Wound Morbidity Rates Research Articles

Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure.

Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. A prospective study with 27 patients with a hernia defect of ≥ 10cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. Imaging post-BTA revealed hernia width reduction of 1.9cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

Stopping prehospital chlorhexidine skin wash does not increase wound morbidity after incisional hernia repair: results of a 4-year quality improvement initiative.

Prehospital chlorhexidine gluconate (CHG) skin washes are used to prevent wound complications, but little evidence supports this practice in hernia surgery. A propensity-matched retrospective review published by our group in 2016 found that prehospital CHG was associated with an increased risk of surgical site occurrences (SSO) and surgical site infections (SSI) after ventral hernia repair. Prehospital CHG was, therefore, abandoned by three of five surgeons at the Cleveland Clinic Foundation (CCF) by April 2017. We aimed to determine if discontinuation of prehospital CHG affected wound morbidity rates after incisional hernia repair. The Abdominal Core Health Quality Collaborative was queried for all patients who underwent open, clean incisional hernia repairs with 30-day follow-up from 2014 to 2019. Using an interrupted time series (ITS) analysis model adjusted for group and mean propensity score, wound morbidity before and after April 1, 2017 (start of Q2) was compared between three groups: CCF surgeons who abandoned prehospital CHG (Group 1), CCF surgeons who continued using prehospital CHG (Group 2), and non-CCF surgeons using prehospital CHG (Group 3). Outcomes included rates of SSOs, SSIs, and surgical site occurrences requiring procedural intervention (SSOPI) at 30days. In total, 4276 patients were included in the analysis (Group 1: 339 before Q2 vs 673 after Q2; Group 2: 211 before Q2 vs 175 after Q2; Group 3: 1312 before Q2 vs 1566 after Q2). Rates of SSO, SSIs, and SSOPIs at 30days were similar across all three groups before and after prehospital CHG discontinuation. Stopping prehospital CHG wash did not result in increased wound morbidity after open, clean, incisional hernia repair. We have abandoned CHG use in this context.

Endoscopic Anterior Component Separation and Transversus Abdominus Release are not Associated with Increased Wound Morbidity Following Retromuscular Incisional Hernia Repair.

Traditional anterior component separation during incisional hernia repair (IHR) is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence (SSO) compared to IHR without component separation (CS). This was a retrospective single-center cohort study of patients undergoing open retromuscular IHR comparing patients with or without the use of CS. Retromuscular mesh repair was performed in all patients, and CS was obtained by eACS or TAR. The primary outcome was 90-day incidence of postoperative SSO. Secondary outcomes included length of stay (LOS), 90-day readmission, 90-day reoperation rate and 3-year recurrence rate. A total of 321 patients underwent retromuscular repair, 168 (52.3%) of whom received either eACS or TAR. The addition of eACS or TAR was associated neither with development of SSO (odds ratio: 1.80, 95% confidence interval: 0.94-3.46, P = 0.077) nor with hernia recurrence (hazard ratio 0.77, 0.26-2.34, P = 0.648). There was no significant difference between the groups regarding the frequencies of 90-day readmission or 90-day reoperation. eACS or TAR as adjuncts to open retromuscular IHR were not associated with increased wound morbidity or hernia recurrence.

