Mesh Insertion Research Articles

181 Comparison of Synthetic Mesh Erosion and Chronic Pain Rates After Surgery for Pelvic Organ Prolapse and Stress Urinary Incontinence: A Systematic Review

Abstract Background The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery. Method A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion and chronic pain rates for POP and SUI surgery. Results Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283529 for SUI surgery) met inclusion criteria. The POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) [OR 2.13; 95% CI 1.91-2.37; p < 0.0001]. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) [OR 11.02; 95% CI 8.15-14.9; p < 0.0001]. Conclusions The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. Since a higher volume of mesh is typically used for POP surgery this supports evidence for a dose-response relationship between the volume of mesh used and the erosion risk.

Abstract No. 523 Pre-operative Botox injection for ventral hernia repair: early experience at a single institution

Ventral wall hernias are a common pathology occurring in 10% of open abdominal operations. Surgical management of hernias can be complex due to chronic muscle contraction resulting in recurrence and significant morbidity. Botulism Toxin A (BTA) has been described as a preoperative therapy utilized to reduce muscle contraction and increase intrabdominal volume. Interventional radiologists may increase procedural accuracy while reducing complications by utilizing ultrasound (US) guidance; however, corresponding literature and data are sparse. The present study describes the efficacy and safety of pre-operative US-guided BTA injection in patients undergoing ventral abdominal wall hernia repair at a single institution. Eight patients underwent BTA injection from 2018 to 2020. Injections were performed via ultrasound guidance targeting the external oblique, internal oblique, and transversus abdominis muscles at three locations along the right and left lateral abdominal wall. Retrospective chart review was performed documenting date of birth, sex, preoperative hernia size by computed tomography (CT) evaluation, postoperative hernia size by CT evaluation, post-operative clinical assessment of hernia repair, number of injections, units of Botox, complications, use of mesh, date of repair, and technical success. Technical success was considered to be the ability to inject the BTA in the target muscles. The cohort consisted of 25% (2/8) women and 75% (6/8) men with an average age of 43.3 ± 8.1 years. The maximal pretreatment diameter of the hernia defect prior to surgery was 14.7 ± 4.6 cm. The technical success was 100% (8/8). The patients each had a total of 18 injections and 7/8 (87.5%) had 300 units of BTA while 1/8 (12.5%) had 240 units of BTA injected. None of the patients suffered complications from the injections. The patients underwent hernia repair at an average of 34.7 ± 4 days following BTA injection. Twenty percent (1/5) of patients did not require mesh insertion. Pre-operative US-guided BTA injection is a safe procedure that can aid in ventral abdominal hernia repair via induction of flaccid paralysis.

Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis.

Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention. PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20). PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

Critical view of robotic-assisted transverse abdominal release (r-TAR).

Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures. We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains. Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Outcome of percutaneous mesh fixation in transabdominal preperitoneal groin hernia repair

Background One of the commonly performed surgical procedures in general surgical practice is groin hernia repair. Different procedures have been prescribed for hernioplasty either by open or laparoscopic approaches. Tension-free hernioplasty and obliteration of myopectineal orifices necessitate mesh insertion with different methods for its fixation. Chronic groin pain post hernioplasty (either open or laparoscopic) has been considered multifactorial and most of it has been attributed to the method of mesh fixation. Aim This study aims to evaluate the outcome of temporary percutaneous mesh fixation in transabdominal preperitoneal repair (TAPP) using a fascial closure device or straight needle suture. Patients and methods This prospective study was carried out in the Department of General Surgery Al-Hussein Hospital, Al-Azhar University, Cairo, from October 2016 to December 2017, during which 30 patients were subjected to laparoscopic TAPP hernioplasty with percutaneous mesh fixation and followed up for 1 year. A full preoperative assessment was carried out on all patients. TAPP hernioplasty with percutaneous mesh fixation was performed for all patients; postoperative follow-up was performed for detection of early and late postoperative complications. All cases were followed up for 1 year to detect late complications such as chronic pain and recurrence. Results In this study, the mean age of the patients was 39.2 years. The operative time ranged from 50 to 90 min. All patients underwent uneventful TAPP repair for groin hernia; only one patient had port site bleeding, which was properly controlled during surgery. All patients were discharged on the second postoperative day with a mean hospital stay of 1 day and allowed to resume daily activities at mean 7.5 days postoperatively. Pseudohernia developed in 10% of patients without true recurrence. Only one patient developed recurrence 6 months postoperatively. One year postoperatively, none of the patients had persistent pain and there was no other recurrence. Conclusion Temporary percutaneous mesh fixation in TAPP hernioplasty either by fascial closure device or by straight needle suture is sufficient, effective in mesh fixation and reasonable in terms of cost, enabling better availability to all patients, and yielding nearly the same recurrence rate as ordinary TAPP without permanent groin pain.

