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Marcolin P, Mazzola Poli de Figueiredo S, Oliveira Trindade B, Bueno Motter S, Brandão GR, Mao RMD, Moffett JM. Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis. Hernia 2024; 28:677-690. [PMID: 38252397 DOI: 10.1007/s10029-023-02943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/08/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy. METHODS We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934). RESULTS We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09 min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation. CONCLUSIONS Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.
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Affiliation(s)
- P Marcolin
- School of Medicine, Universidade Federal da Fronteira Sul, Passo Fundo, RS, Brazil.
| | | | - B Oliveira Trindade
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - S Bueno Motter
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - G R Brandão
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - R-M D Mao
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - J M Moffett
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
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Rodicio Miravalles JL, Méndez CSM, Lopez-Monclus J, Moreno Gijón M, López Quindós P, Amoza Pais S, López López A, García Bear I, Menendez de Llano Ortega R, Díez Pérez de Las Vacas MI, Garcia-Urena MA. Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia. Langenbecks Arch Surg 2024; 409:136. [PMID: 38652308 DOI: 10.1007/s00423-024-03307-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Prophylactic meshes in high-risk patients prevent incisional hernias, although there are still some concerns about the best layer to place them in, the type of fixation, the mesh material, the significance of the level of contamination, and surgical complications. We aimed to provide answers to these questions and information about how the implanted material behaves based on its visibility under magnetic resonance imaging (MRI). METHOD This is a prospective multicentre observational cohort study. Preliminary results from the first 3 months are presented. We included general surgical patients who had at least two risk factors for developing an incisional hernia. Multivariate logistic regression was used. A polyvinylidene fluoride (PVDF) mesh loaded with iron particles was used in an onlay position. MRIs were performed 6 weeks after treatment. RESULTS Between July 2016 and June 2022, 185 patients were enrolled in the study. Surgery was emergent in 30.3% of cases, contaminated in 10.7% and dirty in 11.8%. A total of 5.6% of cases had postoperative wound infections, with the requirement of stoma being the only significant risk factor (OR = 7.59, p = 0.03). The formation of a seroma at 6 weeks detected by MRI, was associated with body mass index (OR = 1.13, p = 0.02). CONCLUSIONS The prophylactic use of onlay PVDF mesh in midline laparotomies in high-risk patients was safe and effective in the short term, regardless of the type of surgery or the level of contamination. MRI allowed us to detect asymptomatic seromas during the early process of integration. STUDY REGISTRATION This protocol was registered at ClinicalTrials.gov (NCT03105895).
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Affiliation(s)
- José Luis Rodicio Miravalles
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain.
| | - Carlos San Miguel Méndez
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
| | - Javier Lopez-Monclus
- Division of General Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - María Moreno Gijón
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain
| | - Patricia López Quindós
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
| | - Sonia Amoza Pais
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain
| | - Antonio López López
- Division of General Surgery, Hospital Universitario Nuestra Señora del Prado, Toledo, Spain
| | - Isabel García Bear
- Division of General Surgery, Hospital Universitario San Agustin, Avilés, Spain
| | | | | | - Miguel Angel Garcia-Urena
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
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Smith L, Wilkes E, Rolfe C, Westlake P, Cornish J, Brooks P, Torkington J. Incidence, Healthcare Resource Use and Costs Associated With Incisional Hernia Repair. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2024; 3:12452. [PMID: 38481877 PMCID: PMC10936754 DOI: 10.3389/jaws.2024.12452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/06/2024] [Indexed: 07/22/2024]
Abstract
Background: Incisional hernia (IH) is a common complication of abdominal surgery affecting between 12.8% and 30% of patients. In spite of this, rates of IH repair remain low, at around 5% in the literature. We aimed to assess the rate of IH repair in the UK across surgical specialties and the cost burden associated with IH repair. Methods: This is a retrospective observational study of patients undergoing abdominal surgery in England between 2012 and 2022 using the Hospital Episode Statistics (HES) database. Index abdominal surgery was identified between March 2014 and March 2017. Diagnostic and surgical procedure codes were used to identify pre-operative risk factors, index surgeries, IH repair and healthcare contact. Healthcare resource use (HCRU) costs were derived for index surgery and all post-index, non-elective inpatient admissions and outpatient visits using Healthcare Resource Group (HRG) codes within HES. Results: Of 297,134 patients undergoing abdominal surgery, 5.1% (n = 15,138) subsequently underwent incisional hernia repair. By specialty, rates were higher in Colorectal (10.0%), followed by Hepatobiliary (8.2%), Transplant (6.8%), Urological (4.0%), Bariatric (3.5%), Vascular (3.2%) and Gynaecological (2.6%) surgery. Patients undergoing IH repair had more healthcare contacts, longer length of inpatient stays and more A+E visits vs. those with no IH repair post index surgery (83% ≥ 1 A+E visit vs. 69%), as well as higher rates of referral to mental health services (19.8% vs. 11.5%). IH repair was associated with an average HCRU cost of £23,148 compared to £12,321 in patients with no IH repair. Conclusion: Patients undergoing IH repair have a greater morbidity than those not undergoing repair, shown by higher HCRU and more healthcare contacts. Despite this, rates of surgery for IH are low, suggesting that most patients with hernias are not undergoing repair. Emphasis must be placed squarely on primary prevention, rather than cure.
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Affiliation(s)
- Laurie Smith
- Department of Colorectal Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Emily Wilkes
- Real-World Evidence, OPEN Health, Marlow, United Kingdom
| | - Chris Rolfe
- Real-World Evidence, OPEN Health, Marlow, United Kingdom
| | - Petra Westlake
- Real-World Evidence, OPEN Health, Marlow, United Kingdom
| | - Julie Cornish
- Department of Colorectal Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Paul Brooks
- Market Access, Becton Dickinson Surgery UK, Wokingham, United Kingdom
| | - Jared Torkington
- Department of Colorectal Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
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4
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DeAngelo N, Perez AJ. Hernia Prevention: The Role of Technique and Prophylactic Mesh to Prevent Incisional Hernias. Surg Clin North Am 2023; 103:847-857. [PMID: 37709391 DOI: 10.1016/j.suc.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Millions of laparotomies are performed annually, carrying up to a 41% risk of developing into a hernia. Incisional hernias are associated with morbidity, mortality, and costs; an estimated $9.6 billion is spent annually on repair of ventral hernias. Although repair is possible, surgeons must prevent incisional hernias from occurring. There is substantial evidence on surgical technique to reduce the risk of incisional hernia formation. This article aims to critically summarize the use of surgical technique and prophylactic mesh augmentation during fascial closure to inform decision-making and reduce incisional hernia formation.
