Elective Open Repair Research Articles

26 Case Report of a Pseudoaneurysm from Distal Anastomosis of Open AAA 32 Years Previously, Contained Within Original Aortic Sac

Abstract An 86-year-old gentleman attended hospital with confusion following collapse at home. On examination the abdomen was soft, non-tender and distended with an expansile mass. He underwent elective open repair of a 7cm AAA 32 years prior to current presentation. His past medical history included severe aortic stenosis and atrial fibrillation for which he was anticoagulated with warfarin. CT imaging of head for intracranial pathology. Triple phase contrast CT studies to assess possible aortic pathology. CT brain excluded intracranial pathology as cause of collapse. CT triple phase aortogram demonstrated an 8.4cm infrarenal abdominal aortic aneurysm. Arterial phased images show contrast in the previous aortic repair, however delayed images showed extravasation of contrast from a potential leak at the distal suture line, with blood filling the original aortic sac, outside the aortic surgical graft. No retroperitoneal leak was identified. This presentation was amenable to relining of the aorta with an EVAR however given the patient was asymptomatic and had significant comorbidities, no further intervention was undertaken. The patient and family agreed with this plan of action, and the patient died 3 weeks later. The duration of this contained leak was unknown.

Socioeconomic disparities in abdominal aortic aneurysm repair rates and survival.

Abdominal aortic aneurysm (AAA) is more prevalent in socioeconomically disadvantaged areas. This study investigated socioeconomic disparities in AAA repair rates and survival. The study used ecological and cohort study designs, from 31 672 census areas in England (April 2006 to March 2018), the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression. Some 77 606 patients (83.4 per cent men) in four age categories (55-64, 65-74, 75-84, 85 or more years) were admitted with AAA from a population aged at least 55 years of 14.7 million. Elective open and endovascular repair rates were 41 (95 per cent c.i. 23 to 61) and 60 (36 to 89) per cent higher respectively among men aged 55-64 years in the most versus least deprived areas by quintile. This differences diminished and appeared to reverse with increasing age, with 26 (-1 to 45) and 25 (13 to 35) per cent lower rates respectively in men aged 85 years or more in the most deprived areas. Men admitted from more deprived areas were more likely to die in hospital without aneurysm repair. Among those who had aneurysm repair, this was more likely to be for a ruptured aneurysm than among men from less deprived areas. For intact aneurysm repair, they were relatively more likely to have this during an emergency admission. The mortality rate after repair was higher for men from more deprived areas, although the hazard diminished with age. Patterns were unclear for women. There were clear socioeconomic disparities in operation rates, mode of presentation, and outcome for AAA surgery. Policies are needed to address these disparities.

Center volume is associated with diminished failure to rescue and improved outcomes following elective open abdominal aortic aneurysm repair: Presented at the Forty-eighth Annual Meeting of the New England Society for Vascular Surgery, Cape Neddick, Me, October 15-17, 2021.

Center volume is associated with diminished failure to rescue and improved outcomes following elective open abdominal aortic aneurysm repair: Presented at the Forty-eighth Annual Meeting of the New England Society for Vascular Surgery, Cape Neddick, Me, October 15-17, 2021.

Hypogastric Artery Flow Interruption is Associated with Increased Mortality After Open Aortic Repair

