Wound Morbidity Research Articles

Robotic Inguinal vs Transabdominal Laparoscopic Inguinal Hernia Repair

Despite rapid adoption of the robotic platform for inguinal hernia repair in the US, to date, no level I trials have ever compared robotic inguinal hernia repair to laparoscopic repair. This multicenter randomized clinical trial is the first to compare the robotic platform to laparoscopic approach for minimally invasive inguinal hernia repair. To determine whether the robotic approach to inguinal hernia repair results in improved postoperative outcomes compared with traditional laparoscopic inguinal hernia repairs. This multicenter, single-blinded, prospective randomized clinical pilot study was conducted from April 2016 to April 2019, with a follow-up duration of 30 days in 6 academic and academic-affiliated sites. Enrolled in this study were 113 patients with a unilateral primary or recurrent inguinal hernia. After exclusions 102 remained for analysis. Standard laparoscopic transabdominal preperitoneal repair or robotic transabdominal preperitoneal repair. Main outcomes included postoperative pain, health-related quality of life, mobility, wound morbidity, and cosmesis. Secondary outcomes included cost, surgeon ergonomics, and surgeon mental workload. A primary outcome was not selected because this study was designed as a pilot study. The hypothesis was formulated prior to data collection. A total of 102 patients were included in the study (54 in the laparoscopic group, mean [SD] age, 57.2 [13.3] years and 48 [88.9%] male; 48 in the robotic group, mean [SD] age, 56.1 [14.1] years and 44 [91.6%] male). There were no differences at the preoperative, 1-week, or 30-day points between the groups in terms of wound events, readmissions, pain as measured by the Visual Analog Scale, or quality of life as measured by the 36-Item Short Form Health Survey. Compared with traditional laparoscopic inguinal hernia repair, robotic transabdominal preperitoneal repair was associated with longer median (interquartile range) operative times (75.5 [59.0-93.8] minutes vs 40.5 [29.2-63.8] minutes, respectively; P < .001), higher median (interquartile range) cost ($3258 [$2568-$4118] vs $1421 [$1196-$1930], respectively; P < .001), and higher mean (SD) frustration levels on the NASA Task Load Index Scale (range, 1-100, with lower scores indicating lower cognitive workload) (32.7 [23.5] vs 20.1 [19.2], respectively; P = .004). There were no differences in ergonomics of the surgeons between the groups as measured by the Rapid Upper Limb Assessment instrument. Results of this study showed no clinical benefit to the robotic approach to straightforward inguinal hernia repair compared with the laparoscopic approach. The robotic approach incurred higher costs and more operative time compared with the laparoscopic approach, with added surgeon frustration and no ergonomic benefit to surgeons. ClinicalTrials.gov Identifier: NCT02816658.

Repair of Ventral Abdominal Wall Hernias

The repair of noninguinal abdominal wall defects is one of the most common procedures general surgeons perform. Despite this, there is little agreement or consensus in the literature as to the ideal approach for this difficult problem. In recent years, population-based studies have provided better data on the true failure rates associated with the various herniorrhaphies. Wound morbidity has also emerged as an important outcome measure, and definitions by the Ventral Hernia Working Group (VHWG) have begun to standardize such benchmarks. Future evidence will come from the large multi-institutional collaborations currently forming. This topic review discusses the classification of ventral hernias, abdominal wall anatomy, and choices of prosthetic materials. Incisional hernia repair is discussed, as are the operative steps and techniques for both an open and a laparoscopic ventral hernia repair. Special circumstances, including loss of abdominal domain and contaminated surgical fields, periumbilical hernia repair, and atypical ventral hernias are also described. This review contains 10 figures, 18 tables, and 71 references. Keywords: Hernia, incisional hernia, mesh, laparotomy, laparoscopy, incarceration, surgical site infection, hernia repair

Transversus abdominis release versus perforator preseving anterior component separation in repair of large midline incisional hernia