Experimental Study of Forced Convection Heat Transfer through Porous Media inside a Rectangular Duct of Fully Developed Region

This prospective study was designed to experimentally investigate the effects of inserting copper mesh in fully developed turbulent flow on the flow and heat transfer characteristics. Experimental work includes designing and manufacturing the test section of rectangular duct with dimensions of (30*3*40 cm) with aspect ratio and hydraulic diameter of 10 and 5.45 mm respectively. A constant heat flux ranged (1.5*102 – 1.8*102 W/m2) was applied to the lower surface of duct with Reynolds number range (3.3*104 – 4.8*104). The porosity rang of (0.98 – 0.99). Also, the effects of porous height ratio (full and partial filling) were considered and considered air as working fluid. The results indicate that inserting mesh wire leads to enhance heat transfer coefficient and increase pressure drop. Taken together, these results show that the obtained values of performance enhancement criteria (PEC) ranged (1.01 -1.98 ), the enhancement in heat transfer coefficient is 315% duo to wire mesh insert. Also, from obtained results empirical correlation for friction factor and Nusselt number were suggested.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review.

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery. A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries. Twenty-six studies on 292,606 patients (n= 9077 for POP surgery and n= 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17months for POP surgery and 39.33 ± 27.68months for SUI surgery. Overall, the POP group were older (p< 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p< 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p< 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31days. The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

Impact response of novel layered two stage fibrous composite slabs with different support type

The performance of novel Layered Two Stage Fibrous Composite slabs (LTSFC) was pioneered under falling mass collisions using a combined experimental and numerical study. Such LTSFC slabs consist of three layers with and without the insertion of glass fibre mesh between the layers. LTSFC techniques were used to fabricate the composite slabs with three layers including 3%, 1.5%, and 3% of fibre content for the top, middle, and bottom layers respectively. Sixteen MLPAFC square slabs were cast with only short hooked end fibres and tested under falling mass collisions by amending two parameters namely the type of support (fixed and hinge) and support layout. Two distinct support layouts on two types of support were considered and tested with and without the glass fibre mesh between layers of LTSFC. A glass fibre mesh was introduced between the three layers to block crack growth propagation and absorb additional collision energy. The glass fibre mesh insertion between the layers and the LTSFC production technique were considered as novel modifications. A numerical study using Auto desk Fusion 360 was conducted and compared with experimental results. The numerical results showed fair agreement with the experimental test results. Based on the validated numerical models, collision energy and cracking pattern evolution were studied. The findings indicated that the glass fibre mesh insertion between the layers combined with steel fibres disrupted crack proliferation, thus exhibiting superior engrossed collision energy and postponing crack growth. Additionally, the engrossed collision energy at crack initiation and ultimate crack for the slabs with four sides fixed and hinged support were greater with respect to two opposite sides fixed and hinged support. Numerical values were in reasonable agreement with the experimental values in terms of collision energy and cracking patterns.