Potential complications of pelvic flow disruption during aortic aneurysm repair include buttock ischemia and mesenteric ischemia. Unilateral or bilateral hypogastric artery flow interruption, either from atherosclerosis or intentionally to facilitate aneurysm repair, is considered problematic in endovascular repair; however, it has not been well studied in open abdominal aortic aneurysm (AAA) repair (OAR). We sought to examine the effect of interruption of flow to one or both hypogastric arteries on outcomes after OAR. The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. (redundant) Patients with appropriate data on their hypogastric arteries postoperatively were stratified into two groups-patent bilaterally (normal pelvic perfusion, NPP) and unilateral or bilateral occlusion or ligation (compromised pelvic perfusion, CPP). Primary endpoints were 30-day major morbidity (myocardial infarction, respiratory complications, renal injury, and lower extremity or intestinal ischemia) and mortality. During the study period, 9.492 patients underwent elective open AAA repair-860 (9.1%) with compromised pelvic perfusion and 8,632 (90.9%) with patent bilateral hypogastric arteries. The groups had similar cardiac risk factors, including a history of coronary artery disease, prior coronary intervention, and the use of P2Y12 inhibitors and statins. A majority of patients in the CPP cohort had concurrent iliac aneurysms (63.3% vs. 24.8%; P<0.001). The perioperative mortality was significantly higher in patients with compromised pelvic perfusion (5.5% vs. 3.1%; P<0.001). Bilateral flow interruption had a trend toward higher perioperative mortality compared to unilateral interruption (7.1% vs. 4.7%; P<0.147). The CPP group also had increased rates of myocardial injury (6.7% vs. 4.7%; P=0.012), renal complications (18.9% vs. 15.9%; P=0.024), leg and bowel ischemia (3.5% vs. 2.1%; P=0.008; and 5.7% vs. 3.4%; P<0.001, respectively). On multivariable analysis, CPP was associated with increased perioperative mortality (OR 1.47, CI 1.14-1.88, P=0.003). On Kaplan-Meier analysis, there was no difference in survival at 2years postdischarge between the NPP and CPP cohorts (86.1% vs. 87.5%, log-rank P=0.275). Compromised pelvic perfusion is associated with increased perioperative complications and higher mortality in patients undergoing OAR. The sequelae of losing pelvic perfusion, in addition to the presence of more complex atherosclerotic and aneurysmal disease resulting in more difficult dissection, likely contribute to these findings. Thus, patients considered for OAR who have occluded hypogastric arteries or aneurysmal involvement of the hypogastric artery preoperatively may be candidates for more conservative management beyond traditional size criteria.

Cost-Effectiveness of Laparoscopic and Open Pediatric Inguinal Hernia Repair.

Aim: Laparoscopic inguinal hernia (IH) repair is an alternative to open surgery. A potential advantage of laparoscopic repair is prevention of contralateral metachronous hernia although some studies report higher recurrence rate. We aim to determine the cost-effectiveness of open versus laparoscopic IH repair taking into account metachronous and recurrence rates. Methods: Retrospective single-center study of children (<5 years) undergoing elective open or laparoscopic repair for a unilateral IH between February 2018 and October 2019. Ten cases in each of four groups were included (open day case, open overnight, laparoscopic day case, and laparoscopic overnight). Cases incurring a higher cost due to comorbidities or additional procedure were excluded. Patient-level information and costing system data were obtained from the hospital finance. Mean (standard deviation [SD]) procedural cost was compared for open and laparoscopic procedures. A financial model was created factoring metachronous and recurrent rates. Results: Cost of open day case repair was £1866.24 (SD: 311.15) compared with £2210.13 (SD: 391.36) for day case laparoscopic repair. For overnight repair, cost of open was £2442.82 (SD: 497.05) compared with £2585.35 (SD: 384.66) for laparoscopic. On calculating the cost-effectiveness point using the difference in metachronous and recurrence rate between the two procedures, laparoscopic is more cost-effective than open day case repair at 18.43%. For overnight repair, the difference rate is 5.84%. Conclusion: Our data suggest that based on metachronous and recurrence rates in the current literature, laparoscopic IH repair is more cost-effective than open repair for cases requiring overnight stay, whereas for day case procedures open IH repair is more cost-effective.