P-131 SHORT TERM RESULTS OF PREOPERATIVE TOXIN BOTULINUM A IN PREPARATION FOR ABDOMINAL WALL RECONSTRUCTION

Abstract Aim to report short term outcomes of preoperative toxin botulinum A (TBA) in preparation for abdominal wall reconstruction (AWR). Material and Methods Patient with a hernia width&amp;gt;10cm and/or loss of domain who underwent elective AWR from April 2021 through March 2022 were included. All patients received ultrasound-guided administration of 300 units of TBA prior the surgery. Outcomes of interest included: changes in hernia dimensions and CT-Scan volumetric measurements after treatment, rates of complete fascial closure, postoperative intraabdominal hypertension, unplanned readmission and hernia recurrence. Results Fifteen patients were included (53% males; mean age 61years, mean body mass index 28.9kg/m2). Median hernia width decreased by 2cm (before 15cm [IQR 14–18.5], after 13cm [IQR 10.3–15]; p=0.002) and median abdominal cavity volume increased by 1.4L (before 4.8L [IQR 3.8–11.1], after 6.2L [4.2–9.2]; p=0.594). Thickness of lateral abdominal wall muscles decreased (before 2cm [IQR 1.6–3], after 1.1cm [IQR 1–1.3]; p=0.008 and the Tanaka Index decreased (12% [IQR 3.6–24.2] and 5% [IQR 1.4–16.8]; p=0.066) Complete fascial closure was achieved in 13cases(87%). Three patients did not require component separation. Mean endotracheal pressure was 19mmHg. There were no intraabdominal hypertension. At a median 9months follow-up [range 6.2–11.5] wound morbidity rate was 20%(N=3), N=1 recurrence, N=1 unplanned readmission. Conclusions TBA promotes changes to the lateral abdominal wall with decrease on defect width and thickness of lateral muscles and increase in cavity volume and Tanaka index. Randomized clinical trials are needed to determine the clinical implication of preoperative TBA in preparation for AWR.

P-138 PREDICTORS OF COMPLICATIONS IN COMPLEX VENTRAL HERNIA REPAIR USING POSTERIOR COMPONENT SEPARATION TECHNIQUE WITH RETRO RECTUS MESH PLACEMENT – AN OBSERVATIONAL STUDY

Abstract Introduction Incisional Hernia has an incidence ranging from 2–20%. Large and complex incisional hernias are difficult to treat with standard procedures. PCS-TAR is a relatively novel procedure. There persists a gap in knowledge regarding its outcomes, especially in the Indian population. Aims &amp; Objective To identify the pre-operative clinical and radiological factors that predict the risk of re-herniation and wound and mesh-related complications after CVH (Complex Ventral Hernia) Methodology In a prospective observational study, patients undergoing open PCS-TAR with retro rectus mesh for Complex Ventral Hernia repair included in the study. The patient demographics, hernia characteristics, radiological details, operative data, post- operative outcomes, and follow-up data were entered in a pre-designed proforma. Data were analyzed with SPSS softwere. Results 35 patients with CVH were included, of which 30 (85%) women and 5 men. The mean age was 51.8 years and the mean BMI was 29.7 kg/m2. The mean size of defect was 12 cm. 83% hernia were midline primary and 255 were recurrent hernias. We observed zero recurrences at six months of follow-up, but a high wound morbidity rate of up to 49%, of which most common was seroma formation. 23% of patients developed SSI. Conclusion In conclusion, PCS-TAR is a promising novel procedure for complex ventral hernias not amenable to primary closure using the traditional retro rectus approach, with excellent short term outcomes. Wound morbidity is a significant concern with this procedure, which can be prevented or reduced by thorough pre-operative optimization on a case-to-case basis.

P160 ENDOSCOPIC ANTERIOR COMPONENT SEPARATION OR OPEN TRANSVERSUS ABDOMINUS RELEASE ARE NOT ASSOCIATED WITH INCREASED WOUND MORBIDITY FOLLOWING INCISIONAL HERNIA REPAIR

Abstract Aim Traditional anterior component separation during incisional hernia repair is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence compared to incisional hernia repair without component separation. Material and Methods This was a retrospective cohort study of patients undergoing open, retro-rectus incisional hernia repair. Component separation during retro-rectus repair was performed using eACS or TAR. The primary outcome was 30-day incidence of postoperative surgical site occurrence. Secondary outcomes included length of stay, 30-day readmission, 30-day reoperation rate and 3-year recurrence rate. Results A total of 322 patients underwent retro-rectus repair, 168 (52%) of whom received either eACS or TAR. Addition of eACS or TAR was neither associated with surgical site occurrence, (odds ratio: 0.82, confidence interval: 0.40-1.68, P = 0.596) nor with hernia recurrence (hazard ratio 0.80, CI 0.27-2.40, P = 0.693). There was no significant difference between the groups regarding the frequencies of 30 day-readmission or 30-day reoperation. Conclusions The addition of eACS or TAR to a retro-rectus incisional hernia repair was not associated with increased wound morbidity or hernia recurrence.