Hybrid approach to ventral wall hernia repair: a single-institution cohort study

Summary Background Ventral hernias pose a substantial challenge for surgeons. Even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardised method that has been widely accepted as standard of practice. Hybrid ventral hernia repair (HVR) is an alternative surgical approach, which has not been adopted widely to date. It combines laparoscopic mesh insertion with closure of the hernia defect. The aim of this retrospective cohort study is to evaluate short- and long-term outcomes in patients undergoing HVR. Methods Between October 2012 and June 2016, 56 HVRs were performed at St Mary’s Hospital, Imperial College London. The medical records of these patients were reviewed retrospectively for demographics, comorbidities, previous surgeries, operative technique, complications and recurrences over a 3-year follow-up. Results HVRs were performed by four surgeons. Mean age was 48 years with a mean body mass index (BMI) of 32.8 kg/m2. 71.4% had incisional hernias and 28.6% had primary hernias. The number of hernia defects ranged from 1 to 4, with average defect size 42.9 cm2 (range 8–200 cm2). Adhesiolysis was performed in 66.1% of patients. Recurrence occurred in 2 patients (3.6%), 16.1% of patients developed postoperative seroma, 0.3% had respiratory complications, 0.3% had paralytic ileus and 0.2% had urinary retention. Only 2 patients required epidural postoperatively, both had a defect size of 150.0 cm2. There were no reoperations within 90 days. Mean length of hospital stay was 2 days (1–10 days). Over the follow-up period, 2 patients (3.6%) developed chronic pain. Conclusion The hybrid technique is safe and feasible, and has important benefits including low rates of seroma formation, chronic pain and hernia recurrence. Future investigations may include randomised controlled trials to evaluate the benefits of VHR, with careful assessment of patient-reported outcome measures including quality of life and postoperative pain.

Growth factors produced by bone marrow stromal cells on nanoroughened titanium-aluminum-vanadium surfaces program distal MSCs into osteoblasts via BMP2 signaling.

Statement of Clinical Significance: There remains the need to develop materials and surfaces that can increase the rate of implant osseointegration. Though osteoanabolic agents, like bone morphogenetic protein (BMP), can provide signaling for osteogenesis, the appropriate design of implants can also produce an innate cellular response that may reduce or eliminate the need to use additional agents to stimulate bone formation. Studies show that titanium implant surfaces that mimic the physical properties of osteoclast resorption pits regulate cellular responses of bone marrow stromal cells (MSCs) by altering cell morphology, transcriptomes, and local factor production to increase their differentiation into osteoblasts without osteogenic media supplements required for differentiation of MSCs on tissue culture polystyrene (TCPS). The goal of this study was to determine how cells in contact with biomimetic implant surfaces regulate the microenvironment around these surfaces in vitro. Two different approaches were used. First, unidirectional signaling was assessed by treating human MSCs grown on TCPS with conditioned media from MSC cultures grown on Ti6Al4V biomimetic surfaces. In the second set of studies, bidirectional signaling was assessed by coculturing MSCs grown on mesh inserts that were placed into culture wells in which MSCs were grown on the biomimetic Ti6Al4V substrates. The results show that biomimetic Ti6Al4V surface properties induce MSCs to produce factors within 7 days of culture that stimulate MSCs not in contact with the surface to exhibit an osteoblast phenotype via endogenous BMP2 acting in a paracrine signaling manner.

New technique of inguinal hernia repair during prostatectomy

Background: Several benefits of inguinal hernia repair concurrent with simple prostatectomy have been proposed recently. For the first time we represent this surgery in the form of retroperitoneal mesh insertion without an additional surgical cut for the inguinal hernia repair. Methods: We selected 19 patients for this trial of a new surgery method. The simple prostatectomy was performed and from the same surgical cut the hernia sac recognized. Two methods of prostatectomy surgery were undertaken: Millin’s and Freyer’s prostatectomy. The retroperitoneal insertion of monofilament polypropylene was undertaken for hernia repair. Results: All patients were prospectively followed for three years for clinical outcomes and hernia recurrence. No complications after surgery, including wound infection, pelvic collections, sepsis and recurrence of the hernia were seen. Conclusions: Our new retroperitoneal mesh insertion technique is safe, effective and simultaneously practical with simple prostatectomy. This new method is strongly recommended to other surgeons, since it has beneficial results with no noteworthy raise in operative duration or further complications.