Mannitol Use is Renal Protective in Patients with Chronic Kidney Disease Requiring Suprarenal Aortic Clamping

Mannitol is often administered during open juxtarenal or suprarenal aortic surgery to prevent ischemic injury to the kidneys. Prior evidence evaluating the benefits of intraoperative mannitol in reducing ischemia/reperfusion injury is conflicting and largely based on small, retrospective series. The aim of this study was to evaluate the effect of mannitol in preventing postoperative hemodialysis in patients undergoing open abdominal aortic aneurysm (AAA) repair where proximal control involved temporary renal ischemia. The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients were included in the current analysis if the proximal aortic clamp was placed above at least one renal artery. Chronic kidney disease (CKD) was defined as Cr > 1.8 mg/dL. Primary end points were 30-day major morbidity (myocardial infarction, respiratory complications, lower extremity or intestinal ischemia, and the need for temporary or permanent hemodialysis) and mortality. Comparisons were made between the mannitol and nonmannitol cohorts and stratified by the presence of preexisting CKD. During the study period, 4,156 patients underwent elective open AAA repair requiring clamp placement more than one (32.7%) or both (67.3%) renal arteries; 182 patients (4.4%) had preexisting CKD. Overall, 69.8% of patients received mannitol during their surgery. Mannitol was more frequently used in cases involving clamp placement above both renal arteries (70.3%) than one renal artery (61.5%). While prolonged ischemia time (more than 40 min) was associated with a higher risk of postoperative dialysis in patients without CKD, it was not significant in patients with baseline CKD. On a univariate analysis, mannitol use in patients with CKD was associated with a lower risk of postoperative dialysis (P = 0.005). This remained significant on a multivariate analysis (P = 0.008). Mannitol use did not appear to confer renal protective effects in patients without baseline CKD. Mannitol use was associated with a decreased risk of need for postoperative hemodialysis in patients with CKD undergoing suprarenal aortic clamping for open aneurysm repair. In appropriately selected patients, particularly those with underlying renal insufficiency, mannitol may confer a renal protective effect in open repair of pararenal AAA requiring suprarenal clamping.

Economic evaluation of expanding inguinal hernia repair among adult males in Ghana.

An unmet need for inguinal hernia repair is significant in Ghana where the number of specialist general surgeons is extremely limited. While surgical task sharing with medical doctors without formal specialist training in surgery has been adopted for inguinal hernia repair in Ghana, no prior research has been conducted on the long-term costs and health outcomes associated with expanding operations to repair all inguinal hernias among adult males in Ghana. The study aimed to estimate cost-effectiveness of elective open mesh repair performed by medical doctors and surgeons for adult males with primary inguinal hernia compared to no treatment in Ghana and to project costs and health gains associated with expanding operation services through task sharing between medical doctors and surgeons. The study analysis adopted a healthcare system perspective. A Markov model was constructed to assess 10-year differences in costs and outcomes between operations conducted by medical doctors or surgeons and no treatment. A 10-year budget impact analysis on service expansion for groin hernia repair through increasing task sharing between the providers was conducted. Incremental cost-effectiveness ratios for medical doctors and surgeons were USD 120 and USD 129 respectively per disability-adjusted life year (DALY) averted compared to no treatment, which are below the estimated threshold value for cost-effectiveness in Ghana of USD 371-491. Repairing all inguinal hernias (1.4 million) through task sharing between the providers in the same timeframe is estimated to cost USD 194 million. Total health gains of 1.5 million DALYs averted are expected. Inguinal hernia repair is cost-effective regardless of the type of surgical provider. Scaling up of inguinal hernia repair is worthwhile, with the potential to substantially reduce the disease burden in the country.

Suture or Mesh Repair of the Smallest Umbilical Hernias: A Nationwide Database Study.