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Affiliation(s)
- Noah DeAngelo
- Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Arielle J Perez
- The University of North Carolina at Chapel Hill, Department of Surgery, 160 Dental Circle, Burnett-Womack, CB #7228, Chapel Hill, NC 27599-7228, USA.
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González-Abós C, Pineda C, Arrocha C, Farguell J, Gil I, Ausania F. Incisional Hernia Following Open Pancreaticoduodenectomy: Incidence and Risk Factors at a Tertiary Care Centre. Curr Oncol 2023; 30:7089-7098. [PMID: 37622995 PMCID: PMC10453869 DOI: 10.3390/curroncol30080514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/26/2023] Open
Abstract
(1) Background: Incisional hernia (IH) is one of the most common complications following open abdominal surgery. There is scarce evidence on its real incidence following pancreatic surgery. The purpose of this study is to evaluate the incidence and the risk factors associated with IH development in patients undergoing pancreaticoduodenectomy (PD). (2) Methods: We retrospectively reviewed all patients undergoing PD between 2014 and 2020 at our centre. Data were extracted from a prospectively held database, including perioperative and long-term factors. We performed univariate and multivariate analysis to detect those factors potentially associated with IH development. (3) Results: The incidence of IH was 8.8% (19/213 patients). Median age was 67 (33-85) years. BMI was 24.9 (14-41) and 184 patients (86.4%) underwent PD for malignant disease. Median follow-up was 23 (6-111) months. Median time to IH development was 31 (13-89) months. Six (31.5%) patients required surgical repair. Following univariate and multivariate analysis, preoperative hypoalbuminemia (OR 3.4, 95% CI 1.24-9.16, p = 0.01) and BMI ≥ 30 kg/m2 (OR 2.6, 95% CI 1.06-8.14, p = 0.049) were the only factors independently associated with the development of IH. (4) Conclusions: The incidence of IH following PD was 8.8% in a tertiary care center. Preoperative hypoalbuminemia and obesity are independently associated with IH occurrence following PD.
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Affiliation(s)
- Carolina González-Abós
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
- Gene Therapy and Cancer, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Catalina Pineda
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Carlos Arrocha
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Jordi Farguell
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Ignacio Gil
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Fabio Ausania
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
- Gene Therapy and Cancer, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
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Barron SL, Morgenstern M, Jia E, Celestin A, Diamond S, Plaster B, Lee BT, Cauley RP, Morris D. The use of abdominal wall tissue expansion prior to herniorrhaphy in massive ventral hernia defects. J Plast Reconstr Aesthet Surg 2023; 83:289-297. [PMID: 37290370 DOI: 10.1016/j.bjps.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 03/24/2023] [Accepted: 05/14/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Massive ventral hernias pose a challenging reconstructive problem. In comparison to bridging mesh repair, the primary fascial repair is associated with significantly reduced rates of hernia recurrence. This study will review our experience with massive ventral hernia repairs using tissue expansion and anterior component separation as well as present the largest case series to date. METHODS A retrospective review was conducted of 61 patients who underwent abdominal wall tissue expansion prior to herniorrhaphy at a single institution between 2011 and 2017. Demographics, perioperative co-variates, and outcomes were recorded. Univariate and subgroup analysis was performed. Kaplan-Meier survival analysis was used to assess the time to recurrence. RESULTS Sixty-one patients underwent abdominal wall expansion via tissue expanders (TE). Of these, 56 subsequently underwent staged anterior component separation for attempted closure of large ventral hernia. Major complications of TE placement included TE replacement (4,6.6%), TE leak (2,3.3%), and unplanned readmission (3,4.9%). Higher BMI groups were significantly associated with comorbid hypertension (BMI<30 kg/m2, 22.7%; BMI 30-35 kg/m2, 68.7%; BMI>35 kg/m2, 64.7%; P = 0.004). 15 patients (32.6%) had hernia recurrence and 21 patients (34.4%) still required bridging mesh during herniorrhaphy after tissue expansion. CONCLUSION The use of tissue expansion prior to herniorrhaphy can be effective in achieving durable closure for most massive abdominal wall defects - especially those associated with musculofascial, soft tissue, or skin deficiencies. In this proof-of-concept analysis, we found that the efficacy and safety profile of this technique compares favorably to other methods for massive hernia repair in the literature.
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Affiliation(s)
- Sivana L Barron
- Division of Plastic and Reconstructive Surgery, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Monica Morgenstern
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Emmeline Jia
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Arthur Celestin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shawn Diamond
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Blakely Plaster
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Donald Morris
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Ulutas ME, Sahin A, Simsek G, Sekmenli N, Kilinc A, Arslan K, Eryilmaz MA, Kartal A. Does onlay mesh placement in emergency laparotomy prevent incisional hernia? A prospective randomized double-blind study. Hernia 2023:10.1007/s10029-023-02770-7. [PMID: 36967415 DOI: 10.1007/s10029-023-02770-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/09/2023] [Indexed: 03/28/2023]
Abstract
PURPOSE The objective of this study is to assess the effectiveness and safety of onlay mesh closure of emergency midline laparotomy to prevent incisional hernia. METHODS This is a prospective randomized double-blind study and was carried out in the General Surgery Clinic, Konya City Hospital, from August 1, 2020 to August, 1, 2021. The study included 108 patients who were randomly grouped in 2 groups: patients with conventional abdominal closure and closure using additional onlay mesh (1:1). The follow-up period was for a year. The primary outcome was the incidence of incisional hernia and secondary outcomes were clinical data like complications, hospital length of stay, re-operations. RESULTS It was observed that incisional hernia was present in 14 patients (27.4%) in conventional abdominal closure group and was in 2 patients using mesh (4%), (p = 0.001). Clavien-Dindo 3B complications were in rise in conventional closure group (p = 0.02). Of all complications, burst abdomen was significantly more common in conventional closure group (p = 0.04). The rate of surgically treated complications were higher in conventional closure group (p = 0.02). Clavien-Dindo 3A complications were more common in patients with contaminated wound in mesh group (p = 0.02). CONCLUSION The use of mesh while closing the abdomen in emergency midline laparotomy reduces the risk of incisional hernia. Thus, to lower the risks of incisional hernia and its complications, prophylactic mesh can be used in high-risk patients.