Randomized controlled trial of single-use negative-pressure wound therapy dressings in morbidly obese patients undergoing cesarean delivery

The single-use negative-pressure wound therapy dressings are designed to use over a closed surgical wound. Early prospective studies suggested that these dressings may be of potential benefit in reducing cesarean wound complications. This study aimed to test the hypothesis that incisional negative-pressure wound therapy decreases postoperative wound morbidity compared with standard surgical dressing in patients with class III obesity undergoing cesarean delivery. In a single-site, parallel, randomized controlled trial, participants with class III obesity (body mass index ≥40 kg/m2) were recruited to participate in the study. Patients were consented in the ambulatory obstetrical units, on admission to the antepartum service, and on labor and delivery before active labor. Patients who had a cesarean delivery were randomized to either the standard surgical dressing or a prophylactic negative-pressure wound therapy device. The randomization was achieved using permuted blocks of 4, 6, and 8 in a 1:1 allocation ratio. The primary outcome was a composite outcome of wound complications. The planned enrollment of 242 subjects was based on the power to detect a 50% decrease in the composite wound outcome, assuming a 30% baseline wound morbidity rate for this population. The outcomes were assessed by study staff blinded to the patient's treatment arm. An unplanned interim analysis was performed because of the slow enrollment and publication of larger trials showing no benefit of the negative-pressure wound therapy. Of 411 eligible patients during the study period, 212 participants with class III obesity were enrolled. Of these, 110 underwent cesarean delivery and were subsequently randomized (55 to standard dressing and 55 to prophylactic negative-pressure wound therapy device). The primary outcome occurred in 29.1% in the standard surgical dressing compared with 20% in the negative-pressure wound therapy group (risk difference, 9.1%; 95% confidence interval, -8.3 to 25.8%; P=.38). The study was stopped early because of a low enrollment rate and lower likelihood of seeing a clinically significant benefit. The trial was stopped after an unplanned, interim analysis showed the use of a prophylactic negative-pressure wound therapy device used for cesarean delivery did not reduce wound complications compared with a standard surgical dressing.

Clinical Evaluation of Desarda’s Repair for Inguinal Hernia

Inguinal hernia repair is a common procedure in general surgery today, and an ideal operation to treat inguinal hernia is still far to define. The synthetic prostheses commonly used in its repair can create a few clinical problems which have influenced many investigators to look for new hernia repair techniques, and an example of such efforts is Desarda’s method of inguinal hernia repair. The objective of this study was to clinically evaluate the technique of Desarda’s repair for inguinal hernia on parameters such as technical feasibility, post-operative pain, incidence of complications in terms of wound morbidity (seroma, surgical site infection, persistent pain), testicular atrophy, and recurrence rates. Among 30 patients selected, Desarda’s technique for inguinal hernia repair was evaluated, and outcome was measured in terms of post-operative pain, surgical site infection, seroma, testicular atrophy, and recurrence at 4 weeks, 6 months, 1 year, 2 years, and 5 years. In this prospective study over a period of 5 years, operating time observed was 49.60 ± 13.45 min; mean pain score observed using visual analogue scale (0–10) at 24 h was 2.4 ± 0.86. Complications noted were minimal, and most common complication noted was scrotal edema; none of the patients had recurrence or any long-term morbidity. Desarda’s technique of biological repair is a logical alternative considering the drawbacks of the use of mesh having shorter operative period, no chronic groin pain, minimal complications with no recurrence, and also being cost-effective.

Abdominal core quality of life after ventral hernia repair: a comparison of open versus robotic-assisted retromuscular techniques.

