 3.8hrs) with an increased incidence of post-operative ileus (40% vs 18%, p&amp;lt;0.05) with increased mean length of stay as expected (7.8 days v/s 5.1 days). There was a slightly higher incidence of SSO but there were no anastomotic leaks. Hernia recurrence rate at 2 years follow up was 10% which is comparable to our cohort (8%). None of the 14 patients required reoperation within 30 days or mesh explantation yet. 11 patients had a synthetic mesh and 3 patients had a bio-synthetic mesh used. Patients informally reported high satisfaction for having undergone combined procedures. Conclusion Concomitant intestinal surgery during complex abdominal wall repair can be performed safely without increased risk of hernia recurrence, mesh infections or anastomotic leak.

38. Pre-operative Glucose Predicts Post-operative Complications following Complex Abdominal Wall Reconstruction

PURPOSE: The primary aim of this study was to determine whether preoperative hyperglycemia predicted surgical outcome after complex abdominal wall reconstruction (CAWR). The secondary aim was to establish glucose thresholds to assist with surgical risk stratification. METHODS: All patients that underwent CAWR by the senior author at a single institution from 2002-2021 were retrospectively reviewed. Patients were stratified into four groups based on pre-operative blood glucose: <100 mg/dl (n=184), 100-140 mg/dl (n=207), 140-180 mg/dl (n=41), and > 180 mg/dl (n=16). Patient demographics, risk factors, surgical techniques, complications, and outcomes were recorded and compared. RESULTS: The study cohort was comprised of 478 patients. Mean age was 53.9 ± 12.3 years. Mean body mass index (BMI) was 32.1 ± 7.8. Higher age (p=0.0085), higher BMI (p=0.0005), the presence of diabetes (<0.0001), and hypertension (0.0004) were significantly associated with higher glucose. Overall complication rates ranged from 26% (glucose <100mg/dL) to 94% (glucose >180 mg/dL) while recurrence rates ranged from 10% (glucose <100 mg/dL) to 37% (glucose 140-180 mg/dL). Multivariate logistic regression analysis revealed pre-operative glucose to have a significant, independent effect on overall complication rate (p<0.0001), major complication rate (p<0.0001), and recurrence rate (p<0.0031). CONCLUSION: Pre-operative hyperglycemia is an important predictor of post-operative complications and recurrence following CAWR. Point of care glucose levels are routinely gathered prior to surgery and may help to establish thresholds for which elective CAWR might be deferred. Strategies to lower pre-operative glucose should be part of an optimization protocol for improving outcomes.

PC15. 14-year Experience with Complex Abdominal Wall Reconstruction after Cancer Resection

PC15. 14-year Experience with Complex Abdominal Wall Reconstruction after Cancer Resection

Prophylactic use of incisional negative pressure wound therapy for the prevention of surgical site occurrences in general surgery: Consensus document.

Surgical site occurrences pose a threat to patient health, potentially resulting in significant increases in health care spending caused by using additional resources. The objective of this study was to reach a consensus among a group of experts in incisional negative pressure wound therapy to determine the indications for using this type of treatment prophylactically and to analyze the associated risk factors of surgical site occurrences in abdominal surgery. A group of experts in incisional negative pressure wound therapy from Spain and Portugal was formed among general surgery specialists who frequently perform colorectal, esophagogastric, or abdominal wall surgery. The Coordinating Committee performed a bibliographic search to identify the most relevant publications and to create a summary table to serve as a decision-making protocol regarding the use of prophylactic incisional negative pressure wound therapy based on factors related to the patient and type of procedure. The patient risk factors associated with surgical site occurrence development such as age, immunosuppression, anticoagulation, hypoalbuminemia, smoking, American Society of Anesthesiologists classification, diabetes, obesity, and malnutrition were analyzed. For surgical procedure factors, surgical time, repeated surgeries, organ transplantation, need for blood transfusion, complex abdominal wall reconstruction, surgery at a contaminated site, open abdomen closure, emergency surgery, and hyperthermic intraperitoneal chemotherapy were analyzed. In our experience, this consensus has been achieved on a tailored set of recommendations on patient and surgical aspects that should be considered to reduce the risk of surgical site occurrences with the use of prophylactic incisional negative pressure wound therapy, particularly in areas where the evidence base is controversial or lacking.

Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction.

Patients often need admission at an Intensive Care Unit (ICU), immediately after complex abdominal wall reconstruction (CAWR). Lack of ICU resources requires adequate patient selection for a planned postoperative ICU admission. Risk stratification tools like Fischer score and Hernia Patient Wound (HPW) classification may improve patient selection. This study evaluates the decision-making process in a multidisciplinary team (MDT) on justified ICU admissions for patients after CAWR. A pre-Covid-19 pandemic cohort of patients, discussed in a MDT and subsequently underwent CAWR between 2016 and 2019, was analyzed. A justified ICU admission was defined by any intervention within the first 24h postoperatively, considered not suitable for a nursing ward. The Fischer score predicts postoperative respiratory failure by eight parameters and a high score (> 2) warrants ICU admission. The HPW classification ranks complexity of hernia (size), patient (comorbidities) and wound (infected surgical field) in four stages, with increasing risk for postoperative complications. Stages II-IV point to ICU admission. Accuracy of the MDT decision and (modifications of) risk-stratification tools on justified ICU admissions were analyzed by backward stepwise multivariate logistic regression analysis. Pre-operatively, the MDT decided a planned ICU admission in 38% of all 232 CAWR patients. Intra-operative events changed the MDT decision in 15% of all CAWR patients. MDT overestimated ICU need in 45% of ICU planned patients and underestimated in 10% of nursing ward planned patients. Ultimately, 42% went to the ICU and 27% of all 232 CAWR patients were justified ICU patients. MDT accuracy was higher than the Fischer score, HPW classification or any modification of these risk stratification tools. A MDT's decision for a planned ICU admission after complex abdominal wall reconstruction was more accurate than any of the other risk-stratifying tools. Fifteen percent of the patients experienced unexpected operative events that changed the MDT decision. This study demonstrated the added value of a MDT in the care pathway of patients with complex abdominal wall hernias.

ASO Visual Abstract: Outcomes of Complex Abdominal Wall Reconstruction After Oncologic Resection: 14-Year Experience at an NCI-Designated Cancer Center.

ASO Visual Abstract: Outcomes of Complex Abdominal Wall Reconstruction After Oncologic Resection: 14-Year Experience at an NCI-Designated Cancer Center.

Outcomes of Complex Abdominal Wall Reconstruction After Oncologic Resection: 14-Year Experience at an NCI-Designated Cancer Center.

Outcomes studies for abdominal wall reconstruction (AWR) in the setting of previous oncologic extirpation are lacking. We sought to evaluate long-term outcomes of AWR using acellular dermal matrix (ADM) after extirpative resection, compare them to primary herniorrhaphy, and report the rates and predictors of postoperative complications. We conducted a retrospective cohort study of patients who underwent AWR after oncologic resection from March 2005 to June 2019 at a tertiary cancer center. The primary outcome was hernia recurrence (HR). Secondary outcomes included surgical site occurrences (SSOs), surgical site infection (SSIs), length of hospital stay (LOS), reoperation, and 30-day readmission. Of 720 consecutive patients who underwent AWR during the study period, 194 (26.9%) underwent AWR following resection of abdominal wall tumors. In adjusted analyses, patients who had AWR after extirpative resection were more likely to have longer LOS (β, 2.57; 95%CI, 1.27 to 3.86, p < 0.001) than those with primary herniorrhaphy, but the risk of HR, SSO, SSI, 30-day readmission, and reoperation did not differ significantly. In the extirpative cohort, obesity (Hazard ratio, 6.48; p = 0.003), and bridged repair (Hazard ratio, 3.50; p = 0.004) were predictors of HR. Radiotherapy (OR, 2.23; p = 0.017) and diabetes mellites (OR, 3.70; p = 0.005) were predictors of SSOs. Defect width (OR, 2.30; p < 0.001) and mesh length (OR, 3.32; p = 0.046) were predictors of SSIs. Concomitant intra-abdominal surgery for active disease was not associated with worse outcomes. AWR with ADM following extirpative resection demonstrated outcomes comparable with primary herniorrhaphy. Preoperative risk assessment and optimization are imperative for improving outcomes.