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Durbin B, Spencer A, Briese A, Edgerton C, Hope WW. If Evidence is in Favor of Incisional Hernia Prevention With Mesh, why is it not Implemented? JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:11000. [PMID: 38312399 PMCID: PMC10831655 DOI: 10.3389/jaws.2023.11000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/16/2023] [Indexed: 02/06/2024]
Affiliation(s)
| | | | | | | | - William W. Hope
- Department of Surgery, Novant/New Hanover Medical Center, Wilmington, NC, United States
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Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, Fortelny RH, Gök H, Harris HW, Hope W, Horne CM, Jensen TK, Köckerling F, Kretschmer A, López-Cano M, Malcher F, Shao JM, Slieker JC, de Smet GHJ, Stabilini C, Torkington J, Muysoms FE. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg 2022; 109:1239-1250. [PMID: 36026550 PMCID: PMC10364727 DOI: 10.1093/bjs/znac302] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/28/2022] [Accepted: 08/05/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. METHODS A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. RESULTS Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. CONCLUSION These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.
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Affiliation(s)
- Eva B Deerenberg
- Department of Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
| | - Nadia A Henriksen
- Department of Hepatic and Digestive diseases, Herlev University Hospital, Copenhagen, Denmark
| | - George A Antoniou
- Department of Vascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stavros A Antoniou
- Mediterranean Hospital of Cyprus, Limassol, Cyprus.,Medical School, European University Cyprus, Nicosia, Cyprus
| | - Wichor M Bramer
- Medical Library, Erasmus MC, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - John P Fischer
- Department of Plastic Surgery, University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Rene H Fortelny
- Certified Hernia Center, Wilhelminenspital, Veinna, Austria.,Paracelsus Medical, University Salzburg, Salzburg, Austria
| | - Hakan Gök
- Hernia Istanbul®, Hernia Surgery Centre, Istanbul, Turkey
| | - Hobart W Harris
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - William Hope
- Department of Surgery, Novant/New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - Charlotte M Horne
- Department of Surgery, Penn State Health Department, Hershey, Pennsylvania, USA
| | - Thomas K Jensen
- Department of Hepatic and Digestive diseases, Herlev University Hospital, Copenhagen, Denmark
| | - Ferdinand Köckerling
- Hernia Center, Vivantes Humboldt-Hospital, Academic Teaching Hospital of Charité University Medicine, Berlin, Germany
| | - Alexander Kretschmer
- Klinikum der Ludwig-Maximillians-Universität München, Munchen, Germany.,Janssen Oncology, Los Angeles, CA, USA
| | - Manuel López-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Unviversitat Autònoma de Barcelona, Barcelona, Spain
| | - Flavio Malcher
- Department of Surgery, NYU Langone Health/NYU Grossman School of Medicine, New York, New York, USA
| | - Jenny M Shao
- Division of Gastrointestinal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Gijs H J de Smet
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Cesare Stabilini
- Department of Surgery, Policlinico San Martino IRCCS and Department of Surgical Sciences, University of Genoa, Genoa, Italy
| | - Jared Torkington
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - Filip E Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
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Dewulf M, Muysoms F, Vierendeels T, Huyghe M, Miserez M, Ruppert M, Tollens T, van Bergen L, Berrevoet F, Detry O. Prevention of Incisional Hernias by Prophylactic Mesh-augmented Reinforcement of Midline Laparotomies for Abdominal Aortic Aneurysm Treatment: Five-year Follow-up of a Randomized Controlled Trial. Ann Surg 2022; 276:e217-e222. [PMID: 35762612 DOI: 10.1097/sla.0000000000005545] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The incidence of incisional hernias (IHs) after open repair of an abdominal aortic aneurysm (AAA) is high. Several randomized controlled trials have reported favorable results with the use of prophylactic mesh to prevent IHs, without increasing complications. In this analysis, we report on the results of the 60-month follow-up of the PRIMAAT trial. METHODS In a prospective, multicenter, open-label, randomized design, patients were randomized between prophylactic retrorectus mesh reinforcement (mesh group), and primary closure of their midline laparotomy after open AAA repair (no-mesh group). This article reports on the results of clinical follow-up after 60 months. If performed, ultrasonography or computed tomography were used for the diagnosis of IHs. RESULTS Of the 120 randomized patients, 114 were included in the intention-to-treat analysis. Thirty-three patients in the no-mesh group (33/58-56.9%) and 34 patients in the mesh group (34/56-60.7%) were evaluated after 5 years. In each treatment arm, 10 patients died between the 24-month and 60-month follow-up. The cumulative incidence of IHs in the no-mesh group was 32.9% after 24 months and 49.2% after 60 months. No IHs were diagnosed in the mesh group. In the no-mesh group, 21.7% (5/23) underwent reoperation within 5 years due to an IH. CONCLUSIONS Prophylactic retrorectus mesh reinforcement after midline laparotomy for the treatment of AAAs safely and effectively decreases the rate of IHs. The cumulative incidence of IHs after open AAA repair, when no mesh is used, continues to increase during the first 5 years after surgery, which leads to a substantial rate of hernia repairs.
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Affiliation(s)
- Maxime Dewulf
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Filip Muysoms
- Department of Surgery, Maria Middelares Hospital Ghent, Ghent, Belgium
| | | | - Marc Huyghe
- Department of Surgery, Sint-Augustinus Hospital, Antwerp, Belgium
| | - Marc Miserez
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Martin Ruppert
- Department of Surgery, University Hospital Antwerp, Edegem, Belgium
| | - Tim Tollens
- Department of Surgery, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | | | - Frederik Berrevoet
- Department of General and HPB Surgery, Ghent University Hospital, Ghent, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, Liege, Belgium
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Bravo-Salva A, Argudo-Aguirre N, González-Castillo AM, Membrilla-Fernandez E, Sancho-Insenser JJ, Grande-Posa L, Pera-Román M, Pereira-Rodríguez JA. Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study. BMC Surg 2021; 21:243. [PMID: 34006282 PMCID: PMC8130379 DOI: 10.1186/s12893-021-01243-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies. METHODS This study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared. RESULTS From an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318-4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142-7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86-7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1-12.2; P = 0.001). CONCLUSION Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate. TRIAL REGISTRATION NCT04578561. www.clinicaltrials.gov.
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Affiliation(s)
- A Bravo-Salva
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain
| | - N Argudo-Aguirre
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain
| | - A M González-Castillo
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències Morfològiques, Universitat Autónoma de Barcelona, Campus Bellaterra, 08193, Cerdanyola del Vallès - Barcelona, Spain
| | - E Membrilla-Fernandez
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - J J Sancho-Insenser
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - L Grande-Posa
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - M Pera-Román
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - J A Pereira-Rodríguez
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain. .,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain.