Robotic-assisted retromuscular repairs reduce length of stay compared to open surgery. However, no study has evaluated the long-term impact on abdominal core quality of life. Retrospective cohort study performed using prospectively collected data from the Americas Hernia Society Quality Collaborative (AHSQC) including adults who underwent open or robotic-assisted retromuscular, incisional hernia repair between 2013 and 2019. Differences in Hernia-Related Quality of Life Survey (HerQLes) scores at baseline and 1 year postoperatively were compared using multivariable regression models. Secondary outcomes included perioperative complications, wound morbidity, and hernia recurrence. 236 patients underwent open (N = 194) and robotic (N = 42) repairs. Median age was 61years. The open group had larger hernia widths (median [IQR], 13 [9-16] vs. 7 [5-9] cm) and longer LOS (5 [4-6] vs. 1.5 [1-3] days). Median HerQLes summary scores at 1year were similar at 88 [67, 93] points for open vs 90 [58, 94] for robotic arm. Wound morbidity rates were similar. On multivariate analysis, there was no difference in HerQLes summary score improvement 1 year after repair between techniques (3.3, CI [- 7.7, 14.3]; p = 0.52), however, patients with a comparatively larger hernia width of 7cm had a 5.9 (CI [1.1, 10.8], p = 0.02) increase in HerQLes scores, and patients with a higher ASA class (3-5) saw an 11-point score improvement (CI [2.2, 20.0], p = 0.02) regardless of approach. Smoking, BMI above 30, or hernia recurrence had no significant impact, while COPD hindered scores (- 17.0, CI [- 32.3, - 1.7], p = 0.03). Improvement in abdominal core quality of life after repair is comparable between open and robotic retromuscular techniques. Larger hernia defects and higher ASA class patients benefitted the greatest. Robotic approaches offer shorter LOS with comparable recurrence and wound morbidity rates 1 year after surgery. The surgical approach should be personalized and guided by the surgeon's individual and institutional expertise.

Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database.

The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70years) with breast cancer and to compare them to younger women (18-69years). The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction. Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p < 0.0001) due to higher rates of infectious, pulmonary, and venous thromboembolic events. Wound morbidity and prosthesis failure occurred equally among age groups. In the autologous reconstruction group, there was no statistically significant difference in the 30-day morbidity rates (older 9.5% vs younger 11.6%, p = 0.15). Both wound morbidity and flap failure rates were similar between the two age groups. For both reconstruction techniques, mortality within 30days of breast surgery was rare. Immediate breast reconstruction is safe in older women. These data support the notion that surgeons should discuss IBR as a safe and integral part of cancer treatment in well-selected older women.

Combined open and laparoscopic approach for repair of flank hernias: technique description and medium-term outcomes of a single surgeon.

A residual bulge in the lateral abdominal wall is a reason for patient dissatisfaction after flank hernia repair (FHR). We hypothesized that combining a laparoscopically-placed intraperitoneal mesh (IPOM) with onlay hernia repair performed through a small open incision would increase repair durability and decrease such residual bulges. We aim to report our medium-term outcomes with this technique. Patients who have undergone FHR using the technique described above from March 2013 through June 2017 were identified in a prospectively maintained database. Outcomes of interest included surgical site infections (SSI), surgical site occurrences (SSO), surgical site occurrences requiring procedural intervention (SSOPI) and hernia recurrence. Sixteen patients were identified (62% females; mean age 59 ± 8 years, mean body mass index 29.5kg/m2). Mean hernia width was. 6.4 ± 3cm and 31% were recurrent hernias previously repaired through an onlay approach. Mean operative time was 159 ± 40min, fascial closure was achieved in all cases, and there were no intraoperative complications. Median length of stay was 3days (IQR 3-4), and there were no unplanned readmissions or reoperations. At a median 37-month follow-up (IQR 21-55), wound morbidity rate was 12.5% (2 seromas). There were no SSI/SSOPI and one hernia recurrence (6%) was detected at 12months postoperatively. Combining laparoscopic IPOM with open onlay hernia repair resulted in low recurrence and acceptable wound morbidity rates, with no residual bulges noted at medium-term follow-up. Further studies with larger number of patients and other surgeon's experiences are necessary to determine the role of such technique in the surgical armamentarium for flank hernia repair.

