Midline Wound Research Articles

MP67-08 MEDICAL COMORBIDITIES, NOT NEOADJUVANT CHEMOTHERAPY, AFFECTS DECLINE IN RENAL FUNCTION FOLLOWING RADICAL CYSTECTOMY AND ELIGIBILITY FOR PLATINUM BASED ADJUVANT CHEMOTHERAPY

muscle invasive bladder cancer. Midline fascial defects including wound dehiscence and incisional hernia are morbid postoperative events. Our objective was to identify predisposing factors for midline fascial defects in this population with multiple morbidities. METHODS: The records of all patients who underwent cystectomy and ileal conduit between 1994 and 2011 were reviewed. Wound dehiscence was defined as a midline separation of the fascia requiring operative reclosure. Post-operative incisional hernia was defined as a palpable fascial defect on follow-up physical exam. Univariate and multivariate logistic regression models of factors that may be predictive of midline fascial defect were conducted. RESULTS: A total of 963 patients were identified with a median age of 71 years and median follow-up of 15.8 months (range, 0.23 e 188.85 months). Ninety-four patients (9.8%) developed a midline fascial defect (51 wound dehiscences, 43 incisional hernias). A multivariate logistic regression model for midline fascial defects demonstrated that steroid usage and post-operative wound infections were independent predictors. Fewer than expected wound events occurred in patients who received neoadjuvant chemotherapy. In the wound dehiscence subgroup, post-operative wound infection was the only significant factor (p1⁄4<0.0001, OR1⁄412.69, 6.15-25.51). Patient age, body mass index, prior abdominal surgery, nutritional factors and post-op pneumonia were not independently predictive of either midline fascial defect or wound dehiscence. The neoadjuvant group had significantly lower albumin, pre-op hemoglobin (Hgb), and Total Lymphocyte Count (TLC) levels in comparison to the non-neoadjuvant group. CONCLUSIONS: In our cohort of 963 of ileal conduit patients, post-operative wound infection is the most important predictor of the devastating complications of wound dehiscence and midline fascial defects. Patients who received neoadjuvant chemotherapy had fewer than expected wound complications despite having lower pre-op albumin, Hgb and TLC.

MP67-06 POST-OPERATIVE WOUND INFECTIONS AND STEROID USE ARE INDEPENDENT RISK FACTORS FOR MIDLINE FASCIAL DEFECTS IN PATIENTS AFTER RADICAL CYSTECTOMY WITH ILEAL CONDUIT

You have accessJournal of UrologyBladder Cancer: Invasive IV1 Apr 2015MP67-06 POST-OPERATIVE WOUND INFECTIONS AND STEROID USE ARE INDEPENDENT RISK FACTORS FOR MIDLINE FASCIAL DEFECTS IN PATIENTS AFTER RADICAL CYSTECTOMY WITH ILEAL CONDUIT Hajar I. Ayoub, Andrew Pisters, Diego Aguilar Palacios, Wei Wei, Colin P. Dinney, H. Barton Grossman, Ashish M. Kamat, Jay B. Shah, and O. Lenaine Westney Hajar I. AyoubHajar I. Ayoub More articles by this author , Andrew PistersAndrew Pisters More articles by this author , Diego Aguilar PalaciosDiego Aguilar Palacios More articles by this author , Wei WeiWei Wei More articles by this author , Colin P. DinneyColin P. Dinney More articles by this author , H. Barton GrossmanH. Barton Grossman More articles by this author , Ashish M. KamatAshish M. Kamat More articles by this author , Jay B. ShahJay B. Shah More articles by this author , and O. Lenaine WestneyO. Lenaine Westney More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2489AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical cystectomy with ileal conduit is the most commonly performed treatment for patients with muscle invasive bladder cancer. Midline fascial defects including wound dehiscence and incisional hernia are morbid postoperative events. Our objective was to identify predisposing factors for midline fascial defects in this population with multiple morbidities. METHODS The records of all patients who underwent cystectomy and ileal conduit between 1994 and 2011 were reviewed. Wound dehiscence was defined as a midline separation of the fascia requiring operative reclosure. Post-operative incisional hernia was defined as a palpable fascial defect on follow-up physical exam. Univariate and multivariate logistic regression models of factors that may be predictive of midline fascial defect were conducted. RESULTS A total of 963 patients were identified with a median age of 71 years and median follow-up of 15.8 months (range, 0.23 – 188.85 months). Ninety-four patients (9.8%) developed a midline fascial defect (51 wound dehiscences, 43 incisional hernias). A multivariate logistic regression model for midline fascial defects demonstrated that steroid usage and post-operative wound infections were independent predictors. Fewer than expected wound events occurred in patients who received neoadjuvant chemotherapy. In the wound dehiscence sub-group, post-operative wound infection was the only significant factor (p=<0.0001, OR=12.69, 6.15-25.51). Patient age, body mass index, prior abdominal surgery, nutritional factors and post-op pneumonia were not independently predictive of either midline fascial defect or wound dehiscence. The neoadjuvant group had significantly lower albumin, pre-op hemoglobin (Hgb), and Total Lymphocyte Count (TLC) levels in comparison to the non-neoadjuvant group. CONCLUSIONS In our cohort of 963 of ileal conduit patients, post-operative wound infection is the most important predictor of the devastating complications of wound dehiscence and midline fascial defects. Patients who received neoadjuvant chemotherapy had fewer than expected wound complications despite having lower pre-op albumin, Hgb and TLC. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e851-e852 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hajar I. Ayoub More articles by this author Andrew Pisters More articles by this author Diego Aguilar Palacios More articles by this author Wei Wei More articles by this author Colin P. Dinney More articles by this author H. Barton Grossman More articles by this author Ashish M. Kamat More articles by this author Jay B. Shah More articles by this author O. Lenaine Westney More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Comparative Study between Karydakis Flap Reconstruction and Double Z-Plasty in Patients with Sacrococcygeal Pilonidal Disease

The most difficult problems that follow surgery for pilonidal disease are persistent unhealed midline wound and recurrence. Various innovations were proposed to deal with these problems. The adipocutaneous flap of Karydakis was devised to shift the natal cleft, while Z-plasty involves fasciocutaneous flap. The present prospective randomized trial was conducted on 50 cases of symptomatic or recurrent pilonidal sinuses divided randomly into two equal groups undergoing Karydakis procedure and Z-plasty. The duration of hospitalization for Karydakis procedure was found significantly lesser than that for double Z-plasty (P < 0.001). Similar observations are obtained for duration of wound healing (P < 0.001), work off period (P < 0.001), and the duration of presence of significant pain postoperatively (P < 0.001). The overall complications were more in double Z-plasty. Recurrence developed in 32% of the cases in double Z-plasty group comparable to no recurrence seen in Karydakis procedure. Thus, Karydakis flap was found superior to double Z-plasty having less seroma formation, no local hematoma, and no flap necrosis. Statistically, this comparison was highly significant (P < 0.001). Karydakis flap has some added advantages over double Z-plasty technique like keeping scar away from the midline and flattening of the natal cleft, thus reducing local recurrence rates.

Laparoscopic Appendectomy in Complicated Appendicitis of Children

I read with great interest your article, which describes the value of laparoscopy in management of complicated appendicitis (1). You should be congratulated for the excellent results and for providing the best standards of care to your patients. I have an experience of about 1000 appendicectomies; half of that number was done by laparoscopic approach in the UK and overseas. The conversion rate was 0.4%. I believe laparoscopic approach should be the gold standard for managing complicated appendicitis with systemic signs of sepsis, for the following reasons: 1) Laparoscopy will provide diagnostic and therapeutic options. It will provide an excellent view and access to the whole peritoneal cavity including liver and splenic areas, paracolics, pelvic and interloop spaces. 2) Using laparoscopy, surgeons can levage the whole peritoneal cavity with copious saline under direct vision until the returning fluid is clear, thus it’s better than open approach when the surgeon is limited by access through grid iron incision. 3) Recovery, post-operative pain, cosmesis and wound complications are far better than open approach. 4) Induction of pneumoperitoneum may be challenging in complicated appendicitis. I had no major difficulties using Veress needle. Hasson’s technique is equally safe and can be used by surgeons who have no experience or not familiar with Veress needle technique. 5) In the UK, about 26% of our peadiatric patients are overweight. Lapraoscopic approach will add the benefits of easy access and again avoids wound complications. My approach in complicated appendicitis is: 1) Any child with complicated appendicitis, history of right iliac fossa pain and show signs of sepsis should undergo an urgent laparoscopy. An urgent laparoscopy rather than laparotomy can be repeated if the patient shows signs of deterioration after initial laparoscopy. 2) If on clinical examination there is a mass and controlled sepsis (no systemic signs): I will start antibiotics and arrange an abdominal scan. If the scan showed collection then this will be drained radiologically under Ultrasound guidance. If the child and family are not happy for radiological drainage under local anesthetics, laparoscopic drainage +/appendicectomy (if seen) is performed. This has worked for me very well without problem. You have cited Horwits et al. and Krisher et al. studies that represent an early laparoscopic experience to manage appendicitis, both studies published in 1997 and 2001 and they are out of date! Both had worse outcomes compared to Yagmurlu A et al. and Esposito C et al. studies, which were published in 2006 and 2007. You have mentioned appendicitis together with peritonitis is mostly managed with open surgery with a midline or large transverse incision and wound would be open for many days as a rule (2). This study is published in 1995, which mean it was reported patients outcome and experience before laparoscopic era. The incidence of complications especially the postoperative abdominal abscess is negligible. Our study of 200 cases (including 7.5% of perforated appendicitis) in 2008 (3) reported no single case of abdominal abscess.

Management of complex open abdominal wounds: Report of two cases

This report discusses the successful management of two complex open abdominal wounds. The wounds were temporarily closed with a silastic sheet. After several dressing changes with vacuum-assisted closure (VAC), bilateral bipedicle advancement flaps were used to close the complex open abdominal wound. Case 1: a 41-year-old man underwent gastric bypass surgery for morbid obesity. Wound dehiscence resulted from a sudden increase in intra-abdominal pressure while weaning from mechanical ventilation. The huge open wound was temporarily covered with a silastic sheet. After serial VAC dressing changes, the wound was progressively reduced. The defect was completely repaired using bilateral bipedicle advancement flaps. The skin defects in the lateral abdominal wall were then covered with a split-thickness skin graft. Case 2: a 65-year-old woman underwent emergency surgery for hypovolemic shock from active upper gastrointestinal bleeding. She had a history of three biliary operations for intrahepatic and common bile duct stones. Hemobilia caused by a ruptured intrahepatic pseudoaneurysm was controlled by intraoperative arterial embolization. To prevent abdominal compartment syndrome, the open wound was initially covered with a silastic sheet. The wound was progressively reduced by serial VAC dressing changes. The midline wound was then successfully closed by bilateral bipedicle advancement flaps. After VAC dressing, the skin defects in the lateral abdominal wall were directly closed 2 weeks later. In our experience, a combination of VAC and bilateral bipedicle advancement flaps is effective for the definitive fascia to fascia closure of huge complex open abdominal wounds.

Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage

Noncompressible torso hemorrhage is a leading cause of death in trauma, with many patients dying before definitive hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct than can be used to expand the window of salvage in patients with end-stage hemorrhagic shock. The aim of this study was to evaluate the effect of continuous and intermittent REBOA (iREBOA) on mortality using a highly lethal porcine model of noncompressible torso hemorrhage. Male splenectomized pigs (70-90 kg) underwent a laparoscopic liver injury (80% resection of left lobe) followed by a 10-min free-bleed period. Animals were then divided into three groups (n = 8) for a 60-min intervention phase (n = 8): continuous occlusion (cREBOA), iREBOA, or no occlusion (nREBOA). Groups then underwent whole blood resuscitation, damage control surgery, and further critical care. Endpoints were mortality and hemodynamic and circulating measures of shock and resuscitation. Systolic blood pressure (in mmHg) at the end of the free-bleed period for cREBOA, iREBOA, and nREBOA was 31 ± 14, 48 ± 28, and 28 ± 17, respectively (P = 0.125). Following the start of the intervention phase, systolic blood pressure was higher in the iREBOA and cREBOA groups compared with the nREBOA (85 ± 37 and 96 ± 20 vs. 42 ± 4; P < 0.001). Overall mortality for the cREBOA, iREBOA, and nREBOA groups was 25.0%, 37.5%, and 100.0% (P = 0.001). Resuscitative endovascular balloon occlusion of the aorta can temporize exsanguinating hemorrhage and restore life-sustaining perfusion, bridging critical physiology to definitive hemorrhage control. Prospective observational studies of REBOA as a hemorrhage control adjunct should be undertaken in appropriate groups of human trauma patients.

A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence

BackgroundIncisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence.Methods/designThe PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up.DisccusionThe use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups.Trial registrationClinical trial.gov NCT00761475.

Negative Pressure Therapy for High-Risk Abdominal Wall Reconstruction Incisions

A high rate of surgical site infection (SSI) accompanies the repair of large ventral hernias in the presence of bacterial contamination. Recent clinical and laboratory studies suggest that negative-pressure therapy (NPT) applied to closed surgical incisions may reduce the risk of SSI in high-risk populations. We hypothesized that NPT would reduce the risk of SSI in patients undergoing the repair of contaminated ventral hernias. We reviewed retrospectively our prospectively collected database for patients undergoing repair of potentially contaminated and infected ventral hernias with or without NPT. All of the patients had primary wound closure. In the NPT group, a vacuum dressing was applied over the closed midline wound. The primary outcome measure was SSI at 30 d post-operatively. We evaluated 119 patients (70 with a standard wound dressing (SWD) and 49 with NPT). The groups were similar in age, gender, body mass index (BMI), the prevalence of chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and smoking; and the number of prior abdominal operations. The SWD group had a higher American Society of Anesthesiologists (ASA) score than did the NPT group (3.0 vs. 2.8; p=0.01). The two groups were similar in the sizes of their hernia defects and duration of surgery, and did not differ in their 30-d rates of SSI (25.8% SWD vs. 20.4% NPT; p=0.50) or in the distribution of major and minor SSIs (SWD: 6 major, 12 minor vs. NPT: 2 major, 8 minor; p=0.56). Factors associated with an increased risk of SSI included ASA score (p=0.02), BMI (p=0.05), defect area (p<0.01), DM (p=0.01), and duration of surgery, (p<0.01). This retrospective, non-randomized study found that NPT in the setting of a closed surgical incision after potentially contaminated or infected ventral hernia repair (VHR) did not reduce the incidence of SSI. Although prophylactic NPT has reduced wound morbidity in some surgical populations, it does not appear to offer the same reduction in wound morbidity in high-risk, contaminated, and potentially contaminated open VHR.

Twelve Common Mistakes in Pilonidal Sinus Care

Healing of pilonidal sinus wounds (PSWs) by secondary intention requires an average of 2 to 6 months, but delayed healing may require 1 to 2 years or even longer. Characteristically, these midline wounds are in the natal cleft of the buttocks or sacrococcygeal area of the back. These PSWs have costly financial consequences to the healthcare system and negatively affect the quality of life of the individual with the wound. This article contains an evidence-based literature review supplemented by the clinical expert opinion of the authors. Twelve leading mistakes in assessment and treatment have been identified with appropriate solutions to optimize patient outcomes. A case study is included to illustrate the common clinical challenges with strategies to optimize healing.

Component Separations

Component separation is a technique used to provide adequate coverage for midline abdominal wall defects such as a large ventral hernia. This surgical technique is based on subcutaneous lateral dissection, fasciotomy lateral to the rectus abdominis muscle, and dissection on the plane between external and internal oblique muscles with medial advancement of the block that includes the rectus muscle and its fascia. This release allows for medial advancement of the fascia and closure of up to 20-cm wide defects in the midline area. Since its original description, components separation technique underwent multiple modifications with the ultimate goal to decrease the morbidity associated with the traditional procedure. The extensive subcutaneous lateral dissection had been associated with ischemia of the midline skin edges, wound dehiscence, infection, and seroma. Although the current trend is to proceed with minimally invasive component separation and to reinforce the fascia with mesh, the basic principles of the techniques as described by Ramirez et al in 1990 have not changed over the years. Surgeons who deal with the management of abdominal wall defects are highly encouraged to include this technique in their collection of treatment options.

Does Prophylactic Biologic Mesh Placement Protect Against the Development of Incisional Hernia in High‐risk Patients?

The purpose of this study was to determine whether the prophylactic use of a biologic prosthesis protects against the development of incisional hernia in a high-risk patient population. A prospective, nonrandomized trial was conducted on 134 patients undergoing open Roux-en-Y gastric bypass by a single surgeon, at two institutions, from January 2005 to November 2007. At Hospital A, all patients (n=59) underwent fascial closure of the abdominal midline wound with the prophylactic placement of a biologic mesh (AlloDerm®) in an in-lay fashion. Patients at Hospital B (n=75) underwent primary abdominal wall closure using #1 PDS in a running fashion. Data collected included patient demographics, abdominal wall closure technique, postoperative wound complications, follow-up period, and incidence of incisional hernia. During the study period 134 patients (mean age=40.4 years, 80.7% female) underwent open Roux-en-Y gastric bypass (59.7% mesh, 41.5% nonmesh). Twenty-eight patients were excluded from the analysis secondary to a short follow-up period (mesh=13, nonmesh=11) and/or reoperative surgery unrelated to the development of an incisional hernia (mesh=2, nonmesh=2). The mean follow-up period was 17.3±8.5 months. The overall incidence of incisional hernia was 11.3% (95% CI: 5.2-17.45). The incidence of incisional hernia was significantly lower in the mesh group versus the nonmesh group (2.3 vs. 17.7%, P=0.014). In a multivariate logistic regression model that adjusted for age, sex, body mass index, albumin, smoking, diabetes, prior surgery, seroma formation, weight loss, and mesh placement, the development of incisional hernia was found to be associated with smoking (adjusted odds ratio [OR] 8.46, 95% CI: 1.79-40.00, P=0.007) while prophylactic mesh was noted to be protective against hernia development (adjusted OR 0.06, 95% CI: 0.006-0.69, P=0.02). The prophylactic use of biologic mesh for abdominal wall closure appears to reduce the incidence of incisional hernia in patients with multiple risk factors for incisional hernia development.

Simple day-case surgery for pilonidal sinus disease

Pilonidal disease is a common and usually minor disease. Although wide excisional surgery has been common practice, there are more simple alternatives. This review focused on the aetiology and management of pilonidal disease. A comprehensive review of the literature on pilonidal disease was undertaken. MEDLINE searches for all articles listing pilonidal disease (1980-2010) were performed to determine the aetiology and results of surgical and non-surgical treatments. Single papers describing new techniques or minor modifications of established techniques were excluded. Further articles were traced through reference lists. Patients with minimal symptoms and those having drainage of a single acute abscess can be treated expectantly. Non-surgical treatments may be of value but their long-term results are unknown. There is no rational basis or need for wide excision of the abscess and sinus. Simple removal of midline skin pits, the primary cause of pilonidal disease, with lateral drainage of the abscess and sinus is effective in most instances. Hirsute patients with extensive primary disease and deep natal clefts, or with recurrent disease and unhealed midline wounds, may also require flattening of the natal cleft with off-midline skin closure. These more conservative procedures are usually done as a day case, require minimal care in the community and are associated with a rapid return to work. They also avoid the occasional debilitating complications of surgical treatment. Simple day-case surgery to eradicate midline skin pits without wide excision of the abscesses and sinus is rational, safe and effective for patients with pilonidal sinus disease.

Postoperative Bowel Perforation due to Heterotopic Ossification (Myositis Ossificans Traumatica): A Case Report and Review of the Literature

Heterotopic ossification (HO) is the ectopic development of normal bone within soft tissue that can occur after traumatic injury. It is uncommon and may be missed or misdiagnosed, which can lead to complications. We report the case of an 84-year-old male with a previous history of a laparotomy who underwent resection of an intra-abdominal tumor through a midline incision. On postoperative day six, the patient was taken to the operating room, as succus was draining from the incision. Upon re-exploration, sharp bone-like material was found in the wound directly adjacent to an enterotomy. Pathology confirmed mature lamellar bone and the diagnosis of HO. This is the first report of postoperative intestinal perforation secondary to HO in a midline wound. We report this case to encourage accurate reporting of HO and its morbidity and complications for the benefit of appropriate surgical planning and epidemiologic tracking of outcomes.

Short-term Outcomes With the Use of Bioprosthetics for the Management of Parastomal Hernias

This study was undertaken to determine the safety and short-term outcomes using bioprosthetics for the management of parastomal hernias. A retrospective review of prospectively collected data for all of the patients who underwent repair of a parastomal hernia was conducted. Between April 2004 and September 2007, 20 consecutive patients had 22 parastomal hernias repaired through a midline incision using a bioprosthetic with the stoma entering the abdomen lateral to the graft. A colostomy was present in 17 patients; an ileostomy was present in 3 patients. All of the patients had parastomal hernia-related complications. Postoperatively there were no infections of the midline wound or the prosthetic, and none of the grafts were removed. There were 4 seromas (40%) that required aspiration in the 10 procedures performed before the routine placement of a drain. No incisional hernias have developed in the midline wound. There have been 2 (9%) recurrent parastomal hernias on physical examination at a median follow-up of 18 months (range, 12-54). These data suggest that bioprosthetics are safe and are effective in the short term for the repair of parastomal hernias.

Healing by primary versus secondary intention after surgical treatment for pilonidal sinus.

Pilonidal sinus arises in the hair follicles in the buttock cleft. The estimated incidence is 26 per 100,000, people, affecting men twice as often as women. These chronic discharging wounds cause pain and impact upon quality of life. Surgical strategies centre on excision of the sinus tracts followed by primary closure and healing by primary intention or leaving the wound open to heal by secondary intention. There is uncertainty as to whether open or closed surgical management is more effective. To determine the relative effects of open compared with closed surgical treatment for pilonidal sinus on the outcomes of time to healing, infection and recurrence rate. For this first update we searched the Wounds Group Specialised Register (24/9/09); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 3 2009; Ovid MEDLINE (1950 - September Week 3, 2009); Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations (September 24, 2009); Ovid EMBASE (1980 - 2009 Week 38); EBSCO CINAHL (1982 - September Week 3, 2009). All randomised controlled trials (RCTs) comparing open with closed surgical treatment for pilonidal sinus. Exclusion criteria were: non-RCTs; children aged younger than 14 years and studies of pilonidal abscess. Data extraction and risk of bias assessment were conducted independently by three review authors (AA/IM/JB). Mean differences were used for continuous outcomes and relative risks with 95% confidence intervals for dichotomous outcomes. For this update, 8 additional trials were identified giving a total of 26 included studies (n=2530). 17 studies compared open wound healing with surgical closure. Healing times were faster after surgical closure compared with open healing. Surgical site infection (SSI) rates did not differ between treatments; recurrence rates were lower in open healing than with primary closure (RR 0.60, 95% CI 0.42 to 0.87). Six studies compared surgical midline with off-midline closure. Healing times were faster after off-midline closure (MD 5.4 days, 95% CI 2.3 to 8.5). SSI rates were higher after midline closure (RR 3.72, 95% CI 1.86 to 7.42) and recurrence rates were higher after midline closure (Peto OR 4.54, 95% CI 2.30 to 8.96). No clear benefit was shown for open healing over surgical closure. A clear benefit was shown in favour of off-midline rather than midline wound closure. When closure of pilonidal sinuses is the desired surgical option, off-midline closure should be the standard management.

Acute Management of Stoma-Related Colocutaneous Fistula by Temporary Placement of a Self-Expanding Plastic Stent

Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post-stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.

Early Results of Midline Hernia Repair Using a Minimally Invasive Component Separation Technique

A minimally invasive component separation may lead to a dynamic abdominal wall after hernia repair, with reduced complications. We present early results of our patients undergoing this technique. Five patients were selected for open midline repairs; three with chronic infections, one with a prior midline skin graft, and one who desired a primary, tension-free repair. These three males and two females had a mean age of 50.8 +/- 21.1 years and body mass index of 30.9 +/- 6.2. The mean number of previous abdominal operations was 7 +/- 3.4 and previous attempted hernia repairs were 4 +/- 2.7. All patients had a midline laparotomy with lysis of adhesions. An endoscopic component separation was then performed bilaterally. Drains were left in the dissection bed. All patients had the midline closed; four received biologic mesh underlays. Mean operative time was 227 minutes +/- 49. Mean length of stay (LOS) was 9.2 days +/- 3.6. Early median follow-up was 6 months (range 0.25-9). Two patients required postop transfusions, and two patients had mild complications of the midline wound (hematoma, infection). To date, one recurrence was diagnosed by CT scan. Early evaluation of adopting the minimally invasive (MIS) component separation demonstrates minimal complications and good initial outcomes.

An ideal suture for midline abdominal closure?