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12
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The incisional hernia epidemic: evaluation of outcomes, recurrence, and expenses using the healthcare cost and utilization project (HCUP) datasets. Hernia 2021; 25:1667-1675. [PMID: 33835324 DOI: 10.1007/s10029-021-02405-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Incisional hernias (IH) following abdominal surgery persist as morbid, costly, and multi-disciplinary surgical challenges. Using longitudinal, multi-state, administrative claims data (HCUP State Inpatient Databases (SID)); (HCUP State Ambulatory Surgery and Services Databases (SASD)), we aimed to characterize the epidemiology, outcomes, recurrence, and costs of IH. STUDY DESIGN 529,108 patients undergoing abdominal surgery in 2010 across six specialties (colorectal, general/bariatric, hepatobiliary, obstetrics/gynecology, urology, and vascular) were identified within inpatient and ambulatory databases for Florida (FL), Iowa (IA), Nebraska (NE), New York (NY), and Utah (UT). IH repairs, complications, and expenditures were assessed through 2014. Predictive regression modeling was validated using a training set of 1000 bootstrapped repetitions. RESULTS 16,169 (3.1%) patients developed hernias requiring repair (4.3-year mean follow-up), 3176 (20%) underwent recurrent repair, and 731 (23%) underwent re-recurrent repair. Patients with IH had increased readmissions (6.6 vs. 2.4), morbidity (39 vs. 8% surgical and 22 vs. 7% medical), and costs ($46,000 vs. $25,000) when compared to patients without IH (p < 0.001). IH expenditures totaled $875 million: initial ($687 million), recurrent ($155 million), and re-recurrent hernias ($33 million). IH predominated in colorectal (10%), hepatobiliary (8%), and vascular (5%) procedures. Of 31 significant independent IH risk factors (p < 0.001), obesity, age, smoking, open surgery, and prior surgery were pervasive across surgical specialties. CONCLUSION IH represents an unremitting surgical epidemic associated with considerable morbidity, costs, and features consistent with a chronic disease state. We define critical pervasive risk factors (obesity, age, smoking open surgery, and prior surgery) independently associated with IH across surgical disciplines. With failed repairs, subsequent success becomes less likely, increasing morbidity and costs-underscoring the critical importance of optimal treatment and prevention.
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13
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Prophylactic Mesh After Midline Laparotomy: Evidence is out There, but why do Surgeons Hesitate? World J Surg 2021; 45:1349-1361. [PMID: 33558998 DOI: 10.1007/s00268-020-05898-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Incisional hernias have an impact on patients' quality of life and on health care finances. Because of high recurrence rates despite mesh repair, the prevention of incisional hernias with prophylactic mesh reinforcement is currently a topic of interest. But only 15% of surgeons are implementing it, mainly because of fear for mesh complications and disbelief in the benefits. The goal of this systematic review is to evaluate the effectiveness and safety of prophylactic mesh in adult patients after midline laparotomy. METHODS An extensive literature search was performed in PubMed, Embase and CENTRAL until 9/5/2020 for RCTs and cohort studies regarding mesh reinforcement versus primary suture closure of a midline laparotomy. The quality of the articles was analyzed using the Scottish Intercollegiate Guidelines Network checklists. Revman 5 was used to perform a meta-analysis. RESULTS Twenty-three articles were found with a total of 1633 patients in the mesh reinforcement group and 1533 in the primary suture group. An odds ratio for incisional hernia incidence of 0.37 (95% CI = [0.30, 0.46], p < 0.01) with RCTs and of 0.15 (95% CI = [0.09,0.25], p < 0.01) in cohort studies was calculated. Seroma rate shows a significant odds ratio of 2.18 (95% CI = [1.45, 3.29], p < 0.01) in favor of primary suture. No increase was found regarding other complications. CONCLUSION The evidence for the use of prophylactic mesh reinforcement is overwhelming with a significant reduction in incisional hernia rate, but implementation in daily clinical practice remains limited. Instead of putting patients at risk for incisional hernia formation and subsequent complications, surgeons should question their arguments why not to use mesh reinforcement, specifically in high-risk patients.
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14
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Klifto KM, Othman S, Messa CA, Piwnica-Worms W, Fischer JP, Kovach SJ. Risk factors, outcomes, and complications associated with combined ventral hernia and enterocutaneous fistula single-staged abdominal wall reconstruction. Hernia 2021; 25:1537-1548. [PMID: 33538927 DOI: 10.1007/s10029-021-02371-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/22/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare two cohorts of patients; those with isolated ventral hernias (VH) and those with VH and enterocutaneous fistulas (ECF). Risk factors for surgical complications (including recurrent ECF) and outcomes during single-stage VH with ECF surgical reconstruction were analyzed. METHODS A retrospective review was performed from 2008 to 2019. We compared two cohorts of patients with single-stage VH repairs: (1) ventral hernia repair alone (hernia alone), and (2) combined VH repair and ECF repair (hernia plus ECF). Inclusion criteria were patients ≥ 18 years of age with pre-operative VH either with or without an ECF, who underwent open hernia repair and ECF repair in a single-stage operation, with a minimum follow-up of 12 months. Patient risk factors, operative characteristics, outcomes and surgical-site complications were compared using univariate and multivariate analyses. RESULTS We included 442 patients (hernia alone = 401; hernia plus ECF = 41) with a median follow-up of 22 months (12-96). Hernia plus ECF patients were more likely to have inflammatory bowel disease (IBD)(OR 4.4, 95% CI 1.1-17.5, p = 0.037), a history of abdominal wound infections (OR 3.4, 95% CI 1.5-7.9, p = 0.004), reoperations (OR 4.9, 95% CI 1.6-15.4, p = 0.006), superficial soft tissue infections (OR 2.5, 95% CI 1.1-6.1, p = 0.044) and hematomas (OR 8.4, 95% CI 1.2-58.8, p = 0.031), compared to hernia alone patients. ECF recurrence was associated with diabetes mellitus (DM) (n = 8, 73% vs. n = 6, 20%; p = 0.003) and surgical-site complications (n = 10, 91% vs. n = 16, 53%; p = 0.048), compared to ECF resolution. CONCLUSION Risk factors for developing ECF were IBD and history of abdominal wound infections. Single-staged combined ECF reconstruction was associated with reoperations, soft tissue infections and hematomas. DM and surgical-site complications were associated with ECF recurrence.
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Affiliation(s)
- K M Klifto
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - S Othman
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - C A Messa
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - W Piwnica-Worms
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - S J Kovach
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA.