Botulunim Toxin Type A Followed by TAR (Transversus Abdominal Release) with Abdominoplasty as the Best Combination for Big Hernia Repair

Introduction: The current incidence of incisional hernia is up to 11%. Botulinum toxin type A shows atrophy in the extrafusal and intrafusal muscle fibers. With the addition of Muscle Paralysis and improving strength, it is possible to perform an effective posterior component separation. Objective: Describe an easy algorithm to treat complex abdominal wall reconstruction and improve the quality of adjacent tissues. Material and Methods: Fifty-nine patients were analyzed over 1 year in the General Surgery and Plastic and Reconstructive Surgery Service, patients with midline abdominal wall hernias, using the effective reconstruction algorithm, placing by ultrasound-guided botulinum toxin in the muscle transverse, 1 month later performing TAR, with Abdominoplasty for skin flap management, and comparing with the control group that did not apply botulinum toxin. Discussion: Botox is a neurotoxin derived from the bacterium Clostridium botulinum (botulinum toxin type A) that has been observed at the sensory level causing atrophy in the extrafusal and intrafusal muscle fibers. Repair of the abdominal wall after incisional hernias has been a great challenge with recurrence rates of 11%. Performing the release of the transverse muscle has a recurrence of 6%, as well as the compensation of skin flaps are ideal for proper management. Results: Within the observed analyzes, the results were divided into trans-surgical (99% of the patients closed the midline), immediate post-surgical (Pain, Seroma and Infection &lt;1%) and late (with &lt;3% recurrence) in the experimental group. Conclusions: Within the study, we will be able to analyze that lowering the recurrence rate &lt;3% in patients properly protocolized, is translated as an adequate and totally reproducible method in our environment.

EGS P25 Innovative use of Alexis ® O System for tissue retraction in hernia and abdominal wall wound repairs

Abstract Background Hernial operations may pose significant challenges due to the relaxed, dissected subcutaneous tissues and skin which obscure the surgical field during open reconstructions of the abdominal wall. Difficulty in the operation is exacerbated, in the morbidly obese patient due to the the weight of skin and subcutaneous tissue where clear retraction is of extra benefit. The key to adequate exposure during abdominal wall surgery is symmetrical retraction, failure of such can prolong operative times and increase the work and requirement of of assistants. Presentation of the use of the Alexis ® O system retractor for skin and subcutaneous tissue retraction in hernia repairs and during abdominal wall closure between Dec 2021 and May 2022. Methods The use of Alexis ® O retractor has been used for skin and subcutaneous retraction in nine cases: four ventral abdominal wall hernia repair (with two cases needing posterior component separation), four umbilical/para-umbilical hernia and one for inguinal hernias. Results This study demonstrated that the Alexis ® O retractor is a useful adjunct to surgery in all four of the abdominal wall hernias and three of the umbilical hernia repairs. It proved initially difficult to place in the first of the umbilical and in the inguinal hernia repairs due to there being inadequate available sizes or shapes of the retractor. The paper presents a novel and efficient approach to skin and subcutaneous retraction by deployment of the Alexis ® O - a self-expanding wound protector - in hernial repairs. The Alexis ® O retractor allowed equal tension retraction at all points of the incision and dissection, enabling improvedexpose of the whole surgical field, improving the symmetrical retraction and thus facilitating planning and unopposed moving between different positions of the surgical field without the requirement of changing retractor position. Furthermore, it increased the freedom of the assistants hands which allowed them to participate in more skilful task aiding the lead surgeon and improving the efficiency of the operation as a whole. The Alexis ® O provided access to surgical field for both the operating and assisting surgeons, along with improving the field that the instruments could operate in without clashing with a fixed and sometimes bulkymetal retractors. Conclusions Conclusions: The use of an Alexis ® O retractor in hernia repairs can improve the overall skin and subcutaneous tissue retraction aiding in abdominal wall closure and hernia repairs including umbilical, para-umbilical and inguinal hernias. It provides effective symmetrical retraction of skin and subcutaneous tissue, providing increased freedom to the surgeons and assistants and helps to avoid instrumental clashes. This study demonstrates that Alexis ® O retractor could be used easily without modification to provide effective subcutaneous and skin retraction in hernia operation including complex abdominal wall reconstruction. Furthermore, more potential application for Alexis ® O retractor could be achieved if wider range and different shapes of the Alexis ® O retractor were made available.