Mesh is recommended for umbilical hernias with defects > 1cm to reduce recurrence. For umbilical hernias with defect width ≤ 1cm, the literature is sparse. The aim of this nationwide cohort study was to assess outcomes after suture and mesh repair of umbilical hernias with defect width ≤ 1cm and to evaluate outcomes after onlay mesh repair specifically. By merging data from the Danish Hernia Database and the National Patients Registry from 2007 to 2018, patients undergoing elective open repair of an umbilical hernia with defect width ≤ 1cm were identified. Available data included details about comorbidity, surgical technique, 90-day readmission, 90-day reoperation and operation for recurrence. A total of 7849 patients were included, of whom 25.7% (2013/7849) underwent mesh repair. Reoperation for recurrence was significantly decreased after mesh repair 3.1% (95% C.I. 2.1-4.1) compared with suture repair 6.7% (95% C.I. 6.0-7.4), P < 0.001. Readmission and reoperation rates were significantly higher for mesh repair 7.9% (159/2013) and 2.6% (52/2013) than for suture repair 6.5% (381/5836) and 1.5% (89/5836), P = 0.036 and P = 0.002, respectively. Onlay mesh repairs had the lowest risk of recurrence 2.0% (95% C.I. 0.6-3.5), and readmission [7.9% (65/826)] and reoperation [3.9% (32/826)] rates within 90 days were comparable to suture repairs [6.5% (381/5836)] and [3.3% (192/5836)], P = 0.149 and P = 0.382, respectively. Even for the smallest umbilical hernias, mesh repair significantly decreased the recurrence rate. Onlay mesh repair was associated with lowest risk of recurrence without increasing early complications.

Nationwide Cross-Sectional Epidemiological Analysis of 3,306 Lower Limb Peripheral Aneurysm Repairs in Brazilian Public Hospitals Between 2008 and 2019: Trends, Mortality and Costs

Although peripheral aneurysms can be limb- or life-threatening, the literature is scarce and there are only two large population-based epidemiological studies on peripheral aneurysm repair, comprising data from high-income countries only. This is a retrospective cross-sectional analysis on open and endovascular peripheral aneurysm repairs performed between 2008 and 2019 in the Brazilian Public Health System, which exclusively insures more than 160 million Brazilians. A total of 3,306 peripheral aneurysm repairs were observed. Most patients were elderly (57.74%) and male (72.66%), and patients treated with endovascular repair were older (P = 0.008). Most repairs were emergency (59.56%) and open (93.8%), and there was an overall downward trend in procedure rates. We observed a decreasing predominance of emergency open repair over elective open repair (P < 0.001), but open repairs prevailed over endovascular procedures, with no tendency to change this predominance. Mortality rates were 3.12% and 3.67% after elective and emergency open repair, respectively, with no difference, and 0 and 4.24% for elective and emergency endovascular repair, respectively. The government reimbursed an average of $1170.05 for open PA repair and $1802.01 for endovascular repair. We presented the largest series of the literature analyzing all 3,306 lower limb peripheral aneurysm repairs performed in public hospitals in a middle-income country. Procedure rates tended to decrease. Open repair predominated. Mortality rates ranged from 0 to 4%. Most procedures were emergency, but there was a relative increase of elective treatments over the years.

352 Improving Consent for Elective Inguinal Hernia Repair

Abstract Introduction Litigation costs the NHS billions each year. To avoid litigation against known risks of elective surgery it is important that proper consent it obtained. The initial aim was to establish the percentage of patients consented fully for inguinal hernia repair at Warrington and Halton teaching hospitals, a moderately sized district general hospital. The Trust uses the information produced by EDIO as their standard of informed consent. One of the main outcomes was the rate of consent for risk of chronic pain as this is the 3rd most commonly litigated complication and an identified risk of inguinal hernia repair. Method A retrospective audit looking at consent forms for adult men who underwent elective open inguinal hernia repair, over a 6-month period in 2019, was undertaken. After the first audit the results were discussed at the local audit meeting and teaching was given for what should be included on a consent form for inguinal hernia repair. A second cycle of the audit was run in 2021, after the COVID pandemic, to assess if consenting had improved. Results 66 vs 22 cases met the inclusion criteria for the first and second 6-month periods respectively. An improvement in consent for chronic pain was observed with 91% of patients in the second cycle being consented for chronic pain vs 79% in the first cycle. In the second cycle 32% of patients were also consented for the risk of “COVID”. Conclusions Teaching proper consent works effectively to improve consenting.