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Messa CA, Sanchez J, Kozak GM, Shetye S, Rodriguez A, Fischer JP. Biomechanical Parameters of Mesh Reinforcement and Analysis of a Novel Device for Incisional Hernia Prevention. J Surg Res 2020; 258:153-161. [PMID: 33010561 DOI: 10.1016/j.jss.2020.08.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Prophylactic mesh augmentation (PMA) is an effective technique utilized to reduce the risk of incisional hernia. This study analyzes the biomechanical characteristics of a mesh-reinforced closure and evaluates a novel prophylactic mesh implantation device (SafeClose Roller System; SRS). MATERIALS AND METHODS A total of eight senior-level general surgery trainees (≥4 years of training) from the University of Pennsylvania Health System participated in the study. Biomechanical strength, mesh stiffness, mesh uniformity, and time efficiency for fixation were compared among hand-sewn mesh fixation, SRS mesh fixation and a no-mesh fixation control. Porcine abdominal wall specimens served as simulated laparotomy models. RESULTS Biomechanical load strength was significantly higher for mesh reinforced repairs (P = 0.009). The SRS resulted in a stronger biomechanical force than hand-sewn mesh (21.2 N stronger, P = 0.317), with more uniform mesh placement (P < 0.01), faster time of fixation (P < 0.001) and with less discrete hand-movements (P < 0.001). CONCLUSIONS Mesh reinforcement for incisional reinforcement has a significant impact on the strength of the closure. The utilization of a mesh-application system has the potential to amplify the advantages of mesh reinforcement by providing efficiency and consistency to fixation methods, with similar biomechanical strength to hand-sewn mesh. Additional in vivo analysis and randomized controlled trials are needed to further assess clinical efficacy.
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Affiliation(s)
- Charles A Messa
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan Sanchez
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Geoffrey M Kozak
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Snehal Shetye
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashley Rodriguez
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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16
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Wong J, Jones J, Ananthapadmanabhan S, Meagher AP. Abdominal wall closure with prophylactic mesh in colorectal operations. ANZ J Surg 2020; 90:564-568. [PMID: 31970887 DOI: 10.1111/ans.15692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/27/2019] [Accepted: 12/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Prospective studies demonstrate that over one-third of patients undergoing standard suture closure of laparotomy wounds will develop incisional hernias (IHs). Whilst prophylactic mesh has been demonstrated to decrease IH rates in clean laparotomy wounds, mesh has been associated with high rates of seroma formation (>30%), infection (>10%) and pain, discouraging many surgeons from using mesh, especially combined with intestinal surgery. The aim of this study is to review the experience of a single colorectal surgeon who, after noting high IH rates in his own patients, started placing prophylactic mesh routinely in patients judged to be at high risk of IH. METHODS The records of all patients undergoing bowel resections and ileostomy closure by one surgeon from 2008 to 2018 were independently retrospectively analysed. RESULTS Of the 935 procedures identified, 662 patients underwent midline laparotomy with bowel resection and 273 patients underwent closure of loop ileostomy. Mesh was placed prophylactically in 221 (23.6%) of 935 procedures. Comparing the mesh and non-mesh groups, wound infections occurred in nine (4.1%) versus 23 (3.2%) (P = 0.53), seromas occurred in nine (4.1%) versus six (0.8%) (P = 0.003) and chronic pain was noted in 12 (5.4%) versus 17 (2.4%) (P = 0.04). The mean follow-up was 33 months in both the mesh and non-mesh groups. IHs have occurred in three (1.3%) of the mesh group compared to 95 (13.3%) of the non-mesh group procedures (P = 0.0001). CONCLUSION In colorectal operations, prophylactic mesh decreases the risk of IH without prohibitive complications.
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Affiliation(s)
- Jean Wong
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Julia Jones
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Alan P Meagher
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
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17
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Long-term results of a prospective randomized trial of midline laparotomy closure with onlay mesh. Hernia 2019; 23:335-340. [DOI: 10.1007/s10029-019-01891-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/14/2019] [Indexed: 01/21/2023]
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18
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Budget Impact Analysis of a Biosynthetic Mesh for Incisional Hernia Repair. Clin Ther 2018; 40:1830-1844.e4. [DOI: 10.1016/j.clinthera.2018.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/08/2018] [Accepted: 09/05/2018] [Indexed: 01/14/2023]
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19
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Long-term outcomes after prophylactic use of onlay mesh in midline laparotomy. Hernia 2018; 22:1113-1122. [DOI: 10.1007/s10029-018-1833-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
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20
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Rhemtulla IA, Messa CA, Enriquez FA, Hope WW, Fischer JP. Role of Prophylactic Mesh Placement for Laparotomy and Stoma Creation. Surg Clin North Am 2018; 98:471-481. [PMID: 29754617 DOI: 10.1016/j.suc.2018.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Incisional and parastomal hernias are a cause of significant morbidity and have a substantial effect on quality of life and economic costs for patients and hospital systems. Although many aspects of abdominal hernias are understood, prevention is a feature that is still being realized. This article reviews the current literature and determines the utility of prophylactic mesh placement in prevention of incisional and parastomal hernias.
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Affiliation(s)
- Irfan A Rhemtulla
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Charles A Messa
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Fabiola A Enriquez
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - William W Hope
- Department of Surgery, New Hanover Regional Medical Center, 1725 New Hanover Medical Park Drive, Wilmington, NC 28403, USA
| | - John P Fischer
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Rhemtulla IA, Mauch JT, Broach RB, Messa CA, Fischer JP. Prophylactic mesh augmentation: Patient selection, techniques, and early outcomes. Am J Surg 2018; 216:475-480. [PMID: 29709271 DOI: 10.1016/j.amjsurg.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Incisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient selection, techniques and early outcomes after PMA. METHODS Retrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017. RESULTS 18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m2). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups. CONCLUSIONS Early results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.
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Affiliation(s)
- Irfan A Rhemtulla
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Jaclyn T Mauch
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Charles A Messa
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Gokani SA, Elmqvist KO, El-Koubani O, Ash J, Biswas SK, Rigaudy M. A cost-utility analysis of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service. Clinicoecon Outcomes Res 2018; 10:105-117. [PMID: 29497321 PMCID: PMC5822843 DOI: 10.2147/ceor.s150176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose This study aimed to perform an economic evaluation of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service (NHS). Methods A cost-utility analysis was conducted using data from a systematic literature review. Large bite sutures placed 10 mm from the wound edge were compared to small bite sutures 3–6 mm from the wound edge. The analysis used a 3-year time horizon in order to take into account complications including incisional hernias and surgical site infections (SSIs). Cost and benefit data were considered from the perspective of the NHS. A two-way sensitivity analysis was conducted to assess the impact of a variation in the clinical effectiveness of small bite sutures. Results The incremental cost-effectiveness ratio was calculated to be −£482.61 per quality-adjusted life year (QALY) using the proposed small bite suture technique, indicating a cost saving to the NHS. Sensitivity analysis demonstrated that small bites are a cost-neutral technique provided that the cost of using small bites is less than £98 per patient. Small bites cost less than £20,000/QALY when they reduce either the rate of SSIs by more than 15% or the rate of hernias by more than 3.4%. Conclusion This study proposes that small bite sutures should become the mainstay suturing technique in the closure of midline laparotomies, replacing large bite sutures, which dominate current practice. The financial savings accompanied by the decrease in SSI rates and herniation warrant the use of this new technique. The sensitivity analysis demonstrates that findings hold true for a wide range of levels of clinical effectiveness for small bites.
