Wound Morbidity Research Articles

Multiple Skin Bridging for No-Touch Saphenous-Vein Grafts Harvesting Can Reduce Wound Morbidity.

Reducing the leg wound morbidity is crucial for the patients undergoing coronary artery bypass grafting (CABG) with great saphenous vein (SV) grafts harvested by no-touch (NT) technique. This study was to summarize the experience of skin bridging technique for reducing wound morbidity and the influence of it on one-year bypass graft patency. According to skin bridging or not, harvesting times, graft length, number of bleeding branches, postoperative subjective perception assessment scale (ASEPSIS) scores and one-year patency rate were analyzed. From June 2018 to February 2019, 60 patients underwent CABG with SV grafts either with open-incision NT or skin bridging NT (30 in each group). There were no significant differences in age (71.4 ± 5.1 years vs. 68.9 ± 5.5 years) or graft length (23.3 ± 1.1 cm vs. 23.9 ± 1.3 cm) between the two groups. The bridging/NT group had a significantly longer harvest time (38.5 ± 4.9 min vs. 18.5 ± 2.6 min; P < 0.001) and a significantly greater number of bleeding branches (1.9 ± 1.2 vs. 0.8 ± 0.8; P < 0.001) than the open NT group. The open NT group had a significantly higher ASEPSIS score (23.8 ± 2.0 vs. 15.7 ± 2.6; P < 0.001). There was no significant difference in patency rate at one-year follow-up. Obtaining the SV by the combined NT/discontinuous skin bridging technique is a satisfactory method for patients who underwent CABG. This method has important clinical significance in reducing wound morbidity in the harvest of NT grafts.

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.

A Systematic Review and Meta-Analysis of Wound Complications after a Caesarean Section in Obese Women.

(1) Background: Caesarean sections in obese patients are associated with an increased risk of surgical wound complications, including hematomas, seromas, abscesses, dehiscence, and surgical site infections. The aim of the present study is to perform a meta-analysis and systematic review of the current literature focusing on the strategies available to decrease wound complications in this population. (2) Methods: We reviewed the data available from the PubMed and the Science Direct databases concerning wound complications after caesarean sections in obese women. The following key words were used: “caesarean section”, “cesarean section”, “wound complication”, “wound morbidity”, and “wound infection”. A total of 540 papers were retrieved, 40 of which were selected for the final systematic review and whereas 21 articles provided data for meta-analysis. (3) Results: The conducted meta-analyses revealed that the use of prophylactic drainage does not increase the risk of wound complications in obese women after a caesarean sections (pooled OR = 1.32; 95% CI 0.64–2.70, p = 0.45) and that vertical skin incisions increase wound complications (pooled OR = 2.48; 95% CI 1.85–3.32, p < 0.01) in obese women, including extremely obese women. (4) Conclusions: Subcutaneous drainage does not reduce the risk of a wound complications, wound infections, and fever in obese women after caesarean sections. Negative prophylactic pressure wound therapy (NPWT) may reduce the risk of surgical site infections. The evidence of using a prophylactic dose of an antibiotic before the caesarean section is still lacking.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis.

Simple SummaryAbdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C.Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

557 Pregnancy outcomes associated with pragmatic use of aspirin at a single tertiary care center

ACOG recommends low-dose aspirin (ASA) for preeclampsia prophylaxis in high-risk women. Randomized trials have also shown decreased preterm birth (PTB) with ASA use. We evaluated rates of PTB, preeclampsia, and other adverse perinatal outcomes associated with pragmatic antepartum ASA use in high-risk women (Table 1). Retrospective cohort study of all deliveries at a single center (2013-2018). Patients with known fetal anomalies were excluded. Women were categorized by documented antepartum use of ASA (irrespective of dose/initiation GA). The primary outcome was any PTB. Other outcomes included preeclampsia, perinatal outcomes, and bleeding parameters. Outcomes were compared between cohorts (ASA vs no ASA); multivariable generalized estimating equations were used to calculate adjusted odds ratios (95% CI) with the no ASA group as the reference. Of 23,602 women who met inclusion criteria, 3069 (13%) had documented ASA use. Women receiving ASA were more likely to be single, Black, obese, multiparous, have medical comorbidities, and use government insurance (all p<0.01). While women in the ASA group had more PTBs in univariate analysis, after multivariable adjustments, they were less likely to have a PTB (aOR 0.63 [0.52-0.77], specifically PTB <34weeks (aOR 0.55 [0.44-0.68]). There was no difference in preeclampsia, placental abruption, fetal or maternal death between groups. Additionally, neonates of women in the ASA group were significantly less likely to be admitted to the NICU (aOR 0.76 [0.60-0.95]) Of note, there was higher EBL with ASA, but there was no increase in uterotonic use, wound morbidity, or blood transfusion in the ASA group (Table 2). Even outside of strict protocols in randomized trials, pragmatic antepartum ASA use is associated with decreased risk of PTB, specifically early PTB, and neonates requiring NICU admission. While there was no reduction in preeclampsia or other rare outcomes, the benefits we confirm in high-risk women should prompt studies in lower-risk women to evaluate if there is a universal benefit to antepartum ASA use.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