Hypogastric Artery Flow Interruption Is Associated With Increased Mortality After Open Aortic Repair

INTRODUCTION The two feared complications of pelvic flow disruption include buttock and mesenteric ischemia. Unilateral or bilateral hypogastric artery flow interruption, either from atherosclerosis or intentionally, is not well studied in open AAA repair (OAR). METHODS The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients with data on their hypogastric arteries were stratified into two groups - patent bilaterally (normal pelvic perfusion, NPP), and unilateral or bilateral occlusion or ligation (compromised pelvic perfusion, CPP). Primary endpoints were 30-day major morbidity and mortality. RESULTS During the study period, 9.492 patients underwent elective open AAA repair - 860 (9.1%) with compromised pelvic perfusion and 8,632 (90.9%) with patent bilateral hypogastric arteries. The groups had similar cardiac risk factors (Table 1). A majority of patients in the CPP cohort had concurrent iliac aneurysms (63.3% versus 24.8%; p<.001). The perioperative mortality was significantly higher in patients with compromised pelvic perfusion (5.5% versus 3.1%; p<.001). Bilateral interruption had a higher perioperative mortality compared to unilateral interruption (7.1% versus 4.7%; p<001). The CPP group had increased rates of myocardial injury (6.7% versus 4.7%; p=.012), leg and bowel ischemia (3.5% versus 2.1%, p=.008; and 5.7% versus 3.4%, p<.001; respectively). On multivariable analysis, CPP was associated with increased mortality (OR 1.47, CI 1.14-1.88, p=.003). However, on Kaplan-Meier analysis, there was no difference on long-term survival. CONCLUSIONS CPP is associated with increased perioperative complications and higher mortality in patients undergoing OAR, with no affect on longer-term survival. Hypogastric artery occlusion or need for ligating these vessels likely signifies presence of more complex disease, and warrants careful technique and appropriate patient selection. The two feared complications of pelvic flow disruption include buttock and mesenteric ischemia. Unilateral or bilateral hypogastric artery flow interruption, either from atherosclerosis or intentionally, is not well studied in open AAA repair (OAR). The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients with data on their hypogastric arteries were stratified into two groups - patent bilaterally (normal pelvic perfusion, NPP), and unilateral or bilateral occlusion or ligation (compromised pelvic perfusion, CPP). Primary endpoints were 30-day major morbidity and mortality. During the study period, 9.492 patients underwent elective open AAA repair - 860 (9.1%) with compromised pelvic perfusion and 8,632 (90.9%) with patent bilateral hypogastric arteries. The groups had similar cardiac risk factors (Table 1). A majority of patients in the CPP cohort had concurrent iliac aneurysms (63.3% versus 24.8%; p<.001). The perioperative mortality was significantly higher in patients with compromised pelvic perfusion (5.5% versus 3.1%; p<.001). Bilateral interruption had a higher perioperative mortality compared to unilateral interruption (7.1% versus 4.7%; p<001). The CPP group had increased rates of myocardial injury (6.7% versus 4.7%; p=.012), leg and bowel ischemia (3.5% versus 2.1%, p=.008; and 5.7% versus 3.4%, p<.001; respectively). On multivariable analysis, CPP was associated with increased mortality (OR 1.47, CI 1.14-1.88, p=.003). However, on Kaplan-Meier analysis, there was no difference on long-term survival. CPP is associated with increased perioperative complications and higher mortality in patients undergoing OAR, with no affect on longer-term survival. Hypogastric artery occlusion or need for ligating these vessels likely signifies presence of more complex disease, and warrants careful technique and appropriate patient selection.

