Fascial Closure Research Articles

Barbed Suture versus Interrupted Suture in Posterior Cervical Spine Surgery: Are They Equivalent?

Posterior cervical spine approaches have been associated with increased rates of wound complications compared to anterior approaches. While barbed suture wound closure for lumbar spine surgery has been shown to be safe and efficacious, there is no literature regarding its use in posterior cervical spine surgery. In a cohort of patients undergoing elective posterior cervical spine surgery, we sought to compare postoperative complication rates between barbed and traditional interrupted suture closure. A retrospective review of demographics, past medical history, and operative and postoperative variables collected from a prospective registry between July 1, 2016, and June 30, 2020 was undertaken. All patients 18 years old and above undergoing elective posterior cervical fusion were included. The primary outcome of interest was wound complications, including surgical site infection (SSI), dehiscence, or hematoma. In addition, numerical rating scale (NRS) neck pain (NP), NRS arm pain (AP), Neck Disability Index (NDI), and operative time were collected. A variety of statistical tests were used to compare the two suture groups. Of 117 patients undergoing posterior cervical fusion, 89 (76%) were closed with interrupted suture and 28 (24%) with barbed suture. The interrupted cohort were more likely to have >1 comorbidity (p<0.001), diabetes mellitus (p=0.013), and coronary artery disease (p=0.002). No difference in postoperative wound complications between interrupted/barbed sutures was observed after univariate (OR 1.07, 95% CI: 0.27-4.25, p=0.927) and multivariable logistic regression analysis (OR 0.77, 95% CI: 0.15-4.00, p=0.756). Univariate logistic regression revealed no differences in achieving minimal clinically important difference (MCID) NRS-NP (OR 0.73, 95% CI: 0.28-1.88, p=0.508) or NRS-AP (OR 0.68, 95% CI: 0.25-1.90, p=0.464) at 3 months between suture groups. The interrupted suture group was less likely to achieve MCID NDI at 3 months (OR 0.29, 95% CI: 0.11-0.80, p=0.016). Barbed suture closure in posterior cervical spine surgery does not lead to higher rates of postoperative wound complications/SSI compared to traditional interrupted fascial closure.

Vacuum-assisted staged omphalocele reduction: A preliminary report.

Omphalocele represents a rare congenital abdominal wall defect. In giant omphalocele, due to the viscero-abdominal disproportion, gradual reintegration of eviscerated organs is often associated with medical challenges. We report our preliminary experience combining staged gravitational reduction with vacuum (VAC) therapy as a novel approach for treatment of giant omphalocele. Retrospective chart review of six patients (five females) born between September 2018 and May 2022 who underwent staged reduction of giant omphalocele in conjunction with VAC therapy was conducted. Treatment was performed at two German third-level Pediatric Surgery Departments. Biometric and periprocedural data were assessed. Main outcome measure was the feasibility of VAC therapy for giant omphalocele. Data are reported as median and interquartile range (Q1-Q3). Gestational age was 37 (37-38) weeks, and birth weight was 2700 (2500-3000) g. VAC dressing was changed every 3 (3-4) days until abdominal fascia closure at the age of 9 (3-13) days. Time to first/full oral feeds was 3 (1-5)/20 (12-24) days with a hospital stay of 22 (17-30) days. Follow-up was 8 (5-22) months and complications were of minor extent (none: n = 2; Clavien-Dindo I: n = 3; Clavien-Dindo II: n = 1), comprising a delayed neo-umbilical cord rest separation (n = 2) and/or concomitant neo-umbilical site infection (n = 2) with no repeat surgery. In neonates with giant omphalocele, VAC constitutes a promising and technically feasible enhancement of the staged gravitational reduction method. This study shows evidence that VAC may accelerate restoration of the abdominal wall integrity in giant omphalocele, thus minimizing associated comorbidities inherent to a prolonged hospitalization.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Posterior component separation with TAR: lessons learned from our first consecutive 52 cases.