764 Operative vaginal delivery as an independent risk factor for maternal postpartum infection

Recent studies suggest prophylactic antibiotics are effective in reducing maternal postpartum (PP) infection following operative vaginal delivery (OVD). There is limited data in the US, where episiotomy and laceration repair practices may differ, affecting the risk of PP infection after OVD. We sought to evaluate whether OVD is an independent risk factor for maternal PP infection. Retrospective cohort study of all singleton vaginal deliveries >34 weeks’ gestation at a single perinatal center (2013-2018). Women were categorized by mode of delivery: spontaneous vaginal delivery (SVD) or OVD (forceps/vacuum assisted). The primary outcome was a composite of confirmed or suspected maternal infection up to 6 weeks after delivery defined as: (1) endometritis (CDC definition), (2) perineal wound morbidity (infection or breakdown) or (3) culture proven urinary tract infection. Outcomes were compared between groups; multivariable generalized estimating equations were used to estimate the adjusted odds ratios (95% CI) with SVD as the reference group. Of 14,646 deliveries meeting inclusion criteria, 732 (5%) were OVDs. The overall composite rate was 1.4%. Women undergoing an OVD were more likely to be nulliparous, undergo labor induction, develop chorioamnionitis, have an episiotomy, and sustain a 3rd/4th degree laceration (Table 1). After controlling for these known confounders, there was no difference in composite infection following OVD compared to SVD (aOR 1.28 [0.73-2.23]) or any of its individual components (Table 2). There were no differences in receipt of PP antibiotics or PP fever. We considered the individual contribution of forceps (p=0.20) vs vacuum (p=0.95) on the adjusted odds of the composite outcome, which indicated no differences by instrument. Accounting for risk factors associated with PP infection and the need for OVD, OVD itself does not appear to be an independent risk factor for maternal PP infection in our population. Routine use of prophylactic antibiotics with OVD may not be warranted based on contemporary 2nd stage labor management patterns in the US.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Robotic hepaticojejunostomy for biliary stricture after liver transplantation: technical description and case series

Presenter: Jason Hawksworth MD | MedStar Georgetown University Hospital Background: Biliary strictures after liver transplantation are common and when refractive to endoscopic and percutaneous intervention require surgical biliary revision. Traditional open biliary revision may result in substantial wound morbidity and prolonged hospitalization in this high-risk population. Robotic technology facilitates minimally invasive biliary reconstruction and has not previously been described following liver transplantation. Methods: A brief description of the robotic approach is as follows: Peritoneal access is obtained at the umbilicus and a 12mm assist port is placed. Robotic ports are placed across the mid abdomen parallel to the umbilical port including 3x 8mm ports and 1x 12mm port. Lysis of adhesions is performed until the liver hilum is isolated. The bile duct is encircled and the stricture resected until healthy appearing donor bile duct is visualized. The hilar inflow structures are carefully preserved during this dissection. The inframesocolic compartment is exposed and the first jejunal loop divided with the robotic stapler. The roux limb is routed retrocolic and an isoperistaltic end-to-side jejunojejunostomy created with the robotic stapler. The common enterotomy is closed with running suture. Attention is returned to the liver hilum where an end-to-side hepaticojejunostomy is created with interrupted monofilament suture. Ultrasound is used during the case to aid in identification of the hilar structures and at the end of the case to confirm patency of the hepatic artery. The robotic cases were retrospectively compared to historical open cases over a time period from May 2013 to October 2020, including demographics, perioperative complications and outcomes. All patients had at least 3 months follow up. Results: During the study period there were 3 robotic and 4 open surgical biliary revisions. All cases were hepaticojejunostomies for choledochocholedochostomy related anastomotic strictures. In one robotic case involving a donation after cardiac death (DCD) graft, the bile duct was also noted to be sclerotic up to the liver hilum and the anastomosis was fashioned to the right and left hepatic ducts. In all cases the biliary strictures presented >90 days after transplant and were refractive to multiple endoscopic and percutaneous interventions. Median (range) case time was longer the in the robotic (373 minutes (286-373)) compared to open (280 minutes (163-321)) group. Blood loss was minimal ( < 50mL) in all robotic and open cases. The median length of stay was lower in the robotic (4 days (1-4)) compared to open (7 days (4-10)) group. Morbidity included 2 wound infections in the open group (grade 2), 1 gastrointestinal bleed requiring a blood transfusion in the robotic group (grade II), 1 infected hematoma in the robotic group (grade IIIa) and 1 bile leak on the open group (grade IIIa). Nadir bilirubin was similar between the robotic (0.2 (0.2-0.3)) and the open (0.3 (0.2-0.4)) group. Nadir alkaline phosphatase was also similar between the robotic (154 (92-245)) and the open (132 (72-166)) groups. There was no mortality in either group. Conclusion: Robotic biliary revision is a safe alternative to traditional open surgery for refractive biliary strictures after liver transplantation.