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Affiliation(s)
| | | | | | - Javier Ash
- Faculty of Medicine, Imperial College London, London, UK
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Using Crowdsourcing as a Platform to Evaluate Lay Perception of Prophylactic Mesh Placement. J Surg Res 2018; 237:78-86. [PMID: 29290370 DOI: 10.1016/j.jss.2017.11.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 10/06/2017] [Accepted: 11/22/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Prophylactic mesh placement (PMP) at the time of open abdominal surgery has gained momentum over the last decade. However, there remains an identifiable gap in the literature regarding patient-reported outcomes and qualitative metrics. In effort to gauge the population's understanding or familiarity with PMP, this study provides an educational framework and uses crowdsourcing as a novel means to assess perception among the general population. METHODS A cross-sectional survey study was conducted among the general public to elicit perspectives on PMP. An online crowdsourcing platform was used to capture responses to a questionnaire. Pearson's correlation coefficients, paired t-test, chi-square test, and Fisher's exact tests were performed. RESULTS Of 433 respondents, 338 (78.1%) were included. Individuals who had previously undergone surgery and those who had prior hernia repair were more likely to choose PMP than surgically naïve patients (P = 0.06). CONCLUSIONS The majority of respondents support the use of PMP. This study contributes to the existing body of literature on PMP and serves as the first qualitative description to gauge the population's perception and understanding of this surgical technique. Within the evolving health care landscape, understanding quality-of-life measures have become increasingly important in defining successful surgical outcomes. Although the data-driven level-I evidence supports the clinical use of PMP, this study intends to establish a framework for future patient-reported outcome studies.
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Lanni MA, Tecce MG, Shubinets V, Mirzabeigi MN, Fischer JP. The State of Prophylactic Mesh Augmentation. Am Surg 2018. [DOI: 10.1177/000313481808400129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and clinicaltrials.gov for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only–based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.
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Affiliation(s)
- Michael A. Lanni
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael G. Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Valeriy Shubinets
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael N. Mirzabeigi
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - John P. Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Blank MM, Papageorge M, Chen L, Driscoll D, Graham R, Chatterjee A. Hidden Bias in Cost-Analysis Research: What Is the Prevalence of Under-Reporting Cost Perspective in the General Surgical Literature? J Am Coll Surg 2017; 225:823-828.e12. [DOI: 10.1016/j.jamcollsurg.2017.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 01/09/2023]
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Rystedt JML, Tingstedt B, Montgomery F, Montgomery AK. Routine intraoperative cholangiography during cholecystectomy is a cost-effective approach when analysing the cost of iatrogenic bile duct injuries. HPB (Oxford) 2017; 19:881-888. [PMID: 28716508 DOI: 10.1016/j.hpb.2017.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/03/2017] [Accepted: 06/09/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The total cost of bile duct injuries (BDIs) in an unselected national cohort of patients undergoing cholecystectomy are unknown. The aim was to evaluate costs associated with treatment of cholecystectomy-related BDIs and to calculate cost effectiveness of routine vs. on-demand intraoperative cholangiography (IOC). METHODS Data from Swedish patients suffering a BDI during a 5 year period were analysed. Questionnaires to investigate loss-of-production and health status (EQ-5D) were distributed to patients who suffered a BDI during cholecystectomy and who underwent uneventful cholecystectomy (matched control group). Costs per quality-adjusted-life-year (QALY) gained by intraoperative diagnosis were estimated for two strategies: routine versus on-demand IOC during cholecystectomy. RESULTS Intraoperative diagnosis, immediate intraoperative repair, and minor BDI were all associated with reduced direct treatment costs compared to postoperative diagnosis, delayed repair, and major BDI (all p < 0.001). No difference was noted in loss-of-production for minor versus major BDIs or between different treatment strategies. The cost per QALY gained with routine intraoperative cholangiography (ICER-incremental cost-effectiveness ratio) to achieve intraoperative diagnosis was €50,000. CONCLUSIONS Intraoperative detection and immediate intraoperative repair is the superior strategy with less than half the cost and superior functional patient outcomes than postoperative diagnosis and delayed repair. The cost per QALY gained (ICER) using routine IOC was considered reasonable.
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Affiliation(s)
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences, Lund University, Sweden
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Meta-analysis of randomised trials comparing the use of prophylactic mesh to standard midline closure in the reduction of incisional herniae. Hernia 2017; 21:843-853. [DOI: 10.1007/s10029-017-1653-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 08/20/2017] [Indexed: 01/16/2023]
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28
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Carney MJ, Weissler JM, Fox JP, Tecce MG, Hsu JY, Fischer JP. Trends in open abdominal surgery in the United States—Observations from 9,950,759 discharges using the 2009–2013 National Inpatient Sample (NIS) datasets. Am J Surg 2017; 214:287-292. [DOI: 10.1016/j.amjsurg.2017.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/05/2016] [Accepted: 01/05/2017] [Indexed: 01/31/2023]
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Balaphas A, Buchs NC, Naiken SP, Hagen ME, Zawodnik A, Jung MK, Varnay G, Bühler LH, Morel P. Incisional hernia after robotic single-site cholecystectomy: a pilot study. Hernia 2017; 21:697-703. [PMID: 28488073 DOI: 10.1007/s10029-017-1621-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/01/2017] [Indexed: 01/12/2023]
Abstract
PURPOSE Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci® Single-Site®) with the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique. METHODS In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected. RESULTS We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24-81 years)]; mean BMI 25.9 kg/m2 [±SD 4.1 kg/m2]. After a median follow-up of 39 months (range: 25-46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients. CONCLUSION This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary.