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39-76) and Body mass index (BMI kg/m2) of 31.2 (24-45). More than half of patients (58%) were active smokers. Mean defect width was 13.6cm (range 6-30) and mean defect area was about 267.9cm2. Mean operative time was 228min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7days. 27% of patients developed minor complications (Clavien-Dindo grade I-II) and one case (1.9%) major complication (Clavien-Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28months. In Univariate analysis Bio-A surface > 600cm2 and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600cm2 was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien-Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients.

Ten-year outcomes following ventral hernia repair: making the case for better post-market surveillance in the USA.

We sought to identify the 10-year complication and recurrence rates and associated sociodemographic and operative characteristics associated with non-mesh versus mesh-based ventral hernia repairs (VHRs). This was an IRB-approved (2020H0317) retrospective longitudinal study of patients undergoing mesh or non-mesh VHR from 2009-2019 at a single tertiary-care institution. The electronic medical record was used to collect sociodemographic, clinical, and intraoperative details, and early (≤ 30days) and long-term (> 30-day) postoperative complications. Up to ten-year follow-up was obtained for long-term complications, categorized as: hernia recurrence reoperation (HRR), major complications requiring emergency surgery (MCES) (defined as non-elective operations related to the abdominal wall), and non-recurrence procedural intervention (NRPI) (defined as any procedures related to the abdominal wall, bowel, or mesh). Kaplan-Meier survival curves were obtained for each long-term complication. Of the 645 patients identified, the mean age at index operation was 52.51 ± 13.57years with 50.70% female. Of the index operations, 21.24% were for a recurrence. Procedure categories included: 57.36% incisional, 37.21% non-incisional umbilical, 8.22% non-incisional epigastric, 3.88% parastomal, 0.93% diastasis recti, and 0.47% Spigelian hernias. Operative approaches included open (n = 383), laparoscopic (n = 267), and robotic (n = 21). Fascial closure (81.55%) and mesh use (66.2%) were performed in the majority of cases. Median follow-up time was 2098days (interquartile range 1320-2806). The rate of short-term complications was 4.81% for surgical site infections, 15.04% for surgical site occurrences, and 13.64% for other complications. At 10years, the HRR-free survival probability was 85.26%, MCES-free survival probability was 94.44%, and NRPI-free survival probability was 78.11%. A high proportion of patients experienced long-term recurrence and complications requiring intervention after index VHR. For many patients, aventral hernia develops into a chronic medical condition. Improved efforts at post-market surveillance of operativeapproaches and mesh location and typeshould be undertaken to help optimize outcomes.

Patients with an Open Abdomen in Asian, American and European Continents: A Comparative Analysis from the International Register of Open Abdomen (IROA)

BackgroundInternational register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents.Material and methodsA prospective analysis of adult patients enrolled in the international register of open abdomen (IROA). Trial registration: NCT02382770.Results1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49–74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2–7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001).ConclusionThere is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome.

Innovations for Incisional Hernia Prevention.

Incisional hernias are the most frequent long-term complication of abdominal surgery, resulting in considerable patient morbidity and increased health care costs. These hernias frequently result from excessive tension concentrated at points along the suture line of the abdominal closure. While ample research is focused on developing improved repair materials, the optimal solution to the problem of incisional hernias is prevention. Accordingly, some investigators have postulated that incisional hernias can be prevented by distributing tension more evenly along the fascial closure. Herein we describe two novel and ingenious strategies for the improved distribution of tension when closing abdomens (T-Line® Hernia Mesh and the REBUILD Bioabsorbable™) that were conceived of and developed by surgeons.