Outcomes of transversus abdominis release in non-elective incisional hernia repair: a retrospective review of the Americas Hernia Society Quality Collaborative (AHSQC).

Elective repair of large incisional hernias using posterior component separation with transversus abdominis release (TAR) has acceptable wound morbidity and long-term recurrence rates. The outcomes of using this reconstructive technique in the non-elective setting remains unknown. We aim to report 30-day outcomes of TAR in non-elective settings. All patients undergoing open TAR in non-elective settings were identified within the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review was conducted and outcomes of interest were 30-day Surgical Site Infections (SSI), Surgical Site Occurrences (SSO), SSOs requiring procedural intervention (SSOPI), medical complications, and unplanned readmissions and reoperations. Fifty-nine patients met inclusion criteria. Mean BMI was 36.6 ± 8.9kg/m2 and mean hernia width was 14.4 ± 7.2cm. Forty (67.8%) were recurrent hernias. Pain (88%) and bowel obstruction (79.7%) were the most frequent indications for surgery. Surgical field was classified as clean in 69.5% of cases, with an 88% use of permanent synthetic mesh and fascial closure achieved in 93.2% of cases. There were 15 (25.4%) total wound events, 8 (13.6%) were SSIs. There were 8 (13.6%) SSOPIs, 6 of which were wound opening, 1 wound debridement, and 1 percutaneous drainage. At least one wound or medical complication was reported for 37% of the patients. There were no mortalities. Not surprisingly, TAR in the non-elective setting is associated with increased wound morbidity requiring procedural interventions and reoperations compared to what has previously been reported for elective cases. The long-term consequences of this wound morbidity with regard to hernia recurrence are as of yet unknown.

The Perineal Turnover Perforator Flap: A New and Simple Technique for Perineal Reconstruction After Extralevator Abdominoperineal Excision.

Extralevator abdominoperineal excision (ELAPE) is increasingly used to treat locally advanced low rectal cancer as it has been related to superior oncological outcomes than traditional abdominoperineal excision.However, ELAPE also has been associated with high perineal wound morbidity rates as it creates a larger perineal cavity than standard abdominoperineal excision. This greater defect, along with the effects of preoperative chemoradiation on wound healing, makes uneventful perineal reconstruction post-ELAPE a real challenge for the plastic surgeon.In this paper, the authors present a new technique for perineal reconstruction post-ELAPE, using a perforator, islanded, turnover, de-epithelialized local flap (perineal turnover perforator [PTO] flap). The PTO flap is raised based on perforators from internal pudendal artery. The flap is based on the concept that thick gluteal dermis can act as an "autologous dermal vascularized" substitute for the excised pelvic floor muscles, whereas the bulk of its subcutaneous tissue is used to obliterate dead space.Fourteen patients underwent perineal reconstruction using this approach. Patients' demographics, neoadjuvant chemoradiotherapy, histopathology, duration of surgery, follow-up, and complications were analysed retrospectively. Median operating time was 49 minutes. There were no flap, donor site, or major wound complications. One patient had superficial skin dehiscence, and one patient developed perineal hernia. None of the patients developed chronic perineal pain. The PTO flap is a quick, simple yet safe and reliable option for perineal reconstruction after ELAPE that offers many advantages over the heretofore used reconstructive techniques including primary closure, myocutaneous flaps, and biological meshes.