Surgeon volume and established hospital perioperative mortality rate together predict for superior outcomes after open abdominal aortic aneurysm repair

Background: In 2018, the Society for Vascular Surgery (SVS) published hospital volume guidelines for elective open abdominal aortic aneurysm (AAA) repair, recommending that elective open surgical repair of AAAs should be performed at centers with an annual volume of ≥10 open aortic operations of any type and a documented perioperative mortality of ≤5%. Recent work has suggested a yearly surgeon volume of at least seven open aortic cases for improved outcomes. The objective of the present study was to assess the importance of hospital volume and surgeon volume at these cut points for predicting 1-year mortality after open surgical repair of AAAs.

Accounting for Hospital Related Factors in the High Mortality in Women Following Elective Abdominal Aortic Aneurysm Repair: Application of a Mixed Effects Logistic Regression Analysis in a Nationwide Cohort Study (2013–2018)

Introduction: Prior studies have focused on patient related risk factors in an effort to explain the higher mortality risk in women versus men following elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). However, there may also be hospital related factors that contribute to this disparity in mortality. A nationwide retrospective study that accounted for both types of factors was undertaken.

Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair.

The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population. This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups. There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable. Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Center volume is associated with diminished failure to rescue and improved outcomes following elective open abdominal aortic aneurysm repair

ObjectiveConflicting annual procedure volumes have been endorsed among different watchdog groups and professional societies, obscuring credentialing paradigms. There has been ample focus on surgeon volume to date but less attention on the effect of center volume. Specifically, whether center volume might be a better proxy for high-quality care. In the present study, we aimed to measure the association of center volume on open abdominal aortic aneurysm (AAA) repair (OAR) outcomes and failure to rescue (FTR). MethodsAll elective OARs (2003-2020) in the Society for Vascular Surgery Vascular Quality Initiative were reviewed (n = 9791). FTR was defined as in-hospital death after the occurrence of a complication (ie, cardiac, stroke, pulmonary, renal, colonic ischemia, return to the operating room for bleeding). The annual center volume for 218 hospitals was calculated, and the volume quartiles (quartile 1 [Q1], ≤3 procedures/y; quartile 2 [Q2], 4-6 procedures/y; quartile 3 [Q3], 7-10 procedures/y; quartile 4 [Q4], >10 procedures/y) were derived for comparison. Logistic regression was used to estimate the effect of center volume and determine the predictors of FTR. ResultsThe center volume quartiles and incidence of FTR varied significantly (Q4, 2.5% vs Q1 and Q2, 4.9%; P < .0001; overall FTR, 3.1% [n = 302]). The patients were demographically similar among the quartiles. High-volume centers had used epidural anesthesia more often (Q4, 53%; vs Q1, 31%; P < .0001) but were less likely to use thrombectomy (Q4, 5%; vs Q1, 10%; P < .0001) or any concomitant procedure (Q4, 19%; vs Q1, 22%; P = .05). High-volume centers had had lower rates of pulmonary, renal, and overall complications (pulmonary: Q4, 7%; vs Q1-Q2, 8%-11%; renal: Q4, 16%; vs Q1-2, 19%-21%; P < .0001; overall mean number of complications: Q4, 0.46; vs Q1, 0.52; P = .0008). The crude 30-day and 1-year mortality rates were reduced at the higher volume centers (30 days: Q4, 3%; vs Q1-Q2, 6%; P < .0001; 1 year: Q4, 7%; vs Q1-Q2, 10%-11%; P < .0001). A strong inverse relationship between center volume and FTR was identified (P < .0001). In the adjusted analysis, OARs performed in high-volume centers (Q4 vs Q1) had a 50% risk reduction in FTR (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.3-0.8; P = .004). Among the complications, a return to the operating room for bleeding was most likely to result in FTR (OR, 11.8; 95% CI, 4.3-33; P < .0001). A 24-fold increased risk of FTR was found for patients experiencing three or more complications vs one complication (OR, 24; 95% CI, 17-35; P < .0001). ConclusionsA greater center volume was strongly associated with significantly diminished FTR, reduced complications, and need for surgical adjuncts during OAR. These findings highlight the utility of center volume as an effective proxy to ensure high-quality aneurysm care.