Comparison of Lichtenstein repair and new mesh implant technique in the treatment of indirect inguinal hernia

Objective: Inguinal hernia surgery is one of the most commonly used surgical procedures in the world. The aim of this study was to compare the recurrence and postoperative complications between a new mesh implant technique in the floor of the inguinal canal with limited tissue repair on it and Liechtenstein technique for inguinal hernia repair.Methods: In this cross-sectional study, patients were studied by Liechtenstein technique and a new technique of insertion of mesh at the foam of the inguinal canal with a limited tissue repair on it. Data were collected by interview and we assessed the recurrence rate, urinary retention and post-operative pain. Data were analyzed using SPSS software version 24. Chi-square test and t test were used for quantitative data and P value less than 0.05 was considered significant.Results: The mean age of patients was 49.28 ± 15.84. The mean age and sex ratio between the two groups were similar. Recurrence was seen in 11 (1.83%) of all patients and the difference between the two groups was not significant. Of all patients, 28 (4.7%) had urinary retention after surgery and the difference between the two groups was significant (p=0.01). Of all patients, 91 (15.2%) had pain after three weeks and 29 (4.8%) had pain after six months.Conclusion: The results showed that the new method had less complications concerning post-operative pain and urinary retention in comparison with the Liechtenstein method as an acceptable method for inguinal hernia repair in future.

Short-term outcomes of laparoscopic intraperitoneal onlay mesh with facial repair (ipom-plus) for ventral hernia: a randomized controlled trial

Background Laparoscopic ventral hernia repair has become a widely used technique. Objective This study evaluates the outcomes of laparoscopic ventral hernia repair with and without fascial repair, with particular reference to complications, seromas, and early recurrence. Patients and methods A total of 177 patients were divided into three groups. Group I underwent laparoscopic [intraperitoneal onlay mesh (IPOM)] hernioplasty without repair. Group II underwent laparoscopic IPOM hernioplasty with intracorporeal repair. Group III underwent laparoscopic IPOM hernioplasty with transfacial closure using PDS loop. Patients were followed for 6 months for early postoperative morbidity, including seroma formation, whereas the secondary end points were the adequacy of transfacial repair and its effect on early hernia recurrence. Conclusion Transfacial suture closure of hernia defect is the simplest method of the hernia repair and effective with less incidence of seroma and early recurrence as compared with nonfascial repair technique. Defect closure strengthens the abdominal wall by regaining its whole function and gives more space for mesh insertion. Whatever technique used for ventral hernia repair, obesity is still the most important risk factor for seroma and hernia recurrence.

Evolution of patients with and without preoperative stress urinary incontinence after surgical cystocele repair by mesh implantation using a vaginal approach

To review the short-term evolution of stress urinary incontinence (SUI) after Uphold™ LITE mesh implantation for genital prolapse repair. Retrospective, descriptive, single centre study of women undergoing genital prolapse surgery with Uphold™ LITE mesh insertion between July 2016 and April 2019. Pre-, peri- and 1-year postoperative follow-up data were collected. Thirty-six women were included (mean age: 72±7years). Most patients (75%) had grade III cystocele and three (8.3%) had recurrent prolapse. Mean operative time was 41±12min. During surgery, no visceral injury or haemorrhagic complications were noted but there were three intraoperative bladder injuries (8.3%). Twelve patients (33.3%) had preoperative SUI, half of which (n=6; 50%) responded to prolapse repair. De novo SUI was noted in 6/24 (25%) patients. The risk of having persistent postoperative SUI was 50% in patients with preoperative SUI, and the risk of developing de novo postoperative SUI was 25% in patients without preoperative SUI. Thus, patients with preoperative SUI were twice as likely to have persistent postoperative SUI as those without preoperative SUI (RR=2.0 [95% CI: 0.8175-4.8928]; P=0.128). Five patients with de novo SUI and three patients with persistent postoperative SUI were subsequently treated with insertion of a mid-urethral sling (MUS). The other patients improved with physiotherapy. Risk of persistent SUI after implantation of an Uphold™ LITE mesh is higher in patients with preoperative SUI. Surgical correction with a MUS can be offered in cases of de novo SUI before or after physiotherapy. 4.