Anterior component separation versus posterior component separation with transversus abdominus release in abdominal wall reconstruction for incisional hernia

Background Abdominal wall reconstruction after huge incisional hernias considered one of challenges that face surgeons, component separations, either anterior component separation (ACS) or posterior component separation (PCS) with transversus abdominus release (TAR), are novel and less expensive solutions for this problem. Aim This prospective randomized trial compares the results of ACS procedure versus PCS with TAR in repair of incisional hernias. Patients and methods This study included 40 patients who underwent surgical repair for midline incisional hernias with defects larger than 5 cm in width between March 2016 and October 2017 at Ain Shams University Hospitals. Patients were randomly assigned to surgical procedures. Patients in group Ι (n=20) underwent ACS, and patients in group II (n=20) underwent PCS with TAR. Results In group Ι (ACS), wound morbidity significantly exceeded that in group II (PCS with TAR) such that 10 (50%) patients in group I developed surgical wound infection compared with four (20%) patients in group II. Regarding wound dehiscence, seven patients in group I had this sequel, whereas two patients in group II had wound dehiscence. Hernia recurrence occurred in seven (35%) patients in group I, but only one (5%) patient in group II developed this. Conclusion PCS with TAR provides equivalent myofascial advancement with significantly less wound morbidity and recurrence rate when compared with ACS.

Single center experience with the modified retromuscular Sugarbaker technique for parastomal hernia repair.

Parastomal hernias are challenging to manage, and an optimal repair has yet to be defined. An open, modified, retromuscular Sugarbaker technique has recently been described in the literature as a technically feasible approach to parastomal hernia repair. This study evaluates our initial institutional experience with parastomal hernia repair with the aforementioned technique with respect to safety and durability. All patients who underwent an open, modified retromuscular Sugarbaker parastomal hernia repair from 2014 through 2016 at our institution were identified. Patient characteristics, hernia variables, operative details, and 30-day and medium-term outcomes were abstracted from the Americas Hernia Society Quality Collaborative database. Outcomes of interest included 30-day wound morbidity, mesh-related complications, and hernia recurrence. Thirty-eight patients met inclusion criteria. 20 (53%) patients presented to our institution for management of a recurrent parastomal hernia. 35 (92%) patients had a concurrent midline incisional hernia with a mean total hernia width of 15.1cm and mean defect size of 353cm2. Thirty-day wound morbidity rate was 13%. At a mean of follow-up of 13months (range 4-30), the hernia recurrence rate was 11%. Three patients (8%) experienced mesh erosion into the stoma bowel, leading to stoma necrosis, bowel obstruction, and/or perforation which required reoperation at day 8, 12, and 120days, respectively. The outcomes of the retromuscular Sugarbaker technique for the management of parastomal hernias have been disappointing at our institution, with a concerning rate of serious mesh-related complications. This operation, as originally described, needs further study before widespread adoption with a particular focus on the technique of mesh placement, the most appropriate mesh selection, and the long-term rate of mesh erosion.

Outcomes of Retromuscular Approach for Abdominal Wall Reconstruction in Patients with Inflammatory Bowel Disease

Ventral hernia repair (VHR) in patients with inflammatory bowel disease (IBD) presents unique surgical challenges including impaired wound healing, concomitant intestinal operations, along with likely future abdominal surgeries. Appropriate techniques and mesh choices in these patients remain under active debate. Herein we report our experience with using a retromuscular approach for major VHR in a consecutive cohort of IBD patients. We identified all patients with IBD undergoing open VHR with retrorectus mesh placement between 2007 and 2013 in our prospectively maintained database. Main outcomes included patient and hernia characteristics, perioperative details, wound complications, and hernia recurrence. A total of 38 patients with IBD met inclusion criteria. Mean hernia defect size was 338 cm(2). Synthetic mesh was used in 16 patients and biologic mesh was used in 22 of patients. A surgical site occurrence (SSO) occurred in 13 (34.2%) patients, 7 (18.4%) of which were surgical site infections (SSIs). There were no instances of postoperative intestinal complications or enterocutaneous fistulae. At the mean follow-up 37 months, there were 3 (9.4%) recurrences. Our retromuscular repairs were associated with a low rate of wound morbidity and no intestinal complications. Furthermore, we report a relatively low rate of recurrences, especially in this series of complex multiply recurrent hernias. Overall, our retromuscular approach seems to be safe and effective in hernia patients with IBD.