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Affiliation(s)
- A Balaphas
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
| | - N C Buchs
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - S P Naiken
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - M E Hagen
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - A Zawodnik
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - M K Jung
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - G Varnay
- Division of Radiology, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - L H Bühler
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - P Morel
- Division of Digestive and Transplantation Surgery, University Hospitals Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
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Weissler JM, Lanni MA, Hsu JY, Tecce MG, Carney MJ, Kelz RR, Fox JP, Fischer JP. Development of a Clinically Actionable Incisional Hernia Risk Model after Colectomy Using the Healthcare Cost and Utilization Project. J Am Coll Surg 2017; 225:274-284.e1. [PMID: 28445797 DOI: 10.1016/j.jamcollsurg.2017.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/10/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Incisional hernia remains a persistent and burdensome complication after colectomy. Through individualized risk-assessment and prediction models, we aimed to improve preoperative risk counseling for patients undergoing colectomy; identify modifiable preoperative risk factors; and encourage the use of evidence-based risk-prediction instruments in the clinical setting. STUDY DESIGN A retrospective review of the Healthcare Cost and Utilization Project data was conducted for all patients undergoing either open or laparoscopic colectomy as identified through the state inpatient databases of California, Florida, and New York in 2009. Incidence of incisional hernia repair was collected from both the state inpatient databases and the state ambulatory surgery and services databases in the 3 states between index surgery and 2011. Hernia risk was calculated with multivariable hierarchical logistic regression modeling and validated using bootstrapping techniques. Exclusion criteria included concurrent hernia, metastasis, mortality, and age younger than 18 years. Inflation-adjusted expenditure estimates were calculated. RESULTS Overall, 30,741 patients underwent colectomy, one-third of these procedures performed laparoscopically. Incisional hernia repair was performed in 2,563 patients (8.3%) (27-month follow-up). Fourteen significant risk factors were identified, including open surgery (odds ratio = 1.49; p < 0.0001), obesity (odds ratio = 1.49; p < 0.0001), and alcohol abuse (odds ratio = 1.39; p = 0.010). Extreme-risk patients experienced the highest incidence of incisional hernia (19.8%) vs low-risk patients (3.9%) (C-statistic = 0.67). CONCLUSIONS We present a clinically actionable model of incisional hernia using all-payer claims after colectomy. The data presented can structure preoperative risk counseling, identify modifiable patient-specific risk factors, and advance the field of risk prediction using claims data.
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Affiliation(s)
- Jason M Weissler
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael A Lanni
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jesse Y Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael G Tecce
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Martin J Carney
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Justin P Fox
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John P Fischer
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Wang XC, Zhang D, Yang ZX, Gan JX, Yin LN. Mesh reinforcement for the prevention of incisional hernia formation: a systematic review and meta-analysis of randomized controlled trials. J Surg Res 2017; 209:17-29. [DOI: 10.1016/j.jss.2016.09.055] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/04/2016] [Accepted: 09/27/2016] [Indexed: 02/07/2023]
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Weissler JM, Lanni MA, Tecce MG, Carney MJ, Shubinets V, Fischer JP. Chemical component separation: a systematic review and meta-analysis of botulinum toxin for management of ventral hernia. J Plast Surg Hand Surg 2017; 51:366-374. [PMID: 28277071 DOI: 10.1080/2000656x.2017.1285783] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ventral hernia represents a surgical challenge plagued by high morbidity and recurrence rates. Primary closure of challenging hernias is often prohibited by severe lateral retraction and tension of the abdominal wall musculature. Botulinum toxin injections have recently been identified as a potential pre-operative means to counteract abdominal wall tension, reduce hernia size, and facilitate fascial closure during hernia repair. This systematic review and meta-analysis reviews outcomes associated with botulinum toxin injections in the setting of ventral hernia, and demonstrates an opportunity to leverage this mainstream aesthetic product for use in abdominal wall reconstruction. METHODS A literature review was conducted according to PRISMA guidelines using MeSH terms 'ventral hernia', 'herniorrhaphy', 'hernia repair', and 'botulinum toxins'. Relevant studies reporting pre- and postinjection data were included. Outcomes of interest included changes in hernia defect width and lateral abdominal muscle length, recurrence, complications, and patient follow-up. Qualitative findings were also considered to help demonstrate valuable themes across the literature. RESULTS Of 133 results, 12 were included for qualitative review and three for quantitative analysis. Meta-analysis revealed significant hernia width reduction (mean = 5.79 cm; n = 29; p < 0.001) and lateral abdominal wall muscular lengthening (mean = 3.33 cm; n = 44; p < 0.001) following botulinum injections. Mean length of follow-up was 24.7 months (range = 9-49). CONCLUSIONS Botulinum toxin injections offer tremendous potential in ventral hernia management by reducing hernia width and lengthening abdominal wall muscles prior to repair. Although further studies are needed, there is a significant opportunity to bridge the knowledge gap in preoperative practice measures for ventral hernia risk reduction.
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Affiliation(s)
- Jason M Weissler
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Michael A Lanni
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Michael G Tecce
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Martin J Carney
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Valeriy Shubinets
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - John P Fischer
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
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Borab ZM, Shakir S, Lanni MA, Tecce MG, MacDonald J, Hope WW, Fischer JP. Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis. Surgery 2016; 161:1149-1163. [PMID: 28040255 DOI: 10.1016/j.surg.2016.09.036] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure. METHODS A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications. RESULTS Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03). CONCLUSION Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at-risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.
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Affiliation(s)
| | - Sameer Shakir
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael A Lanni
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John MacDonald
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - William W Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
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Prophylactic mesh can be used safely in the prevention of incisional hernia after bilateral subcostal laparotomies. Surgery 2016; 160:1358-1366. [DOI: 10.1016/j.surg.2016.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/07/2016] [Accepted: 05/13/2016] [Indexed: 02/07/2023]
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A risk model and cost analysis of post-operative incisional hernia following 2,145 open hysterectomies-Defining indications and opportunities for risk reduction. Am J Surg 2016; 213:1083-1090. [PMID: 27769544 DOI: 10.1016/j.amjsurg.2016.09.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 09/16/2016] [Accepted: 09/29/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Incisional hernia (IH) is a complication following open abdominal hysterectomy. This study addresses the incidence and health care cost of IH repair after open hysterectomy, and identify perioperative risk factors to create predictive risk models. METHODS We conduct a retrospective review of patients who underwent open hysterectomy between 2005 and 2013 at the University of Pennsylvania. The primary outcome was post-hysterectomy IH. Univariate/multivariate cox proportional hazard analyses identified perioperative risk factors. We performed cox hazard regression modeling with bootstrapped validation, risk stratification, and assessment of model performance. RESULTS 2145 patients underwent open hysterectomy during the study period. 76 patients developed IH, and all underwent repair. 31.3% underwent reoperation, generating higher costs ($71,559 vs. $23,313, p < 0.001). 8 risk factors were included in the model, the strongest being presence of a vertical incision (HR = 3.73 [2.01-6.92]). Extreme-risk patients experienced the highest incidence of IH (22%) vs. low-risk patients (0.8%) [C-statistic = 0.82]. CONCLUSIONS We identify perioperative risk factors for IH and provide a risk prediction instrument to accurately stratify patients in effort to offer risk reductive techniques. SUMMARY Open hysterectomies account for a magnitude of surgical procedures worldwide. This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2145 cases. With an increasing emphasis on prevention in healthcare, we create a risk model to improve outcomes after open hysterectomies in effort to identify high-risk patients, facilitate preoperative risk counseling, and implement evidence-based strategies to improve outcomes.