The effect of geometrical modifications on the performance of co-linear chambers for non-thermal radio frequency electric fields processing: A numerical study with experimental validation

The effect of modifying the geometrical configuration of a co-linear chamber to improve its performance and to increase the microbial inactivation was investigated numerically and validated experimentally. In non-thermal radio frequency electric fields (RFEF) processing, co-linear chambers exhibit low tendency to dielectric breakdown and arcing, especially in liquid food products with high electrical conductivities, but they show low energy efficiency and poor uniformity of processing conditions. Accordingly, a standard co-linear chamber (C1) with 1 mm of length and 3 mm of diameter was selected. The chamber included a gap between the end of electrodes and the treatment zone, as well as a diameter contraction at that zone. The geometry of the standard co-linear chamber was modified by removing the recirculation/stagnation zones adding stainless steel tubes (C2), as well as through the additional insertion of stainless steel mesh to contain the electric field within the treatment zone (C3). These configurations were evaluated numerically using COMSOL Multiphysics modelling. The model was validated by comparing experimental measurements of outlet temperature and power consumption with the model predictions. The numerical study showed that C3 exhibited a more uniformly distributed electric field and temperature profiles as well as higher velocities and turbulent kinetic energy that were also more evenly distributed within the treatment zone, compared to other configurations. In experimental studies, C3 achieved the highest microbial inactivation at constant values of peak voltage, electric field strength, and energy levels. Furthermore, C3 showed the most energy efficiency among the three geometrical configurations. Industrial relevanceAs an alternative to thermal processing, radio frequency electric fields (RFEF) processing needs to ensure the microbial safety of the food products in an energy-efficient manner due to the challenges on controlling Joule heating, which can lead to arcing and the dielectric breakdown of the treatment chamber. This can be achieved by designing treatment chambers that can enclose the electric field within the treatment zone while providing a more evenly distributed electric field, hydrodynamic and temperature profiles within that zone. This study proves that the geometrical configuration of co-linear chambers can be altered to minimize the energy consumption while maximizing the microbial inactivation. The findings can be used for scaling up and advancing the industrial application of RFEF technology for food processing.

Incidence and risk factors for venous thromboembolism events after different routes of pelvic organ prolapse repairs