No difference in 1-year wound morbidity following no-touch versus conventional vein harvesting for coronary artery bypass surgery: a new beginning

Controversy surrounding the issue of greater wound morbidity when using the ‘no-touch’ (NT) saphenous vein graft (SVG) when compared with the conventional (CON) harvesting technique has been addressed for the first time by the recent study of Verma et al .[ 1], who showed no significant difference in wound complications and functional recovery after 1 year of follow-up. Due to the relatively low use of the NT technique, introduced in 1996, data are limited to a single randomized study showing that NT harvesting of the SVG results in a superior patency over CON [2]. Various vasculoprotective mechanisms in NT SVGs have been demonstrated. Although the primary outcome measure of the paper by Verma et al. shows a decreased vascular injury in NT SVGs, we find the results of the secondary study, regarding leg wound healing and functional outcome, to be crucial for the NT technique to attain warranted popularity. We congratulate the authors on conducting this study and point out a few additional factors that we believe should be considered when interpreting the results. It is difficult to understand why no differences in intima, media and adventitial thicknesses were seen between the two groups particularly as CON veins were stripped of its adventitial layer. Also, an earlier study on NT versus CON vessel morphology has shown differences in media thickness [3]. Although there appears no clear evidence of a difference in the risk of infection when staples rather than sutures are used to close leg wounds after SVG harvesting during coronary artery bypass grafting (CABG) [4], information regarding the proportion of wounds closed using staples is missing. To maintain as high homogeneity of the sample as possible all patients should either have staples or absorbable cuticular sutures, particularly in the larger, ongoing, SUPERIOR-SVG trial (clinicaltrials.gov identifier: NCT01047449). In the light of recent data indicating that antibacterial sutures reduce the incidence of infections after CON harvesting in CABG patients by 35% [5], we consider that the data regarding the suture material used are both relevant and necessary for adequate interpretation of the results. SVG harvest-site complications are often managed in legs with arterial insufficiency. Did the patient with peripheral vascular disease have an equal severity of the disease in both legs and was he/she included in the leg assessment analysis? The importance of accounting for arterial insufficiency in the donor site is crucial when comparing postoperative leg wound morbidity rates between groups. The vast majority of patients included in the study by Verma et al .[ 1] were men (94%). Whether these results will remain similar in a mixed sex population remains to be seen. The Materials and Methods section points to Supplementary data on leg wound healing and functional outcomes, although no such data can be found. Finally, there was a single crossover; a CON SVG was harvested from the leg assigned to NT. This patient developed a leg wound infection of the leg assigned to NT and analysed according to intention to treat. What impact would per treatment analysis have on the 3-month follow-up results of leg assessment? When considering that reduced leg wound morbidity has resulted in the recent adoption of endoscopic vein harvesting as a standard of care in spite of dubious graft patency [6], resolving the issue of NT wound morbidity is more important for greater uptake of the technique. We congratulate the authors once again on conducting this study and hope they find our comments useful for the SUPERIOR-SVG ‘NT versus CON’ trial that is underway.

A 5-Year Clinical Experience With Single-Staged Repairs of Infected and Contaminated Abdominal Wall Defects Utilizing Biologic Mesh