Ultrasound-guided transverse abdominis plane block, ilioinguinal/iliohypogastric nerve block, and quadratus lumborum block for elective open inguinal hernia repair in children: a randomized controlled trial

Background and objectivesUltrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve blocks and transverse abdominis plane (TAP) blocks are widely used for postoperative analgesia in children undergoing inguinal hernia repair (IHR). Quadratus lumborum block (QLB)...

Can the preemptive use of lornoxicam or paracetamol prevent pain after inguinal hernia repair? A randomized prospective double-blind placebo controlled trial

INTRODUCTION: Nonsteroidal anti-inflammatory drugs have become a popular part of multimodal analgesic regimens particularly in ambulatory surgery. This study was designed to search the efficacy of preoperative administration of lornoxicam or paracetamol in patients who underwent open inguinal hernia repair. MATERIALS AND METHODS: American Society of Anesthesiologists Classification (ASA) I–III male patients with unilateral primary inguinal hernia scheduled for elective prosthetic repair under general anesthesia were randomly assigned to three groups. Group I patients were infused 100-ml normal saline 30 min before anesthesia (placebo), whereas Group II and Group III patients were given 8 mg lornoxicam or 1,000 mg paracetamol intravenously in 100-ml normal saline. Postoperative pain was treated with patient controlled intravenous morphine. Postoperative pain scores were evaluated with visual analog scale (VAS) in the recovery room and at 1st, 6th, 12th, and 24th hours postoperatively in all groups. Total amount of analgesics. Liker scale and SF-36 form was also used at 4th week follow-up in order assess quality of life. RESULTS: Totally 88 patients were completed the study (G1 = 28, G2 = 30, and G3 = 30). Preemptive use of both lornoxicam and paracetamol resulted in significantly lower recovery room VAS scores in comparison with placebo group (3.93, 3.73, and 5.25). Both lornoxicam and paracetamol groups (G2 and G3) displayed better results at 12th h than placebo group (P = 0.04). VAS scores at 24th hour were similar in three groups. Total morphine consumptions were also similar between the groups at all times. Total postoperative 1-week oral analgesic use was significantly less in G2 (lornoxicam), and G3 (paracetamol) in comparison with G1 (placebo). Quality of life indicators in Likert Scale and SF-36 form were also not different. CONCLUSION: Preemptive use of both lornoxicam and paracetamol may be effective in early postoperative pain control in patients undergo elective open inguinal hernia repair. However, there seems to be no difference between the efficacies of the two agents.

Identifying Women at High Risk of 90 Day Death after Elective Open Abdominal Aortic Aneurysm Repair: A Multicentre Case Control Study

The aim of this study was to identify risk factors for 90 day death after elective open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in women. This was a multicentre case control study. The nationwide Dutch Surgical Aneurysm Audit registry (2013-2019) was solely used to identify women who underwent elective OSR as eligible patients. Data for this study were subsequently collected from the patients' medical files. Women with AAA were included and those who died (cases) were compared with those who survived (controls) 90 days after surgery. Inflammatory, mycotic, or symptomatic or ruptured AAA were excluded. The association between pre- and peri-operative risk factors and death was assessed by logistic regression analysis in the whole sample and after matching cases to controls of the same age at the time of repair. Mesenteric artery patency was also assessed on pre-operative computed tomography and used in the analysis. In total, 266 patients (30 cases and 236 controls) from 21 hospitals were included. Cases were older (median [interquartile range; IQR] 75 years [71, 78.3] vs. 71 years [66, 77]; p= .002) and more often had symptomatic peripheral arterial disease (PAD) (14/29 [48%] vs. 49/227 [22%]; p= .002). Intra-operative blood loss (median [IQR] 1.6 L [1.1, 3.0] vs. 1.2 L [0.7, 1.8]), acute myocardial infarction (AMI) (10/30 [33%] vs. 8/236 [3%]), renal failure (17/30 [57%] vs. 33/236 [14%]), and bowel ischaemia (BI) (17/29 [59%] vs. 12/236 [5%]) were more prevalent among cases. Older age (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.03-1.19) and PAD (OR 3.91, 95% CI 1.57-9.74) were associated with death. Multivariable analysis demonstrated that, after adjustment for age, AMI (OR 9.34, 95% CI 1.66-52.4) and BI (OR 35.6, 95% CI 3.41-370) were associated with death. Superior mesenteric artery stenosis of >70% had a clinically relevant association with BI (OR 5.23, 95% CI 1.43-19.13; p= .012). Age, symptomatic PAD, AMI, and BI were risk factors for death after elective OSR in women. The association between a >70% SMA stenosis and BI may call for action in selected cases.