Venous thromboembolism events, including deep venous thrombosis and pulmonary embolism are the most common cause of preventable deaths in hospitalized patients in the United States. Although the risk of venous thromboembolism events in benign gynecologic surgery is generally low, the potential for venous thromboembolism events in urogynecologic population is significant because most patients undergoing the pelvic organ prolapse surgery have increased surgical risk factors. This study aimed to investigate the incidence and risk factors for venous thromboembolism events within 30 days after different routes of the pelvic organ prolapse surgery in a large cohort population using the American College of Surgeons-National Surgical Quality Improvement Program. This retrospective cohort study used Current Procedural Terminology codes to identify pelvic organ prolapse repairs with and without concurrent hysterectomy performed during 2011-2017 in the American College of Surgeons-National Surgical Quality Improvement Program database. Demographics, preoperative length of hospital stay, operative time, preoperative comorbidities, smoking status, American Society of Anesthesiologists classification system scores, along with other variables were collected. Postoperative 30-day complications, including readmission, reoperation, and mortality, were collected. The incidence rates of venous thromboembolism, as defined by American College of Surgeons-National Surgical Quality Improvement Program, were compared among different surgical routes. Descriptive statistics were used, and logistic regression was performed to identify associations. Among 91,480 pelvic organ prolapse surgeries identified, 63,108 were analyzed: 43,279 (68.6%) were performed vaginally, 16,518 (26.2%) laparoscopically, and 3311 (5.2%) abdominally. A total of 34,698 (55.0%) underwent a concurrent hysterectomy. Of 63,108 subjects, 133 developed venous thromboembolism within 30 days after surgery (0.21%; 95% confidence interval, 0.18-0.25; P<.0001). More than half (60%) of venous thromboembolism events occurred within 10 days after surgery. For all surgical routes, older age (P<.041), higher body mass index (P=.002), race or ethnicity (P=.04), longer operating time (P<.0001), inpatient status (P<.0001), American Society of Anesthesiologists 3 or 4 (P<.0001), having preoperative renal failure (P=.001), and chronic steroid use (P=.02) were significantly associated with venous thromboembolism. In addition, in the vaginal pelvic organ prolapse repair group, concurrent hysterectomy (P=.03) and preoperative dyspnea (P=.01) were associated with development of venous thromboembolism. In the abdominal pelvic organ prolapse repair, concurrent hysterectomy (P=.005) and hypertension requiring medication (P=.04) were also independently associated with venous thromboembolism development (Table1). The incidence of venous thromboembolism was highest in abdominal repairs (0.72%), followed by laparoscopic repairs (0.25%) and vaginal repairs (0.16%). After adjusting for confounders, abdominal compared with vaginal approach (adjusted odds ratio, 3.27; 95% confidence interval, 1.93-5.41; P<.0001), longer operative time (adjusted odds ratio, 1.005; 95% confidence interval, 1.003-1.006; P<.0001), older age (adjusted odds ratio, 1.020; 95% confidence interval, 1.00-1.037; P=.015), greater body mass index (adjusted odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P=.0006), American Society of Anesthesiologists 3 or 4 (adjusted odds ratio, 1.55; 95% confidence interval, 1.03-2.31; P=.03), and preoperative renal failure (adjusted odds ratio, 8.87; 95% confidence interval, 1.16-44.15; P=.04) remained significantly associated with developing venous thromboembolism. Neither laparoscopic repair (compared with vaginal repair) nor concurrent procedures (hysterectomy, antiincontinence procedure, vaginal mesh insertion) were found to be significantly associated with the development of venous thromboembolism. The abdominal pelvic organ prolapse repairs were associated with an increased hazard of venous thromboembolism (hazard ratio, 3.27; 95% confidence interval, 1.96-5.45; P<.0001). Venous thromboembolism development was associated with 30-day mortality, readmission, and reoperation (all P<.0001). The overall incidence of venous thromboembolism after pelvic organ prolapse repairs based on a recent, large cohort database was very low, confirming the finding in previous smaller cohort studies. The highest venous thromboembolism risk was associated with abdominal route, and more than 60% of venous thromboembolism events occurred within 10 days after surgery. Thus, focus should be placed on risk-reducing strategies in the immediate postoperative period, with greater emphasis on patients undergoing abdominal surgery.

Surgical reconstruction of the foramen tympanicum: What is known and how we do it

Defects affecting the anterior wall of the tympanal bone can result from trauma, infection, neoplasm or previous local surgery. An anatomic variation, namely the persistence of the foramen tympanicum, can also be encountered. When symptomatic, surgical reconstruction may be indicated. The aim of this study was to identify the surgical treatments of symptomatic foramen tympanicum found in the literature and detail our innovative reconstruction technique. A bibliographic research was conducted in PubMed database in March 2020, without time limitation. Papers dealing with surgical management of a foramen tympanicum were included. Data collected were the publication date, the number of patients, their age and gender, the symptoms and the surgical treatment performed. We report, in addition, the case of a symptomatic persistent foramen tympanicum in a 30-year-old man with a follow-up of 18-months. A total of 17 studies (n=23 patients) were included for analysis. The main reconstruction techniques were, in equal proportion, cartilage graft (30%) and insertion of a titanium mesh (30%). We carried out an iliac crest bone graft using a preauricular approach on a patient suffering from chronic tinnitus and fullness in the left ear resulting from a persistent foramen tympanicum, confirmed by clinical and radiological examinations. It allowed the complete resolution of symptoms and no complication such as temporomandibular ankylosis occurred. Based on the review of the literature, we believe this technique has the advantage of providing durable reconstruction thanks to osseointegration.