Surgical treatment of children with pilonidal cysts

BACKGROUND: Pilonidal cyst (other names: pilonidal disease and epithelial coccygeal tract) is a common congenital pathology and most often manifested in adolescence.&#x0D; AIM: To determine the optimal treatment and diagnostic measures that lead to a reduction in complications and improvement in the quality of life of sick children with pilonidal cysts.&#x0D; MATERIALS AND METHODS: Case histories of 310 children with pilonidal cysts who were treated at the N.F. Filatov Childrens City Clinical Hospital (Moscow) and Republican Childrens Clinical Disease in Izhevsk in 20132018 were analyzed. The patients (95%) were predominantly adolescents. The patients were divided into four groups: group 1 (n = 78), acute inflammation of the cyst; group 2 (n = 75), cyst without signs of inflammation; group 3 (n = 125), cyst with chronic inflammation; group 4 (n = 32), disease relapse. For diagnosis, clinical and ultrasound examination was conducted for uncomplicated cysts. The surgery was performed after fistulography and consisted of cyst excision to the sacral fascia with tight tightening or installation of an aspiration drain. Surgical intervention was preceded by laser treatment in the surgical field.&#x0D; RESULTS: The severity of infiltration of the surrounding tissues in the postoperative period, depending on the drainage of the wound, was significantly different. More pronounced infiltrative changes were noted in patients with drainage and, accordingly, later terms of wound healing. Following double epilation with a neodymium laser, the frequency of postoperative purulent inflammatory complications was reduced (7.3%). The excision of the pilonidal cyst 1 month after acute inflammation with wound closure and involvement of the sacral fascia without drainage was the most effective.&#x0D; CONCLUSIONS: Ultrasound examination is a highly informative method that allows for determining the parameters of uncomplicated cysts. Laser epilation in the preoperative period helps reduce purulent inflammatory complications.

Continuous and interrupted abdominal-wall closure after primary emergency midline laparotomy (CONIAC-trial): study protocol for a randomised controlled single centre trial

IntroductionThe optimal closure of the abdominal wall after emergency midline laparotomy is still a matter of debate due to lack of evidence. Although closure of the fascia using a continuous,...

8776 Perioperative Outcomes of Robotic Versus Open Midline Specimen Extraction Fascial Site Closure

<h3>Study Objective</h3> Laparoscopic sacrocolpopexy (SCP) is typically performed to repair advanced stage pelvic organ prolapse. Surgeons often opt to perform a supracervical hysterectomy (SCH) rather than total during combination SCP to avoid mesh erosions/infections. Tissue extraction is accomplished by extending a midline port site and may be closed by either a traditionally open or intra-abdominal robotic technique. This study aims to evaluate the outcomes of these two closures. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Academic-affiliated community hospital. <h3>Patients or Participants</h3> All patients (n=183) undergoing a robotic-assisted SCH, SCP, and midurethral sling placement by a single urogynecologist in which the uterus was extracted from an extended midline port between January 2021 and March 2022 were included in this study. <h3>Interventions</h3> Cases (n=105) of extraction sites closed via an intra-abdominal robotic approach were compared to controls (n=78) of a traditional open approach. <h3>Measurements and Main Results</h3> Casesand controls had similar operative times (251 vs 258 mins, p=0.35). Cases required less pain medication use in morphine milligram equivalents (MME) during the hospital stay (12.1 vs 18.4 MME, P<0.05). Body mass index (BMI) averages were also greater amongst cases (28.3 vs 26.3 kg/m², p<0.05). No difference was observed in other demographic data including age, race, and comorbid medical conditions. No statistical difference was noted comparing returns to the emergency department or hospital readmissions between groups. <h3>Conclusion</h3> Robotic and open fascial closure after tissue extraction requires similar operative times. Robotic closure has decreased pain requirements with similar complication profiles and was performed on patients with greater BMI reflecting surgeon bias for its use in obese patients. Surgeons should consider intra-abdominal robotic closure especially when patient body habitus makes secure fascial closure from an open approach more challenging.