Evaluating the Effect of Socioeconomic Status on Complex Abdominal Wall Reconstruction Outcomes.

In complex abdominal wall reconstruction, maintenance and follow-up are vital to effective long-term patient care. This can present a challenge for individuals from a low-income household who may have less ability to afford time away from work or caring for dependents as well as challenges with transportation to and from follow-up appointments. Given the expenses and high complication rate in abdominal wall reconstruction, we elected to determine whether socioeconomic status had an impact on patient outcomes. After obtaining institutional review board approval, all patients who underwent complex abdominal wall reconstruction between 2002 and 2021 by the senior author were reviewed in a retrospective cohort analysis of a prospectively maintained database. Complications were classified into overall, major, infection, and delayed wound healing. Outcomes were classified into recurrence and reoperation. The cohort was divided by median household income (MHI) level and race. A total of 478 patients received complex abdominal wall repair over a 19-year interval. A total of 324 patients identified MHI as <$75,000 (low MHI), and 154 patients identified MHI as > $75,000 (high MHI). Mean patient age was 53.9 (SD, 12.3) years. Mean patient body mass index (BMI) was 32.1 (SD, 7.8) kg/m 2 . There was no significant difference in age between the 2 MHI cohorts. There was a significant difference in BMI between MHI cohorts, with higher BMI among patients with low MHI ( P = 0.0001). The majority of risk factors and surgical techniques were comparable. There was a statistically significant difference in hernia etiology, with higher rates of recurrent hernia repair among patients with low MHI ( P = 0.007). The risk of overall complications ( P = 0.0307) and delayed wound healing ( P = 0.0263) was higher among patients with low MHI. Median household income was found to be an independent risk factor for complications after controlling for BMI, diabetes mellitus, and hernia etiology. There was no significant difference in follow-up time between cohorts. Patients with low MHI who undergo complex abdominal wall reconstruction are at an increased risk for complications and poor outcomes, including delayed wound healing and hernia recurrence. This indicates the need to provide resources to address barriers to follow-up and maintenance following complex abdominal wall reconstruction in this patient cohort.

Gastrointestinal procedures and anastomoses can be safely performed during complex abdominal wall reconstruction.

The literature regarding combined abdominal wall reconstruction and gastrointestinal surgery is limited and largely suggests staged procedures due to a reported increased incidence of surgical site infections (SSIs), hernia recurrence and anastomotic leak, but this exposes patients to the risks of two substantial procedures. This study evaluates the outcomes of single-stage GI surgery with complex abdominal wall reconstructions (CAWR) by a single surgeon. Analysis of 10years of a prospectively maintained single surgeon CAWR database compared those who had CAWR-alone with those having concomitant gastrointestinal surgery (CAWR-GI) such as stoma reversal or bowel resection but excluding cholecystectomy, gynaecological surgery and adhesiolysis alone. Groups were compared using the paired t test (continuous data) and Fisher's exact test (nominal data). Overall, 62 elective cases (42 CAWR-alone vs. 20 CAWR-GI) were analysed. Baseline demographics (age, BMI, co-morbidities, smoking status and hernia size) showed no differences; CAWR-GI mean operating time was significantly longer compared to the CAWR-alone group (5.4h vs. 4.1h) with an increased incidence of post-operative ileus in the intestinal group (40% vs. 11.9%, p < 0.05). Post-operative complications were common (chest infection (32.3%) and SSI (41.9%)), but similar between groups. There were no anastomotic leaks, and the hernia recurrence rate at almost 4years median follow-up was 10% in both groups. Performing simultaneous intestinal surgery during complex abdominal wall repair can be performed safely without increasing the risk of hernia recurrence, mesh infections or anastomotic leak. A careful choice of mesh implant is required.