Perineal Turn over Perforator Flap: A Novel Surgical Technique for Combined Perineal and Posterior Vaginal Wall Reconstruction

Extralevator Abdominoperineal Excision (ELAPE) and Abdominoperineal Resection create complex perineal defects made more challenging when combined with additional resection of the posterior vaginal wall. This composite defect requires the restoration of a functional vagina, in addition to the obliteration of the large perineal dead space, a need to reduce donor site, and perineal wound morbidity. Previously described fasciocutaneous and myocutaneous flaps for such defects are associated with long operations requiring intra-operative mobilization and are linked to post-operative complications including herniation, evisceration, flap loss, donor site morbidity and poor cosmetic outcome, amongst other issues. Herein we describe the case of a 60-year-old female patient that underwent combined ELAPE and posterior vaginectomy for anal squamous cell carcinoma. This complex defect was reconstructed using an extended version of the Perineal Turn-Over (PTO) flap based on the Internal Pudendal artery perforator.

Predictors and Consequences of Hematoma After Thyroidectomy: An American College of Surgeons National Surgical Quality Improvement Program Database Analysis

BackgroundHematoma after thyroid surgery is a serious complication. The purpose of this study was to determine the predictors and consequences of hematoma after thyroid surgery. Materials and methodsA retrospective analysis of 11,552 open thyroidectomies was conducted using the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 main and thyroidectomy-targeted procedure databases. Predictors of hematoma and the effect of hematoma on outcomes were analyzed by multivariate logistic regression, resulting in risk-adjusted odds ratios of hematoma and morbidity/mortality, respectively. Statistical analysis was performed using R version 3.5.1. ResultsWe found that male gender (odds ratio 1.71, 95% confidence interval 1.25-2.32; P value 0.0007), Black race (1.89, 1.27-2.77; 0.0014), other race (1.76, 1.23-2.50; 0.0017), hypertension (1.68, 1.20-2.35; 0.0026), diabetes (1.45, 1.00-2.06; 0.0460), and bleeding disorders (3.63, 1.61-7.28; 0.0007) were independent risk factors for postoperative hematoma. The use of an energy device for hemostasis (0.63, 0.46-0.87; 0.0041) was independently associated with decreased hematoma rate. Postoperative hematoma was an independent risk factor for overall morbidity (3.04, 2.21-4.15; <0.0001), hypocalcemia (1.73, 1.08-2.66, 0.0162), recurrent laryngeal nerve injury (2.42, 1.57-3.60, <0.0001), pulmonary morbidity (18.91, 10.13-34.16, <0.0001), wound morbidity (10.61, 5.54-19.02, <0.0001), readmission (5.23, 3.34-7.92, <0.0001), return to operating room (90.73, 62.62-131.97; <0.0001), and length of stay greater than the median (5.10, 3.62-7.15, <0.0001). ConclusionsIdentified by this study are the predictors of postthyroidectomy hematoma and the consequences thereof. Notably, the use of energy devices for hemostasis was shown to be protective of postoperative hematoma. The results of this study may guide pre- and intra-operative decision-making for thyroidectomy to reduce rates of postoperative hematoma.

Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh

Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain.A registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh.The trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost.Seventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.ClinicalTrials.gov Identifier: NCT03283982.

Discontinuation of Prehospital Chlorhexidine Gluconate Does Not Increase Risk of Wound Morbidity after Ventral Hernia Repair: Results of a 3-Year Quality Improvement Initiative

Thomas, Jonah D. MS; Zolin, Samuel J. MD; Fafaj, Aldo MD; Alkhatib, Hemasat MD; Horne, Charlotte M. MD; Petro, Clayton C. MD; Krpata, David M. MD; Rosen, Michael J. MD, FACS; Prabhu, Ajita S. MD, FACS Author Information

Tertiary closure for high risk-patients undergoing gynecological abdominal surgery

Objective: Wound closure by secondary intention lowers the risk of SSI in high-risk patients undergoing gynecological abdominal surgery. However, this technique is associated with delayed wound closure, long-term disability, poor cosmesis, and significant cost. The purpose of this study is to describe an alternative wound closure technique (tertiary closure) aimed at improving wound morbidity.