Our objective was to evaluate the safety and durability of biologic mesh for single-staged reconstruction of contaminated fields. The presence of contamination during ventral hernia repair (VHR) poses a significant challenge. Some advocate for a multistaged reconstructive approach with delayed definitive repair, whereas others perform definitive repair at the initial operation. Patients undergoing single-staged VHR in a contaminated field with biologic mesh over a 5-year period were retrospectively reviewed from a prospectively maintained database. Outcome measures included wound complication and hernia recurrence. A total of 128 patients (76 F, 52 M) were identified, with a mean age of 58.2 years, mean American Society of Anesthesiologist (ASA) score 3.1, and mean body mass index (BMI) 34.1 ± 9.7 kg/m2. Comorbidities included COPD (n = 29), diabetes (n = 65), smoking (n = 29), and immunosuppression (n = 8). Mean hernia defect size was 431 cm2 (range 40-2450 cm2). Reasons for contamination included the presence of infected mesh (n = 45), stoma (n = 24), concomitant gastrointestinal (GI) surgery (n = 17), enterocutaneous fistula (n = 25), open nonhealing wound(s) (n = 6), enterotomy/colotomy (n = 5), and chronic draining sinus (n = 6). Postoperative wound complications were identified in 61 (47.7%) patients. Predictors of wound complications included ASA score, diabetes, smoking, number of previous abdominal surgeries or hernia repairs, hernia defect size, and operative time. With a mean follow-up time of 21.7 months, hernia recurrence was identified in 40 (31.3%) patients. The majority of recurrent hernias were asymptomatic and 7 patients underwent repair. Despite the high rate of wound morbidity associated with single-staged reconstruction of contaminated fields, it can safely be performed with biologic mesh reinforcement. Although biologic mesh in these situations is safe, the long-term durability seems to be less favorable.

Open versus endoscopic component separation: a cost comparison

The components separation technique (CST) is performed through an open or endoscopic approach. It is unclear whether the costs associated with the endoscopic instruments outweigh any clinical benefit derived from their use and the avoidance of lipocutaneous flaps. This study aimed to compare the direct costs associated with each approach. A retrospective review of patients undergoing open or endoscopic CST between 2005 and 2009 was performed. The review compared patient-related variables, length of hospital stay, wound morbidity, and costs associated with the index operation and encounters within a 6-month period. Of the 54 patients identified, 59% underwent endoscopic repair, and 41% had an open CST repair. The patients were similar in age, American Society of Anesthesiology (ASA) score, gender, body mass index (BMI), number of prior surgeries, active abdominal infection, defect size, operating room time, and length of hospital stay. The overall median direct costs were similar between endoscopic and open CST ($9,942 vs. $17,701; p=0.09). No difference was detected in median operating room costs, but an approximate $7,000 difference was noted between endoscopic and open CST ($1,871 vs. $8,705; p=0.96). The median mesh costs differed significantly between endoscopic and open CST ($733 vs. $8,415; p=0.05) as did stapler use costs ($35 vs. $190; p=0.002). The median cost of endoscopic instruments was $848. Open CST had a 41% major wound morbidity rate compared with 19% in the endoscopic group (p=0.07). Most of the encounters in the 6-month follow-up period (85%) were related to wound morbidity. The median cumulative direct costs differed between endoscopic and open CST at 3 and 6months ($12,528 vs. $20,326; p=0.05). In a similarly complex group of patients, the total direct costs associated with endoscopic and open CST were similar. Endoscopic instruments made a marginal contribution to the total overall costs, but significant cost contributors were the use of biologic grafts and wound morbidity.

ON-Q Anesthetic Pump in Gynecologic Oncology: Feasibility Study of a Novel Placement Technique at an Army Hospital

The goals were (1) to describe a novel placement technique for the ON-Q anesthetic system based on somatic neural anatomy and (2) to determine its feasibility, efficacy, and associated morbidity among surgical patients on a gynecologic oncology service. A retrospective observational study of 100 consecutive patients who underwent a vertical laparotomy and received an ON-Q system was performed. The ON-Q system was composed of a soaker catheter (threaded longitudinally within the rectus sheaths) and an elastomer pump that infused 0.5% bupivacaine at 2 mL/hour for up to 5 days. The average duration of ON-Q system use was 4.4 days (range, 2-5 days). The median numeric pain scores (range, 0-10) were 3, 2, 1, 0, and 0 on postoperative days 1, 2, 3, 4, and 5, respectively. Complications encountered included suturing of the catheter to the fascia (n = 1), wound hematomas (n = 2), and device failure (n = 1). Intrafascial placement of the ON-Q soaker catheter for bupivacaine infusion appears effective for incisional analgesia, with negligible wound morbidity and device failure rates.