Authors Response: Letter to Editor: Lower Urinary Tract Mesh Perforations Following the Insertion of Mid-Urethral Tapes or Transvaginal Mesh: A Tertiary Unit's Experience - Saidan, et al. 2019

Our published paper [2] relates to a small retrospective case-series of women undergoing surgery for management of their urinary tract mesh perforation only. It therefore has its limitations, which we have acknowledged in our paper. We are grateful to the Editor, and the scientific team who reviewed our paper as part of the peer-reviewed process, for considering it worthy of publication despite these.

A preliminary evaluation of two different meshes in minimally invasive inguinal hernia surgery.

Many meshes are available for use in laparoscopic inguinal hernia repair. The surgeon must consider several factors when choosing a mesh for hernia repair including clinical outcomes, cost, and ease of use. The purpose of this study was to compare two different lightweight polypropylene meshes for laparoscopic and robotic inguinal hernia repairs. Subjects were randomized immediately before surgery. Data were reported in N (%) and median [Q1-Q3], comparisons of mesh insertion time were tested using a 2 × 2 ANOVA on the ranked times, comparisons between categorical variables were tested with Fisher's Exact, and all data were analyzed using SAS® 9.4 (SAS Institute, Inc.). Between January 2015 and June 2016, 50 subjects were enrolled; two were excluded. Of 48 eligible subjects, most were Caucasian (N = 42, 88%), male (N = 37, 77%), with a median age of 63, and were randomized evenly between 3DMax™ mesh and Ultrapro® mesh. Robotic mesh placement significantly increased insertion time regardless of mesh type (p < .0001). When comparing NASA-TLX self-assessment surveys, there was no significant difference between the meshes in difficulty of placement. The type of mesh did not significantly impact the insertion time regardless of robot use (p = 0.523). Our data demonstrate that mesh insertion times comparing two different lightweight polypropylene meshes were not significantly different. Increased insertion times associated with robotic repair are likely due to the mechanics of robotic suturing and associated learning curve. Our data suggest that these meshes can be used interchangeably based on the surgeon's preference. NCT01825187.

Multi-layered two stage fibrous composites against low-velocity falling mass and projectile impact

The Multi-layer Two Stage Fibrous Composite (MTSFC) is an innovative type of composite that has gained popularity in recent years and pulled the attention of researchers on global level. The process of preparation composes the subsequent two key actions; first, the natural coarse aggregate skeleton is formed by piling the coarse aggregates and fibres in a particular way; second, the artificially formed skeleton is fully filled with cement grout by gravity method. In the present study, the effect of Glass Fibre Mesh (GFM) insertion on MTSFC is researched by subjecting to falling mass and projectile impacts. Totally, twenty one mixtures with insertion of GFM of varied diameters and with different layout in between the layers are designed and tested under falling mass and projectile impacts. Additionally, the hooked end fibre at a dosage of 2.5% volume of composite was constantly used for all designed mixtures. The purpose of inserting glass fibre mesh in between the top-middle and middle-bottom layer is to play a role of trapping layer in order to prevent/delay the crack propagation. The multiple number of hits to provoke crack initiation and crack ultimate, impact energy at crack initiation and crack ultimate, impact ductility index, front damage area, bottom damage area, damage ratio, depth of penetration and damage pattern are studied hereby. The findings revealed that the GFM reinforcement stratagem combined with steel fibres in MTSFC, turned out to deliver high resistance against impact load and extends the failure duration by absorbing more energy. Also, findings indicated that the depth of penetration, damage area and damage ratio were raised with the number of hits and were lessened by the high content steel fibres together with GFM and coarse aggregate. Consequently, the effect of GFM insertion is minimal when it is placed inbetween top-middle layer. Preferably, it is best to insert GFM inbetween mid-bottom layer in the MTSFC, which extends to delay the crack proliferation while tensile stress are being transformed and offers more impact energy absorbance. The research outcomes obtained from this study is to deliver a baseline information for continuing a deeper research work on MTSFC under impact.