8418 Fascial Closure Technique after Gynecologic Laparoscopic Surgery and Postoperative Pain: A Randomized Controlled Trial

<h3>Study Objective</h3> To compare postoperative pain between closing port site fascia > 10 mm via traditional direct method versus fascial closure device (FCD) in patients undergoing minimally invasive gynecologic surgery. <h3>Design</h3> Prospective, singled-blinded, randomized controlled trial. Primary outcome was pain on postoperative days (POD) 1, 2, 7, and 14. <h3>Setting</h3> Tertiary care academic affiliated hospital. <h3>Patients or Participants</h3> Patients 18 years undergoing laparoscopic or robotic gynecologic procedure with one port site > 10 mm for any indication (benign and malignant) were eligible. Patients were identified in preoperative holding and consented. 123 participants were enrolled from March 2021 to March 2022. <h3>Interventions</h3> Participants were randomized to fascial closure with FCD or traditional direct closure on the day of surgery. Postoperative pain scores were assessed using digital 100-point Visual Analog Scale. Fascial closure was timed, and narcotics utilized while admitted were converted into morphine equivalents per hour. <h3>Measurements and Main Results</h3> Descriptive statistics were run on all variables and group comparisons made using independent sample t-tests, chi-squares, or Mann Whitney U. 60 patients (48.8%) were randomized to FCD group and 63 patients (51.2%) to traditional direct closure. There was no statistical difference in pain scores between FCD (POD1: 60.27±22.90, POD2: 48.61±23.01, POD7: 33.60±24.12, POD14: 23.00±24.99) and traditional closure (POD1: 53.60±29.33, POD2: 26.94±28.59, POD7: 29.31±24.05, POD14: 18.57±24.62) groups or narcotic use in morphine equivalents per hour (1.54±1.11 vs 1.98±1.23, FCD and traditional closure, respectively). Length of fascial closure was statistically significantly lower using the FCD (<i>Mdn</i> = 77.0) compared to traditional closure (<i>Mdn</i> = 137.0), <i>p</i> = .001. <h3>Conclusion</h3> This study demonstrates no significant difference in postoperative pain scores at multiple time points or narcotic use between use of FCD versus traditional direct closure, but it does show a statistically significant lower fascial closure time using the FCD.

8387 Instructional Video on Tandem Vaginal Cuff Closure

<h3>Study Objective</h3> To demonstrate the steps of tandem vaginal cuff closure, outline specific movements of the surgeon and assistant, and provide suggestions for efficient closure. <h3>Design</h3> Instructional Video. <h3>Setting</h3> Operating room of large academic hospital. <h3>Patients or Participants</h3> Single patient undergoing a laparoscopic vaginal cuff closure at the time of hysterectomy. <h3>Interventions</h3> In this technique, two surgeons close the vaginal cuff at the time of hysterectomy through an umbilical port for the 5mm camera and two 5mm lateral ports for instrumentation. This eliminates the need for fascial closure and improves cosmesis. The surgeon stands at the patient's left and holds the needle driver in the right hand. The surgeon positions the needle correctly to facilitate an efficient and effective cuff closure starting from the patient's right and proceeding toward the left. The direction of closure is from posterior to anterior. At least 5mm of vaginal mucosa is incorporated into each bite, and uterosacral and cardinal ligaments are incorporated bilaterally to provide support. A key component is to push the needle through the tissue, with over supination of the surgeon's wrist while lifting the needle cephalad. This over-supination allows better visualization and provides the correct angle for needle reloading. The assistant, standing on the patient's right, provides visualization, places the loop of the barbed suture over the needle, and manipulates the anterior or posterior cuff over the needle. <h3>Measurements and Main Results</h3> Complete and efficient vaginal cuff closure with incorporation of uterosacral and cardinal ligaments for support. <h3>Conclusion</h3> With the use of two skilled surgeons, we demonstrate the efficient movements required to carry out a tandem vaginal cuff closure.