Effects of Suprarenal Aortic Cross-Clamping and Adjunctive Renal Reconstruction on Outcomes of Open Abdominal Aortic Aneurysm Repair.

Purpose: To analyze our contemporary experience in open abdominal aortic aneurysm (AAA) repair. We focused on the effects of suprarenal (SR) aortic cross-clamping and adjunctive renal reconstruction (RR) on postoperative outcomes.Methods: We retrospectively reviewed our institutional data of 141 consecutive patients who received elective open AAA repair between January 2014 and December 2020.Results: Seventy-five procedures were performed with SR aortic cross-clamping, 20 of which required an adjunctive RR. Patients in the SR group had a higher incidence of postoperative acute kidney injury (AKI) (18.7% vs. 7.6%, P = 0.045). There were no significant between-group differences in other major complications. The 30-day mortality rate in the infrarenal (IR) and SR groups was 0% and 1.3%, respectively. After a median follow-up of 33 months, the rates of chronic renal decline in the IR (18.2%) and SR (21.3%) groups were similar. All reconstructed renal arteries were patent without reintervention. The 5-year overall survival rate in the IR and SR groups was 88.8% and 83.2%, respectively.Conclusions: SR aortic cross-clamping was associated with postoperative AKI but neither SR aortic cross-clamping nor RR affected the long-term renal function or mortality. Open repair remains an essential option for patients with AAA, especially those with complex anatomy.

Safety and Feasibility of Laparoscopic Transabdominal Preperitoneal Hernia Repair for Octo- and Nonagenarians.

Background: The feasibility of laparoscopic hernia repair in octo- and nonagenarians has not been investigated in detail. The aim of this retrospective study was to evaluate the safety and feasibility of laparoscopic hernia repair in octo- and nonagenarians. Methods: This study included 607 patients who underwent transabdominal preperitoneal laparoscopic hernia repair at our hospital between April 2014 and October 2020. Patients were divided into an over 80 group (112 patients aged 80 years and older) and a control group (495 patients younger than 80 years). The clinical outcomes were compared between the groups. In addition, among patients aged 80 years and older, those who underwent elective laparoscopic hernia repair (laparoscopic group: 111 patients) were compared with patients who underwent elective open hernia repair during the same study period (open group: 79 patients). Results: The number of patients who underwent bilateral hernia repair was significantly larger in the over 80 group (26.7% versus 11.7%, P < .001). The incidence of postoperative complications was not significantly different between the over 80 group and the control group. Compared with open group, the number of patients who underwent bilateral hernia repair was significantly larger in the laparoscopic group (27.0% versus 2.5%, P < .001). The incidence of postoperative complications (2.7% versus 10.1%) and the incidence of readmission (0.9% versus 6.3%) were significantly greater in the open group. Conclusions: Laparoscopic hernia repair in octo- and nonagenarian patients yields safe and noninferior outcomes. Laparoscopic hernia repair in octo- and nonagenarian patients is considered more suitable for detecting and repairing contralateral hernias simultaneously.