A systematic review of the association between parastomal hernia and sarcopenia

BACKGROUND

Sarcopenia is a multifactorial loss of muscle mass that can complicate surgical outcomes and increase morbidity and mortality. Parastomal hernias can occur after any surgery requiring stoma formation and is an area of concern as a complication as it can require a second surgery or emergency surgical intervention.

AIM

To assess the impact of sarcopenia on parastomal hernia formation in the postoperative period.

METHOD

A systematic search of publications using MEDLINE, CINAHL, and Cochrane databases was conducted in June 2022. Data were extracted, and a narrative synthesis was undertaken. The Crowe Critical Appraisal Tool (CCAT) assessed the quality of the included studies. The systematic review included original research studies, prospective and retrospective designs, and human studies written in English. Reviews, conference papers, opinion papers, and those including participants < 18 years old were excluded. No restrictions on the date of publication and study setting were applied.

RESULTS

Nine studies met the inclusion criteria, and these were conducted between 2016 and 2021; 56% (n = 5) used a retrospective study design. The mean sample size was 242.5 participants (SD = ±358.6). No consistent or standardized way of defining sarcopenia or measuring muscle mass was seen between the studies reviewed. However, 45% (n = 4) of the studies reported a significant relationship between sarcopenia and wound healing complications, including an increased incidence of parastomal and incisional hernias. The average CCAT score was 27.56 (SD = ±4.39).

CONCLUSION

There is no definitive relationship between sarcopenia and hernia development; however, four studies found a significant relationship between sarcopenia and hernia formation. It must also be considered that different disease processes can cause sarcopenia either through the disease process itself, or the treatment and management. More research and consistent measurements are needed before comparable and consistent outcomes can be compiled.

Severe wound infection by MRCNS following bilateral inguinal herniorrhaphy

BACKGROUND

Wound infection after inguinal hernia surgery is not uncommon in the clinical setting. The common microbial aetiology of postoperative inguinal hernia wound infection is Gram-positive bacteria. Staphylococcus aureus is a common pathogen causing wound infection while Staphylococcus epidermidis and Pseudomonas are rare. Staphylococcus epidermidis as a cause of severe wound infection is rarely described in literature. We herein present a case of a 79-year-old man with a rare wound infection after bilateral inguinal herniorrhaphy caused by MRCNS (Methicillin Resistant Coagulase Negative Staphylococcus).

CASE PRESENTATION

We present a case of wound infection accompanied by fever with a temperature of 38.8 °C after bilateral inguinal herniorrhaphy in a 79-year-old man. Bilateral inguinal wounds were marked by redness and swelling, with skin necrosis. In addition, an abscess of approximately 1.5 cm × 1.5 cm was seen on the left wrist. A small amount of gas under the skin in the wound area was observed after pelvic computed tomography (CT) scans. No bacteria were cultured from the inguinal wound discharge, while blood culture detected MRCNS, and Acinetobacter lwoffi was cultured from the pus in the left wrist. We chose appropriate antibiotics based on the results of the bacterial culture and the drug susceptibility results. Vacuum assisted closure (VAC) therapy was used after debridement. The patient was discharged after the wounds improved. He was followed up for ten months and showed no signs of complications. We are sharing our experience along with literature review.

CONCLUSIONS

We are presenting a rare case of MRCNS wound infection following open inguinal hernia surgery. Although a rarity, clinicians performing inguinal hernia surgery must consider this entity in an infected wound and follow up the patient for complications of MRCNS.

Technical aspects of inguino scrotal hernia surgery in developing countries

PURPOSE

Technical aspects of inguinoscrotal herniorrhaphy performed in low to middle income countries (LMICs) are described here to help surgeons who will operate on these challenging hernias in austere settings.

METHODS

Technical considerations related to operative repair were delineated with the consensus of 7 surgeons with extensive experience in inguinoscrotal hernia repair in LMICs. Important steps and illustrations were prepared accordingly. The anatomical and pathologic differences and technical implications of operating in limited resource settings are emphasized with suggestions to approach anticipated challenges. Pre-operative evaluation, anesthetic considerations, and technical guidelines are offered in context.

RESULTS

The authors have cumulatively performed over 1775 inguinoscrotal Lichtenstein operations in LMICs. While dedicated, reliable, long-term follow-up is unavailable from LMICs, one author reports outcomes with 5 year follow-up from the HerniaMed registry using the identical technique in similarly classed hernias. In 90 inguinoscrotal Lichtenstein repair patients (78.3% follow-up), there was one recurrence, low rates of chronic pain (2.2% at rest, 4.4% with activity), and low rates of reintervention (1.1%).

CONCLUSION

There is a difference between inguinal hernias found in LMICs and those seen in high-income countries with larger, chronic, and more technically challenging pathology. The consequences of intra-operative complications can be catastrophic in a LMIC. Technical measures are offered to improve outcomes, avoid and manage complications, and provide optimal care to this important population.

Hospital-level variation in mesh use for ventral and incisional hernia repair

BACKGROUND

Placement of prosthetic mesh during ventral and incisional hernia repair has been shown to reduce the incidence of postoperative hernia recurrence. Consequently, multiple consensus guidelines recommend the use of mesh for ventral hernias of any size. However, the extent to which real-world practice patterns reflect these recommendations is unclear.

METHODS

We performed a retrospective review of the Michigan Surgical Quality Collaborative Hernia Registry (MSQC-HR) to identify patients undergoing clean ventral or incisional hernia repair between January 1, 2020 and December 31, 2021. The primary outcome was mesh use. We used two-step hierarchical logistic regression modeling with empirical Bayes estimates to evaluate the association of hospital-level mesh use with patient, operative, and hernia characteristics.

RESULTS

A total of 5262 patients underwent ventral and incisional hernia repair at 65 hospitals with a mean age of 53.8 (14.5) years, 2292 (43.6%) females, and a mean hernia width of 3.2 (3.4) cm. Mean hospital volume was 81 (49) cases. Mesh was used in 4098 (77.9%) patients. At the patient level, hernia width and surgical approach were significantly associated with mesh use. Specifically, mesh use was 6.2% (95% CI 4.8-7.5%) more likely with each additional centimeter of hernia width and 28.0% (95% CI 26.1-29.8%) more likely for minimally invasive repair compared to open repair. At the hospital level, there was wide variation in mesh use, ranging from 38.0% (95% CI 31.5-44.9%) to 96.4% (95% CI 95.3-97.2%). Hospital-level mesh use was not associated with differences in hernia size (β =  - 0.003, P = 0.978), surgical approach (β =  - 1.109, P = 0.414), or any other patient factors.

CONCLUSIONS

Despite strong evidence supporting the use of mesh in ventral and incisional hernia repair, there is substantial variation in mesh use between hospitals that is not explained by differences in patient characteristics or operative approach. This suggests that opportunities exist to standardize surgical practice to better align with evidence supporting the use of mesh in the management of these hernias.

Adult groin hernia surgery in sub-Saharan Africa: a 20-year systematic review and meta-analysis

PURPOSE

To realize a systematic review to evaluate groin hernia surgery for adults in sub-Saharan Africa.

METHODS

We conducted a systematic review and meta-analysis, the primary objective of which was to determine the surgical techniques used for unilateral groin hernia surgery in sub-Saharan Africa. Studies published in the last 20 years were considered. A meta-analysis estimated the pooled prevalence with 95% confidence interval (CI) of mortality, chronic pain and recurrence. A subgroup analysis compared the rate of complications between complicated or uncomplicated hernia.

RESULTS

We included 113 articles. The most used technique was Bassini in 40.1%, followed by Lichtenstein in 29.9% and Shouldice in 12.6%. The overall mortality rate was 0.6% (95% CI 0.4-0.9). The pooled recurrence rate was 1.4% (95% CI 1.05-1.9). The pooled rate of chronic pain was 2.7% (95% CI 1.9-3.7). We found that mortality rate for complicated hernias (6.4%) was higher compared to uncomplicated hernias (0.2%). This difference was statistically significant [p ≤ 0.001; OR = 47.7; 95 CI (27.2-83.47)].

CONCLUSION

This review showed that pure tissue repairs are the most used techniques with Bassini and Shouldice as leading procedures. The post-operative rates of recurrence and chronic pain are low. However, there is a high heterogeneity between studies than can underestimate these pooled prevalences. The consultation at complication stage remains frequent and associated with a higher mortality. Futures studies should focus on improving the quality of studies in terms of design and follow-up to increase the degree of evidence.

Traumatic abdominal wall hernias in the pediatric population: a 13-year institutional review

BACKGROUND

Pediatric traumatic abdominal wall hernias are rare but potentially devastating injuries. Although classically considered to be caused by handlebar injuries from bicycle accidents, our anecdotal experience suggests pediatric traumatic abdominal wall hernias are far more likely to occur following road traffic accidents and have a high association with other significant intra-abdominal injuries.