Abstract Background Ventral hernia repair can be challenging, particularly in patients with serious comorbidity. Perforator preserving anterior component separation (ACS) by transverse skin incisions for external oblique aponeurosis release preserves both the rectus abdominis myocutaneous perforator vessels that supply the overlying skin and the connection between the subcutaneous fat and anterior rectus sheath, thereby reducing subcutaneous dead space and potentially improving overlying skin flap vascularity. Also posterior component separation via transversus abdominis release (TAR) provides effective fascial advancement while reducing wound morbidity during abdominal wall reconstructions. Both techniques give better results than classic ACS. Objectives to evaluate postoperative morbidity and recurrence rate when using transversus abdominis release technique in management of large midline incisional hernia in comparison with open perforator preserving anterior component separation. Patients and Methods the present study is a prospective study that was conducted at Ain Shams University Hospitals in Egypt, between October 2016 and October 2018. It included sixty (60) patients with large midline incisional hernia divided into two groups. First group include thirty patients who underwent transversus abdominis release with retromuscular polyprolene mesh placement. Second group include also thirty patients that underwent open perforator preserving anterior component separation and also with retromuscular placement of polyprolene mesh. Patients compared as regards operative time, length of hospital stay, postoperative pain, postoperative ileus, postoperative wound complications, rate of recurrence. Results Patients in both groups were similar with respect to age, the patients ages ranged from 20 to 70 years, with mean age in both groups around 46 years and between 20-23% have DM in each group. Perforator preserving technique has less operative time by about 40 minutes when compared with TAR technique. The postoperative pain assessment at 48hrs postoperative show that the mean pain score for TAR was (6.77 ± 1.70) and for perforator preserving group (5.47 ± 1.85). We also found that the mean hospital stay was slightly higher when performing TAR technique (5.2days) while it was (4.3days) after perforator preserving approach. There is nearly equal incidence of postoperative wound complications and also no statistically significant different rate of recurrence between two methods Conclusion both TAR and perforator preserving technique are effective and reliable method in experienced hands and if there is no special indication to one of them, the choice between both should depend on surgeon preference and experience.

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.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society.

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias. The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019. Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity. This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

Comparing outcomes of the endoscopic and open external oblique myofascial release

AIMS: The external oblique release (EOR) is a well-described technique for myofascial advancement during hernia repair. One of the reported drawbacks of an open approach is the high wound morbidity associated with this procedure. One proposed technique to reduce wound morbidity is the endoscopic EOR. The purpose of this study was to compare the outcomes of the open and endoscopic EOR. METHODS: Data from the Americas Hernia Society Quality Collaborative were queried on May 10, 2017. All patients undergoing open or endoscopic incisional hernia repair with an EOR were evaluated with comparative outcomes including hernia recurrence, quality of life, and 30-day wound complications. RESULTS: Four hundred and eighty-five patients met inclusion criteria of undergoing open or endoscopic EOR. Surgical site infections (SSIs) occurred in 6% of the patients undergoing open EOR and 14% undergoing endoscopic EOR. There were no differences in outcomes comparing open and endoscopic EOR for hernia recurrence, quality of life, or 30-day SSI rate (P > 0.05). Laparoscopic EOR had a significantly higher rate of surgical site occurrences (SSOs) compared with open EOR (P 0.05). CONCLUSIONS: Equivalent outcomes were achieved using the open or endoscopic EOR technique in open repair of incisional hernia. Both techniques offer good outcomes and are important adjuncts in the repair of complex incisional hernias.

A 2-year Review of Wound Outcome Following Primary Skin Closure After Laparotomy for Typhoid Ileal Perforation in Bida, Nigeria

Introduction: Laparotomy wound for typhoid ileal perforation is a dirty wound and is usually associated with wound complications and prolonged hospital stay. Delayed primary wound closure which for long has been the most common practice after laparotomy for typhoid peritonitis is now considered to be of little significance in preventing surgical site infection (SSI). We aimed to document the incidence, severity and management of wound complications when primary closure of abdominal wounds was performed following laparotomy for typhoid ileal perforation. Patients and Methods: This was a retrospective study of all patients who had primary abdominal wound closure following laparotomy for typhoid ileal perforation in Federal Medical Centre, Bida from January 2017 to December 2018. Results: There were 71 patients with the age ranges from 2 to 41 years and their median age was 15 years who had laparotomy for typhoid ileal perforation during the study period. All 71 patients had primary closure of their abdominal wounds, however two of them died within 72 hours of operation and were excluded from the study. There were males 38 (55.1%) and females 31 (44.9%) with a male to female ratio of 1.2:1. There was primary wound healing in 23 (33.3%) patients while 44 (63.8%) of them developed incisional surgical site infections (SSI) and 2 (2.9%) developed organ space SSI. Of the 44 patients that had incisional SSI, 33 (75.0%) were superficial and 11 (25.0%) were deep. Other complications noted from the study were faecal fistulae 3 (4.3%) and incisional hernia (4.3%). Conclusion: Though a high incidence of wound morbidity is not unexpected in situation of primary closure of laparotomy wound for bacteria peritonitis, an aggressive wound management may help to reduce the incidence and severity of wound complications in such situations.

Closed Incision Negative Pressure Therapy in Morbidly Obese Women Undergoing Cesarean Delivery: A Randomized Controlled Trial.

To evaluate the efficacy of incisional negative pressure wound therapy in the prevention of postoperative wound morbidity in women with class III obesity undergoing cesarean delivery. In an open label randomized controlled trial, women admitted for delivery with class III obesity (body mass index 40 or higher) measured within 2 weeks of admission for delivery were offered participation in the study. They were consented either in the outpatient maternal-fetal medicine specialty clinic, during admission to labor and delivery and before a decision to perform cesarean delivery, or in the preoperative area of the hospital before scheduled cesarean delivery. Exclusion criteria included anticoagulation therapy, human immunodeficiency virus infection, and silver or acrylic allergy. Those who ultimately underwent cesarean delivery were randomized to standard surgical dressing or incisional negative pressure wound therapy dressing. The primary outcome was wound morbidity. Preplanned secondary outcomes included characteristics of composite wound morbidity, and hospital, emergency room, and clinic utilization. The sample size estimate required randomization of 440 women to detect a 50% decrease in composite outcome. Between January 1, 2015, and July 31, 2016, 850 women were screened and 677 women with class III obesity were enrolled. Of these, 441 underwent cesarean delivery and were subsequently randomized (219 to standard dressing and 222 to incisional negative pressure wound therapy). The primary outcome, overall composite wound morbidity rate, was 18%. This was not different between the two cohorts (incisional negative pressure wound therapy 17% vs standard dressing 19%, relative risk 0.9 [95% CI 0.5-1.4]). Prophylactic incisional negative pressure wound therapy use did not reduce postoperative wound morbidity when compared with a standard surgical dressing in women with class III obesity. ClinicalTrials.gov, NCT02289157.

A prospective study in peritonitis patients to compare the impact of subcutaneous negative suction closure, conventional primary closure of skin and subcutaneous tissue and open skin technique following laparotomy

Background: Abdominal wall closure in the presence of sepsis presents a challenge to the surgeon. The objective of this study is to determine the advantages and disadvantages of each method to individualise the techniques based on patient profile about surgical site infection, duration of hospitalisation and morbidity.Methods: A prospective comparative study was conducted among 102 operated patients of peritonitis in the Department of General Surgery at St John’s Medical College and Hospital. The patients were divided into three groups, group A, group B and group C. In group A, skin and subcutaneous tissue was closed after draining the subcutaneous space by a negative-suction drain. In group B, the patient’s skin and subcutaneous tissues were closed primarily with continuous sutures without negative suction drain. In group C, the laparotomy wound was closed and the skin was left open. And the outcome compared in the form of wound infection, hospital stay and morbidity. Patients on immunosuppressive therapy and paediatric patients were excluded. Demographic and clinical variables were recorded at the time of admission. SPSS version 18 was used for analysis.Results: The study showed male preponderance and the mean age was 43.2 years. Duodenal perforation was the commonest cause of peritonitis in this study (38.2%). Incidence of surgical site infection was less in Group A (20.6%) compared to group B (52.9%) and group C (29.4%). Duration of hospital stay was also less in Group A patients (9.3±3.6 days) compared to other two groups. 37 patients who were included in the study were diabetic, out of which 25 patients (67.6%) developed surgical site infection.Conclusions: It can be concluded from this study that abdominal wall closure using a sub cutaneous negative suction drain in peritonitis cases reduces the incidence of surgical site infection, duration of hospital stays, subsequent surgeries related to wound dehiscence and its associated morbidity.

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer

BackgroundAbdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR.MethodsConsecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures.ResultsOut of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35–44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8–12 days).ConclusionsThe GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.

Adrenal natural orifice transluminal endoscopic surgery (NOTES): a step too far?

Surgical approach to adrenal gland has evolved from open to minimally invasive surgery. With the advent of technology, multiple techniques and approaches are available in a surgeon's armamentarium today to deal with adrenal nodules that require surgical intervention. Each approach has its own advantages and disadvantages. The era of minimal invasive surgery has fuelled our quest for better cosmesis, faster recovery, early return to work and reduced hospital stay. While minimal invasive method is the preferred approach for most benign adrenal masses less than 6 cm, its application for large adrenal lesions as well as adrenocortical carcinoma is still debatable. Single incision minimal invasive procedures further try to reduce the incisions and wound morbidity. With the aim to completely remove visible scars and possibly reduced morbidity, the concept of natural orifice transluminal endoscopic surgery (NOTES) has been proposed by some surgeons as well as interventional gastroenterologist. In NOTES, the peritoneal cavity is accessed through a hollow viscus to perform therapeutic as well as diagnostic procedures. While the theoretical advantages of scar less surgery and its advantages sound encouraging, the precise indications and its potential advantages for adrenal pathologies is yet to be defined. It should in no way, compromise our goal of safe patient surgery and outcomes.

The Handling of the Rectal Stump Does Not Affect Severe Morbidity After Subtotal Colectomy For Ulcerative Colitis: A Retrospective Cohort Study

Colectomy due to ulcerative colitis is associated with complications. One severe complication is the risk for blow-out of the remaining rectal remnant. The aim of this study was to compare the frequency and severity of complications in patients with the rectal remnant left subcutaneously versus patients with the rectal remnant left intra-abdominally. A secondary aim was to identify risk factors for complications. Consecutive patients at two tertiary centers in Sweden were retrospectively reviewed regarding surgical procedures; complications classified according to Clavien-Dindo; and possible risk factors for complications such as preoperative medication, emergency surgery, and body mass index. 307 patients were identified. Minor complications were more common than previously reported (85%-89%). Severe surgical complications were not related to the handling of the rectal remnant. Leaving the rectal remnant subcutaneously was associated with local wound problems. Risk factors for severe complications were emergency surgery and preoperative medication with 5-aminosalicylic acid. Minor complications after colectomy for ulcerative colitis are very common and need to be addressed. Leaving the rectal stump intra-abdominally seems safe and may be advantageous to reduce local wound morbidity.

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.

Impact of modifiable comorbidities on 30-day wound morbidity after open incisional hernia repair

BackgroundWe aimed to assess the impact of modifiable comorbidities—obesity, diabetes, and smoking—and their aggregate effect on wound complications after incisional hernia repair. MethodsData on all open, elective, incisional hernia repair with permanent synthetic mesh in clean wounds were collected from the Americas Hernia Society Quality Collaborative and reviewed. Three groups were defined: those with 0, 1, or 2+ modifiable comorbidities, with associations described for each specific comorbid condition. Primary outcomes included surgical site occurrences, surgical site infections, and surgical site occurrences requiring procedural intervention. ResultsA total of 3,908 subjects met the inclusion criteria. Mean hernia width was 9.6 ± 6.5 cm, mean body mass index was 32.1 ± 6.6 kg/m2, 21% of patients had diabetes, and 9% were smokers. Of those, 31% had no modifiable comorbidities, 49% had 1 modifiable comorbidity, and 20% had 2+ modifiable comorbidities. Compared with having no modifiable comorbidities, having 1 modifiable comorbidity, or 2+ modifiable comorbidities significantly increased the odds of a surgical site occurrence (odds ratios 1.33 and 1.61, respectively). However, only patients with 2+ modifiable comorbidities had significantly increased odds of surgical site occurrences requiring procedural intervention compared with no modifiable comorbidities and 1 modifiable comorbidity (odds ratios 2.02 and 1.65, respectively). Patients with all 3 comorbidities had a two-fold increase in odds for all wound morbidity, followed similarly by obese patients with diabetes. ConclusionThe presence of any number of comorbidities (1 modifiable comorbidity or 2+ modifiable comorbidities) increases the odds for wound events. However, having multiple comorbidities was associated with more procedural interventions for wound management. This was most evident in patients with all 3 comorbidities, and, in obese diabetics, underscoring the importance of preoperative counseling on expected recovery in such patients.

A randomized trial comparing octyl cyanoacrylate tissue adhesive and sutures in the management of facial lacerations

Facial laceration is one of the most common injuries encountered by plastic surgeons. The right material to be used for epidermal closure is a controversial topic with pros and cons of each. The aim of this study was to compare 2-octyl cyanoacrylate tissue adhesive and monofilament sutures for epidermal closure in facial lacerations considering closure time, wound morbidity, and cosmetic outcome. In this study, 90 patients visiting St. John’s hospital, Bangalore, emergency department for facial lacerations were randomly allocated to 1 of 3 groups for the closure using octyl-2-cyanoacrylate–group 1, monofilament nylon 8/0 interrupted sutures–group 2, or monofilament nylon 5/0 subcuticular sutures–group 3 based on simple randomization by computer-generated sequence. All procedures were carried out in the operation theater under sterile precautions by plastic surgery residents. Post-operative follow-up was done on day 1, day 7, and at 3 months. Statistical analysis was done using the one-way ANOVA test and Student’s t test. Time taken for closure using 2-OCA was 4 times faster than the other 2 groups using monofilament sutures. There was no significant statistical difference among the 3 groups with respect to wound morbidity and cosmetic outcome at the end of 3 months. Epidermal closure with tissue adhesive for facial lacerations was faster compared to monofilament sutures with comparable cosmetic outcome at the end of 3 months.

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.

The effect of increasing body mass index on wound complications in open ventral hernia repair with mesh

BackgroundThere is a paucity of data delineating the relationship between body mass index (BMI) and wound complications. We investigated the association between BMI and wound morbidity following open ventral hernia repair with mesh (OVHR). DesignPatients undergoing elective OVHR were identified within the Americas Hernia Society Quality Collaborative. Multivariate logistic regression identified predictors of 30-day surgical site infection (SSI) and surgical site occurrences requiring procedural intervention (SSOPI). BMI was treated as a continuous variable in the models. Results8949 patients were included (median age 58, median BMI 31.3 kg/m2, median defect width of 7 cm). Repairs typically included synthetic mesh (89%), placed as a sublay (70%). SSI rate was 4.5% and SSOPI was 6.7%. BMI was associated with increased relative log-odds for SSI (p = 0.01) and SSOPI (<0.0001), with a proportional increase in relative log-odds for complications according to escalations in BMI. ConclusionEscalating BMI progressively increases relative log-odds for SSI and SSOPI after OVHR. Further studies are necessary to determine whether preoperative weight loss can reduce the impact of this association.

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.

Ascending the Learning Curve of Robotic Abdominal Wall Reconstruction.

Background:Robotic complex abdominal wall reconstruction (r-AWR) using transversus abdominis release (TAR) is associated with decreased wound complications, morbidity, and length of stay compared with open repair. This report describes a single-institution experience of r-AWR.Methods:A retrospective chart review was performed on patients who underwent r-AWR by a single surgeon (D.H.) from August 2015 through October 2018.Results:Fifty-five patients underwent r-AWR (16 males [29%] and 39 females [71%]) with a mean age of 60.2 (range 33 to 87) years and a mean body mass index of 34.6 (range 23 to 54) kg/m2. Forty-one patients presented with an initial ventral hernia (74.5%) and 14 with a recurrent hernia (25.5%). Five patients had a grade 1 hernia (9.1%), 46 had a grade 2 hernia (83.6%), and 4 had a grade 3 hernia (7.3%) according to the Ventral Hernia Working Group system. Thirty-four (62%) patients underwent TAR, 21 (38%) patients underwent bilateral retrorectus release, and 10 (18.2%) patients underwent concomitant inguinal hernia repair. Mean operative time with TAR was 294 (range 106 to 472) minutes and 183 (range 126 to 254) minutes without TAR. Mean length of stay was 1.5 (range 0 to 10) days. Mean follow-up was 10.7 (range 1 to 52) weeks with no hernia recurrences. Seromas occurred in 6 (10.9%) patients, with 2 (3.6%) requiring drainage. Two (3.6%) 30-day readmissions occurred with no conversions to open or 30-day mortalities.Conclusions:r-AWR with and without TAR is a safe and feasible procedure associated with a short LOS, low complication rate, and low recurrence even within the surgeon's learning curve experience.

Alternative specimen extraction techniques complimenting enhanced recovery after surgery protocol in gastrointestinal malignancies: An early experience

Background Minimally invasive surgery is being increasingly implemented for Gastrointestinal (GI) malignancies. Site of specimen extraction after surgery influence the postoperative course by adding up-to the parietal wound morbidity. We studied the effect of alternative specimen extraction techniques on postoperative recovery and ease of implementation of ERAS protocol. Results A single center prospective data of 32 patients were compiled and the alternative specimen extraction sites studied were Natural Orifice Specimen Extraction-Vagina (n=8), Proposed Stoma Site Specimen Extraction (n=19), Trans Anal Specimen Extraction (n=5). All the patients had ease in the implementation of ERAS protocol and showed enhance recovery after the surgery with minimal wound related morbidity. The average duration of stay in the hospital was 5.8 days (SD=1.4) and the time to start adjuvant therapy when needed was an average of 21.7 days (SD= 5.46). Conclusion Alternative Specimen extraction techniques other than routine laparotomy compliment ERAS protocol initiation and implementation in patients undergoing Minimally invasive GI Oncological Surgery.