Retrograde Retroperitoneal Type B1 Radical Hysterectomy in Distorted Pelvic Anatomy: Our Experience

Retrograde hysterectomy is indicated when adhesion around the uterus is strong and the usual surgical method is not possible. We describe a technique of retrograde retroperitoneal type B1 radical hysterectomy in patients with distorted pelvic anatomy. We performed the retrograde retroperitoneal type B1 radical hysterectomy in 17 patients during the period 2017–2019 in the department of surgical oncology at our centre. Eleven patients underwent this procedure for ovarian tumour as part of primary or interval cytoreduction, three patients for Grade IV endometriosis, one patient for locally advanced carcinoma rectum as part of posterior pelvic exenteration, and one patient for advanced carcinoma endometrium and as part of cytoreductive surgery (peritonectomy with HIPEC) in one patient with pseudomyxoma peritonei. Out of the 17 patients, only one patient had prolonged bladder morbidity which settled with conservative management. The patient who underwent the procedure as part of cytoreductive surgery had persistent increased frequency of stools for 1 month following the ileorectal anastomosis. She settled with conservative management and frequency of stools decreased. Two patients had wound morbidity. Retrograde retroperitoneal type B1 radical hysterectomy with preservation of pelvic nerves is technically feasible thereby decreasing the postoperative morbidity in patients with distorted pelvic anatomy. The technique described by us is a boon to the surgeon on encountering a difficult pelvic anatomy during the surgery.

Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study.

The aim of the study was to compare the incidence of perineal hernia and the perineal wound morbidity following extralevator abdominoperineal excision (ELAPE) between two groups - primary perineal closure and reconstruction with a biological mesh. One hundred and forty-seven consecutive patients who underwent ELAPE for primary rectal cancer between January 2007 and December 2018 in two tertiary referral centres were retrospectively identified from prospective databases. Perineal closure was carried out via primary closure or with a biological mesh (porcine dermal collagen mesh). Outcome measures were perineal hernia and perineal wound morbidity (infection, dehiscence, persistent sinus and chronic pain). A total of 139 patients were included in the study. A prophylactic mesh was used in 80 (57.5%) and primary closure was practised in 59 (42.4%) patients. The median follow-up was 30 (interquartile range 46.88) months. Thirty patients (21.6%) developed perineal hernia. No significant differences were found between prophylactic mesh and primary closure (16.3% vs 23.3%, P=0.07). The median period between surgery and hernia diagnosis was 8months in the primary closure group and 24months in the mesh group (P<0.01). Perineal wound morbidity was significantly higher in the prophylactic mesh group (55% vs 33.9%, P<0.01). In our study, the use of a biological mesh did not reduce the rate of perineal hernia, although it did delay its appearance. Perineal closure using a biological mesh may increase perineal morbidity, both acute and chronic.

Non-coated versus coated mesh for retrorectus ventral hernia repair: a propensity score-matched analysis of the Americas Hernia Society Quality Collaborative (AHSQC).

The outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space. Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI). 3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group. Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.

Implementing preoperative Botulinum toxin A and progressive pneumoperitoneum through the use of an algorithm in giant ventral hernia repair.

Repair of large ventral hernias with loss of domain can be facilitated by preoperative Botulinum toxin A (BTA) injections and preoperative progressive pneumoperitoneum (PPP). The aim of this study is to evaluate the outcomes of ventral hernioplasty using a standardized algorithm, including component separation techniques, preoperative BTA and PPP. All patients between June 2014 and August 2018 with giant hernias (either primary or incisional) of more than 12cm width were treated according to a previously developed standardized algorithm. Retrospective data analysis from a prospectively collected dataset was performed. The primary outcome was closure of the anterior fascia. Secondary outcomes included complications related to the preoperative treatment, postoperative complications, and recurrences. Twenty-three patients were included. Median age was 65years (range 28-77) and median BMI was 31.4 (range 22.7-38.0kg/m2). The median loss of domain was 29% (range 12-226%). For the primary and secondary endpoints, 22 patients were analyzed. Primary closure of the anterior fascia was possible in 82% of all patients. After a median follow-up of 19.5months (range 10-60months), 3 patients (14%) developed a hernia recurrence and 16 patients (73%) developed 23 surgical site occurrences, most of which were surgical site infections (54.5%). Our algorithm using both anterior or posterior component separation, together withpreoperative BTA injections and PPP, achieved an acceptable fascial closure rate. Further studies are needed to explore the individual potential of BTA injections and PPP, and to research whether these methods can prevent the need for component separation, as postoperative wound morbidity remains high in our study.