OBJECTIVE

The purpose of this study was to determine the frequency, mechanisms of injury, and associated injuries of traumatic abdominal wall hernias in the pediatric population.

MATERIALS AND METHODS

This is a retrospective observational cohort study from two large urban level 1 trauma centers. Institutional trauma registries were queried from January 1, 2008, to December 31, 2020, for patients under 18 years of age diagnosed with traumatic abdominal wall hernias, excluding those without initial abdominopelvic CT imaging. Finalized CT reports and images were reviewed to confirm the presence of a traumatic abdominal wall hernia and document any associated secondary injuries. The medical record was reviewed to extract pertinent physical findings, interventions performed, and outcomes. Injury Severity Score (ISS) for each patient was calculated by the trauma registrar.

RESULTS

A total of 19 patients with TAWH met inclusion criteria, with an overall frequency of 0.095% and a mean age of 10.6 years (range 3-17). Eleven patients were male (57.9%) with a mean ISS of 18.6 (range 1-48, including 63.2% with ISS > 15). The most common mechanism of injury was motor vehicle collision (N = 11, 57.9%) followed by bicycle accident (N = 3, 15.8%). A total of 17 (89.5%) had associated injuries, including 11 (57.9%) with intestinal injuries, 5 (26.3%) with pelvic fractures, 4 (21.1%) with femur fractures, 3 (15.8%) with splenic injuries, 3 (15.8%) with kidney injuries, and 3 (15.8%) with Chance fractures of the lumbar spine. All patients required surgery for the traumatic abdominal wall hernias and associated injuries.

CONCLUSION

Pediatric traumatic abdominal wall hernias are more likely to be seen following motor vehicle collisions, with a majority (89.5%) having associated injuries, most frequently to the bowel (57.9%). Handlebar injuries were seen in a minority of patients (15.8%) and were less likely to be associated with additional injuries.

CLINICAL IMPACT

Pediatric patients with a traumatic abdominal wall hernia on admission CT should be thoroughly evaluated for bowel injuries, especially in the setting of a motor vehicle collision.

Evaluation of inguinal hernia repair using post-operative pain and quality of life metrics

BACKGROUND AND PURPOSE

Elective inguinal hernia repair is a ubiquitous procedure that carries risks; chronic pain and impacts on quality of life (QoL) must be considered when advising patients around repair. The length of time from surgery date and impacts on quality of life are often limited to only a few years of follow-up and despite hernia repair being quite common, long-term outcomes are not often reported.

METHODS

A cohort of patients who had received Lichtenstein inguinal hernia repair over the previous 10 years were contacted and surveyed using the Brief Pain Inventory Short Form (BPI) to assess chronic pain and its effects on their QoL. Patient and operative factors were correlated with pain through linear regression and t-test analysis provided statistical significance for mean comparisons (P < 0.05).

RESULTS

The rate of chronic pain was 17.2% with recurrence of 3.1% at an average post-operative interval of 5.84 years. Of the various metrics compared between groups, age was one of the only significant predictors of chronic pain with younger patients reporting higher pain. Further time from surgery also translated to significantly less pain with a difference of 1.3 years. BPI respondents identified pain that interfered to varying degrees in different aspects of life but had relatively low average magnitudes (range: 1.82/10-2.91/10).

CONCLUSIONS

These long-term considerations of post-surgical impact should be considered alongside potential benefits when advising patients about surgery and may help moderate post-operative expectations to optimize the outcome of common inguinal hernia repairs.

The effect of mesh fixation on migration and postoperative pain in laparoscopic TEP repair: prospective randomized double-blinded controlled study

PURPOSE

The development of chronic pain is one of the major post-surgery problems after inguinal hernia repair. Although the possibility of chronic pain formation decreases with laparoscopic methods, pain may develop due to the staples used. It is thought that absence of mesh fixation in total extra-peritoneal (TEP) repair does not increase the recurrence rate. This study aims to investigate the absence of mesh fixation in the TEP on the development of postoperative pain, mesh displacement, and recurrence rate.

METHODS

Between December 2019 and December 2020, 100 patients who underwent TEP repair due to unilateral inguinal hernia in the General Surgery Clinic of Hitit University were included in the study. Study was registered at http://Clinicaltrials.gov (NCT05152654). Patients were divided into two groups as repairs in which the mesh was fixed with a tacker and no-fixation (NF) was used. The mesh is marked with radiopaque clips. Patients were compared in terms of postoperative pain, mobilization time, hospital stay, return to work, chronic pain, early-late mesh displacement, and recurrence.

RESULTS

While there was no significant difference between the groups in terms of mesh displacement and recurrence, it was observed that the NF group developed significantly less pain in the early and late postoperative period compared to the other group. The time-dependent reduction rate of postoperative pain was higher in NF group than in other group. In addition, operation time was shorter in the NF group.

CONCLUSION

While the absence of mesh fixation in TEP hernia repair does not increase the recurrence rate, it can be used safely, because it causes less acute and chronic pain.

TRAIL REGISTRATION

Clinicaltrials number: NCT05152654.

Esophageal Hypocontractile Disorders and Hiatal Hernia Size Are Predictors for Long Segment Barrett's Esophagus

Background/Aims

Presently, there is paucity of information about clinical predictors, especially esophageal motor abnormalities, for long segment Barrett's esophagus (LSBE) as compared with short segment Barrett's esophagus (SSBE). The aims of this study are to compare the frequency of esophageal function abnormalities between patients with LSBE and those with SSBE and to determine their clinical predictors.

Methods

This was a multicenter cohort study that included all patients with a diagnosis of BE who underwent high-resolution esophageal manometry. Motility disorders were categorized as hypercontractile disorders or hypocontractile disorders and their frequency was compared between patients with LSBE and those with SSBE. Multivariable logistic regression modeling was used to calculate the odds of being diagnosed with LSBE relative to SSBE for demographics, comorbidities, medication use, endoscopic findings, and the type of motility disorders.

Results

A total of 148 patients with BE were identified, of which 89 (60.1%) had SSBE and 59 (39.9%) LSBE. Patients with LSBE had a significantly larger hiatal hernia and higher likelihood of erosive esophagitis than patients with SSBE (P = 0.002). Patients with LSBE had a significantly lower mean LES resting pressure, distal contractile integral, distal latency, and significantly higher failed swallows and hypocontractile motility disorders than those with SSBE (P < 0.05). Hiatal hernia and hypocontractile motility disorder increased the odds of LSBE by 38.0% and 242.0%, as opposed to SSBE.

Conclusions

The presence of a hypocontractile motility disorder increased the risk for LSBE. Furthermore, the risk for LSBE was directly associated with the length of the hiatal hernia.

Surgery for Diaphragmatic Hernia Repair: A Longitudinal Single-Institutional Experience

Background

This study analyzed and described the clinical characteristics and surgical outcomes of diaphragmatic hernia (DH) repair according to the operative approach.

Methods

After excluding cases with a combined approach and hiatal hernias, we analyzed 26 patients who underwent DH repair between 1994 and 2018. The baseline and perioperative characteristics of the thoracic approach group and the abdominal approach group were described and analyzed.

Results

Fifteen of the 26 patients were treated through the thoracic approach, including 5 patients who underwent video-assisted thoracic surgery (VATS). Eleven patients underwent the abdominal approach. The thoracic approach was associated with a longer duration of DH than the abdominal approach (2 vs. 0.1 months), herniation of the right-sided abdominal organs, and herniation of the retroperitoneal organs. During the median follow-up of 23 months, there was no recurrence of DH.

Conclusion

The surgical approach should be chosen considering the duration of DH and the location of herniated organs. VATS might be a safe and feasible option for repairing DH.

Case Report: Spontaneous lung intercostal hernia series and literature review

Spontaneous lung intercostal hernia (SLIH) is a rare condition potentially carrying severe morbidity. About 120 cases have been described so far, with an apparently increasing number of reports in recent years. The main presenting findings are chest pain and bulging, with ecchymosis in the affected area, hemoptysis, respiratory distress, and signs of infection or incarceration being described as well. The gold standard treatment has not been established, and conservative management has been advocated as first-line treatment for asymptomatic patients. Here, we report a case series of five patients, and surgical repair was deemed necessary for four of them either at first evaluation or after failure of conservative management. One patient remains under surveillance and conservative management. We believe that SLIH surgical repair should be considered as first-line treatment for fit patients, due to the uncertainty of its mid- and long-term impact and described pejorative trend/defect enlargement. A proposed algorithm for SLIH management is also presented.

State-of-the-art abdominal wall reconstruction and closure

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

Short-term complications after onlay versus preperitoneal mesh repair of umbilical hernias: a prospective randomized double-blind trial

PURPOSE

To compare the incidence of surgical site occurrences (SSOs) following onlay versus preperitoneal mesh placement in elective open umbilical hernia repairs.

METHODS

This study presents a secondary analysis of a randomized double-blind trial conducted on female patients with primary umbilical hernias admitted to a general hospital, in a residency training program setting. Fifty-six subjects were randomly assigned to either onlay (n=30) or preperitoneal (n=26) mesh repair group. Data on baseline demographics, past medical history, perioperative details, postoperative pain (visual analogue scale (VAS)), wound-related complications, and recurrence were assessed using a standardized protocol.

RESULTS

No statistically significant differences were observed between groups regarding patients' demographics, comorbidities, or defect size. Operative time averaged 67.5 (28-110) min for onlay and 50.5 (31-90) min for preperitoneal repairs, p=.03. The overall rate of SSOs was 21.4% (n=12), mainly in the onlay group (33% vs 7.7%; p=0.02, 95% CI 0.03-0.85) and mostly due to seromas. There were no between-group significant differences in postoperative VAS scores at all timepoints. After a maximum follow-up of 48 months, one recurrence was reported in the onlay group. By logistic regression, the onlay technique was the only independent risk factor for SSOs.

CONCLUSION

The presented data identified a decreased wound morbidity in preperitoneal umbilical hernia repairs, thus contributing to the limited body of evidence regarding mesh place selection in future guidelines. Further cases from this ongoing study and completion of follow-up are expected to also compare both techniques in terms of long-term outcomes.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ReBEC) UTN code: U1111-1205-0065 (date of registration: March 27, 2018).

Incidence and risk factors of symptomatic Petersen's hernias in bariatric and upper gastrointestinal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study was to investigate the actual incidence of symptomatic Petersen's hernias (PH) as well as identify risk factors for their occurrence.

METHODS

Search was performed in Medline (via PubMed), Web of Science, and Cochrane library, using the keywords "Petersen Or Petersen's AND hernia" and "Internal hernia." Only studies of symptomatic PH were eligible. Fifty-three studies matched our criteria and were included. Risk of bias for each study was independently assessed using the checklist modification by Hoy et al. Analysis was performed using random-effects models, with subsequent subgroup analyses.

RESULTS

A total of 81,701 patients were included. Mean time interval from index operation to PH diagnosis was 17.8 months. Total small bowel obstruction (SBO) events at Petersen's site were 737 (0.7%). SBO incidence was significantly higher in patients without defect closure (1.2% vs 0.3%, p < 0.01), but was not significantly affected by anastomosis fashion (retrocolic 0.7% vs antecolic 0.8%, p = 0.99). SBO incidence was also not significantly affected by the surgical approach (laparoscopic = 0.7% vs open = 0.1%, p = 0.18). However, retrocolic anastomosis was found to be associated with marginally, but not significantly, increased SBO rate in patients with Petersen's space closure, compared with the antecolic anastomosis (p = 0.09).

CONCLUSION

PH development may occur after any gastric operation with gastrojejunal anastomosis. Contrary to anastomosis fashion and surgical approach, defect closure was demonstrated to significantly reduce SBO incidence. Limitations of this study may include the high heterogeneity and the possible publication bias across the included studies.

The pedicled sartorius flap and mesh (PSM) technique vs no reconstruction in repairing the defect after type III pelvic bone tumor resection: a retrospective study

BACKGROUND

Type III pelvic bone tumor resections are often accompanied by postoperative complications. In order to reduce complications, we developed a novel pedicled sartorius flap and mesh (PSM) technique to reconstruct the pelvic ring defect. In this study, we evaluated the efficacy and risks of this PSM technique in type III pelvic bone tumor resections by comparing outcomes between patients that underwent PSM reconstruction and patients that did not receive any reconstruction.

METHODS

We retrospectively reviewed a consecutive set of patients that underwent type III pelvic bone tumor surgeries in our center from January 2020 to January 2021 with either PSM reconstruction (designated as the PSM group) or without any reconstruction (designated as the control group). General information such as age, gender, tumor type, tumor size, and surgical-related information such as duration of surgery, blood loss, and the surgical margins was collected. Outcome data recorded included wound complications such as infection and dehiscence, local recurrence, and Musculoskeletal Tumor Society (MSTS) scores for postoperative functional evaluation. Statistical analysis between both groups was performed with GraphPad Prism v7.

RESULTS

A total of 20 patients were included in this study (PSM group n = 12, control group n = 8). While no herniation was found in the PSM group, it occurred in 6 of 8 cases in the control group. The control group showed a significantly higher rate of bacterial infection (p = 0.03) and wound dehiscence (p = 0.02) but lower MSTS scores (p < 0.05) compared to the PSM group.

CONCLUSIONS

The use of the PSM technique can significantly reduce postoperative complication rates and enhance postoperative function following type III pelvic bone tumor resection.

Patient-reported outcomes of laparoscopic versus robotic primary ventral and incisional hernia repair: a systematic review and meta-analysis

BACKGROUND

Patient-Reported Outcome Measures (PROM's) are increasingly used to assess surgical outcomes in low-risk surgeries such as minimally invasive primary ventral and incisional hernia repair. The purpose of this meta-analysis was to systematically summarize the available evidence for the effect of laparoscopic versus robotic primary ventral and incisional hernia repair on PROM's.

METHODS

A systematic review and meta-analysis were performed in accordance with PRISMA guidelines. Randomised control trials, retrospective and prospective studies were included. Medline, Embase, SCOPUS, Web of Science, and Cochrane CENTRAL, and two trial registers were searched. Pooled effect sizes and 95% confidence intervals were calculated using the Mantel-Haenszel method. The overall quality of evidence was assessed using GRADE.

RESULTS

Of the 2728 titles screened, eight studies involving 41,205 participants were included. Return to activities of daily living, return to work day and recurrence rate were statistically better in the robotic group. Length of stay, readmission, postoperative pain, quality of life, body image, and patient satisfaction were similar in both groups. The GRADE rating of the quality of evidence was moderate for postoperative pain and low to very low for the quality of life, length of stay, recurrence and readmission.

CONCLUSION

The available data of PROM's of laparoscopic and robotic primary ventral and incisional hernia repair is scarce and highly heterogeneous, thus making it difficult to assess the superiority of the laparoscopic technique over the robotic technique. Further studies with uniform reporting of PROM's in laparoscopic and robotic primary ventral and incisional hernia repair are needed.

Anti-adhesive bioresorbable elastomer-coated composite hernia mesh that reduce intraperitoneal adhesions

Intraperitoneal adhesions (IAs) are a major complication arising from abdominal repair surgeries, including hernia repair procedures. Herein, we fabricated a composite mesh device using a macroporous monofilament polypropylene mesh and a degradable elastomer coating designed to meet the requirements of this clinical application. The degradable elastomer was synthesized using an organo-base catalyzed thiol-yne addition polymerization that affords independent control of degradation rate and mechanical properties. The elastomeric coating was further enhanced by the covalent tethering of antifouling zwitterion molecules. Mechanical testing demonstrated the elastomer forms a robust coating on the polypropylene mesh does not exhibit micro-fractures, cracks or mechanical delamination under cyclic fatigue testing that exceeds peak abdominal loads (50 N/cm). Quartz crystal microbalance measurements showed the zwitterionic functionalized elastomer further reduced fibrinogen adsorption by 73% in vitro when compared to unfunctionalized elastomer controls. The elastomer exhibited degradation with limited tissue response in a 10-week murine subcutaneous implantation model. We also evaluated the composite mesh in an 84-day study in a rabbit cecal abrasion hernia adhesion model. The zwitterionic composite mesh significantly reduced the extent and tenacity of IAs by 94% and 90% respectively with respect to uncoated polypropylene mesh. The resulting composite mesh device is an excellent candidate to reduce complications related to abdominal repair through suppressed fouling and adhesion formation, reduced tissue inflammation, and appropriate degradation rate.

Inguinoscrotal Bladder Hernia Mimicking Testicle Tumor

Bladder hernias usually begin asymptomatically and are discovered incidentally at the time of discovery. Preoperative diagnosis of bladder hernias is important to reduce the risk of bladder injury during surgery. Although F-18 FDG PET/CT is applied for oncological purposes, benign conditions should also be taken into account when evaluating the implants. In this article, a case of bladder hernia, which can be confused with pathological cancer involvement, with the diagnosis of F-18 FDG PET/CT performed in a 73-year-old male patient with renal cell carcinoma is presented.

Operative time tracking for umbilical hernia patients

BACKGROUND

Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms.

METHODS

This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Center from January 2013 to June 2018.

RESULTS

A total of 442 patients were included in the study with a mean age of 45.74 years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant.

CONCLUSION

This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.

Predictivity of aspartate aminotransferase to alanine aminotransferase (De Ritis) ratio for detecting bowel necrosis in incarcerated inguinal hernia patients

PURPOSE

Early diagnosis of necrotic bowel segment resulting from incarcerated inguinal hernia (IIH) is crucial for reducing morbidity and mortality. The aim of this study was to investigate the efficacy of the De Ritis ratio (DRR), also known as the ratio of aspartate aminotransferase to alanine aminotransferase, as a biomarker for intestinal necrosis.

METHODS

This retrospective study included 132 patients who underwent emergency surgery for IIH. Patients were divided into two groups: those who underwent bowel resection for necrosis (Group 1) and those who did not (Group 2). Patients' demographic and clinical data were recorded. Using laboratory test results, DRR, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and lymphocyte-to-CRP ratio (LCR) were calculated.

RESULTS

The morbidity and mortality rates and the length of stay for Group 1 were statistically significantly different (p < 0.0001). The DRR, NLR, PLR, LMR, and LCR values of the same group were also significantly different (p < 0.05).

CONCLUSION

DRR can be used as a biomarker for early diagnosis of bowel necrosis in patients with IIH.

Evaluation of long-term performance of an intraperitoneal biomaterial in the treatment of ventral hernias

BACKGROUND

One-year device safety and clinical outcomes of ventral hernia repair with the GORE® SYNECOR Intraperitoneal Biomaterial, a hybrid composite mesh was evaluated.

METHODS

This retrospective, multicenter, case review analyzed device/procedure endpoints and patient-reported outcomes in patients treated for hernia repair ≥ 1 year from study enrollment.

RESULTS

Included were 459 patients (with 469 ventral hernias) with a mean age of 58 ± 15 years; 77.1% met Ventral Hernia Working Group 2 (VHWG2) classification. Mean hernia size was 18.9 cm² and 57.3% of hernias were incisional. Laparoscopic or robotic approach was utilized in 95.4% of patients. Mesh location was intraperitoneal for 75.6% and bridging repair was performed in 57.3%. Procedure-related adverse events within 30-days occurred in 5.0% of patients and included surgical site infection (SSI), surgical site occurrence (SSO), ileus, readmission, and re-operation. Procedure-related SSI or SSO events were 3.8% through 12 months. SSO events requiring procedural intervention (SSOPI) were 2.6% through 24 months. Four patients (0.9%) had confirmed hernia recurrence through the study (the mean follow-up was 32-months, range 14-53 months). Subgroup comparisons were conducted for all type recurrence; only diabetes was found to be statistically significant (p = .0506).

CONCLUSION

In this analysis, ventral hernia repair with hybrid, composite mesh results in successful outcomes in most patients. This study represents a heterogeneous patient population undergoing repair using various approaches, mesh fixation, and mesh placement locations. These data appear to confirm long-term acceptable safety and device performance with a low rate of recurrence in a predominantly VHWG2 population.

Spontaneous posterior rectus sheath hernia: A case report and literature review

INTRODUCTION

Hernias of the posterior rectus sheath are very rare abdominal wall hernias with only around 15 reported cases to date.

CLINICAL PRESENTATION

This case report examines a 27-year-old female who is presented with epigastric abdominal pain and vomiting. An Abdomen CT scan was done and showed signs of SBO and herniation of the small bowel at the posterior rectus sheath. The patient underwent exploratory laparotomy that showed right-sided posterior rectus sheath obstructed hernia, which was repaired with primary closure. Postoperatively, the patient was doing well and was discharged on postoperative day 3 in good general condition.

CONCLUSION

The patient had no complaints during her follow-up at one month. Due to its rarity and potential complications, it is also important to report this case to enhance the evidence base for posterior rectus sheath hernia and to familiarise this uncommon condition to radiologists, clinicians, and surgeons.

Robotic Hiatal Hernia Repair Associated with Higher Morbidity and Readmission Rates Compared to Laparoscopic Repair: 10-Year Analysis from the National Readmissions Database (NRD)

BACKGROUND

Laparoscopic techniques have been used for hiatal hernia repair. Robotic-assisted repairs have been increasingly used with unproven benefits. The aim of this study was to compare outcomes between laparoscopic and robotic-assisted hiatal hernia repair.

METHODS

The Nationwide Readmissions Database (NRD) was used to identify hospitalizations for laparoscopic or robotic hiatal hernia repair from 2010 to 2019. Primary outcomes included post-operative complications and 30- and 90-day readmission rates. Secondary outcomes included in-hospital death, length of stay, and inflation-adjusted hospital cost. Multivariable models were estimated for overall complication and readmission rates.

RESULTS

Approximately 517,864 hospitalizations met inclusion criteria with 11.3% including robotic repairs. Robotic repair was associated with a higher overall complication rate (9.2% vs. 6.8%, odds ratio [OR]: 1.4, 95% CI: 1.3-1.5, p < .001); however, the trend showed more similar complication rates across years. The higher overall complication rate remained after adjusting for patient and facility characteristics (adjusted OR [aOR]: 1.3, 95% CI: 1.2-1.4, p < .001). Robotic repairs were associated with higher 30-day (6.1% vs. 7.4%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001) and 90-day readmission rates (9.4% vs. 11.2%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001). In-hospital mortality and length of stay were similar, although, higher hospital costs were associated with robotic repairs. Both complications and readmission rates were lower as annual procedural volume increased.

CONCLUSION

Robotic repairs had higher unadjusted and adjusted complication and readmission rates. The overall complication rate has shown a trend towards improvement which may be a result of increasing experience with robotic surgery.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study

BACKGROUND

Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH).

METHODS

Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence.

RESULTS

TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model.

CONCLUSION

Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Sugarbaker Versus Keyhole Repair for Parastomal Hernia: a Systematic Review and Meta-analysis of Comparative Studies

INTRODUCTION

Parastomal hernia is a debilitating complication of stoma creation. Parastomal hernia repair with mesh reduces recurrence rates in open and laparoscopic settings. Recent comparative studies conflict with previously pooled data on optimal mesh repair technique. The objective of this study is to examine parastomal hernia recurrence rates after Sugarbaker and keyhole repairs by performing an updated systematic review and meta-analysis of comparative studies.

METHODS

A systematic review of PubMed, MEDLINE, EMBASE, the Cochrane database, SCOPUS, and the PROSPERO registry was performed according to PRISMA 2020 guidelines (PROSPERO ID: CRD42021290483). Studies comparing parastomal hernia recurrences after Sugarbaker and keyhole repairs were included. Studies with overlapping patient cohorts (duplicate data), non-comparative studies, studies that did not report the primary outcome of interest, and studies not in the English language were excluded. Study bias was assessed using the Newcastle-Ottawa scale. Pooled mean differences (MD), odds ratios (OR), and risk ratios (RR) with 95% confidence intervals (CI) were calculated. Heterogeneity was assessed using the I² statistic. Forest plots and funnel plots were generated. Study quality was analyzed using MINORS. Additional subgroup analysis of modern studies was performed.

RESULTS

Ten comparative studies published between 2005 and 2021 from 5 countries were included for analysis comprising 347 Sugarbaker repairs and 246 keyhole repairs. There were no differences in patient age, sex, or BMI between the groups. There was no difference between the groups regarding surgical site infection (OR 0.78; CI 0.31-1.98; P = 0.61) or post-operative bowel obstruction (OR 0.76; CI 0.23-2.56; P = 0.66). Sugarbaker repairs were significantly less often associated with parastomal hernia recurrence when compared to keyhole repairs (OR 0.38; CI 0.18-0.78; P = 0.008). There was no significant heterogeneity among the studies comparing parastomal hernia recurrence (I² = 32%; P = 0.15). Quality analysis revealed a median MINORS score of 11 (range 6-16). Subgroup analysis of studies performed after the previously published pooled analysis (2015-2021) revealed no significant difference in parastomal hernia recurrence between the two groups (OR 0.58; CI 0.24-1.38; P = 0.22) with a significant subgroup effect (P = 0.05).

CONCLUSIONS

Though there were lower rates of parastomal hernia recurrence with Sugarbaker repairs on overall analysis, this phenomenon disappeared on subgroup analysis of modern studies. Randomized controlled trials with contemporary cohorts would help further evaluate these repairs and minimize potential bias.

Skin closure following abdominal wall reconstruction: three-layer skin suture versus staples

Skin closure following abdominal wall reconstruction (AWR) has received little attention, even though these patients have demonstrated insufficient wound healing. This study assessed the postoperative wound-related complications and patient-reported outcomes after skin closure using single- or triple layer closure following AWR. This was a retrospective study at a University Hospital from 2016 to 2018. Patients were grouped into a single-layer cohort (SLC) and a triple-layer cohort (TLC). Skin incisions closed with either technique were compared. Postoperative complications were registered from chart review (SLC: n = 48, TLC: n = 40). Patient reported-outcomes were assessed through the Patient Scar Assessment Questionnaire (PSAQ) and the Hernia Related Quality of Life survey. A total of 51 patients were included (SLC: n = 26, TLC: n = 25). There was no difference in wound complications after single- or triple-layer skin closure; seroma (SLC: 16.7% vs. TLC: 15%, p = 1.00), surgical site infection (SLC: 4.2% vs. TLC: 7.5%, p = .834), hematoma (SLC: 6.2% vs. TLC: 2.5%, p = .744) and wound rupture (SLC: 2.1% vs. TLC: 2.5%, p = 1.00). Patients who had incisions closed using single-layer closure were more satisfied; PSAQ satisfaction with scar symptoms (SLC: 6.7 points (IQR 0.0-18.3) vs. TLC: 26.7 points (IQR 0.0-33.3), p = .039) and scar aesthetics (SLC 25.9 points (IQR 18.5-33.3) vs. TLC: 37.0 (IQR 29.6-44.4), p = .013). There was no difference in 30-day wound complications after either skin closure technique. The results favoured the single-layer closure technique regarding the cosmetic outcome.Abbreviations: AWR: abdominal wall reconstruction; SLC: single-layer cohort; TLC: triple-layer cohort; PSAQ: patient scar assessment questionnaire; IH: incisional hernia; QOL: quality of life; BMI: body mass index; HerQLes: hernia-related quality of life; ASA: American Society of Anesthesiologists; SSO: surgical site occurence; SSI: surgical site infection; LOS: length of stay; RCT: randomized controlled trial.

Impact of insurance type in postoperative emergency department utilization and clinical outcomes following ventral hernia repair (VHR)

BACKGROUND

Access to care and barriers to achieving health equity remain persistent and prevailing issues in the USA, particularly for low socioeconomic (L-SES) populations. Previous studies have shown that public insurance (a surrogate marker for L-SES) is an independent predictor of emergent hernia repair. However, the impact of insurance type on postoperative healthcare utilization, including emergency department (ED) care, following ventral hernia repair (VHR) remains unknown.

METHODS

The 2013-2020 Abdominal Core Health Quality Collaborative (ACHQC) database was used to identify patients aged 18-64 undergoing ventral hernia repair (VHR) who had private or Medicaid insurance. Patients with no health insurance were also included. Using insurance type, the cohort was divided into three groups: private, public (Medicaid), and uninsured (self-pay). Multivariate logistic regression analyses were used to assess the impact of insurance type on emergency department (ED) utilization, postoperative complications, and readmission.

RESULTS

A total of 17,036 patients undergoing VHR were included in the study, out of which 13,980 (85.8%) had private insurance, 2,451 (8.4%) had public, and 605 (5.8%) were uninsured. Following adjustment for demographics (age, gender, race), comorbidities (hypertension, diabetes, smoking), and clinical characteristics (emergent procedure, ASA class, surgical approach), public insurance was associated with 1.7 times greater odds of returning to the emergency department (ED) within 30 days of surgery compared to private insurance (95% CI 1.4, 2.0; p = 0.01). Public insurance or being uninsured was also associated with increased odds of experiencing any postoperative complications compared to those who were privately insured (public: OR 1.3, p < 0.01; self-pay: OR 1.67, p < 0.01).

CONCLUSION

Our study demonstrates that public and self-pay insurance are associated with increased emergency department (ED) utilization and worse postoperative outcomes compared to those with private insurance. In an effort to promote health equity, healthcare providers need to assess how parameters beyond physical presentation may impact a patient's health.

A rare presentation of appendicitis contained within an incisional hernia post loop ileostomy reversal - A case report

INTRODUCTION AND IMPORTANCE

Appendicitis within an incisional hernia is rare, with current literature describing a small number of cases, occurring through a variety of surgical incisions. We describe a case of appendicitis contained within an incisional hernia following reversal of a loop ileostomy, on a background of previous sigmoid cancer resection. This is the second such case we were able to identify on literature review.

CASE PRESENTATION

A 45 year old man presented with one day of migratory abdominal pain, predominantly focused at a tender, irreducible lump in his right lower quadrant, underlying the scar from previous reversal of loop ileostomy. CT on admission revealed an incisional hernia, containing an inflamed appendiceal tip. He underwent an uncomplicated laparoscopic appendicectomy and primary suture closure of the hernia defect, and was discharged the following day. Acute appendicitis was confirmed on histopathology.

DISCUSSION

Placement of a defunctioning ileostomy is common in the management of colonic cancers, and incisional hernias are a common complication. It is however rare for an appendix to be contained within a hernia sac, and even rarer for appendicitis to develop in this setting. As a result, the presentation of this condition may mimic that of an incarcerated or strangulated incisional hernia, with pre-operative diagnosis typically relying on diagnostic imaging.

CONCLUSION

Incisional hernia appendicitis is rare and presents a diagnostic challenge. Early recognition of this dual pathology is necessary to allow for prompt surgical management of both the appendicitis and hernia, as well as guiding the approach for hernia repair.

At least ninety days of follow-up are required to adequately detect wound outcomes after open incisional hernia repair

INTRODUCTION

Incisional hernia repair (IHR) carries a high risk of wound complications. Thirty-day outcomes are frequently used in comparative-effectiveness research, but may miss a substantial number of surgical site occurrences (SSO) including surgical site infection (SSI). The objective of this study was to determine an optimal length of follow-up to detect SSI after IHR.

METHODS

All adult patients undergoing open IHR at a single academic center over a 3 year period were reviewed. SSIs, non-infectious SSOs, and wound-related readmissions were recorded up to 180 days. The primary outcome was the proportion of SSIs detected at end-points of 30, 60, and 90 days of follow-up. Time-to-event analysis was performed for all outcomes at 30, 60, 90, and 180 days. Logistic regression was used estimate the relative risk of SSI for relevant risk factors.

RESULTS

A total of 234 patients underwent open IHR. Median follow-up time of 102 days. Overall incidence of SSI was 15.8% with median time to occurrence of 23 days. Incidence of non-infectious SSO was 33.2%, and SSO-related readmission was 12.8%. At 30, 60, and 90 days sensitivity was 81.6%, 89.5%, and 92.1 for SSI, and 46.7%, 76.7%, and 83.3% for readmission. In regression analysis, body mass index (RR 1.08, 95% CI 1.00, 1.15, p = 0.04) anterior component separation (RR 4.21, 95% CI 2.09, 6.34, p = 0.003), and emergency surgery (RR 3.25, 95% CI 1.47, 5.02, p = 0.01), were independently associated with SSI after adjusting for age, sex, contamination class, and procedure duration.

CONCLUSION

A considerable proportion of SSIs occurred beyond 30 days, but 90-day follow-up detected 92% of SSIs. Follow-up to 90 days captured only 83% of SSO-related readmissions. These results have implications for the design of trials evaluating wound complication after open IHR, as early endpoints may miss clinically relevant outcomes and underestimate the number needed to treat. Where possible, we recommend a minimum follow-up of 90 days to estimate wound complications following open IHR.

ACR Appropriateness Criteria® Hernia

Abdominopelvic hernias are common clinical entities composed of a wide variety of congenital, traumatic, and iatrogenic etiologies. Any weakness in the body wall may result in hernia of cavity contents with concomitant risks of morbidity and mortality. Presentations may be specific, palpable body wall mass/bulge, or vague, nonspecific pain through bowel obstruction. This document focuses on initial imaging of the adult population with signs of symptoms prompting suspicion of abdominopelvic hernia. Imaging of the abdomen and pelvis to evaluate defects is essential for prompt diagnosis and treatment. Often CT and ultrasound are the first-line modalities to quickly evaluate the abdomen and pelvis, providing for accurate diagnoses and management of patients. MRI protocols may be useful as first-line imaging studies, especially in patients with orthopedic instrumentation. Although often performed, abdominal radiographs and fluorographic procedures may provide indirect evidence of hernias but are usually not indicated for initial diagnosis of hernia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Transient Hiatal Separation During Straight Leg Raise Can Predict Reflux Burden in Gastroesophageal Reflux Disease Patients With Ineffective Esophageal Motility

Background/Aims

Straight leg raise (SLR) can be utilized to evaluate the integrity of the esophagogastric junction during high-resolution manometry (HRM). We aim to assess the value of transient hiatal separation during SLR in symptomatic reflux patients.

Methods

Consecutive reflux patients undergoing esophageal HRM and pH monitoring were included. Transient hiatal separation was defined by a ≥ 1 cm separation between the lower esophageal sphincter and crural diaphragm during SLR. We compared esophageal motor patterns and reflux monitoring parameters between patients with normal, transiently abnormal and consistently abnormal esophagogastric junction morphology during SLR.

Results

Of 85 (56.3% female, mean age: 46.7 ± 12.3 years) completed SLR, esophagogastric junction morphology was normal in 31 (36.5%), transient hiatal separation in 19 (22.3%), and consistently hiatal hernia in 35 (41.2%). The values of total acid exposure time (P = 0.016), longest acid reflux episodes (P = 0.024), and DeMeester scores (P = 0.016) were higher in hiatal hernia compared to patients with non-transient hiatal separation, but there were no differences between those with and without transient hiatal separation. Within ineffective esophageal motility, the presence of transient hiatal separation during SLR significantly associated with a higher total acid exposure time (P = 0.014), higher DeMeester scores (P = 0.019), higher total acid reflux events (P = 0.037), and higher longest acid reflux episodes (P = 0.006).

Conclusion

Our work suggests that SLR may have value as a provocative test during HRM, and future outcome studies are warranted to elucidate the clinical relevance of motor abnormalities depicted from SLR.

Tension-reduced closure of large abdominal wall defect caused by shotgun wound: A case report

BACKGROUND

Large abdominal wall defect (LAWD) caused by shotgun wound is rarely reported.

CASE SUMMARY

Herein, we describe a case of LAWD caused by a gunshot wound in which the abdominal wall was reconstructed in stages, including debridement, tension-reduced closure (TRC), and reconstruction with mesh and a free musculocutaneous flap. During a 3-year follow-up, the patient recovered well without hernia or other problems.

CONCLUSION

TRC is a practical approach for the temporary closure of LAWD, particularly in cases when one-stage abdominal wall restoration is unfeasible due to significant comorbidities.

Acute abdomen with a parasitic smooth muscle tumor of uncertain malignant potential (STUMP) in pregnancy; a unique case report

INTRODUCTION AND IMPORTANCE

Diagnosis of a smooth muscle tumor of uncertain malignant potential (STUMP) during pregnancy is rare. Furthermore; the investigation of an intra-abdominal mass during pregnancy is clinically challenging due to anatomical changes and additional considerations of the developing fetus and radiation exposure. The unusual nature and diagnostic dilemma of such a case warrants a case report to serve as an educational prompt to clinicians who may encounter pregnant patients with undifferentiated intra-abdominal masses and/or suspecting of STUMP.

CASE PRESENTATION

We report a rare case of a parasitic STUMP diagnosed during pregnancy. The patient presented with a new umbilical hernia and deranged liver function tests (LFT's) during her third trimester. MRI reported a large mass in the left mid flank with intra-abdominal varices extending into the umbilical hernia. She went on to develop an acute abdomen requiring laparotomy where a parasitic fibroid adherent to the omentum was excised and a preterm infant was delivered via caesarean section. Histology was difficult due to pregnancy related changes but ultimately confirmed a diagnosis of STUMP.

CLINICAL DISCUSSION

STUMP in pregnancy is rare and diagnosis is further complicated by histological challenges due to pregnancy related changes. Postoperative diagnosis is challenging due to lack of universally accepted diagnostic criteria and Uncertainty regarding prognostic factors makes management and follow-up of patients with STUMP challenging. Studies have shown that younger patients are more likely to demonstrate recurrence.

CONCLUSION

Investigation and management of intra-abdominal masses in pregnancy is challenging. It requires timely multi-disciplinary team (MDT) input. Additional complications and considerations relate to the preterm fetus. Knowledge and understanding of these difficulties will better equip clinicians working with such patients to formulate a structured and well informed approach to the pregnant patient with a new intra-abdominal mass. Diagnosis of STUMP during pregnancy may be challenging for the pathologist and require further exert opinion.

A global surgery project focusing on hernia surgery

BACKGROUND

The aim of international health cooperation projects is to alleviate the deficiencies in the area of health in low resource settings. Hernia surgery is a procedure that is well suited to these missions, due to its low morbidity, the fact that it can be performed on an outpatient basis, and the improvement in quality of life that it provides.

OBJECTIVE

To describe the results of Benefica Chirurgia (BC), a Spanish non-profit humanitarian association in hernia pathology.

METHODS

Five one-week surgical campaigns were carried out in Ecuador between 2015 and 2019, involving anesthetists, general and pediatric surgeons. Surgical and medical equipment was provided and transported by BC. ASA I/II patients underwent surgery.

RESULTS

Surgery was performed on 240 patients with hernia pathology on 27 days. Sixty-three per cent of patients were male and the mean age was 48.2 years (range: 1-83). Hernia location was inguinal in 113 patients, umbilical in 101, and other in 26. The anesthetic technique used was spinal in 185 patients (77.1%), local plus intravenous sedation in 31 (12.9%), and general in 24 (10%). The surgical technique used was hernioplasty in 191 patients, herniorrhaphy in 31, incisional hernia repair in 15 and herniotomy in three. Surgery was performed on an outpatient basis in 98.4% of cases. Morbidity was 2%. Long-term postoperative evaluation is very complex.

CONCLUSION

These campaigns make a significant contribution to health in low resource settings and provide great personal satisfaction for those involved. Standards achieved in the immediate postoperative period were similar to those obtained at the surgeons' centers in Europe. However, it is difficult to establish the rates of recurrence and chronic pain.

Obstructive acute abdomen due to Meckel's diverticulum in adult: Case report

INTRODUCTION

Meckel's diverticulum is anatomically considered as a true diverticulum, with its embryological origins arising from a persistent omphalomesenteric duct. In adults, the disease is usually asymptomatic, often being accidentally diagnosed during imaging tests or surgery to treat other diseases, or due to further complications.

PRESENTATION OF THE CASE

We report the case of a 26-year-old female patient was admitted to the emergency room complaining of pain and abdominal distension for 3 days, progressing to cessation of the elimination of gas for 1 day together with nausea and vomiting. Since the cause of the obstruction was not clearly identified, the patient's clinical status did not improve with non-operative measures and laparoscopy was not available, an exploratory laparotomy was conducted. In the cavity inventory, an approximately 20 cm wide MD was found in the terminal ileum adhered to the distal portion of the anterior abdominal wall.

DISCUSSION

MD is the most common congenital anomaly of the gastrointestinal tract, with an estimated prevalence of between 0.3 % and 2.9 % in the general population. The clinical picture is usually asymptomatic, with the diagnosis made either via imaging tests performed to investigate other diseases, or during surgery to treat complications.

CONCLUSION

MD is the most common anomaly of the digestive tract, despite its low prevalence. It presents even rarer complications, including obstruction, digestive bleeding, or diverticulitis. It is important to consider the diverticulum as a diagnostic hypothesis in cases of obstruction without apparent causes, but it does not alter the initial management of the patient.

A Biomechanical Analysis of Prophylactic Mesh Reinforced Porcine Laparotomy Incisions

INTRODUCTION

Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing.

METHODS

In each specimen, a 10-cm incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5 cm, 3 cm, 4 cm, 6 cm, 8 cm) and tack separation (1.5 cm, 2 cm apart) and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 N to 140 N were applied to simulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed.

RESULTS

All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4-cm mesh specimens (567.51 N) than those with suture, 2.5-cm, and 3.0-cm mesh (all P < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance.

CONCLUSIONS

A 4-cm mesh reenforcement was superior to suture-only and smaller meshes at preserving strength in laparotomy closure in a porcine model but larger meshes (6 cm, 8 cm) did not provide an additional benefit. Meshes with more fixation points may be advantageous, but additional data are needed to make definitive conclusions.

Topographical relationships of the yolk sac remnant and vitelline vessels with the midgut loop in the extra-embryonic coelom of human embryos

The yolk sac is supplied by the vitelline artery and vein (VA, VV), which run through the yolk stalk in combination with the omphaloenteric duct. Moreover, the VV takes a free posterior course outside the midgut mesentery containing the secondarily-developed superior mesenteric vein (SMV). However, the regression process of these structures has not been demonstrated photographically. The present study evaluated serial histological sections from 20 embryos of stages 15–19 or crown-rump length (CRL) 7.5–20 mm. All specimens carried the SMV as sequential tissue slits. However, an omphaloenteric duct with epithelia continuous with the midgut loop was not observed. In smaller embryos (CRL <13 mm) the VA extended distally or anteriorly from the midgut apex in the extra-embryonic coelom, whereas in larger embryos (CRL 16–20 mm) the artery was absent from the distal side of the apex. The entire course or part of the VV outside the mesentery was always seen, but four larger embryos lacked the venous terminal near the duodenum. A vacuole-like remnant of the yolk sac was present in all smaller embryos (CRL <10 mm), but was absent from 7 of the 11 larger embryos. The size of the remnant was equal to the thickness of the VA or VV, with the remnant being sandwiched between the VA and VV. Moreover, the regressing yolk sac often communicated with or opened to the VV. Consequently, the yolk sac regressed first, followed by the regression of the VA until 6 weeks. The yolk stalk was clearly observed until 5 weeks.

Emergency repair and smoking predict recurrence in a large cohort of ventral hernia patients

PURPOSE

Ventral hernias are frequent and hernia repair is regularly performed by general surgeons. Emergency repair is less frequent and can be challenging. Long-term data comparing outcomes of emergency- vs. elective ventral hernia repair are scarce.

METHODS

Consecutive patients undergoing emergency and elective ventral hernia repair at our institution were prospectively entered in our HerniaMed database between August 2013 and February 2020. Patients were contacted after 1 and 5 years to assess long-term complications. Risk factors for emergency repair and hernia recurrence were assessed by univariate and multivariate analysis.

RESULTS

We included 1307 patients. Emergency and elective hernia repair were performed in 11% and 89% of patients with 1-year follow-up rates of 94% and 92%. Female gender, BMI > 40 kg/m², ASA class 3 and 4, large size umbilical herniation (> 4 cm) and epigastric herniation were more frequent in emergency hernia repair. Binary logistic regression analysis identified emergency repair and smoking as predictors of recurrence (Odds ratio: 4.04 and 95% confidence interval: 1.67-14.21, p = 0.004; Odds ratio: 2.94 and 95% confidence interval: 1.33-9.15, p = 0.011). Furthermore, female gender and significant comorbidity (ASA class 3 and 4) were risk factors for emergency repair (Odds ratio: 1.98 and 95% confidence interval: 01.05-3.74, p = 0.034; Odds ratio: 3.54 and 95% confidence interval: 1.79-6.98, p < 0.001).

CONCLUSIONS

Emergency repair and smoking predicted hernia recurrence. Females and highly comorbid patients are at increased risk for emergency repair and should be prioritized for early elective hernia repair.

Socioeconomic disparities in the utilization of primary robotic hernia repair

OBJECTIVE

This study aimed to examine socioeconomic disparities in the utilization of primary robotic hernia repair (RHR), utilizing statewide population-level data. It was funded by the SAGES Robotic Surgery Research Grant.

METHODS AND PROCEDURES

The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify adult patients who underwent primary open, laparoscopic, and robotic hernia repair (inguinal, femoral, umbilical, ventral) from 2010 through 2016. Utilization trends were compared between the surgical approaches, assessing for difference in age, sex, race, insurance status, and socioeconomic status (as defined by median income for zip code). Multivariable regression models were used with statistical significance set at 0.05.

RESULTS

A total of 280,064 patients underwent primary hernia repair: n = 216,892 (77.4%) open, n = 61,037 (21.8%) laparoscopic, and n = 2,135 (0.8%) robotic. After adjusting for confounding variables, senior age (OR 1.01, p = 0.002), male sex (OR 1.35, p < 0.001), and non-Hispanic race (OR 1.3-1.54, p < 0.001) were significantly associated with the use of robotic compared to open or laparoscopic surgery. Additionally, patients with commercial insurance were more likely to undergo RHR compared to those with Medicare (OR 1.32) or Medicaid (OR 1.54) (p < 0.0001). Income was significantly correlated with RHR such that every $10,000 increase in income would increase the odds of having RHR by 6% (OR 1.06, p < 0.0001). Academic facilities were also associated with a significantly higher likelihood of utilizing RHR (OR 1.88, p < 0.0001).

CONCLUSION

There are significant socioeconomic disparities in the utilization of robotic compared to laparoscopic or open hernia repair. While the robotic approach is overall increasing in popularity, adoption of new technology should not be limited to specific socioeconomic cohorts of the population. Recognizing these disparities is a necessary first step in providing equal and consistent care.

Five year trends in surgical technique and outcomes of groin hernia repair in the United States

INTRODUCTION

Despite being one of the most commonly performed operations in the US, there is a paucity of data on practice patterns and resultant long-term outcomes of groin hernia repair. In this context, we performed a contemporary assessment of operative approach with 5 year follow-up to inform care for the 800000 persons undergoing groin hernia repair annually.

METHODS

This was a retrospective cohort study of adult patients undergoing elective groin hernia repair in a 20% representative Medicare sample from 2010-17. Surgical approach [minimally invasive (MIS) vs open] was defined using appropriate CPT codes. The primary outcome was operative recurrence at up to 5 years following surgery. We estimated the overall risk of operative recurrence using a multivariable Cox proportional hazards model.

RESULTS

Among 118119 patients, the majority (76.4%) underwent an open repair. Compared to patients who underwent MIS repair, patients in the open surgery cohort were older (mean age 72.7 vs 71.0, p < 0.001), more often female (14.4 vs 10.9%, p < 0.001), less often white (86.9 vs 87.7%, p < 0.001), and had a higher prevalence of nearly all measured comorbidities Patients in the open cohort had a lower incidence of operative recurrence at 1-year (1.0 vs 1.5%, p < 0.001), 3-years, (2.5 vs 3.5%, p < 0.001), and 5-years (3.7 vs 4.7%, p < 0.001). In the Cox proportional hazards model, we found that patients who underwent an open groin hernia repair were significantly less likely to experience operative recurrence (HR 0.86, 95% CI 0.79-0.93).

CONCLUSIONS

In this study, we found that open groin hernia repair was associated with a lower risk of operative recurrence over time. While this may be related to patient comorbidity and age at the index operation, future work should focus on the impact of surgeon volume on outcomes in the modern era.

Posterior component separation with transversus abdominis muscle release versus mesh-only repair in the treatment of complex ventral-wall hernia: a randomized controlled trial

Background

Complex ventral hernias (VHs) represent a real challenge to both general and plastic surgeons. This study aims to compare Sublay Mesh-Only Repair to Posterior Component Separation “PCS” with Transversus Abdominis Release “TAR” in the treatment of complex ventral-wall hernias (VHs).

Methods

This a randomized, controlled, intervention, including two parallel groups: A; Sublay Mesh-Only Repair and Group B; “TAR”. Consecutive patients of both genders aged between 18 and 65 years old with complex VHs presented at Mansoura University Hospitals including large-sized abdominal-wall hernia ≥ 10 cm in width, loss of domain ≥ 20%, multiple hernial defects, or recurrent hernias. Immuno-compromised patients, patients with liver impairment, or severe heart failure were considered an exclusion criterion. The primary outcome is the recurrence rate after 12-months following the procedure.

Results

Fifty-six patients were recruited in this study. There was no significant difference between both groups regarding recurrence. However, there was significant differences between both groups regarding seroma favoring mesh-only repair.

Conclusions

Although TAR may be associated with longer operative times and more blood losses, these were not found to be statistically significant. Postoperative complication, except for seroma, and recurrence rates were comparable in both groups.

Trail registration The study was registered on clicaltrials.gov “NCT04516031”.

Traumatic abdominal wall hernia and Morel-Lavallee lesion in a pediatric patient

Traumatic abdominal wall hernias and abdominal Morel-Lavallee lesions rarely occur in blunt abdominal trauma. There are only a few documented cases of these occurring simultaneously, especially in the pediatric population. We report a case of a 15-year-old boy with a concomitant traumatic abdominal wall hernia and Morel-Lavallee lesions. Abdominal wall reconstruction was performed successfully via the collaboration of trauma, minimally invasive surgery, and plastic surgery teams.

Similar collagen distribution in full-thickness skin grafts in intraperitoneal and onlay positions, an experimental mice-study

PURPOSE

Autologous full-thickness skin grafting (FTSG) has the potential to become an option in abdominal wall repair. An understanding of tissue remodelling in the extracellular matrix (ECM) is crucial as this interplay determines such parameters as tissue strength and flexibility. This cross-sectional preclinical laboratory study in mice provides information on the distribution of collagen types and matrix metalloproteinases (MMPs) in the ECM of FTSGs in the intraperitoneal and onlay positions compared with internal controls. The aim was to evaluate morphologic changes after tissue remodelling and repair in FTSGs applied in the two positions and to detect any adverse host response.

METHODS

ECM components were evaluated as follows: qualitative examination of collagen bundle thickness using Picrosirius Red staining (collagen types I, III and IV); and evaluation of collagen types IV and V, as well as MMPs 1, 8 and 9 using immunohistochemical staining. Full-thickness grafts transplanted between female twin mice were examined as this best mimics autologous transplantation.

RESULTS

At 8 weeks, FTSGs in the intraperitoneal position did not show any noticeable differences in morphologic appearance to those in the onlay position. Both intraperitoneal and onlay FTSGs showed increases in the amount of thick collagen bundles compared to internal controls. No correlation was seen between distribution of MMPs 1, 8 or 9 and distribution of collagen types I, III, IV or V.

CONCLUSION

This preclinical study shows that FTSGs in both intraperitoneal and onlay positions are possible application site options and, by extension, promising application site options for abdominal wall reinforcement in hernia surgery. Clinical studies in humans are required to confirm these findings.

Incidence and trends of decision regret following elective hernia repair

BACKGROUND

One approach to evaluate decision-making is using the concept of decision regret, which measures patient remorse after a healthcare decision. This is particularly important for elective, preference-sensitive conditions with multiple treatment options, such as ventral and inguinal hernia repair. In this study, we assessed decision regret among patients who pursued surgical management of ventral and inguinal hernias.

METHODS

We retrospectively reviewed a statewide registry of adult patients who underwent elective ventral and inguinal hernia repair between January 2017 and March 2020 and completed a validated survey measuring decision regret. 30-day outcomes included complications, emergency department (ED) utilization, readmission, and reoperation. Multivariable logistic regression examined the association of regret with age, sex, race, insurance status, ASA, tobacco use, diabetes, admission status, surgical approach (open vs. laparoscopic vs. robotic), year, and outcomes.

RESULTS

8315 patients underwent surgery during the study period with a mean age of 60.5 (14.7) years and 1812 (22%) female patients. Among 2159 patients who underwent ventral hernia repair, 248 (11%) reported regret to undergo surgery, 64 (3%) experienced a complication, 160 (7%) visited an ED, 86 (4%) were readmitted, and 29 (1%) underwent reoperation. Outcomes associated with regret after ventral hernia repair included complications (OR 2.33, 95% CI 1.26-4.29) and readmission (OR 2.67, 95% CI 1.51-4.71). Among 6,156 patients who underwent inguinal hernia repair, 533 (9%) reported regret to undergo surgery, 41 (1%) experienced a complication, 304 (5%) visited an ED, 72 (1%) were readmitted, and 63 (1%) underwent reoperation. Outcomes associated with regret after inguinal hernia repair included ED visits (OR 2.03, 95% CI 1.44-2.87) and readmission (OR 4.23, 95% CI 2.35-7.61).

CONCLUSION

Roughly 1 in 10 patients undergoing hernia repair report regret with their decision to undergo surgery. Developing a better understanding of the factors associated with decision regret after hernia repair may better inform both patients and surgeon decision-making.

An Exploratory Study on Pediatric Inguinal Hernia Videos on the YouTube Platform

AIM

A study was conducted to explore the characteristics of the videos on pediatric inguinal hernia repair on YouTube and compare the most popular videos (MPV) with the least popular ones in terms of educative value vis-a-vis their popularity.

MATERIALS AND METHODS

The term "Pediatric inguinal hernia repair" was searched for on YouTube on August 15, 2021, with the filter set to "view rate." Pertinent data were collected from the 50 MPV and the 50 least popular videos (LPV) and then compared. The h-index and affiliation of the surgeon were obtained from the Scopus database, and their affiliation was further categorized as academic or nonacademic.

RESULTS

One hundred and seventy-five videos were found with median views of MPV: LPV being 9270 (interquartile range [IQR] - 12099):127 (IQR - 194), respectively (P < 0.0001). Most of the videos in the MPV and LPV groups were uploaded from the United States of America (USA) (MPV - 17 and LPV - 13) and India (MPV - 15 and LPV - 15). The MPV were on YouTube for a median duration of 3.1 (IQR - 5.5) years as compared to 1.2 (IQR - 2.3) years for the LPV (P < 0.0001). Ninety-two surgeons were identified. The median h-index of the surgeons of MPV was 3 (IQR - 12) in comparison to 1 (IQR - 10) of LPV (P = 0.13). The ratio of academic versus nonacademic affiliation among MPV and LPV was almost equal in both the groups.

CONCLUSIONS

On either end of the spectrum of popularity, the majority of the pediatric inguinal hernia videos on YouTube were surgical videos uploaded from the USA and India. The educative value of these videos was found to be low and widely dispersed. Surgeons from both academic and nonacademic affiliations had contributed similarly.

Variation in approach for small (< 2 cm) ventral hernias across a statewide quality improvement collaborative

INTRODUCTION

Operative technique for hernias < 2 cm is highly controversial. Limited data exist about this practice at a population level. Within this context we sought to describe practice patterns and use of mesh among patients undergoing repair of small hernias within the setting of a statewide quality improvement collaborative.

METHODS

Retrospective cohort study of patients undergoing hernia repair in the Michigan Surgical Quality Collaborative Hernia Registry was conducted. Patients who underwent repair of a hernia < 2 cm from January 1, 2020 to July 8, 2021 were included. Descriptive statistics were performed to describe cohort characteristics and compare patients who did and did not receive mesh. Logistic regression was performed to estimate the odds of receiving mesh after accounting for patient and hernia characteristics.

RESULTS

Among 570 patients, 56.1% (n = 320) had mesh placed. Most repairs were conducted via open approach (n = 437, 76.5%). Patients who received mesh were older (51.8 vs 48.6, p < 0.01), had higher BMI (31.7 vs 30.0, p < 0.01), were more often ASA Class III (35.9% vs 24.4%, p < 0.01), more often had diabetes (15.9% vs 10.0%, 0.04) and hypertension (44.7% vs 30.4%, p < 0.01), and had higher hernia width (1.2 cm vs 1.0 cm, p < 0.0001). After adjustment, ASA Class III (aOR 3.41, 95% CI 1.31-8.89), current smoking status (aOR 1.81, 95% CI 1.04-3.18), higher mean hernia width (aOR 5.68, 95% CI 2.97-10.85), and laparoscopic (aOR 12.9, 95% CI 5.02-32.96) or robotic (aOR 24.3, 95% CI 6.96-84.96) were associated with mesh use, while COPD (aOR 0.36, 95% CI 0.07-0.96) was associated with less mesh use.

CONCLUSIONS

Use of mesh for small hernias remains controversial. We found that patients who had mesh placed at the time of surgery were potentially patients at higher risk for complications. The decision to use mesh may be driven by patient-related factors that predispose to complications and operative recurrence rather than evidence indicating that it is superior in this population.

The sensitivity of ultrasound in the clinical diagnosis of inguinal hernias in adults: a comparative study

OBJECTIVE

Ultrasonography (US) is a non-invasive, non-ionizing radiation modality highly successful at diagnosing inguinal hernia. The aim of this study is to demonstrate the accuracy of ultrasound in evaluating defects of fascia in inguinal hernias and compare with surgical findings.

MATERIAL AND METHODS

A total of 33 patients with a sonographic diagnosis of an inguinal hernia are included to study. After US, all patients underwent a blinded surgery and the surgical findings are compared with the US results.

RESULTS

The sensitivity of US was found to be 100% and 80% for indirect and direct types, respectively. The mean size of the defect was found to be 22 mm (max: 70 mm, min: 6 mm) with US; and 27 mm (max: 50 mm, min: 4 mm) at surgery. The size of defects at US and in surgery were correlated with each other (p = 0.001).

Polypropylene mesh combined with electrospun poly (L-lactic acid) membrane in situ releasing sirolimus and its anti-adhesion efficiency in rat hernia repair

This study developed, a novel polypropylene (PP) mesh combined with poly (L-lactic acid) (PLA) electrospun nanofibers loaded sirolimus (SRL). The PP mesh was combined with PLA/SRL (1/0, 1/0.01, 1/0.02; mass ratios) composed electrospun membrane characterized by FTIR spectroscopy, XPS and SEM, and evaluated for cytocompatibility in vitro. In an in vivo study, a total of 84 Sprague-Dawley rats were employed to evaluate the efficacy of the novel composite PP mesh anti-adhesion, mechanical properties and inflammation. As a results, the PLA/SRL membrane could compound with PP mesh stably and load SRL. Although tensile testing showed that the mechanical properties of composite mesh decreased in vivo, the integration strength between the tissue and mesh was still able to counteract intra-abdominal pressure. Compared with the native PP mesh group, the novel PP mesh group showed a lower score for abdominal adhesion and inflammation. More importantly, the novel PP mesh completely integrated with the abdominal wall and had sufficient mechanical strength to repair abdominal wall defects.