Description of the Current Da Vinci® Training Pathway for Robotic Abdominal Wall Surgery by the European Hernia Society.

Background: Robot assisted laparoscopic abdominal wall surgery (RAWS) has seen a rapid adoption in recent years. The safe introduction of the robot platform in the treatment of abdominal wall hernias is important to safeguard the patient from harm during the learning curve. The scope of this paper is to describe the current European training curriculum in RAWS. Methods and Analysis: The pathway to competence in RAWS will depend on the robot platform, experience in other abdominal procedures (novice to expert) and experience in the abdominal wall repair techniques. An overview of the learning curve effect in the initial case series of several early adopters in RAWS was reviewed. In European centres, current training for surgeons wanting to adopt RAWS is managed by the specific technology-based training organized by the company providing the robot. It consists of four phases where phases I and II are preclinical, while phases III and IV focus on the introduction of the robotic platform into surgical practice. Conclusion: On behalf of the Robotic Surgery Task Force of the European Hernia Society (EHS) we believe that the EHS should play an important role in the clinical phases III and IV training. Courses organized in collaboration with the robot provider on relevant surgical anatomy of the abdominal wall and procedural steps in complex abdominal wall reconstruction like transversus abdominis release are essential. Whereas the robot provider should be responsible for the preclinical phases I and II to gain familiarity in the specific robot platform.

Practical Mouse Model to Investigate Therapeutics for Staphylococcusaureus Contaminated Surgical Mesh Implants

IntroductionThe use of prosthetic mesh in hernia repair provides a powerful tool to increase repair longevity, decrease recurrence rates, and facilitate complex abdominal wall reconstruction. Overall infection rates with mesh are low, but for those affected there is high morbidity and economic cost. The availability of a practicable small animal model would be advantageous for the preclinical testing of prophylactics, therapeutics, and new biomaterials. To this end, we have developed a novel mouse model for implantation of methicillin-resistant Staphylococcus aureus–infected surgical mesh and provide results from antibiotic and immunotherapeutic testing. Materials and MethodsImplantation of surgical mesh between fascial planes of the mouse hind limb was used to approximate hernia repair in humans. Surgical mesh was inoculated with methicillin-resistant Staphylococcus aureus to test the efficacy of antibiotic therapy with daptomycin and/or immunotherapy to induce macrophage phagocytosis using antibody blockade of the CD47 “don't eat me” molecule. Clinical outcomes were assessed by daily ambulation scores of the animals and by enumeration of mesh-associated bacteria at predetermined end points. ResultsA single prophylactic treatment with daptomycin at the time of surgery led to improved ambulation scores and undetectable levels of bacteria in seven of eight mice by 21 days postinfection. Anti-CD47, an activator of macrophage phagocytosis, was ineffective when administered alone or in combination with daptomycin treatment. Ten days of daily antibiotic therapy begun 3 days after infection was ineffective at clearing infection. ConclusionsThis fast and simple model allows rapid in vivo testing of novel antimicrobials and immunomodulators to treat surgical implant infections.

Separating the components of an abdominal wall fellowship.

Complex abdominal wall reconstruction is an emerging subspecialty yet, despite the abundance of abdominal wall hernias requiring treatment and the increasing complexity of this type of surgery, there are few opportunities for surgeons to gain subspecialist training in this field. In this paper we discuss the need for focused training in complex abdominal wall reconstruction, outline some of the problems that may be hindering the availability of such opportunities and propose potential solutions to these issues.

Observational study of complex abdominal wall reconstruction using porcine dermal matrix: How have outcomes changed over 14 years?

BackgroundOur center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction. MethodsProspective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008–2014) and Recent (2015–2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed. ResultsComparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm2; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6–13] vs 7 [6–9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively.Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16–5.98; P = .020), panniculectomy (2.63, 1.21–5.73; P = .014), and anterior component separation (5.1, 1.98–12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032). ConclusionPorcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate.