Risk Of Dehiscence Research Articles

505. USE OF INDOCYANINE GREEN FOR ASSESSMENT OF GASTROPLASTY VASCULARIZATION AFTER MCKEOWN ESOPHAGECTOMY

Abstract Background Anastomotic leakage is one of the most feared complications of esophagogastric surgery, conferring significant morbidity and mortality in these patients. It is known that inadequate vascularization of the gastroplasty is a major risk factor for anastomotic dehiscence. The aim of this study is to evaluate and demonstrate the utility of intraoperative use of indocyanine green (ICG) in patients undergoing esophagectomy and reconstruction with gastroplasty to assess the relationship between its vascularization and the presence of anastomotic leakage in the postoperative period. Methods Prospective, longitudinal, observational, and analytical study of 36 consecutive cases in which intraoperative ICG was used for patients undergoing McKeown esophagectomy and reconstruction with gastroplasty and cervical anastomosis from June 2021 to December 2023. The distance traveled by the ICG in a proximal direction from the pylorus at 30 and 90 seconds after its intravenous infusion was measured. An automatic baseline point or point of maximum fluorescence was also recorded and compared both in net value and in percentage at 30, 60, 90, and 120 seconds after the infusion of ICG with the theoretical zone of anastomosis construction (zone reaching the sternal manubrium after extending the graft over the sternum). Statistical analysis was performed using SPSS version 24.0. Results The rate of leaks and necrosis of the graft was 19.4% and 2.8%, respectively. There is a significant relationship (p<0.05) between the rate of anastomotic dehiscence and the net value and percentage compared with the automatic baseline point of ICG at the anastomosis site and at the apex of the gastroplasty at 30, 60, 90, and 120 seconds. Using a ROC curve (figure 1) that analyzed the time it takes for ICG to reach the anastomosis, a cutoff point of 19.5 seconds was established, which gives ICG greater profitability as a diagnostic test with an AUC of 0.821 (0.642-1). The positive predictive value of this test is 0.36, and the negative predictive value is 1. Conclusion The use of indocyanine green appears to be a good method for identifying those anastomoses and gastroplasties that present a high risk of dehiscence and/or necrosis. The time it takes for ICG to reach the anastomosis, the speed at which it does so, as well as the quantitative value provided by the platform used, seem to be valid parameters for identifying high-risk cases. This would allow for the performance of additional measures to reduce the risk of dehiscence and/or necrosis. Randomized prospective studies with a larger sample size would be necessary.

Fastening the Future: Surgical Zip Ties for Enhanced Wound Closure and Patient Well-Being

Surgical zip tie skin closures are emerging as a revolutionary approach in wound management, promising significant advancements in patient safety and surgical success. Current research emphasizes the efficacy of zip tie closures in promoting wound healing, reducing the risk of dehiscence, and enhancing cosmetic outcomes across various surgical procedures. Compared to traditional suturing techniques, zip tie closures offer secure wound approximation, minimize tension on wound edges, and contribute to faster recovery times with lower incidences of infection and scarring. Case studies and clinical trials demonstrate the effectiveness of these closures, emphasizing their role in improving surgical outcomes. Future investigations should focus on optimizing zip tie design and material properties to ensure compatibility with different skin types and surgical sites. Innovations in biodegradable and antimicrobial materials could further enhance the utility and applications of zip ties. The potential for using zip tie closures in minimally invasive and robotic-assisted surgeries offers precision and ease of use in complex procedures. Multidisciplinary collaboration between surgeons, engineers, and biomaterial scientists is essential for refining zip tie closure systems, conducting clinical trials, and establishing standardized protocols for integration into routine surgical practice. Addressing challenges related to material biocompatibility, mechanical strength, and user ergonomics will be essential for navigating challenges and limitations. Ultimately, the adoption of surgical zip tie skin closures has the potential to revolutionize wound management and improve patient care, setting new standards in surgical care through innovation and evidence-based practice.

Maternal and Fetal Outcomes after Multiple Cesarean Deliveries.

Background/Objectives: Cesarean delivery (CD) is a common procedure, but it can be associated with some increasing risks as the number of previous CD increases. Although women undergoing multiple CDs is very unusual in Spain, our center serves pregnant women with a history of three or more previous CDs with some frequency. We aimed to assess whether women who undergo multiple CDs (≥4) have more risks than those who undergo a third CD. Material and Methods: A retrospective cohort study was conducted with 161 pregnant women who had undergone ≥ 2 previous CDs and were monitored during their next pregnancy. The primary endpoint was to evaluate the obstetric hemorrhage rate in the multiple CD group and compare it with that in the third CD group. Secondary outcomes regarding maternal and neonatal complications were also analyzed. Results: Hemorrhage (7% and 10%; p = 0.522) and transfusion (3% and 8%; p = 0.141) rates were similar in both groups. The risk of dehiscence of the uterine segment (6% and 24%; p < 0.006), as well as hysterectomy (0 and 6.6%, p = 0.019), difficult abdominal opening (49% and 82%; p = 0.001), peritoneal adhesions (3% and 22%; p < 0.001), and difficult bladder separation (36% and 73%; p < 0.001), was higher in the multiple CD group. No uterine rupture or maternal-neonatal mortality was observed in either of the groups. Conclusions: Since undergoing multiple CD is uncommon, our study may be the largest sample in our environment. Our findings suggest that despite the potential risks of undergoing multiple CDs, maternal and neonatal outcomes are overall favorable.

Practice Patterns in Sternal Closure and Evaluation of Adoption of a Novel Sternal Closure Device.

The technique for sternal closure has remained largely unchanged owing to the efficacy, simplicity, and low cost of stainless-steel sternal wires. Despite their ubiquity, several other closure devices designed to address the complications associated with sternal wires such as sternal bleeding and dehiscence have become popular. We have developed a novel sternal closure device that reduces sternal bleeding and dehiscence. This study quantifies the use of currently available sternal closure devices and determines predicted uptake of the novel device. An electronic survey, designed to determine practice patterns for sternal closure, was distributed to 70 US cardiac surgeons. The survey included a discrete choice section in which surgeons evaluated relative value of device attributes including cost, ease of emergent sternal reentry, and dehiscence risk. There were 70 surgeons from 30 states who completed the survey. The most frequent means of sternal closure was straight sternal wires (35.8%), followed by straight sternal wires plus figure-of-8 sternal wires (18.1%), double wires (10.9%), plates (10.2%), and other (25%). The relative utilization shifted from sternal wires to sternal plates as the risk for dehiscence increased. The adoption of the novel closure device was estimated at 34.6%. The standard stainless-steel sternal wire remains the most common means of sternal reapproximation, but its utilization is lower in patients at high risk for sternal dehiscence. Based on this survey, there is acceptance in the community for a novel sternal closure device designed to address the limitations of traditional sternal closure methods.

ZAGA Double Pedicle Palatal Flap for Soft Tissue Management in Zygomatic Surgery.

Oral rehabilitation of the atrophic maxilla using prostheses anchored on zygomatic implants is a well-documented process. To prevent the risk of sinusitis and or oro-antral communications, the placement of zygomatic implants with an externalized path has been proposed. In these cases where the sealing of the implant neck depends exclusively on a hemidesmosomal junction, there is a risk of dehiscence of the soft tissue. This can lead to esthetic problems, bone resorption, oro antral communication, cellulitis, and even orbital infection. To avoid soft tissue recession when implants are placed in a buccal position to the remaining ridge, different procedures have been proposed, the simplest being a good buccal coverage of the implant by keratinized tissue. In this technical note, we propose the use of a double pedicle palatal flap to increase the keratinized tissue buccal to the implant and, at the same time, to facilitate the incision closure by initial intention.

Non-Thermal Plasma Treatment of Poly(tetrafluoroethylene) Dental Membranes and Its Effects on Cellular Adhesion.

Non-resorbable dental barrier membranes entail the risk of dehiscence due to their smooth and functionally inert surfaces. Non-thermal plasma (NTP) treatment has been shown to increase the hydrophilicity of a biomaterials and could thereby enhance cellular adhesion. This study aimed to elucidate the role of allyl alcohol NTP treatment of poly(tetrafluoroethylene) in its cellular adhesion. The materials (non-treated PTFE membranes (NTMem) and NTP-treated PTFE membranes (PTMem)) were subjected to characterization using scanning electron microscopy (SEM), contact angle measurements, X-ray photoelectron spectroscopy (XPS), and electron spectroscopy for chemical analysis (ESCA). Cells were seeded upon the different membranes, and cellular adhesion was analyzed qualitatively and quantitatively using fluorescence labeling and a hemocytometer, respectively. PTMem exhibited higher surface energies and the incorporation of reactive functional groups. NTP altered the surface topography and chemistry of PTFE membranes, as seen through SEM, XPS and ESCA, with partial defluorination and polymer chain breakage. Fluorescence labeling indicated significantly higher cell populations on PTMem relative to its untreated counterparts (NTMem). The results of this study support the potential applicability of allyl alcohol NTP treatment for polymeric biomaterials such as PTFE-to increase cellular adhesion for use as dental barrier membranes.

Use of a barrier membrane to repair congenital hard palate defects and to close oronasal fistulae remaining after cleft palate repair: seven dogs (2019-2022).

To describe the use of a barrier membrane in dogs for repair of congenital hard palate defects and closure of oronasal fistulae (ONF) remaining after previous cleft palate (CFP) repair. 7 client-owned dogs. The hard palate defect was closed with medially positioned flaps (Von Langenbeck technique) or pedicle flaps (2-flap palatoplasty) and a membrane composed of autologous auricular cartilage from the pinna or allogenous fascia lata underlying the mucoperiosteal flaps. All palate defects were considered to have a high risk of dehiscence based on their type and size and the characteristics of the surrounding tissue. The barrier membrane was used in 5 dogs for repair of congenital hard palate defects and in 2 dogs for closure of ONF remaining after previous CFP repair. Resolution of clinical signs occurred in all cases. Complete success (ie, complete closure of the palate defect and absence of clinical signs) was achieved in 5 dogs (4 with congenital hard palate defects and 1 with an ONF remaining after previous CFP repair). The persistent ONF in 1 dog with functional success (incomplete closure, but no clinical signs) was smaller than prior to surgery. Barrier membranes underlying mucoperiosteal flaps may constitute an alternative technique in dogs for repair of congenital hard palate defects and closure of ONF remaining after previous CFP repair.

The Feasibility and Outcome of Integra® Bilayer Matrix in the Reconstruction of Oral Cavity Defects.

To evaluate the feasibility, safety, and failure rate of Integra® Bilayer Wound Matrix (Integra) in the reconstruction of oral cavity defects. Retrospective cohort study. All study information was collected from a single academic tertiary care hospital. Subjects included adult patients who underwent oral cavity resection and immediate subsequent reconstruction with Integra® Bilayer Wound Matrix at MD Anderson Cancer Center between the years 2015 and 2020. The following variables were collected: patient's demographics, comorbidities, disease stage, treatment and reconstruction modalities, and surgical outcome from the medical records. Statistical analysis included distribution analysis for all collected parameters and Pearson's χ2 tests to find correlation between variables and take rate of Integra. Eighty-three patients underwent reconstruction with Integra® Bilayer Wound Matrix dressing. Average age was 66 years old. Thirty-nine patients (47%) had history of previous resections for oral cavity tumors. Fourteen patients (17%) had history of radiation therapy to the Head and Neck region. Most common pathology was invasive squamous cell carcinoma (75%) followed by dysplasia (12%). Complete wound healing with good cellular integration occurred in 83 patients (96%) with only 3 failures requiring additional surgery. Reconstruction of mandibulectomy defects was associated with increased risk of dehiscence and bone exposure (0.66, P = .03). This study shows promising results with high take rate of Integra® Bilayer Wound Matrix dressing in the reconstruction of various oral cavity defects. We encourage surgeons to adopt this technique as a viable and versatile option into the reconstruction ladder of oral cavity defects.

Tension Reduction With Force Modulating Tissue Bridges Reduces Wounds in Breast Surgery.

Tension on healing wounds increases the risk of dehiscence and poor or pathologic scar formation. Force modulating tissue bridges (FMTBs) represent a new class of wound closure and support devices designed to offload tension on healing wounds to improve wound healing and scar outcomes. The study was undertaken to assess the efficacy of FMTBs to reduce the risk of wound healing complications in elective breast surgery. One hundred twenty-two consecutive patients undergoing bilateral aesthetic breast surgery underwent intraoperative placement of FMTBs on the vertical limb closure site. A matched case-control cohort of 121 consecutive patients was established for comparison. Wounds were considered significant if larger than 3 mm in diameter. The primary outcome of breast wounds >3 mm was reported with a relative risk, and all outcomes were framed with number needed to treat. The control and intervention cohorts had similar demographics, comorbidities, type of operation, and incision pattern utilized. Within the FMTB group, 96.7% (n = 118) patients completed treatment per protocol. Significant wounds occurred in 1.7% (n = 2) of patients in the tissue bridge vs 15.2% (n = 19) in controls on a per patient/per protocol basis (89% reduction, P < .001). Statistically significant improvements were maintained on sensitivity analyses with intention to treat, even when minor wounds were included. There were no complications noted related to FMTBs. FMTBs are safe and highly effective at reducing the risk of wound formation in elective breast surgery. Results are consistent with sensitivity analyses based on clinical and methodological factors. Further research will assess long-term scar outcomes.

A novel tension relief technique to aid the primary closure of traumatic equine wounds under excessive tension.

To achieve an excellent functional and cosmetic result, primary closure is preferred over leaving wounds to heal by secondary intention. However, traumatic wounds are often under excessive tension during wound closure and incorrect suture technique can compromise microcirculation, leading to skin necrosis and impaired wound healing. To describe an inexpensive and effective tension relief technique that helps the successful primary closure of a variety of equine wounds at high risk of dehiscence. Retrospective case series. All wounds that were managed with the Tension Tile System (TTS) at four Equine Hospitals between March 2017 and May 2021 were evaluated. The wounds were classified according to various criteria including anatomical location, time elapsed prior to surgery, depth of wound and post-surgical use of immobilisation. Outcome criteria were based on the success of primary intention healing. The duration of convalescence (weeks) after surgery was also recorded. During the study period, the TTS was used in 191/860 (22%) wounds repaired under general anaesthesia or standing sedation. Overall, primary intention healing (Group A) was achieved in 132 of 191 cases (69%, CI 62%-75%), with partial dehiscence (Group B) in a further 30/191 cases (16%, CI 11%-22%). Severe dehiscence (Group C) was recorded in 29/191 cases (15%, CI 11%-21%). The median convalescence time was 4 weeks (Range 3-15, interquartile range 4-6) in Group A. Retrospective nature of the study and subjective outcome assessment. The technique was applied to wounds under significant tension; however, this was based on a subjective assessment by the surgeons involved. The Tension Tile System is an economical and effective technique for challenging equine wounds under tension, in a variety of anatomical locations.

Послеоперационные осложнения при редукционной маммопластики

An analysis of the literature indicates that reduction mammoplasty continues to be a widely popular procedure in the treatment of macromastia. At the same time, there is inconsistency in reporting risk factors predisposing to postoperative complications. According to various studies, the frequency of postoperative complications during reduction mammoplasty ranges from 4.3- 8.2% to 14.0-23.0%. The most common complications were minor hematomas (8.1%), bleeding (4.0%), skin and nipple necrosis or suture dehiscence (8.9–41.7%), and delayed healing due to superficial infection (7.3-26.0%), which resulted in hypertrophic scars (13.0-20.0%), deep infection (1.1-8.0%) and seroma formation (1.2-14,0%) and change sensitivity of the nipple (8.4%) or breast (7.8%). Reoperation rates were 6.7% for scars, 1.4% for fat necrosis, and 1.0% for wounds. The incidence of complications in patients with and without concomitant diseases was 10.2% and 4.6%, respectively, i.e. 2.2 times more. Fat necrosis and infection were more common in obese patients. Smokers had a 2.03 times higher risk of infection and a 2.34 times higher risk of dehiscence. These studies can serve as the basis for preoperative patient education, choice of surgical method for reduction mammoplasty, and determination of the amount of postoperative care. In most cases, patients who have undergone reduction mammoplasty note an improvement in their quality of life, a decrease in pain and an increase in self-esteem. At the same time, the proportion of older patients wishing to improve their quality of life and physical function is increasing.

Risk Factors and Complications in Reduction Mammaplasty: A Systematic Review and Meta-analysis.

Reduction mammaplasty (RM) has become established as the standard effective method for treating macromastia, but reports on the risk factors that predispose to postoperative complications have been conflicting. This meta-analysis aimed to pool the available data to identify predictors of complications following RM. The PubMed, Web of Science, Embase, and Cochrane databases were screened from inception to 1 Jan 2022, and studies were included based on predefined criteria. The perioperative risk factors BMI, smoking, age, diabetes, radiation therapy, and tissue resection weight were extracted and their correlation with complications assessed. A total of 40 studies comprising of 5908 patients were included. BMI ≥ 30kg/m2 (OR = 1.65, 95% CI 1.35-2.02; p < 0.01) and ≥ 40kg/m2 (OR = 1.97, 95% CI 1.26-3.08; p < 0.01), smoking (OR = 2.57, 95% CI 2.01-3.28; p < 0.01), diabetes (OR = 2.21, 95% CI 1.19-4.07; p < 0.05), a unilateral resection weight ≥ 1000g (OR = 1.76, 95% CI 1.02-3.05; p < 0.05), and radiation therapy (OR = 11.11, 95% CI 2.01-3.28; p < 0.01) were associated with higher rates of postoperative complications. Obese patients (BMI ≥ 30kg/m2) were more likely to experience fat necrosis (OR = 3.00, 95% CI 1.37-6.57; p < 0.01) and infection (OR = 1.66, 95% CI 1.15-2.40; p < 0.05). Smokers had a 2.03 times higher risk of infection (95% CI 1.24-3.31; p < 0.01) and 2.34 times higher risk of dehiscence (95% CI 1.38-3.98; p < 0.01). No association between complication occurrence and age 40 or 50 years or total tissue resection weight ≥ 1000g was identified. This meta-analysis provides evidence that obesity, smoking, diabetes, unilateral resection weight ≥ 1000g, and preoperative radiation therapy predispose to complication occurrence in RM. This information can optimize the ability of surgeons to provide preoperative patient education, perioperative assessment, and postoperative care planning. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vaginal Cuff Dehiscence and a Guideline to Determine Treatment Strategy.

In this retrospective study, our aim was to investigate a novel treatment strategy guideline for vaginal cuff dehiscence after hysterectomy based on the mode of operation and time of occurrence in patients who underwent hysterectomy at Severance Hospital between July 2013 and February 2019. We analyzed the characteristics of 53 cases of vaginal cuff dehiscence according to the mode of hysterectomy and time of occurrence. Out of a total of 6530 hysterectomy cases, 53 were identified as vaginal cuff dehiscence (0.81%; 95% confidence interval: 0.4-1.6%). The incidence of dehiscence after minimally invasive hysterectomy was significantly higher in patients with benign diseases, while malignant disease was associated with a higher risk of dehiscence after transabdominal hysterectomy (p = 0.011). The time of occurrence varied significantly based on menopausal status, with dehiscence occurring relatively earlier in pre-menopausal women compared to post-menopausal women (93.1% vs. 33.3%, respectively; p = 0.031). Surgical repair was more frequently required in cases of late-onset vaginal cuff dehiscence (≥8 weeks) compared to those with early-onset dehiscence (95.8% vs. 51.7%, respectively; p < 0.001). Patient-specific factors, such as age, menopausal status, and cause of operation, may influence the timing and severity of vaginal cuff dehiscence and evisceration. Therefore, a guideline may be indicated for the treatment of potentially emergent complications after hysterectomy.