Use of Novel Configuration with Suture Kit Device for Robotic-assisted Minimally Invasive Sacrocolpopexy

<h3>Study Objective</h3> To assess safety and efficacy of performing robotic-assisted laparoscopic sacrocolpopexy (RA-SCP) using a four-arm robotic configuration and suture kit system. <h3>Design</h3> Retrospective case series. <h3>Setting</h3> Tertiary care referral center. <h3>Patients or Participants</h3> Patients undergoing RA-SCP with or without concomitant hysterectomy. <h3>Interventions</h3> All procedures were performed using four-arm robotic configuration and the Stitch Kit® polytetrafluoroethylene (PTFE) (Origami Surgical) suture kit device. The configuration included four 8 mm ports: one camera port and three working ports. No bedside assistant port was used. The Stitch Kit® PTFE, a canister with 6 polytetrafluoroethylene sutures and a separate compartment for used needles, was inserted into the abdominal cavity through a 8 mm umbilical skin incision prior to robotic docking. After suturing, each needle was replaced in the canister. The canister was closed and removed through the umbilical port site at the end of the case. No fascial closure of port sites was required. <h3>Measurements and Main Results</h3> 422 patients underwent RA-SCP for pelvic organ prolapse from 2018-2021. Mean age was 60 ± 10 years and mean BMI was 27 ± 6 kg/m². Most patients had stage III prolapse (73%) and underwent concomitant total hysterectomy (70%). 99% (n=416) of cases were completed robotically; of the 1% (n=6) not completed robotically, 5 had sacrospinous ligament suspensions due to presence of prior eroded foreign body material or extensive adhesions and 1 was aborted due to colorectal mass. The Stitch Kit® canister was successfully inserted and removed in all cases completed robotically with correct needle counts. 337 (80%) of participants followed up at 3 months. No umbilical or port site hernias were reported. <h3>Conclusion</h3> Our case series illustrates that RA-SCP can be performed safely using a four-arm robotic configuration with a suture kit device. This setup eliminates the need for any incisions greater than 8 mm and an assistant port. These modifications allow for surgical efficiency without compromising patient outcomes.

8718 Novel Use of Viscera Retainer for Safer Resection of Posterior Fibroids during Laparoscopic Myomectomy

<h3>Study Objective</h3> To demonstrate a novel use of an abdominal viscera retainer for improving safe access to the posterior aspect of the uterus during laparoscopic myomectomy. <h3>Design</h3> Surgical film. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> Patient with a large 7 × 7cm subserosal and intramural fibroid at the posterior aspect of the uterine body and fundus. <h3>Interventions</h3> A viscera retainer is a device widely used by surgeons to retain omentum and protect underlying bowel during fascial closure of laparotomy cases. The device has been used to improve speed of closure while significantly reducing the risk of unintended needle punctures. During this laparoscopic myomectomy case, we used an umbilical port for the camera, left and right lower quadrant ports, and a midline suprapubic mini-laparotomy incision using a mini GelPoint. We used a medium sized viscera retainer, measuring approximately 6 × 9 inches. The retainer is able to be easily rolled for placement in the pelvis through the mini GelPoint. Once in the abdomen, the retainer can be positioned into the posterior cul-de-sac overtop of any underlying bowel. The weighted center spine helps to keep the device in place and prevents bowel from inadvertently moving into the surgical field. <h3>Measurements and Main Results</h3> The viscera retainer was able to be used as an intra-abdominal retraction device and physical protective barrier for the bowel during laparoscopic myomectomy, specifically during enucleation of the fibroid and suturing of the hysterotomy. <h3>Conclusion</h3> This unique use of a device typically reserved for laparotomy improved surgeon's access to the posterior aspect of the uterus for dissection and enucleation of posterior fibroids during laparoscopic myomectomy.

Abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysm: A case report and literature review