Within the last decade the customary trend of using non absorbable sutures has changed, with numerous studies and meta-analyses advocating the use of slowly absorbable sutures, claiming comparable wound strength with significantly lower incidence of wound complications. It was the objective of this randomized clinical trial to compare two universally accepted suture materials, the non-absorbable Nylon and the slowly absorbable Polydioxanone for midline abdominal closure in the Indian context. 64 patients undergoing midline laparotomy were allocated, using block randomization, to mass closure of the abdominal wall with continuous polyamide (34 patients) or continuous polydioxanone (30 patients). There was an alarmingly higher incidence of wound dehiscence in the PDS group requiring secondary suturing (Nylon 0; PDS 5). Mid-way through the trial, an interim analysis was performed which revealed an unacceptably high incidence of wound dehiscence in the PDS group. This necessitated a premature curtailment of the study. There was, however, a statistically significantly higher incidence of scar pain in the Nylon group (Nylon 9; PDS 1). There is a need for a study with larger series, and PDS as a choice of suture for midline wound closure cannot be recommended.

Treatment of Large Skin Necrosis following a Modified Avelar Abdominoplasty with the Erchonia EML 635 nm Laser and Platelet-Rich Plasma

Objective: Skin necrosis of the flap and delayed wound healing are common complications of abdominoplasty surgery. A case report is presented of a patient who was treated with the 635 nm or low-level laser therapy (LLLT) and platelet-rich plasma (PRP). Both of these modalities have been shown to accelerate wound healing and improve the appearance of the scar. Materials and Methods: Case report. Case Presentation: A 62-year-old female with chronic hypertension underwent a modified Avelar abdominoplasty. She developed skin necrosis at the midline from her umbilicus to the lower horizontal incision. Also, mild necrosis was noted in her upper abdomen in the area of the left superior epigastric vessel. The patient had negative bacterial cultures and was given daily 635 nm laser treatments for the first month. PRP (Smart PReP System, Harvest Technologies Corp, Plymouth, Mass) was used for the early small open wounds and then on the large midline wound after the eschar had lifted. Discussion: Skin necrosis is a complication that can occur after abdominoplasty surgery. The area between the umbilicus and the lower incision is the area where profound devascularization occurs, as was demonstrated by Mayr. Despite upper abdominal undermining limited at the midline to 3 cm, skin necrosis still occurred in this patient and was evident 6 days postoperatively. LLLT was started on the first postoperative day to treat surgical pain and inflammation; treatments were provided daily after necrosis was diagnosed on the sixth postoperative day. When the patient developed open wounds near the umbilicus, activated PRP (PRP with calcium chloride and topical thrombin) was placed in the deepithelialized wounds to accelerate healing. The activator was made by combining 5 ml of 10% calcium chloride with 5000 units of bovine thrombin in a PRP-to-activator ratio of 10:1. An increase in tissue exudate was noted with LLLT. When the eschar had lifted, the wound was treated with activated PRP and with daily 635 nm laser treatments. The patient healed within 3 months. Conclusion: Ischemic flaps can be treated with LLLT and with PRP. When both modalities are used, the healing is accelerated, and the final aesthetic appearance of the scar is improved, so future corrective surgery is avoided.

Delayed Wound Healing in Sacrococcygeal Pilonidal Sinus Coincides with an Altered Collagen Composition

Despite the availability of a range of surgical techniques, wound healing after pilonidal sinus surgery can be problematic. There is a paucity of scientific data regarding this problem, and Binnebosel et al. [1] should be congratulated for their careful study of wound healing after pilonidal sinus surgery. They have shown a clear relationship between disturbances of several components of the extracellular matrix at the excision margins and subsequent wound healing in patients who underwent pilonidal sinus surgery. What is the clinical relevance of these findings? It is not clear from this study whether the demonstrated differences in the extracellular matrix are due to a systemic problem in wound healing in a subgroup of patients or active inflammation at the excision margins. Would more radical excision back to ‘‘normal tissue’’ result in a higher rate of primary wound healing? There was a relatively high rate of failure of primary wound healing (27%) in this series. This may reflect the fact that wounds were closed in the midline and that no antibiotic prophylaxis was used. Techniques of pilonidal sinus surgery that avoid a midline wound have much lower reported rates of wound failure [2]. It would be interesting to see whether similar changes in the extracellular matrix are found in patients who have wider, eccentric excisions for pilonidal sinus, for example, the Karydakis procedure [3].