Bone regeneration as treatment of peri-implant disease: A narrative review.

Analysis of the 3-dimensional implant position, the bone defect morphology, and the soft tissue situation guides the decision to preserve or to remove an implant with a severe peri-implantitis lesion. The aim of this narrative review was to analyze and to comprehensively illustrate the treatment options focusing on peri-implant bone regeneration in presence of severe peri-implant bone loss. A database search was performed independently by the two reviewers to identify case reports, case series, cohort, retrospective, and prospective studies about peri-implant bone regeneration with a follow-up of at least 6 months. Of the 344 studies issued during the database analysis, 96 publications were selected by the authors for this review. Deproteinized bovine bone mineral remains the best documented material for defect regeneration in peri-implantitis in combination with or without a barrier membrane. While studies using autogenous bone in peri-implantitis therapy are rarely found, they do report favorable potential of vertical bone regeneration. Moreover, while membranes are an inherent part of the guided bone regeneration, a 5-year follow-up study demonstrated clinical and radiographic improvements with and without a membrane. The administration of systemic antibiotics is frequently performed in clinical studies observing regenerative surgical peri-implantitis therapy, but the analysis of the literature does not support a positive effect of this medication. Most studies for regenerative peri-implantitis surgery recommend the removal of the prosthetic rehabilitation and the use a marginal incision with a full-thickness access flap elevation. This allows for a good overview for regenerative procedures with a certain risk of wound dehiscences and incomplete regeneration. An alternative approach referring to the poncho technique may reduce the risk of dehiscence. The effectiveness of implant surface decontamination might have an impact on peri-implant bone regeneration without any clinical superiority of a certain technique. The available literature reveals that the success of peri-implantitis therapy is limited to the reduction of bleeding on probing, the improvement of the peri-implant probing depth and a small amount of vertical defect fill. On this basis, no specific recommendations for bone regeneration in surgical peri-implantitis therapy can be made. Innovative approaches for flap design, surface decontamination, bone defect grafting material, and soft tissue augmentation should be followed closely to find advanced techniques for favorable peri-implant bone augmentation.

O169 A systematic review on the effect of bone wax application in cardiac surgery

Abstract Introduction Limited and conflicting evidence exists on whether bone wax usage in cardiac surgery increases risk of infection. A systematic review was conducted to examine the cardiac surgery postoperative outcomes following bone wax application. Method Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to in this review. The EMBASE, MEDLINE and Scopus databases were searched for studies evaluating perioperative bone wax usage, excluding non-English papers. All relevant synonyms of Cardiac Surgery, Bone Wax, Infection, and Healing were used for paper identification. Wound infection, sternal dehiscence, postoperative sternal bleeding, postoperative chest drainage and mortality were outcomes of interest. Results From the 66 articles identified, 5 were included following full-text screening. No statistically significant difference in infection risk between the bone wax (BW) and comparator groups existed. However, the evidence suggests bone wax significantly increases sternal dehiscence risk. Studies reporting postoperative bleeding showed a significantly greater mean volume in the BW group. All studies reporting postoperative chest drainage (n=3) showed a greater mean volume in the BW group, of which two were significant. Of the three papers reporting mortality, two showed increased risk in the BW group. Conclusion Current evidence indicates no significant association between bone wax and wound infection. Bone wax is associated with increased risk of sternal dehiscence, postoperative sternal bleeding, postoperative chest drainage and mortality. Greater emphasis should be placed on bone wax alternatives in clinical practice. Limited data necessitates larger studies, and for clearer guidelines to be established around them.

Frequency and Associated Factors of Postoperative Wound Dehiscence in Posterior Cervical Spine Surgery.

Wound dehiscence after cervical spine surgery is a well-known complication that can be a challenge for spine surgeons to manage, especially in cases of exposed implants. However, few studies have focused primarily on this phenomenon in cervical spine surgery to date. This investigation sought to determine the frequency of wound dehiscence following posterior cervical spine surgery and identify patient-based risk factors. The medical data of 405 consecutive patients (290 male and 115 female; mean age: 68.9years) who underwent posterior cervical spine surgery were retrospectively examined. Logistic regression models were employed to examine the prevalence, characteristics, and risk factors of postoperative wound dehiscence. We observed that 5.2% of cervical spine surgery patients experienced procedural postoperative wound dehiscence. In comparisons of dehiscence and non-dehiscence groups, significant differences were found for posterior instrumented fusion (81.0% vs. 45.3%; P < 0.01), extended T1 fusion (57.1% vs. 12.8%; P < 0.01), occipitocervical fusion (19.0% vs. 6.2%; P= 0.048), fused intervertebral levels (4.0 vs. 1.5; P < 0.01), surgical time (246minutes vs. 165minutes; P < 0.01), blood loss volume (228mL vs. 148mL; P= 0.023), and dialysis (14.3% vs. 1.8%; P= 0.011). Multivariate analysis identified extended T1 fusion and dialysis to be significantly associated with wound dehiscence with odds ratios of 5.82 and 10.70, respectively. The observed frequency of postoperative wound dehiscence in cervical spine surgery was 5.2%. As extended T1 fusion and dialysis may increase the risk of dehiscence after surgery, patients who display such risk factors may require additional observation and care.

Fascial dehiscence: predictable complication? Development and validation of a risk model: a retrospective cohort study.

Fascial dehiscence is still an important cause of morbidity and mortality in the postoperative period of abdominal surgery. Different authors have sought to identify risk factors for this entity. Two risk scores have been developed, but they include postoperative variables, which hinder preventive decision-making during the early surgical period. Our aim is to identify preoperative and intraoperative risk factors for fascial dehiscence and to develop and validate a risk prediction score that allows taking preventive behaviors. All adult patients, with no prior history of abdominal surgery, who underwent midline laparotomy by a general surgery division between January 2009 and December 2019 were included. Recognized preoperative risk factors for fascial dehiscence were evaluated in a univariate analysis and subsequently entered in a multivariate stepwise logistic regression model. A prognostic risk model was developed and posteriorly validated by bootstrapping. This study was conducted following the STROBE statement. A total of 594 patients were included. Fascial dehiscence was detected in 41 patients (6.9%). On multivariate analysis, eight factors were identified: chronic obstructive pulmonary disease (COPD), immunosuppression, smoking, prostatic hyperplasia, anticoagulation use, sepsis, and overweight. The resulting score ranges from 1 to 8. Scores above 3 are predictive of 18% risk of dehiscence with a sensitivity of 70% and specificity of 80% (ROC 0.88). We present a new preoperative prognostic score to identify patients with a high risk of fascial dehiscence. It can be a guide for decision-making that allows taking intraoperative preventive measures. External validation is still required.

Topical vanadate improves tensile strength and alters collagen organisation of excisional wounds in a mouse model.

Wound dehiscence, oftentimes a result of the poor tensile strength of early healing wounds, is a significant threat to the post-operative patient, potentially causing life-threatening complications. Vanadate, a protein tyrosine phosphatase inhibitor, has been shown to alter the organisation of deposited collagen in healing wounds and significantly improve the tensile strength of incisional wounds in rats. In this study, we sought to explore the effects of locally administered vanadate on tensile strength and collagen organisation in both the early and remodelling phases of excisional wound healing in a murine model. Wild-type mice underwent stented excisional wounding on their dorsal skin and were divided equally into three treatment conditions: vanadate injection, saline injection control and an untreated control. Tensile strength testing, in vivo suction Cutometer analysis, gross wound measurements and histologic analysis were performed during healing, immediately upon wound closure, and after 4 weeks of remodelling. We found that vanadate treatment significantly increased the tensile strength of wounds and their stiffness relative to control wounds, both immediately upon healing and into the remodelling phase. Histologic analysis revealed that these biomechanical changes were likely the result of increased collagen deposition and an altered collagen organisation composed of thicker and distinctly organised collagen bundles. Given the risk that dehiscence poses to all operative patients, vanadate presents an interesting therapeutic avenue to improve the strength of post-operative wounds and unstable chronic wounds to reduce the risk of dehiscence.