Background: Abdominal compartment syndrome (ACS) arises in approximately 7% after ruptured abdominal aortic aneurysm (RAAA) treatment. Decompressive laparotomy is a satisfactory way to treat ACS. The problem is deciding when to complete abdominal closure with appropriate alternative treatments.[1]&#x0D; Methods: This is a case report of successful ACS treatment following RAAA intervention at Ho Chi Minh University Hospital of Medicine and Pharmacy with a literature review.&#x0D; Clinical case: A 61-year-old male patient was hospitalized for abdominal pain. Computed tomography angiography demonstrated RAAA. He underwent the emergency endovascular repair of ruptured aneurysms (rEVAR). At 30 minutes post-intervention, the patient's abdomen was distended following intraabdominal hypertension measured via bladder catheter. Within ACS diagnosing, emergency decompressive laparoscopy was performed. The abdominal wall was left open and covered with a sterile nylon cover. The fascial closure was performed on the sixth postoperative day with the support of vacuum-assisted wound closure (VAC) and mesh-mediated fascial traction. On the 27th postoperative day, the wound could close completely, and the patient could be discharged successfully.&#x0D; Conclusion: A bladder pressure is required to monitor intraabdominal pressure postoperatively after decompressive laparotomy. Delayed fascial closure is appropriate with supporting VAC until total abdominal closure.

Retrospective Study of Indications and Outcomes of Open Abdomen with Negative Pressure Wound Therapy Technique for Abdominal Sepsis in a Tertiary Referral Centre.

In patients with advanced sepsis from abdominal disease, the open abdomen (OA) technique as part of a damage control surgery (DCS) approach enables relook surgery to control infection, defer intestinal anastomosis, and prevent intra-abdominal hypertension. Limited evidence is available on key outcomes, such as mortality and rate of definitive fascial closure (DFC), which are needed for surgeons to select patients and adequate therapeutic strategies. Abdominal closure with negative pressure wound therapy (NPWT) has shown rates of DFC around 90%. We conducted a retrospective study to evaluate in-hospital survival and factors associated with mortality in acute, non-trauma patients treated using the OA technique and NPWT for sepsis from abdominal disease. Fifty consecutive patients treated using the OA technique and NPWT between February 2015 and July 2022 were included. Overall mortality was 32%. Among surviving patients, 97.7% of cases reached DFC, and the overall complication rate was 58.8%, with one case of entero-atmospheric fistula. At univariable analysis, age (p = 0.009), ASA IV status (&lt;0.001), Mannheim Peritonitis Index &gt; 30 (p = 0.001) and APACHE II score (p &lt; 0.001) were associated with increased mortality. At multivariable analysis, higher APACHE II was a predictor of in-hospital mortality (OR 2.136, 95% CI 1.08-4.22; p = 0.029). Although very resource-intensive, DCS and the OA technique are valuable tools to manage patients with advanced abdominal sepsis, allowing reduced mortality and high DFC rates.

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.

Botulinum Toxin Use for Abdominal Wall Reconstruction

INTRODUCTION: Preoperative botulinum toxin (BTX) injection may assist in fascial closure of large incisional hernia repair. We examine outcomes of incisional hernia patients who receive BTX injections before abdominal wall reconstruction (AWR). METHODS: A retrospective cohort study of patients from 2019–2021 who underwent BTX abdominal wall injections and interval AWR was conducted. A matched cohort who underwent IH repair without BTX treatment was selected for comparable defect size and BMI. Clinical and demographic data were extracted from charts. RESULTS: Twenty patients received BTX injections, and 30 comparable patients did not. There was no difference in average age (58.6 and 61.4 years, p = 0.514), BMI (32.9kg/m2 and 32.4kg/m2, p = 0.813), or defect size (663.9 cm2 and 608.43 cm2, p = 0.513). Primary outcome of fascial closure was achieved in every patient in the BTX group (20 of 20) vs 86.7% (26 of 30) in the non-BTX group (p = 0.089). The BTX group had a lower rate of component separation (65.0% of the BTX group vs 93.3%, p = 0.01). The BTX group had higher rates of seroma (p = 0.03) and longer surgery time, 4:07 vs 3:58 (p < 0.01). The postoperative period had one dehiscence (non BTX group). There was no difference in incidence of surgical site infection, abscess, delayed healing, respiratory failure, pulmonary embolism, acute kidney injury, or length of stay. CONCLUSION: Patients receiving botulinum toxin injections into their abdominal wall musculature achieved greater rates of closure with good outcomes. We conclude that botulinum toxin injection for large incisional hernias is an effective method for relaxation of abdominal wall muscle and closure of large abdominal wall.