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Dasari M, Wessel CB, Hamad GG. Prophylactic mesh placement for prevention of incisional hernia after open bariatric surgery: a systematic review and meta-analysis. Am J Surg 2016; 212:615-622.e1. [PMID: 27659158 DOI: 10.1016/j.amjsurg.2016.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 03/14/2016] [Accepted: 06/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prophylactic mesh during laparotomy has been shown to be effective in preventing postoperative incisional hernia (IH) in high-risk patients. Since obesity is a risk factor for IH, we wished to determine whether mesh prevents IH in open and laparoscopic bariatric surgery patients. METHODS We conducted a systematic review of the literature with meta-analysis. Seven studies met inclusion criteria. We abstracted data regarding postoperative IH development, surgical site infection, and seroma or wound leakage and performed meta-analysis. RESULTS The prophylactic mesh group had significantly decreased odds of developing IH than the standard closure group (odds ratio, .30, 95% CI, .13 to .68, P = .004). No included studies evaluated outcomes after prophylactic mesh during laparoscopic bariatric surgery. CONCLUSIONS Prophylactic mesh during open bariatric surgery appears to be beneficial in reducing postoperative IH without significant increasing the odds of surgical site infection or seroma or wound leakage. Higher quality studies, including those in laparoscopic patients, and cost-utility analysis, are needed to support routine use of this intervention.
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Affiliation(s)
- Mohini Dasari
- Department of Surgery, University of Pittsburgh, F1263.3, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Charles B Wessel
- Department of Digital Library Services, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Giselle G Hamad
- Department of Surgery, University of Pittsburgh, Magee-Women's Hospital of UPMC, Pittsburgh, PA, USA
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Fischer JP, Basta MN, Mirzabeigi MN, Bauder AR, Fox JP, Drebin JA, Serletti JM, Kovach SJ. A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention. Ann Surg 2016; 263:1010-7. [PMID: 26465784 PMCID: PMC4825112 DOI: 10.1097/sla.0000000000001394] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objectives: Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. Methods: All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. Results: A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2 ± 26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded $17.5 million. Notable independent risk factors for IH were ostomy reversal (HR = 2.76), recent chemotherapy (HR = 2.04), bariatric surgery (HR = 1.78), smoking history (HR = 1.74), liver disease (HR = 1.60), and obesity (HR = 1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic = 0.78). Conclusions: This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.
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Affiliation(s)
- John P Fischer
- *Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA †Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
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A Cost-Utility Assessment of Mesh Selection in Clean-Contaminated Ventral Hernia Repair. Plast Reconstr Surg 2016; 137:647-659. [PMID: 26818303 DOI: 10.1097/01.prs.0000475775.44891.56] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mesh reinforcement can reduce hernia recurrence, but mesh selection is poorly understood, particularly in contaminated defects. Acellular dermal matrix has enabled single-stage ventral hernia repair in clean-contaminated wounds but can be associated with higher complications and cost compared with synthetic mesh. This study evaluated the cost-utility of synthetic mesh and acellular dermal matrix for clean-contaminated ventral hernia repairs. METHODS A systematic review of articles comparing outcomes for synthetic and acellular dermal matrix repairs identified 14 ventral hernia repair-specific health states. Quality-adjusted life years were determined through Web-based visual analog scale survey of 300 nationally representative individuals. Overall expected cost and quality-adjusted life-years for ventral hernia repair were assessed using a Monte Carlo simulation with sensitivity analyses. RESULTS Synthetic mesh reinforcement had an expected cost of $15,776 and quality-adjusted life-year value gained of 21.03. Biological mesh had an expected cost of $23,844 and quality-adjusted life-year value gained of 20.94. When referencing a common baseline (do nothing), acellular dermal matrix (incremental cost-effectiveness ratio, 3378 ($/quality-adjusted life years)) and synthetic mesh (incremental cost-effectiveness ratio, 2208 ($/quality-adjusted life years)) were judged cost-effective, although synthetic mesh was more strongly favored. Monte Carlo sensitivity analysis demonstrated that synthetic mesh was the preferred and most cost-effective strategy in 94 percent of simulations, supporting its overall greater cost-utility. Despite varying the willingness-to-pay threshold from $0 to $100,000 per quality-adjusted life-year, synthetic mesh remained the optimal strategy across all thresholds in sensitivity analysis. CONCLUSION This cost-utility analysis suggests that synthetic mesh repair of clean-contaminated hernia defects is more cost-effective than acellular dermal matrix.
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Basta MN, Mirzabeigi MN, Shubinets V, Kelz RR, Williams NN, Fischer JP. Predicting incisional hernia after bariatric surgery: a risk stratification model based upon 2161 operations. Surg Obes Relat Dis 2016; 12:1466-1473. [PMID: 27425834 DOI: 10.1016/j.soard.2016.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/28/2016] [Accepted: 03/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Incisional hernia (IH) is a persistent cause of morbidity and diminished quality of life and a substantial source of healthcare resource utilization. The literature suggests prophylactic mesh augmentation reduces IH risk in bariatric surgery, but no predictive models are available. OBJECTIVES Identify factors associated with IH after bariatric surgery to develop a clinically actionable preoperative risk stratification tool to optimize outcomes and mitigate healthcare costs after bariatric surgery. SETTING University hospital, United States. METHODS All patients undergoing open or laparoscopic bariatric surgery from January 2005 to June 2013 at one institution were identified. Co-morbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia,<1-year follow-up, or body mass index<40 kg/m2 were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. RESULTS A total of 2161 bariatric patients were included, 2.4% of whom developed IH (follow-up 28.3±25.4 mo). Predictors for IH included open surgical approach (hazard ratio [HR] = 10.3), malnutrition (HR = 3.10), prior abdominal surgery (HR = 2.89), and body mass index>60 kg/m2 (HR = 2.60). Based on these risk factors, patients were stratified into low-, moderate-, and high-risk categories for IH development. Of the high-risk patients, 15.2% developed IH compared with .6% of low-risk patients (C-statistic = .85). Treatment of IH and associated complications exceeded $3.5 million in healthcare costs. CONCLUSION Bariatric surgery conferred an IH risk of 2.4%. IH was associated with additional readmissions and complications and substantially greater costs and resource utilization. This risk stratification tool identifies candidates for prophylactic mesh augmentation, which may optimize outcomes while mitigating costs.
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Affiliation(s)
- Marten N Basta
- Department of Plastic & Reconstructive Surgery, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Michael N Mirzabeigi
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Valeriy Shubinets
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Division of Endocrine and Oncologic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Noel N Williams
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
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