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.

Is there an advantage to laparoscopy over open repair of primary umbilical hernias in obese patients? An analysis of the Americas Hernia Society Quality Collaborative (AHSQC).

The most common techniques used to repair umbilical hernias are open and laparoscopic. As the obesity epidemic in the United States is growing, it is essential to understand how this morbidity affects umbilical hernia repairs. This study compares laparoscopic versus open umbilical hernia repairs in obese patients. All patients with body mass index (BMI) ≥ 30kg/m2 who underwent elective, open or laparoscopic repair of a primary umbilical hernia with mesh were identified from the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review of the prospectively collected data was conducted. Outcomes of interest included surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), hernia-related quality-of-life survey (HerQles), and long-term recurrence. A logistic regression model was used to generate propensity scores. Of 1507 patients who met the inclusion criteria, 322 were laparoscopic, and 1185 were open cases. The laparoscopic group had higher mean BMI (37 ± 6 vs. 35 ± 5kg/m2 , P < 0.001 ) and mean hernia width (3cm ± 1 vs. 2cm ± 2, P < 0.001). Using a propensity score model, we controlled for several clinically relevant covariates. Propensity score adjustment showed no differences in the 30-day HerQles score (OR 0.93, 95% CI 0.58-1.49), SSI (OR 1.57, 95% CI 0.52-4.77), SSOPI (OR 2.85, 95% CI 0.84-9.62) or hernia recurrence (hazard ratio 0.86, 95% CI 0.50-1.49). In obese patients with primary umbilical hernias, there is likely no benefit to laparoscopy over open umbilical hernia repair with mesh with regard to wound morbidity. Although, the long-term recurrence also showed no difference between these two approaches, overall follow up was lacking.

Is concomitant cholecystectomy safe during abdominal wall reconstruction? An AHSQC analysis.

Unlike routine ventral hernia repair, abdominal wall reconstruction (AWR) can results in large pieces of mesh and extensive manipulation of the intra-abdominal contents, rendering subsequent laparoscopic cholecystectomy challenging. This study addresses the additional wound morbidity of concomitant cholecystectomy. The Americas Hernia Society Quality Collaborative (AHSQC) was retrospectively reviewed and logistic regression modeling was used to control for multiple covariates. Patients that underwent open AWR with cholecystectomy were compared to a similar group of patients undergoing uncomplicated, open, clean, AWR alone. 130 patients undergoing concomitant cholecystectomy were compared to a control group of 6440 patients. The addition of a cholecystectomy did not cause a significant change in wound morbidity (SSI: p = 0.16; SSOPI: p = 0.65). This study noted that a concomitant cholecystectomy does not increase the wound morbidity as compared to an uncomplicated, clean, AWR. This provides support for consideration of routine cholecystectomy in patients with cholelithiasis undergoing AWR.

Modified retrorectus procedure for repair of midline incisional hernias

Background: Incisional hernias develop after abdominal operations. Primary closure procedures carry high recurrence rates. Prosthetic repairs with different modifications have reduced the recurrence rates and are the procedures of choice for incisional hernia repair.Methods: Our study is a prospective study conducted on 30 patients of midline incisional hernia. Hernia repair was done by modified retrorectus technique with in which the mesh is placed between the rectus abdominis muscle and the posterior rectus sheath.Results: In our study, the hernia defect ranged from 25-40 cm2.The mesh size used ranged from 15×15 to 30×20 cm. Mean duration of hospital stay was 9.9±2.3 days. Operative time ranged from 90-150 minutes. Follow up period ranged from 3-15 months. There were no post-operative complications in 73.3% cases. Seroma formation occurred in 10% cases and wound infection was seen in 10% cases. One patient developed mesh infection which required partial removal of mesh. There was no recurrence, no mortality, no bowel injury or adhesion obstruction. Wound related complications and morbidity was higher in patients with risk factors and comorbidities like diabetes, obesity, anaemia, COPD, hypoalbuminemia and patients on steroids.Conclusions: The retrorectus technique for the repair of midline incisional hernia using polypropylene mesh is a safe and durable procedure with excellent long-term results, minimal comorbidities and least recurrence rates and is an open procedure of choice for the repair of large incisional hernias.