Evaluation of Treatment Differences Between Men and Women Undergoing Ventral Hernia Repair: An Analysis of the Abdominal Core Health Quality Collaborative

INTRODUCTION: Sex is emerging as an important clinical variable associated with surgical outcomes and decision-making. Its impact on baseline and treatment differences in primary and incisional ventral hernia repair remains unclear. METHODS: This retrospective cohort study uses the Abdominal Core Health Quality Collaborative (ACHQC) database to identify elective umbilical, epigastric, or incisional hernia repair. Propensity matching was performed to investigate confounder-adjusted treatment differences between men and women. Treatments of interest included surgical approach, mesh use, mesh type, mesh position, anesthesia type, myofascial release, fascial closure, and fixation use. RESULTS: A total of 8,489 umbilical, 1,801 epigastric, and 16,626 incisional hernia repairs were identified. Women undergoing primary ventral hernia repair were younger (umbilical 46.4 vs 54 years, epigastric 48.7 vs 52.7 years), with lower BMI (umbilical 30.4 vs 31.5, epigastric 29.2 vs 31.1), and less likely diabetic (umbilical 9.9% vs 11.4%, epigastric 6.8% vs 8.8%). Women undergoing incisional hernia repair were also younger (mean 57.5 vs 59.1 years), but with higher BMI (33.1 vs 31.5), and more likely diabetic (21.4% vs 19.1%). Propensity analysis included 3,644 umbilical, 1,232 epigastric, and 12,480 incisional hernias. Women with incisional hernia were less likely to undergo an open repair (60.2% vs 63.4%, p < 0.001) and have mesh used (93.8% vs 94.8%, p = 0.02). Women had a higher rate of intraperitoneal mesh placement, and men had a higher rate of preperitoneal and retromuscular mesh placement. CONCLUSION: Small but statistically significant treatment differences regarding operative approach, mesh use, and mesh position exist between men and women undergoing ventral hernia repair.

Occult Hypoperfusion Is Common among Adult Patients Undergoing Emergency Trauma Laparotomy and Is Associated with Worsened Postoperative Outcomes in Elderly Patients

INTRODUCTION: Occult hypoperfusion (OH), defined as global hypoperfusion with normal vital signs, is often underrecognized in elderly trauma patients and may lead to worse outcomes. We hypothesized that elderly patients with OH who undergo emergency trauma laparotomy have worse postoperative outcomes than those with overt shock. METHODS: A retrospective cohort study of adult patients undergoing emergency trauma laparotomy from January 2011 to September 2019 was performed. Patients were stratified by age (young, less than 55 years, or elderly, older than 55 years) and arrival perfusion status with shock defined as systolic blood pressure less than 90 mmHg or heart rate greater than 120 bpm, OH as heart rate 120 bpm or less and systolic blood pressure 90 mmHg or greater and BE <-2 mmol/L, and others as normal. The primary outcome was major abdominal complication (MAC), a composite of organ/space surgical-site infection, fascial dehiscence, anastomotic leak, enteroatmospheric/enterocutaneous fistula, or reopening of laparotomy after fascial closure. Bayesian logistic regression was performed, controlling for Injury Severity Score, mechanism, and damage control laparotomy. RESULTS: Of 1,570 patients, the majority were male (78%), had blunt injury (53%), median age of 33 years (interquartile range 23 to 46), and were severely injured (median Injury Severity Score 19, interquartile range 10 to 29). Of the 14% elderly patients, 27% had OH on arrival. Elderly patients with arrival OH or shock had greater odds of MAC than patients with normal perfusion. There was an 87% probability that elderly patients with OH had greater odds of MAC than those with arrival shock (Figure).Figure.: MAC, major abdominal complication; OH, occult hypoperfusion.CONCLUSION: Elderly patients with OH experienced increased odds of MAC compared with those with overt shock or normal perfusion. Attention should be paid to identifying and treating OH in elderly trauma patients.