Management of Vaginal Vault Dehiscence after Laparoscopic Hysterectomy

<h3>Study Objective</h3> To review the epidemiology, diagnosis and management of vaginal vault dehiscence, and to illustrate a 5-step surgical approach to laparoscopic vault repair. <h3>Design</h3> Surgical footage was obtained from an emergency case after appropriate consent from the patient. <h3>Setting</h3> A tertiary care centre. <h3>Patients or Participants</h3> A 34-year-old female who presented 8 weeks after a total laparoscopic hysterectomy with a complete vault dehiscence. <h3>Interventions</h3> Vaginal vault dehiscence complicates 0.64% to 1.35% of laparoscopic hysterectomies, and can be categorized as complete cuff dehiscence, partial cuff dehiscence or partial thickness. Protective factors include the use of barbed sutures as compared to non-barbed sutures and laparoscopic closure as compared as compared to vaginal closure. Smoking and low BMI have been associated with an increased risk of dehiscence. <h3>Measurements and Main Results</h3> The surgical approach to a laparoscopic repair of cuff dehiscence can be standardized in 5 reproducible steps: abdominal survey, bladder and/or rectal dissection, vault debridement, vault closure and cystoscopy. <h3>Conclusion</h3> Vaginal vault dehiscence being uncommon, residents may graduate without being exposed to a case. This video represents an educational tool that covers the clinical and surgical approaches to the reproducible management of vaginal vault dehiscence.

Vaginal Cuff Dehiscence Rates by Mode of Hysterectomy: An Update

<h3>Study Objective</h3> To report vaginal cuff dehiscence rates by mode of hysterectomy as the surgical landscape has shifted towards minimally invasive approaches. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Large academic medical center and affiliated community hospital. <h3>Patients or Participants</h3> 4722 patients who underwent hysterectomy for benign and malignant indications between January 2010 and August 2021. <h3>Interventions</h3> Hysterectomy patients and vaginal cuff dehiscences were identified by ICD and CPT codes. <h3>Measurements and Main Results</h3> There were 663 supracervical hysterectomies and 4059 total hysterectomies identified (1360 robot-assisted total laparoscopic hysterectomies [RA-TLH, 28.8%], 1107 total abdominal hysterectomies [TAH, 23.4%], 938 total laparoscopic hysterectomies [TLH, 19.9%], 498 total vaginal hysterectomies [TVH, 10.5%], and 156 laparoscopic-assisted vaginal hysterectomies [LAVH, 3.3%]). Supracervical hysterectomies were excluded from analysis. Among 4059 total hysterectomies, there were 15 vaginal dehiscences (0.37%). The dehiscence rate was highest after RA-TLH at 0.66% (n=9), followed by TLH at 0.32% (n=3), and TAH at 0.27% (n=3), with no dehiscences after TVH or LAVH; these differences were not statistically significant (<i>p</i>=0.31). Compared to TAH, the relative risk for dehiscence after RA-TLH was 2.44 (95% CI 0.66 – 9.00), and after TLH was 1.18 (95% CI 0.24 – 5.83), which were also not statistically significant. Patient characteristics were reviewed including age, hysterectomy indication, colpotomy type, suture type, medical comorbidities, and presentation. The mean time to dehiscence was 39 days (range 8 – 145). The most common trigger event was coitus (41%). Most dehiscences followed benign hysterectomies (88%). <h3>Conclusion</h3> Our study offers the largest representation of robotic hysterectomies to date. Although dehiscence rates were higher after laparoscopic hysterectomy (RA-TLH 0.66%, TLH 0.32%) compared to abdominal hysterectomy (TAH 0.27%), the differences were not significant. Our 0.66% RA-TLH dehiscence rate is much lower than previously reported in large studies (1.6 – 4.1%). While broad conclusions are limited, dehiscences are overall rare (0.37%). More research is needed to evaluate factors responsible for increased risk.